Top 7 Lessons From My First Year in Practice

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Before I left for physical therapy school, I had one great fear: no matter how hard I tried, I was going to be a bad PT. I confided this fear to a mentor of mine, a well-respected PT himself. His response is one I’ve thought about regularly since that day- that with a solid foundation in school and good mentorship afterwards, there was no doubt I would be a great PT.

 Having now completed my education and practiced for a year, I realized that my mentor’s comments ring true for not just me, but for anyone entering the profession.With a new cohort of freshly licensed PT’s and PTA’s coming in to the profession, I took some time to reflect upon the major lessons I have learned over my first year in practice. The below points have resonated with me most, but please feel free to add your own in the comments section below!

 1. Mentorship is made by you, not provided by someone else. When interviewing for jobs, we all hear promises of weekly mentorship time and guided learning. Yet, if you do not prioritize this time, it’s likely to get lost in the pressures of the day. It’s our responsibility to make sure our mentorship time actually happens and is effectively used. Here are a few practices I have found helpful: a) block off your mentor time on your schedule- it’s simple, but makes the time more official; b) make sure your mentor is someone who you want to learn from; c) plan it out- set individual goals for yourself each time you meet with your mentor.

 2. Don’t compromise your values. Coming out of school, the lines between right and wrong seem pretty clear. However, those lines may quickly blur by pressures to bill more units, see more patients, or take on a practice outside of your ethical comfort zone. Remember that these decisions are ultimately in your hands- it’s your license and happiness that’
s on the line by being in a job that challenges your morals, ethics, and ability to take quality care of your patients.

 3.   Develop self-management strategies and remember your role. Patient care is hard. And a lot of responsibility. While we may see 60 patients per week, our patients only see us once or twice. Many times, we are the only health professional caring for their well-being. Because of the time we spend with our patients and trusting relationships we develop, many patients often end up airing all of their concerns to us. We may not be trained as social workers or psychologists, but the nature of our job demands we play a role as a quasi director of their care. There’s no doubt about it- doing this for patient after patient is mentally, physically, and emotionally draining. In response to this fatigue, I’ve developed a couple strategies to make my day more manageable. First and foremost, I always try to remember my role- we don’t have the time or training to be everything to everyone, so I make sure to refer to other professionals when appropriate, even when it means embarking on a difficult conversation. Second, I try to take 2-3 minutes between patients to decompress. Just a few minutes allows me to refresh, knock out a bit of documentation, and ensure I approach the next patient as a clean slate. I find I can bring more to the treatment session with those couple minutes to myself, even if it means I’m slightly late to the next treatment session.

 12080051_m4. Attitude is truly infectious. It’s easy to fall down the wormhole of complaining about patients or co-workers, but finding ways to stay positive, smile, and bring joy to the clinic is much more rewarding. We all have difficult days, but bringing a positive attitude to work can change the entire culture within a clinic. I challenge you to be that compassionate and empathetic person that brings positivity to a clinic. Once you do, your colleagues will start to look at you as a leader and your patients will notice.

5. Recognize your needs. Then verbalize and fight for them. Everyone has an idea of what it means to be successful, but only you know what you need to be successful. Too often, I see new employees try to conform to a system and environment that does not work for them. Whether you feel you need more mentorship, want to attend a continuing education course, or even would like something as simple as a slightly longer lunch, do not let a resentful feeling brew- approach your employer in a respectful fashion. Chances are that your employer is looking to support you, but does not see your needs. If your employer is not willing to acknowledge or support your needs, it might be time to consider a change.

 6. Reflection really is important. Be a conscious practitioner. In PT school, our class reflected on everything. In fact, I’m pretty sure we reflected on our reflections. We reflected so much that reflection became a dirty word. However, I have come to find great power held within reflection. Make sure to periodically ask yourself, “what could I have done better during my last treatment session,” or “what could I improve upon from last week?” It’s easy to go through the motions, but approaching your treatment session consciously, by analyzing what you are doing, why you are doing it, and how you can improve will lead to greater growth and fulfillment.

 7. It’s worth it. Patient care is challenging. Most days are exhausting. Yet, if you give it your all and fully engage with your patients, it can be extremely rewarding. The feeing you get when someone looks you in the eye, shakes your hand, and says a genuine ‘thank you for your help,’ is a feeling I have never reproduced elsewhere in the world. We play a special role in our patients’ lives, giving them our time, touch, and knowledge. Cherish your relationships with your patients and never forget what it feels like to help someone achieve their goals.

 Any big lessons I missed? Please consider adding your own lessons to the list in the comments section below!

About the Guest Blogger: Josh D’Angelo, PT, DPT served as APTA Student Assembly President in 2013 and is now active with APTA’s DC Chapter and Private Practice Section. He graduated from George Washington University’s Doctorate of Physical Therapy program in 2013, where he was the University’s sole student to win the George Washington Award. Josh is also a former APTA Mary McMillan Scholarship awardee and is currently practicing in the outpatient orthopedic setting in Washington, D.C.  He is a regular contributor at PTHaven.

What is Quality in Physical Therapy?

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I have had some interesting interactions in social media over the past few weeks that have had me thinking about the definition of quality in physical therapy. Therapists are paid for our time and the procedures we perform. Because of this (or at least I blame this system) we tend to define quality around ‘actions taken’ and method of work. For example:

  • Quality providers are able to manipulate an acute low back
  • Quality providers avoid modalities
  • Quality providers provide good home exercise programs
  • Quality providers set and track goals
  • Quality providers use evidence based interventions
  • Quality providers spend (however long) with each patient
  • Quality providers do not use PT Assistants or Aides
  • Quality providers have this or that certification
  • Quality providers have/avoid the latest gadgets
  • Quality providers use/have/do whatever is important to you…

We do this in large part because these are the most visible parts of a practice we might judge it by. However, I would argue that while there are a host of factors that the best practices have in common, quality is not defined by actions or our broken reimbursement system. Quality is defined by patient outcome and by patient experience. In this post, I’d like to provide a window into how we measure quality at Texas Physical Therapy Specialists.

In our practice, we measure outcome using a national database called Focus on Therapeutic Outcomes (FOTO). This system uses adaptive surveys to determine a risk adjusted baseline when a patient starts physical therapy, and then tracks their progress. The results can then be used to provide feedback to individual therapists (i.e.”Dr.____, your outcomes with ankle patients aren’t as good as Dr.___’s, lets see what they are doing that you are not) and more importantly can be used to compare outcomes with other participating practices across the nation.

The other component of quality in physical therapy practice is patient experience. We break this into two components: customer service (all staff interactions) and providing quality connection between the therapist and the patient.

We measure customer service with a survey that has multiple components but centers around the ‘net promoter score‘. Often called ‘the most important question in business’ it is simple and captures the desired customer service outcome for most practices.11268773_m

“How likely is it that you would recommend us to a friend or colleague?”

Much harder to measure but equally important to patient experience is the quality of connection between patient and therapist. This is how well a therapist listens and how much empathy they show. These things have a powerful impact on clinical outcome so we measure them separately using a survey specifically for these items (Consultation and Relational Empathy instrument or CARE) at the completion of the first visit. Interestingly, our therapists scored significantly better in this area after receiving training specific to compassion and empathy.

The confluence of these three things is the product our practice produces.

The amount we charge a cash-paying patient, the contract we sign with an insurer or the assignment we accept from the federal government is simply how we receive payment for that product.  Our current payment system bases this on time spent and a host of other items that have no direct relationship to quality.  Paying for time without accounting for outcome is like paying a mechanic for the time spent on your car without accounting for whether the problem is solved.  Regulating work methods is like mandating that a mechanic can’t use helpers and again not accounting for whether the problem is solved.  We have to comply with these external definitions (which vary wildly by state and payer) but we do not have to let them define what Quality is.  In my opinion, quality in physical therapy is a simple equation:

Quality = Outcome + Patient Experience.

There are many ways to get there, and undoubtedly some are better than others.  Having the ability to measure quality gives us the opportunity to find bright spots and emulate best practices.  How do you measure the quality of your service?

Jobs Applied: Know Both the Big Picture and The Details

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Steve Jobs had a penchant for dreaming big.  His far-reaching vision brought personal computers into the home, revolutionized the music industry and contributed to the advent of today’s world of cloud computing.  Yet at the same time, he also kept his hands in the nitty-gritty details of the products Apple was producing.  He set not only the destination of Apple, but he paid attention to every turn along the way.  This ability to ‘zoom out’ to the big picture and ‘zoom in’ to focus on details is part of what made him so effective.

Small business owners, particularly in service industries like physical therapy, are often pulled in a thousand directions.  We have to make decisions on a grand scale – ‘Do I buy this building?’, ‘How big do I want to grow?’, ‘should I participate in this ACO?’.  However, we also have an overwhelming flood of details to oversee.  ‘who has the best price on theraband?’, do I have time to put another patient in my 2:30 slot?, ‘should I give my technician a $.25 raise?’.

“Details matter, it’s worth waiting to get it right.” – Steve Jobs

Focusing in on just the big picture can create problems.  In today’s challenging payment environment, the margin is often found in our management of expense details and avoiding unnecessary costs.  It takes almost $1.25 of revenue growth to equal $1.00 of cost savings.  This means that controlling costs is often an underutilized mechanism for improving performance.  The success of our teams often also happens due to paying attention to details.  Getting the right people on the bus and making sure that we only tolerate A players has everything to do with careful selection of every member of our team.14866993_m

However, focusing only on the details stifles innovation.  Strategic thinking, big picture goal setting and innovation are necessary ingredients for a vibrant culture and practice growth.  We have to have a vision and a strategic plan for reaching that vision.  As Vince Lombardi said “hope is not a strategy.”  As leaders in healthcare, we have to be part of the nationwide conversation going on right now.  We need to be involved in coming up with the ideas that guide our changing healthcare system, and we will need to be ready to adapt to the new reality that is coming.

“I want to put a ding in the Universe” – Steve Jobs

To grow and to be successful we have to know both the big picture and the details.  

This Jobs Applied lesson reminds me of one of my favorite principles from Jim Collins.  My next #Browdering series will apply this principle and several others from ‘Good to Great’, ‘Great by Choice’ and ‘How the Mighty Fall’ to our world of physical therapy management and leadership.  I hope you will join me next week as we discuss ‘The Stockdale Paradox’.

Jobs Applied: Impute

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Have you ever noticed that the packaging for Apple products is simply beautiful?  I hate to throw these things away – its obvious great attention and time goes into each one.  Steve Jobs personally spent time on the design of the packaging for the iPhone, believing that it set the tone for the experience.  He put his own stamp onto every facet of the product so that there was intention behind every aspect of it.

“They ‘do’ judge a book by its cover.”  -Steve Jobs

 

Everybody utilizes first impressions to make judgements.  Patients ascribe (or ‘impute’) characteristics to their therapist based on the packaging.  Can we intentionally design the patient’s first impression to create confidence that we can solve their problem?  I suggest that how we appear and how we dress plays a role in patient confidence, and thus in our ultimate outcome with that patient.

How do we want to be perceived?  I think patient’s for the most part don’t really know where to put us in the hierarchy of healthcare professionals.  What style of dress gives the best impression?  Is it different for different people?  There has been a little bit of research in this area, but nothing all that definitive and it seems obvious to me that setting makes a difference.  Interestingly, this research did not include the style I would choose for men in outpatient settings (dress shirt no tie).

‘Scrubs’    – I loved that show. Have you washed those recently?

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‘The Coach’   – Are physical therapists like really smart personal trainers? Hey – P.T. – the initials are the same!

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‘The Golfer’  – Are physical therapists like athletic trainers? I had one of those in high school.

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‘Business Casual’     – Nice shirt! Is that stain from massage lotion?

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‘The Coat and Tie’    – Did you just come from the bank?  Is that tie uncomfortable?

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’The White Coat’    –  Are physical therapists like physicians?

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What kind of ‘packaging’ sends the best message in your opinion?  I’d love to discuss it with you below and we’ll be #browdering on twitter as well.

 

Jobs Applied: Put Products Before Profits

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Steve Jobs, when creating the first Macintosh computer, famously ignored cost trade-offs and profitability in favor of making the computer ‘insanely great’ and with a mantra ‘don’t compromise’. This actually led to his ouster in the early ’80s as the Macintosh ended up both amazing and too expensive to compete with the cheaper PCs of the day. In response, Apple hired a less product-oriented CEO recruited from Pepsi, John Sculley, who focused on profits. Focusing on profits led to a decline in quality and Apple nearly died before Jobs’ return in the early ’90s. The return to a focus on innovative, ‘amazing’ products led to Apple’s emergence as a market leader.  Even in the face of challenges, such as we are facing in healthcare today, Steve Jobs kept the focus on providing the best product, rather than on profits.

A few weeks ago I  posted ‘Jobs Applied: When Behind, Leapfrog‘-  a discussion of Harvard strategy guru Michael Porter and Thomas Lee’s timely HBR article “The Strategy That Will Fix Health Care”. One of the key principles Dr. Porter brings up is the definition of value in healthcare.

“Value is defined as the health outcomes achieved that matter to patients relative to the cost of achieving those outcomes. Improving value requires either improving one or more outcomes without raising costs or lowering costs without compromising outcomes or both.” (Porter and Lee, HBR Oct 2013)

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In health care and other service industries the ‘product’ is a patient’s experience and a health outcome… so the lesson here would be ‘Put the patient’s experience and health outcome before profits’. As the payments for providing health care services decline this is a reminder to continue to put the patient’s needs first.

Our physical therapy practice has been a leader embracing a care model that allows for improved efficiency, but keeps the physical therapist (PTs) firmly engaged with each patient. Texas allows physical therapists to utilize technicians (unlicensed assistants)to assist with some treatments under the direct supervision of the physical therapist. While when we first started in this model we were challenged by PTs providing ‘1 patient for 1 therapist for 1 hour’, these practices are increasingly failing in states with the greatest payment challenges and have either evolved or are hanging on by a thread. While in part due to other issues, the 2013 chapter 11 filing of the largest physical therapy provider in the US accentuates the idea that this lesson might be better termed ‘put products before survival’.

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Many states have strict requirements requiring care be provided by only licensed personnel (PTs and PT assistants – or PTAs) and federal payers (i.e. Medicare and Medicaid) will only pay for services provided directly by one of these licensed personnel. These regulations in our ‘over-licensed society’ (Litan, R. HBR Apr 2012) have created a perverse incentive where a model that may decrease value to the patient actually becomes the most easily sustainable model of provide PT services.

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For the first 10 years of my career I was a physical therapist in the US Air Force. I am proud to say that the US Military employs perhaps the finest orthopedic and sports oriented PTs in the US. Direct access to PT services and an advanced level of musculoskeletal screening and cross-collaboration with other specialties is integrated in a manner that the public sector should look to when reforming our health care system. There is mounting evidence that early referral to PT, which is sometimes available in the military system and now available in some states improves outcomes and reduces downstream costs.

One of the challenges, particularly in military medical centers, is that many of the actual treatments are not provided by PTs. A typical patient encounter would include an evaluation with a PT, then multiple treatment sessions with personnel roughly equivalent to a physical therapy assistant (PTA) with a follow-up visit with the physical therapist at somewhere between 2 weeks and 1 month after treatment.

PTAs have associates degrees and are licensed to provide PT treatments under supervision. Manual therapy is a key challenge to providing care that is centered around the utilization of PTAs in an outpatient orthopedic setting. The APTA has issued guidance discouraging PTs from allowing their assistants to provide manual therapy interventions. One of the reasons I eventually left the military medical system was to be able to provide these evidence based interventions without requiring a lesser-trained intermediary.

The regulations imposed primarily by the federal government in conjunction with steadily declining payment for services have created a concerning incentive. The care model long utilized by the US military looks as if it may become one of the few viable business models for private practice. Driven by a high median income ($52,160 in 2012)there is a flood of interest in becoming a PTA. With the median salary for physical therapists (doctoral degree) at $79,860 this is no surprise. There are now 21 PTA programs in Texas (compared to 12 PT programs) with more on the way.  In my opinion, the relatively high cost of PTAs (and their wages) will likely dramatically decrease as demand is met and then exceeded over the next few years. At that time the incentives provided by declining payment for services  and regulatory requirements align very well with a business model where a single physical therapist provides minimal oversight to multiple PTAs.

1194984910785474358stop sign miguel s nchez svg medI have encountered this model recently, when interviewing PTs for director’s positions within our practice. One PT I encountered reported evaluating over 100 new patients while supervising 2 PTAs providing over 900 visits in a single month. By his report he was able to follow up with his patients for a short time approximately every 4-5 visits.

Utilization of PTAs, in itself, is not what I would argue is the problem with this business model. I believe there are models where PTAs can be leveraged as part of a tightly knit team to improve efficiency and to maintain or improve quality. However, as the ratio of PTAs supervised by each PT increases, the level of involvement of the PT in the patient’s care invariably diminishes. In the Air Force we would see this in the variability in the quality of care provided at medical centers versus in the smaller outpatient facilities or the deployed setting. My wife, Alexis, has experienced this in the home health setting, where she was asked as the PT to provide an initial evaluation and a follow-up visit at 30 days. I believe it is hard to make the argument that the patient’s progression is meaningfully guided by the physical therapist in that scenario.

A counter-argument would be to compare this scenario to the increase in utilization of care extenders to decrease the cost for primary care providers to care for patients or even the explosion of ‘minute clinics’ and the like. While the situation is similar on the surface, it is perhaps more extreme when looked at more closely. To compare these arguments would put the doctorally trained physical therapist in the provider role (not inappropriate from my perspective), but would put the PTA in the same category as a physician assistant or nurse practitioner. While I have worked with excellent PTAs, the training received at an associates degree level is not comparable to the masters degree level that physician’s assistants and nurse practitioners receive.

The lesson of putting the patient’s experience and outcome before profits may come into play if we allow over-utilization of PTAs or any other extender to disconnect the PT from the patient’s intervention. In the face of ever-increasing costs of doing business, it is my hope that we can continue to ‘put products before profits’ and create innovative care models that meet Dr. Porter’s charge of improving patient experience and outcomes while doing so at a decreased cost. Removing well-meant but misguided regulatory hurdles would improve our ability to meet the charge to provide high quality care by PTs in a model that can accept lower payments for services while maintaining the patient’s experience and outcomes.

I suspect that this post might touch a few nerves – even in some of my good friends and fellow private practice owners – and I am looking forward to engaging in respectful debate on the topic. Please add your perspective!  I don’t pretend to know the answers and freely admit I might be wrong.  Maybe we can come up with some ideas together to move our profession forward in these challenging times.

Jobs Applied: When Behind, Leapfrog

When Apple found itself behind, Steve Jobs would innovate his way out of the problem.  The best known example of this is finding that the original iMac, great for creatives and photo handling, wasn’t any good at music… it didn’t even have a CD burner!  Apple was getting trounced by PCs in this area.  Apple not only gained ground, but leaped ahead by creating iTunes and the iPod.  These products literally restructured the entire music industry for everyone but Garth Brooks and a few other holdouts.

Got a job girlLast week as I was pondering this week’s post I thought to myself … ‘Self, how are you going to turn this obviously tech related, innovative ‘leadership lesson’ into something that has utility in the private practice physical therapy world?  I was stumped.

Then I read a fascinating article in HBR by business strategy icon Michael Porter and Thomas Lee titled ‘The Strategy That Will Fix Health Care –  Providers must lead the way in making value the overarching goal.’  You can find the abstract here and I recommend buying the article.  Everybody in the the US healthcare chain should be forced to read it.

” At its core is maximizing value for patients: that is, achieving the best outcomes at the lowest cost”

Here’s the gist: Providers (OK so he really means hospital systems and physicians) need to do 6 things all at once to fix America’s ailing healthcare system.

  1. Organize into Integrated Practice Units (IPUs).
  2. Measure outcomes and costs for every patient.
  3. Move to bundled payments for care cycles.
  4. Integrate care delivery across separate facilities.
  5. Expand excellent services across Geography.
  6. Build and enabling information technology platform.

What struck me when reading this is that we are already behind!  Dr. Porter did bring us up a few times as excellent examples of how we can save costs and how utilization of ancillary providers (like PTs and nurse practicioners) creates efficiency and cost savings.  For example, we are < 1/4 the cost of a physician visit and there is plenty of evidence to show we can save downstream costs.  As a profession, this single article may do more for us in terms of positioning us as a part of the solution than anything else I’ve seen to date.  However – it was always in the context of the PT in the medical center.

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This model would create Integrated practice units, which PTs are certainly a part of and have a role in. IPUs are like a next generation Center of Excellence focused on being the best at one diagnosis or patient type.  These already exist – the example Dr. Porter uses is Virginia Mason Medical Center in Seattle – which focuses on treating low back pain.  After calling a single number, patients are scheduled to visit a PT and later that day a PM&R physician (just in case?).  If the patient needs anything other than PT then they can receive it right there in the same hospital.   In the IPU strategy the expected outcome is that IPUs become bright spots in care delivery for particular diagnoses.  Employers and health systems are then to be encouraged to send exclusively to them to handle the entire course of care… including rehabilitation.  So how then do they take care of the outpatient PT piece? Answer:  they ‘expand excellent services across geography’.  Ouch.

“Organizations that progress rapidly in adopting the value agenda will reap huge benefits, even if regulatory change is slow.”  (Porter and Lee)

So how do we leapfrog ahead of this (admittedly brilliant and needed) strategy to ensure that private practice physical therapists have a place in this New HealthCare World Order.  More to the point – how to we do that in whatever less well thought-out version we end up with?  Do we all have to go work for the hospital?  I think there are two ways we lead our organizations to get there:

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First – measure outcomes.  Our company uses FOTO to measure functional outcomes on every patient.  This is the first step in participating in the new healthcare world.  We have to be able to achieve and demonstrate a high level of value for our patients and ‘what gets measured gets managed’ (Peter Drucker).  If we don’t measure it – how do we know how much value we are adding?  How can we improve?

Second, we have to be ahead of the need for efficiency.   We need to figure out the innovative care models that stretches the PT’s capacity to see more patients effectively in a day.  The days of 1 PT caring for 1 Patient for 1 hour are gone… to the same place that the family practice physician visiting your home went.

Where we will continue to have demand for our services is in our ability to be where our patients live, play and work.   People will go across town to see a specialist.  If they work for Wal-Mart and a few other enterprising companies they will travel, expenses paid, across the country to get a new hip.  However – what they can’t or won’t do is travel any real distance to attend physical therapy sessions.  IPUs will have to figure out how to provide high quality rehabilitation to remote patients.  That isn’t the clinics owned by physicians (POPTS) or hospitals (HOPTS) – that’s us.

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IPUs face the challenge of trying to be good at all aspects of care delivery for a given condition. High quality physical therapy providers who measure outcomes and have some geographic spread away from the IPUs can leapfrog ahead by being ready to participate in these IPUs.  Perhaps we can participate as partners through hospital contracts or at minimum by being a provider of choice for the IPUs, who by definition care about outcomes enough to care about the value we provide.

What that means is that your practice will probably be judged in part on your therapist’s ability to communicate back to a coordinating physical therapist at the IPU.  Think this isn’t already happening?  We regularly see patients from the Andrews Institute in Florida (our practice is in Texas).  Why?  Because this high quality orthopedic practice, which receives patients mostly from domestic medical tourism, knows that we use their protocols and are open to discussing cases with the therapist that sees the patients on follow up.  Some good outcomes on initial cases have earned us preferred provider status and they typically call us about patients even before the patients call to schedule.

Steve Jobs was a master at innovation and leapfrogging over Apple’s competition.  We can do the same thing by focusing on what will be important in the New HealthCare World Order.  That is likely to be the best outcomes with the lowest cost.

Annual Mean Wage of Physical Therapists, by state, May 2012

Physical Therapist Mean wages May 2012

Here is a chart with the annual mean wage of physical therapists, by state from May 2012 from the US Department of Labor, Bureau of Labor Statistics.

For my staff… don’t get too excited, Texas’ wildly inflated salaries include such locations as my hometown of Amarillo, Texas and beautiful Nuevo Laredo, where a friend of mine will give you a six figure salary tomorrow.

My point is that you should take this information with a grain of salt. It includes all practice areas, experience and responsibility levels.  For example, starting salaries in Austin, TX for outpatient physical therapy in a private practice setting are in the mid $50s.  Unless you work in home health or are a manager of some kind you are unlikely to see $80s, much less the upper end of that register.

Oddly enough, Colorado was featured as the #2 state to be a PT in the article I mentioned here.  Look for more of this kind of information coming soon under the category ‘Geography of PT’ – my new hobby.

Do these numbers seem real to YOU?

 

The Best States for Physical Therapists (ish)

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In October of 2013, the APTA’s monthly publication PTinMotion published an article which sounded like it was going to be really cool.  Donald Tepper did an analysis of which states had the most to offer physical therapists and physical therapy assistants.  The article was titled “The Best States in Which to Practice“.  Rounding out the top 5 were:

  1. Utah
  2. Colorado
  3. Minnesota
  4. Virginia
  5. Idaho

My home state, Texas was at a respectable #12.  The only thing I found odd is that there seems to be a virtual flood of PTs migrating from the two states at the top.  My PT friends in Colorado all seem to be concerned that the decline in payment for services will take the salaries there even lower.  When we lived in Virginia, the cost of living was so high, that I was surprised to see it on the list as well.  It made me wonder… what went into this list?  The criteria they used “after examining other similar lists and seeking input from state chapters” was 6 criteria:

  1. Well-being and future livability
  2. Literacy and health literacy
  3. Employment and employment projections (projected growth in PT jobs from 2010 to 2020)
  4. Business and practice friendliness
  5. Technology and innovation ranking
  6. PT and student engagement with APTA

This is where I get confused… why does this list read like it was put out by US News and World Report?  Where are all the PT issues that APTA is advocating for in trying to reach Vision 2020?  There are big differences in the states when it comes to the practice of physical therapy.  Especially in the private practice world, where you practice can make all the difference. If it were me making the list of ‘Best States in Which to Practice’ this is the list I would use.

  1. Status of direct access legislation
  2. Payment for services and regulatory burden for a typical PT visit
  3. Licensure restrictions or lack thereof  (Can I manipulate?  Can I utilize trigger point dry needling?)
  4. Density of physician owned and hospital owned physical therapy services
  5. Cost of living index
  6. Median physical therapist salary

These are some of the things that impact how the business of physical therapy works.  In Texas I receive almost double for the same services as my colleagues in New Jersey.  At the same time median salaries also range from a little more than $26/hour to almost $38/hour depending on your state.  I think that the payment for the service you provide or the salary you receive might be more important than the technology and innovation ranking for the state… at least in a list published by our professional organization.  Financial aspects of well-being and professional concerns aren’t everything, but I find it nonsensical that a list published in our professional organization’s publication almost entirely failed to include them as important.

Note to self: Future blog post: ‘The Best States to Own a Private Practice’.

What’s on YOUR list?  How does your state stack up when you use my list?

Lets discuss on twitter – #solvePT, Tues Nov. 19 at 8-9pm CST or lets discuss them in the comments below.