Physical Therapy Joins the Movement

By Susan Carr

This year’s annual conference of the American Physical Therapy Association’s Massachusetts chapter (APTAMA) focused on a microcosm of issues in healthcare improvement: value, collaboration, measurement, and spread. After hearing Alan M. Jette, PT, PhD, FAPTA, deliver the keynote address, “System Thinking to Thrive in a Changing Health Care Environment,” I participated on a panel that included Jette in a discussion of the issues he raised.

Leaders in physical therapy are working hard to inspire practicing physical therapists (PT) to pursue improvement efforts within their profession, in healthcare more broadly, and with consumers directly. Leaders such as Jette and Mary Duffy Zupkus, PT, MPA, president of the APTAMA (and—full disclosure—my PT), believe that physical therapy offers unique opportunities to advance healthcare delivery and must reposition itself as a profession in order to survive the new demands of the healthcare marketplace. The enthusiasm and savvy of those who attended the conference, presented on the panel, and asked insightful questions were reminders that important stakeholders continue to join the improvement movement.

In his keynote, Jette observed that PTs have been just as siloed as other specialties in medicine; however, they must now collaborate with physicians and others to coordinate patient care for best value and outcomes. Jette cited Dr. Atul Gawande’s New Yorker article “Cowboys and Pit Crews” as evidence of healthcare’s shift away from specialists working independently toward tightly coordinated teams working together. It was refreshing to hear Jette replace the stereotypical surgeon-as-cowboy exemplar with a PT. Despite the stylistic differences between surgeons and PTs, the inefficiencies and risks in the cowboy clinician model are similar.

In addition to teamwork, Jette emphasized the need for data-driven improvements in physical therapy practice and wide-scale dissemination of best practices and innovation. Quoting Don Berwick, MD, Jette observed that dissemination is more difficult to accomplish and sustain than innovation. He attributed some of the problem to the reluctance of PTs—and other caregivers—to leave the comfort of their known professional community for the uncertain demands of interprofessional activities. In human terms, to disseminate knowledge as well as to learn, you have to be willing “to leave the village.”

Movement in practice salon

Mary Zupkus modeled the post-keynote panel discussion on salons held in 17th– and 18th-century France, when private citizens—often women—invited intellectuals into their homes for lively discussion of issues of the day. Nine of us joined Zupkus, Alan Jette, and a moderator for the APTAMA salon. We applied our collective experience in journalism, innovation, marketing, education, hospital administration, public policy, and primary care practice—as well as physical therapy—to the question:

Is there something about the culture of the profession of physical therapy that makes us reluctant to lead in an era of change?

In response, the panel discussed more questions, including: Does physical therapy attract and support individuals who are likely to be “positive deviants,” willing to challenge the status quo and lead others in changing practice? Does physical therapy education prepare PTs to measure their own practices, use evidence-based medicine, and collaborate with other clinicians to foster improvement? What effect does gender have on the culture of physical therapy and opportunities for change?

A number of panelists observed that physical therapy is a natural partner for primary care. Andy Waldeck, senior partner at Innosight, described the opportunities and demands of the PT’s role in that partnership:

You are frontline care, even more frontline than primary care. We don’t have enough primary care doctors, and they’re overburdened. Physical therapists, as well as pharmacists and nurse practitioners, have tremendous roles to play because you can touch a patient much more frequently, you can understand what’s actually going on in patients’ daily lives. But that requires you to be integrated into a system.

Suzanne Koven, an author and primary care physician at Massachusetts General Hospital, said that PTs are de facto primary care providers in some circumstances. Describing treatment she received for a complex arm injury, Koven credited her orthopedic surgeon, primary care physician, and physician assistant for contributing to her recovery, but Zupkus (Koven’s PT) provided her “primary” care and was “the only one focusing on my experience.”

Other panelists agreed that PTs fill a unique role by connecting ongoing treatment to the realities of a patient’s daily life, expectations, abilities, and goals. Panelists also concurred that it is up to PTs to develop evidence about their practices and raise awareness about their contributions, something the profession has not done well in the past.

Engaging with the larger medical community to collaborate or simply diffuse knowledge among patients and the public is a new challenge for PTs. Partnerships with physicians and direct outreach are obvious opportunities to change the system, but specific plans for PT activism are lacking. In his recap of the salon, Cody Weisbach, PT, acknowledged that publishing scientific data in physical therapy journals is important but not as effective as storytelling for reaching broad audiences and leading change.

Physical therapy must assert its strength as a unique hub of patient engagement and efficient health promotion to help design changes to healthcare delivery and payment models—and, ironically, to survive those changes. During the salon, Zupkus quoted a lobbyist mentioned in America’s Bitter Pill, Steven Brill’s book about healthcare policy and financing, saying, “If you’re not at the table, you’re on the menu.”

With this keynote and salon, the APTAMA produced ideas and indicated possible future actions, but that doesn’t mean designing and implementing the changes will be easy. I was reminded that opportunities sometimes imply responsibility. For each of us, holding something back that we know is needed—an idea, an action, an endorsement—because we’re too busy, too shy, too indecisive, or simply content to perform our work on a daily basis, can have real cost. Our actions don’t have to be dramatic to make a difference, but leaving the comfort of our own villages takes courage and determination.

 

References

Brill, S. (2015). America’s bitter pill: Money, politics, back-room deals, and the fight to fix our broken healthcare system. New York: Random House.

Gawande, A. (2011, May 26). Cowboys and pit crews. The New Yorker. Retrieved from http://www.newyorker.com/news/news-desk/cowboys-and-pit-crews

Jette, A. M. (2012). Face into the storm. Physical Therapy, 92(9), 1221–1229. doi: 10.2522/ptj.2012.mcmillan.lecture