The Next Evolution

Roger M. Nelson, PT, PhD, FAPTA

Roger M. Nelson, PT, PhD, FAPTA, has served the profession as a clinician, educator, researcher, and mentor for close to 50 years.

Dr Nelson received his bachelor of science degree in physical therapy from New York University in 1965. He received his master of science degree from the Sargent College of Allied Health Professions, Boston University, in 1971 and his doctor of philosophy degree from the University of Iowa in 1981.

His record of service includes 25 years as a commissioned officer in the US Public Health Service. He has created both national and international collaborations for education, research, and patient care and has been instrumental in gaining the recognition of physical therapists as core members of the health care team. Past Vice President of Expert Clinical Benchmarks at MedRisk Inc, he is professor emeritus at Lebanon Valley College and a former professor at Thomas Jefferson University and the College of Staten Island.

Dr Nelson has authored and co-authored more than 50 publications in the peer-reviewed literature and has made more than 180 presentations to local, national, and international scientific meetings. He has published 2 textbooks. He served on the APTA Board of Directors and in the APTA House of Delegates and chaired the task force that developed APTA's Guide to Physical Therapist Practice. Dr Nelson has received numerous US Public Health Service awards and has been honored by APTA as a Catherine Worthingham Fellow.

44th Mary McMillan Lecture

Mr President, McMillan lecturers of prior years, Board of Directors, fellow physical therapists, family, and friends, I want to thank you for this opportunity to share with you today my vision for the next evolution in the physical therapy profession (Figure).

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Figure.

Dr Nelson presenting the 44th Mary McMillan Lecture.

I would like to start off with a question for you. What is the first thing that comes into your mind when I say the word evolution? I imagine your response is most likely Darwin, survival of the fittest, or maybe even Esmeralda. Esmeralda, you may ask? Esmeralda is the giant turtle that lives on Bird Island in the Indian Ocean and is estimated by experts to be more than 170 years old. Clearly, Esmeralda's long life is evidence of her adaptation to her environment.

Webster defines evolution as “the gradual development of something into a more complex or better form” over time.¹ It is true that evolution can lead to the extinction of some forms of nature or even products and services, as illustrated by the fate of the dinosaurs, the 8-track tape player, and elevator operators. Today, however, I hope to present a more positive tone in a discussion of the evolution of the physical therapy profession in this new health care environment and the role of physical therapists, the physical therapy education program, and the professional organization in assisting the profession in its adaptation.

The phrase survival of the fittest was actually coined by Herbert Spencer² after reading Darwin's text, On the Origin of Species.³ The term fittest was further explained by Darwin to mean better adapted for the immediate environment. We are seeing and will continue to see changes in our immediate health care environment, and those changes will require that we adapt, as a profession and as professionals. Our adaptations will help us to ensure not only that we survive as a profession, but also that we maintain our focus on the very reason we are all here today, to deliver quality care to the patient. The evolution of our profession in recent decades can be described as significant, and the pace of change is expected to increase in the next decade. Today, I want to describe my vision for the profession, as we face a health care environment with both challenges and opportunities. But as Henry Ford said, “Vision without execution is just hallucination.”⁴ I know it will take many talented individuals to develop and implement a plan to address this vision, but we must start the process now and not wait for someone or some agency to hand us its plan for our future. Although planning for change and the implementation of new and revised processes are difficult tasks, they are nevertheless essential.

Today, I would like to address 3 questions:

1. What changes are occurring or are expected to occur over the next decade in the health care environment?

2. How can physical therapists and the physical therapy profession adapt to this new health care environment?

3. What changes must be made in our educational system and our professional association in preparation for the next evolution in the physical therapy profession?

Now, for the first question.

What Changes Are Occurring or Are Expected to Occur Over the Next Decade in the Health Care Environment?

Researchers, consultants, think tanks, and policy-making groups expect the health care environment to change in significant ways in the next decade.^5–7 For example:

• Health care reform will emphasize the overall health and well-being of the patient population, with a focus on preventive care to maintain ongoing good health. Care will be customized to each patient's individual needs.

• Key metrics in assessing the quality of health care delivery will focus more intently on clinical outcomes, functionality, patient satisfaction, and value.

• Payment systems will require a focus on the value delivered from treatment. Payment systems will no longer reimburse for services for which no proof of efficacy is reported. Value-based payments will demand transparency in outcome reports.

• As health records are increasingly uploaded to electronic databases, treatment information will be available to all caregivers and providers in the system.

• Health care decisions will be based on scientific evidence. Each individual treatment will be monitored for its effectiveness based on factors such as patient characteristics, the timing of treatment, and data on past treatment approaches. The efficacy of specific treatments will be constantly updated with feedback to monitor the effectiveness or value of treatment.

• Innovation and improvement in quality of services will be rewarded and serve as the bases for the distribution of resources.

• Patients will have easy access to clinical knowledge and resources for their care and will have the ultimate control in the system, not the clinician and not the institution.

• Consumers will demand value, simplicity in navigation to get information, and trust in their health care providers.

Now, to the second question.

How Can Physical Therapists and the Physical Therapy Profession Adapt to This New Health Care Environment?

To prepare for this lecture, I reviewed, with the help of a graduate student, the manuscripts of earlier McMillan lecturers. I found it quite interesting to see how previous speakers over the years had identified the shifts and changes in the profession—or the profession's evolution. Speakers addressed the history and identity of our profession, as well as issues of education and the expansion of knowledge; the integration of education, practice, and research; and the patient focus of our profession.

I spoke with many other individuals, including members of my mentor group who meet monthly and champion the profession over and above the political/administrative process. In addition, I have had conversations with clinical physical therapists, therapists who work mainly in administrative roles in various areas of the United States, physical therapists and other professionals who work in the health policy area, and faculty members of doctor of physical therapy (DPT) programs. I have visited several times with American Physical Therapy Association (APTA) administrative staff, read articles from thought leaders in the health care world, and listened to many Technology, Entertainment, and Design (TED) sessions and many Harvard Business Review podcasts.

Today, the question being asked across all health care segments and among all providers is: How can practitioners best anticipate and adapt to the new health care environment while preserving optimal patient care? My objective in all of my conversations and readings has been to gather insights into how our profession will change in the next 10 years and how we could best prepare for the changes that are to come, rather than just reacting to the changes after they occur.

I am convinced that, by drawing on the unique characteristics that physical therapists have developed over generations through the patient-therapist relationship, we not only can adapt efficiently to the coming changes but also can serve to lead the transition of the rest of the health care industry by example. I will describe the steps we can take to reach this goal in a moment. But first:

I invite you to take a moment to imagine you are a volunteer in a university experiment. Your fellow students have blindfolded you and are driving you in a car, destination unknown. They drive for 2 full hours. At the end of that period, they remove your blindfold and tell you to drive to Cincinnati, Ohio. Now, what would your first question in this situation be? Of course, it would be, where am I? Now I am not saying we have been blindfolded as a profession over the years. Certainly not! But as we face the future like that newly assigned driver, we need to first assess where we have been and where we are right now, to be able to effectively get to where we want to go. So, let's take a look back.

Each of us has a different history that has led us to this profession. As a McMillan lecturer, I have been asked to include a few historical markers that, in some way, helped prepare me for my professional life. I'll offer 2 brief stories.

As a high school sophomore in 1957, the olden days, according to my 5 grandsons, I began working in an aide position at St. Vincent's Hospital in Staten Island with my brother Art, who was 10 years older.

I worked 3 or 4 hours for 2 evenings and again on Saturday mornings. Art would finish his teaching in the New York University (NYU) Physical Therapy Education Program, run to the subway through Greenwich Village, take the ferry to Staten Island, and then drive from the ferry car park to St. Vincent's Hospital. Our 4 treatment areas were along the hallway leading to the convent, and the patients received Art's skilled intervention 3 times a week. I started with a salary of $1.00/hour, and I received a 25-cent raise per hour after 2 years. There were no clinical prediction rules, no guidelines, no Cochrane Institute, and no corporate-owned practices. Working on a shoestring, against many odds, one thing was clear to us: The patient was our sole focus.

A few years later—actually, a year after I graduated from the NYU Physical Therapy Education Program, while working in the US Public Health Service Hospital in Baltimore, Maryland—I was assigned the care of a seaman who worked in a ship's galley serving food and performing general cleanup activities. This particular patient case helped me to understand what it meant to focus on the whole patient.

The seaman had been diagnosed with sarcoma of the thumb of his dominant hand, and surgery was performed to amputate the thumb. When I first met with him after the surgery, I knew I needed to prepare him to return to work in the ship's galley. I also knew that 85% of his hand function depended on a prehensile thumb and believed that he would need the thumb to return to work. Finding that prosthetic thumbs were not available, I enlisted the assistance of the hospital's dental department. The dentists cast both my thumb in the prehensile position and the hand of my patient without a thumb. Long story short, following a course of physical therapy intervention to restore the function of his dominant hand, the seaman returned to work with his prosthetic thumb attached to his hand with Velcro bands. About 9 months later, the seaman stopped for a visit—with no thumb. I, of course, asked him about the thumb, and he replied that he had “thrown it overboard.” He explained that he had received many complaints from his fellow seamen when they found his prosthetic thumb in the dishes he served them. Needless to say, he had learned how to function in his job without an opposing thumb on his dominant hand.⁸

Now as a young practitioner, I saw a man who had lost his thumb, and set about making a new thumb, instead of considering alternatives to assist him in regaining function without a replacement thumb. Although the patient had indeed been my focus from the beginning, this experience helped me to see the importance of looking beyond the pathology and obvious impairment—to interact with all aspects of the patient and understand the patient's environment and his individual expectations for the services received.

So, my vision for the physical therapy profession in this next decade begins with an emphasis on a thorough, encompassing patient focus—and the ongoing importance of the patient-therapist interaction. Physical therapists have long created a unique oasis, so to speak, in the health care industry—teaming with the patient to assist in the healing process. The ability to combine the best of science with the art of a healer is ultimately what we are about as a profession. In this new health care environment that appears focused on data and costs, physical therapists will make their biggest contribution as the caring individuals working by the patient's side in one-to-one teamwork.

Let's take a look at the steps we must take to make this happen. I have been fortunate to have had opportunities in my 47 years in the profession to work in the clinic, serve in the US Public Health Service, teach in several different physical therapy education programs in the United States, serve as a visiting professor in the Netherlands, develop educational programs in clinical electrodiagnosis, participate in nationally and internationally based research projects, work in the workers' compensation insurance industry, and serve on the board of directors of APTA and on several APTA committees. Based on what I have learned from these experiences, I conclude that, to adapt to the new health care environment, the profession has 4 important practical tasks to accomplish: (1) delineate value, (2) collect data, (3) understand the role of costs in care delivery, and (4) understand the concept of entrepreneurship.

What Changes Must Be Made in Our Educational System and Our Professional Association in Preparation for the Next Evolution in the Physical Therapy Profession?

Let's first look at our educational system. To address this question, we need to look not only at the academic programs of physical therapy but also at the processing of criteria by the Commission on Accreditation in Physical Therapy Education (CAPTE).

The future of our profession lies with the students who will graduate from our academic programs now and in the upcoming years. Our DPT academic programs need to ensure that these students are prepared at graduation to adapt to the new health care environment. To that end, physical therapist professional education must increase its emphasis on 3 areas that will most benefit our graduates in their future careers.

The first area is the development of communication skills, including communication with the patient, communication with the caregiver, communication with other health care professionals, and communication with the third-party payer. We need to continually reinforce that patients, knowledgeable and informed, manifest unique physical, mental, and social characteristics that affect treatment outcomes. The importance of communicating with the patient, as well as the importance of observing unique patient and caregiver behaviors, cannot be overemphasized in the management of patient care.¹⁶

Learning to communicate with the nurse case manager, the medical director of the insurance company, and the case adjuster also has proven helpful in the planning of each treatment intervention and the assessment of the value of physical therapist services in reimbursement decisions.

We need to keep in mind that third-party payers are not physical therapists. How do we, as a profession, educate third-party payers about our professional abilities and our role in the healing process, if their value metrics are focused on the bottom line?

I realize, of course, that communication comes in many forms, and certainly this decade will see a growth in the availability of health care information through electronic means. Information concerning the patient's diagnosis, the availability of alternative treatments, and data relative to outcomes, identified by each clinic and individual provider and risk-adjusted for the patient's comorbidities, are expected to be available to health care stakeholders in the near future. To play a vital role in this new environment, we must have effective systems in place to collect reliable clinical data and to monitor subsequent modifications to that data. The format of the data must allow for easy access by patients, health care providers, and third-party payers.

Recently, a group, of which I am a member, conducted an informal survey in which several physical therapist professional audiences were asked if they were happy with their electronic record system. The response was overwhelmingly negative. To make changes in the system, physical therapists must be able to communicate their needs to information technology specialists, thus ensuring that the design of the electronic health record and outcome databases systems are user-friendly to the health care provider. The administrative burden placed on the physical therapy clinic to maintain electronic health records must be reduced.

A second area for increased emphasis in education is the development of practical research skills with consideration given to the costs associated with the delivery of physical therapist services. We need to continue to afford our students opportunities to conduct practical research based on clinical experiences, in addition to the library and web-based research that already are a part of their course requirements. Opportunities to discuss and work with faculty in clinical areas in which the faculty are engaged is another way of showing the importance of research skills to our students. Finally, encouraging students to present their research in institutional research fairs and in regional and national conferences stresses the importance of practice-based results and their value to patients, health care professionals, third-party payers, and health care policy makers.

Emphasis on cost-effectiveness and cost-efficiency in the new health care environment demands that our graduates understand at least the basic principles of cost analysis. This will allow them to contribute to research studies exploring the relationships of clinical, functional, and satisfaction outcomes to both the costs of resources put into physical therapist services and the costs borne by patients and third-party payers for those services.

Third and finally, I believe there should be more emphasis on fostering entrepreneurship and innovation in patient care, teaching students to think outside of the box and adapt quickly to the changes in the health care environment that they will encounter throughout their careers in physical therapy. Our DPT programs do an excellent job of preparing students for a position in physical therapy as the position now exists, but not for the position of the future. We need to encourage broader and more creative thinking and problem solving, teaching our students to think about the most efficient ways to deliver patient care and how to build on their competencies. Students need to learn that effort put into generating new ideas creates not only desired outcomes but also more opportunities for expanding their business.

Certainly, our courses present many ideas for solving problems that therapists have encountered in the past. Our students would benefit, however, from becoming involved in activities in the community outside of the classroom in which opportunities are given to them to solve existing problems through creative and critical thought processes. Outside speakers with real-life experience and faculty from other departments in our institutions could be invited to address the areas of innovation and entrepreneurship in the health care professions. We need to provide the foundation for our students to become lifelong learners, never forgetting to point out that there are times that they will fail. Failure is part of the learning process—or, as Henry Ford said, “Failure is simply an opportunity to begin again, this time more intelligently.”⁴

Of course, the current academic physical therapy curriculum is already extensive. What areas might we consider for less emphasis to balance those areas in which the emphasis is increased? Two immediately come to mind.

First, I suggest we give thought to reducing the time spent in courses teaching impairment ratings such as range of motion (ROM) measurement and manual muscle testing. The health care professional has moved away from the evaluation of impairments to the measurement and reporting of a patient's functional status. Range of motion and manual muscle testing measures are not particularly reliable and are irrelevant to the more important measure of the patient's ability to function in his or her environment. Research studies by colleagues in 2006, which included the review of 300 workers' compensation cases, found less than 10% of the case documentation reported an actual ROM value to show improvement from the initial ROM measurement.¹⁷ That is, most studies reported simply that ROM was improved. The same researchers in documentation relative to manual muscle testing found similar results.¹⁷ Although insurance companies may request ROM and manual muscle testing measurements, many physical therapists have bypassed these evaluation metrics for the more important metrics of functional change.

The second area in which emphasis should be reduced in our academic programs is the use of passive modalities. Successful outcomes are related to the therapist's skilled intervention to maximize the patient's functional outcome, not to the type and amount of modalities used. Recently, Paul Beattie, Kevin Basile, and I conducted a study, supported by APTA, in which we examined the reporting of Physical Medicine and Rehabilitation (97000 CPT) codes across specific clinic types.¹⁸ We found that physician-owned physical therapy groups had a higher ratio of the use of passive modalities to therapeutic exercise than private practice physical therapy groups. There is little evidence that modalities are helpful in most conditions, with their use more likely related to the clinic in which treatments are received.¹⁸

CAPTE must, of course, support all changes in the academic curriculum of DPT programs. CAPTE is nationally recognized by the US Department of Education and the Council for Higher Education Accreditation as the accrediting agency for entry-level physical therapist programs and is well-respected by state licensing boards. CAPTE currently accredits more than 500 physical therapist and physical therapist assistant education programs in the United States and is supported by 31 members with various backgrounds, in addition to 250 volunteers trained to conduct on-site program reviews. At each of its semiannual meetings, it reviews approximately one third of the education programs in the United States.

A strong recommendation by CAPTE, in the form of white papers or position papers, supporting the use of functional measures, not impairments measures, in the documentation of patient progress and discouraging the wide use of passive modalities, could serve as the basis not only for change in the educational criteria for physical therapy education programs but also for discussion among therapists working in the areas of health policy, insurance companies, medical directors of third-party payers, nurse case managers, and adjusters.

Many individuals have contributed incalculable hours to the development of criteria that are used as standards in the accreditation process. It takes more than a few years for a criterion that is submitted to CAPTE for review to become part of the accreditation handbook and subsequently enacted in the educational process. The handbook serves as the foundation for the academic and clinical components of the DPT programs. Given the fast pace of change in the health care environment, I question whether the process to develop and review criteria is structured to allow for the introduction and consideration of relevant criteria in a timely fashion. For instance, is adequate time allotted in the CAPTE semiannual meetings for discussion of any changes anticipated in the health care landscape and how these changes might affect CAPTE criteria? Given the sometimes overwhelming task of DPT programs to support more than 70 clinically based criteria, some with multiple parts, in an accreditation review, has consideration been given to prioritizing criteria and eliminating outdated criteria when new criteria are added to prevent criterion “creep”? And finally, could physical therapy education programs be granted some freedom in curriculum development to explore new ideas, such as the addition of entrepreneurship and innovation courses?

Now, let's consider the changes our association needs to make to prepare for the next evolution of the profession. The APTA 2013 Strategic Plan identifies its purpose as “to improve the health and quality of life of individuals in society by advancing physical therapy practices.”¹⁹ Recognizing the changes in the health care landscape, APTA has set goals in the areas of effectiveness of care, patient- and client-centered care across the life span, professional growth and development, and value and accountability and has defined objectives to achieve these goals.¹⁹ The Association is certainly forward-looking.

What I would like to address, however, is how membership in the professional association could become relevant to all physical therapists or how it can support all physical therapists in the profession's evolution. Currently, 70% of physical therapists in the United States are not members of our national professional association. An important question to address is: What value do physical therapists attach currently to the benefits of APTA membership relative to the cost of membership? And taking that a step further: Can we expect that an increase in the relevancy of the Association's product/service to physical therapists would result in increased membership? If we answer “yes” to that second question, the natural question that follows is: What actions must we take to increase the benefits of APTA membership to today's physical therapists?

Let us assume that physical therapists make the membership decision based on a cost-benefit ratio. That is, they weigh the benefits of membership against the cost of that membership. Lowering the cost of or increasing the benefits from membership are 2 ways that we could change the cost-benefit ratio to appear more favorable to non-APTA member physical therapists.

The cost of membership and the strain on members' budgets of the annual lump sum payment have been considered, and members are allowed to make quarterly payments of their annual dues. Perhaps a provision needs to be made for a tiered membership, as exists in other professional organizations, in which membership dues are based on the role, industry, or work status of the individual—with associate, nonvoting memberships also available.

Maybe it is even more important, however, that we step back and think of ways to increase the benefits provided by APTA to its members. A starting point would be the gathering of ideas from a diverse group of physical therapists, both APTA members and nonmembers. What supportive activities would they value from their professional organization? What areas of professional practice enhancement are possible through different initiatives at the association level? Some ideas I have gathered in conversations with other physical therapists include the following suggestions.

First, let's use technology to deliver clinical and administrative information to APTA members on the basis of each member's interest. Provide digital information summaries and updates that members can read in a few seconds with a link to more in-depth information. A daily type of message board, tailored to the interest of the member, could be developed to include clinical information, as well as information about APTA programs and events, and delivered through social media channels. Challenge members to submit their clinical and management ideas to share with others. Include ideas from APTA to members for increasing the value of their practices and for extending their businesses by building on their unique competencies. Consider developing forums for community-powered problem solving.²⁰ Let the Association serve as an active source of knowledge for the lifetime learner, once he or she has graduated from the DPT program.

Give members something they cannot get elsewhere. Do you remember when mobile phones were solely mobile phones? They were used to make and receive calls with the bonus of a voicemail component. Fast forward to 2007 and the introduction of the iPhone with a touch screen, the ability to receive and send e-mail, make Internet connections, and download applications such as maps, games, etc. Soon iPhones were associated with cameras, music, and Siri, the voice-based personal assistant. Steve Jobs introduced a phone that no one knew they needed until the product was created. And now, a recent survey has shown that close to one half of all iPhone users would rather give up their toothbrush for a week than give up their iPhone. In other words, the iPhone concept changed customers—the customers did not create the iPhone. APTA needs to change its customers.

In a similar fashion, the Association needs to discover what it is that will make members want to belong, what it is that they can get only from APTA membership. How can APTA change our customers (members) into the customers we want them to be?

Second, the Association needs to encourage more clinically oriented physical therapists to present their ideas in a TED-like talk—a presentation that is 18 minutes or less in which the speaker introduces a new idea to an audience. TED talks could be part of every APTA Board of Directors (BOD) meeting, with BOD members invited to present ideas that they think are innovative and creative in a nonthreatening, informal environment. A time could be scheduled in each mid-winter and annual meeting for TED-like presentations, thus providing an opportunity for conference attendees to hear from those who would be reluctant to plan a 50-minute formal presentation. Video recording of presentations and podcasting also provide opportunities for others to hear presentations at their leisure, as well as opportunities for presenters who are averse to public speaking.

Lastly, the Association must be prepared for change. Some predict that the Patient Protection and Affordable Care Act will lead to a consolidation of health care and the eventual movement of virtually all health care professionals to a salary-driven position. It is estimated that in this decade, 80% of medical doctors will hold a salaried position, most likely in a large health care facility.²¹ We already see this movement to some extent in the physical therapy profession in certain areas of our country where 100% of all physical therapy services are provided by a specific health care entity.

If this prediction becomes reality, APTA will be offered both challenges and opportunities. Will it play a major role in the collective bargaining for physical therapists employed by large health care systems? Should APTA offer a form of corporate membership for all therapists employed by one health care corporation? How will the flavor of APTA's services change, if the large majority of therapists are employed by corporate practices? These are important issues to address, and planning for the anticipated change is required right now. Our leaders must position themselves in front of the pack—guiding change. We cannot delay and find ourselves surrounded by threats to our well-being and unable to survive.

In conclusion, today's physical therapists, as well as the physical therapy education programs and the professional association, must adapt quickly to match the logarithmic increase in the rate of health care evolution. As I suggested earlier, this will include acting with certainty along multiple fronts. We need the thought leaders who are willing to take measured but decisive steps forward—to, in fact, move forward! We need to encourage our clinicians, our education program leaders in both DPT institutions and CAPTE, and our association directors to accept the challenges and the opportunities that await our profession. To compete and survive in the current and future health care industry, we must be ready to adapt to a new health care environment.

And as I have outlined today, we as physical therapists are uniquely qualified to do so. We can begin today to help lead the health care industry into a future where an increasingly sophisticated technological and financial delivery system still preserves, at its very core, the patient-practitioner relationship.

I suppose if I were asked to state in one sentence my vision for the physical therapy profession, I would say: I envision a profession that is truly valued as an integral component of the health care system now and well into the future. If allowed 2 sentences, I would add that my vision includes a profession that is well supported by education programs and a professional association that continually and consistently challenge therapists to engage in critical thinking and creative problem solving.

Lao-tzu is quoted as saying, “If you do not change direction, you may end up where you are heading.”²² The question then becomes: Are we headed in the right direction—where we truly want to go? We cannot stand at this fork in the road, fearful of where each new path will lead us. As Abraham Lincoln warned, “You cannot escape the responsibility of tomorrow by evading it today.”²³

We need to be ready for the next evolution in physical therapy. We need to be prepared to meet the challenges of the future. With the right focus, I believe we can move forward together.