Friday, February 20, 2015

The Physical Therapist of TOMORROW

I'd like to talk about a little experience I had recently. Having changed health insurance carriers, I was instructed to have an establishing appointment with my primary care physician which primarily included an interview and a "physical." I was actually quite excited to see what the primary care physician's physical examination had evolved into since it had been literally YEARS since I had received a "complete physical." Much to my disappointment, the most physical thing I had to do was lay down and sit up on the examination table for abdominal palpation. Auscultation occurred, visual observation of my skin, blood pressure and temperature was taken.... however, no range of motion testing, no manual muscle testing, no gait analysis, no assessment of functional movement... all this despite an industry branding of a "complete physical." As if the results of this physical was a complete analysis of one's health, inferring the promise or at least projection of longevity, good health, and absence of disease should the "physical" return normal values.

It became more of a let down when I was told that the industry movement was towards proactive healthcare through means of exercise, clean eating, and a general sense of healthy living. But, how could such a physical evaluate a patient's needs, abilities, impairments, and risk factors in regards to exercise and healthy living?

In any case, while I was supremely happy with my physician, I was a little bummed out as a consumer. There was nothing truly physical about the "physical" I just had. The most valuable information I would eventually walk away with was going to be my lab values -- however, there really isn't much compelling evidence that the labs would determine, predict, or even be successfully utilized to prevent health, injury, or illness.

My impression is that this physical is a little formality performed because physician physicals have always been done this way. In my humble opinion, anything that has always been done a certain way without justification, standing up to academic challenge, or refined from the crucible of competition requires severe revisitation.

After a few tweets venting my professional frustration based on my position taken here:

I received some social response. And, finally, this tweet came about:

And, it lead to this collaborative post to which I'm very proud to say is the first post on this blog with guest authorship!

Taking it away for the rest of this blog (with my most sincere thanks and appreciation for his thoughts) will be Chris Bise representing Pitt Physical Therapy on how they are training, preparing, and empowering the physical therapists today for the strategic environment of tomorrow!

The Physical Therapist of Tomorrow

It’s been a few weeks since @PittPT and myself engaged in this conversation. Since that time, CSM and a number of Twitter engagements have only reinforced my thought that the time for the “Musculoskeletal Primary Care Professional” is now. In my opinion, this goal is mission critical for the health of the profession.

The experience that Ben had with his PCP, unfortunately, is not isolated. Countless patients and professionals relate stories of doctor / patient interaction that consisted of little or no “physical” interaction. The physical examination has been swapped for diagnostic studies. Even physicians recognize the loss of the physical exam is concerning. Dr. Lisa Sanders (House MD consultant and NYT author) is quoted as saying “The physical exam will die completely or it will be resuscitated.”

Our vision and mission here at the University of Pittsburgh is the education of the modern physical therapist. The mantra here starts with “practice at the top of your license” and ends with “don’t send me patients, let me manage them.” Those two statements encompass what we feel are the essential elements of physical therapy practice. Let’s start with the first:

“Practice at the top of your license.”
This has long been the vision of many of the leaders here at the University of Pittsburgh. Our curriculum is designed around the independent musculoskeletal practitioner, operating without a referral (unrestricted direct access), managing the full range of musculoskeletal conditions. Thus, mastery of the physical exam is the first step in the journey to become a musculoskeletal expert. With this mastery comes an expectation that the knowledge gained will be applied. Many students in their transition to “new grad” are subjected to environments where they are expected to work under the supervision of a physician or have a diagnosis handed to them. The physical exam, or at least the screening elements, begin to fall to the side and become skills lost to those physical therapists. Practice patterns change, and in some cases critical thinking declines. At this point many will rationalize this decline with “I don’t have direct access in my practice environment.” I would posit that direct access, though a tangible element of outpatient practice, is in every practice environment available to the physical therapist. At CSM this year Karen Litzy, Dr.Kyle Ridgeway & Ann Wendel participated in a panel on this subject. They proposed that physical therapists practice with a “direct access mindset” across the entire range of practice environments. Some may see this as broadening our scope of practice. This isn’t an increase in our scope; rather, it is a call to assume ownership of the title “musculoskeletal expert.” Direct access isn’t an issue for only the outpatient therapist, but for the profession as a whole if we are to evolve from technicians to managers. We are musculoskeletal experts and physicians, nurses and other medical professionals know too look for the closest physical therapist when they need help.

“Don’t send me patients, let me manage them”
The role of the therapist has long been one of dependence on the physician for referrals and thus for employment. This arrangement clearly undervalues the education of the physical therapist, but as a profession, we’ve accepted this as the status quo. As physician sponsored studies here, here, and here recognize that PCPs are undereducated when it comes to musculoskeletal medicine, the proposed solution has been more physician education, and/or extender (PA/NP) specialization. Instead of increasing the burden on the physician or providing additional education to extenders I’d propose that there is a ready, well educated, musculoskeletal expert ready to fill this role. Enter the modern physical therapist.

The modern physical therapist no longer simply treats patients, he/she manages them. The modern physical therapist is part of the diagnostic team, taking the lead on all musculoskeletal problems or impairments. This occurs “across the practice continuum” and lets the therapist lead when it comes to access, diagnosis, dose, frequency, intervention. But we need to embrace different practice environments and see the physical therapist as a portal of entry into the healthcare system. Our relationships with physicians (and other therapists for that matter) needs to become lateral rather than up and down. In a perfect world, we would actually increase referrals to physicians for non-musculoskeletal problems. We know early access to Physical Therapy (here, here) reduces cost and utilization, and that physical therapists are effective differential diagnosticians for musculoskeletal conditions. With this knowledge, the next practice environment should be the office of the PCP.

My vision for the future of physical therapy involves the earliest possible access to PT. You call your PCP and tell them you have knee pain, back pain (insert musculoskeletal complaint here). Your first stop after the waiting room is the PT who makes sure you’re appropriate for treatment and either treats you that day, gives you an HEP and schedules a follow-up. With conditions that require extended care, the patient is referred to the appropriate PT provider. I can hear the critics already complaining about follow up and visits, but I can play the same game. Seriously, when was the last time your ankle sprain needed more than 1 visit and a follow-up to make sure he’s progressing? This would require a significant paradigm shift for some, but gone would be the days of inappropriate referrals. Now, in regards to musculoskeletal conditions, the PT is responsible for getting the right provider, in the right place, at the right time.

We can’t continue to subsist on the beneficence of physicians, and I’m pretty sure this isn’t the relationship they want. We need to own what we do best, musculoskeletal evaluation and treatment. The path to a sustained reality is one of ownership and responsibility of the “direct access mindset”. It’s not acute care, neuro and outpatient, it’s “neuromusculoskeletal care”, and physical therapists are the best at prescribing it.

Wednesday, February 11, 2015

Developing Brand Dominance

I love talking brands! Why? Because, it's always -- and I mean, ALWAYS a popular topic. In 2011, I finally came out of my shell to bring my thoughts out for public discussion on social media. Myself and many other like minded PTs passionately shared our ideas via the hashtag I helped start: #brandPT. The strength of that hashtag was a centralized search marker for internal insights. However, the weakness was just that, it didn't focus on our consumers enough. This post will help bridge that gap.

Developing Brand Dominance

Brand dominance is a really interesting concept within the construct of positioning. As the brand is the image our minds have of a specific firm's representative qualities, it gets interesting when we have all these mental representations and in turn, select one as our brand of choice.

Just like when we seek out a drink of choice, we have a general selection we favor then finally a winning brand. If you like vodka, you probably know the names Smirnoff, Grey Goose, Belvedere, and Ketel One. Which one would you choose if someone was buying you a drink? Probably Grey Goose or Belvedere, right? Why? Because they are top shelf. They are known to taste the best, feel the smoothest, and hold the most favorable undertones one can appreciate. THEY have brand dominance.

How did they get there? Well...! Through these following Ps:
  1. Position. Brand dominance is all about positioning. Belvedere stamped itself at the top. This is where they are located. This is where they are priced. And, no matter the competition, people still buy it -- all for the same odorless, colorless, tasteless spirit.
  2. Presence. Grey Goose is loud about its brand. It is trumped by celebrities and holds the best advertisements. Not only that, the bottle itself is a work of art. When it comes to presence, make it known, make it loud, and hold your ground!
  3. Proactivity. Having an active brand which either joins or cultivates a community is a sure way to attain brand dominance. The interesting thing about Grey Goose (GG) was how many people attested to the brand promise of being the best taking vodka around as the company came out with that very loud presence. Consumers rallied together as vodka snobs, buying only the best for drink - this is community. Not only that, blind taste tests were popular on television shows (to which sometimes, GG held up, other times... not so much). But, GG still sells, right? Exactly. BRAND DOMINANCE.
  4. Profits. Brands that make money are wise to reinvest their profits. Let me say that again. Brands that are making money, do well to REINVEST IT! You don't need to be a top shelf brand for this to be a choice strategy. Look at Walmart and Target. They reinvest in their brand all the time. Why? They need to continually secure their position in the eyes of the consumer.
  5. Preparation. Brands that forecast the changes in their industry, market, and world event at large do the best in retaining brand dominance through any company crisis or disruptive innovation. This is best done with the popular #JobsToBeDone approach. It's no secret, if you provide what your customer wants, they'll buy it! So, what job are your customers hiring you for? More importantly, what jobs in the future might they need to be fulfilled? Can you fulfill their needs? Can you make them want to hire you first? Perhaps more intriguing is the question, can you provide for their future needs and let them know that as they realize their emerging needs?
If you want to become relevant and stay relevant, you have to continually battle for the top. Dominance is a hard place to defend. Keeping an audience engaged is tricky and can be quite challenging. Engaging your consumers with a visible brand (link to guest blog) is a wonderful place to start. As for the rest of it, it means you have to follow these five steps because these 5 Ps develop POWER behind your brand. And, power is a good resource for developing a dominant brand.

One last (shameless plug) THING!
I've been slowly sharing the exciting new that I'm scheduled to give a webinar titled: "Advanced Branding Concepts for Physical Therapy" through the Private Practice Section of the American Physical Therapy Association. It's going to be a very exciting time as I'll be sharing some of the most cutting edge concepts, and more importantly, METRICS in how to account for the financial effects of your branding initiatives.

Sunday, February 8, 2015


More accurately, I missed out physically. However, thanks to all you wonderful people on social media, I was able to follow the American Physical Therapy Associations Combined Sections Meeting 2015 (#APTACSM) with live play by plays, selfies, videos, snapshots, and more.

It was almost like I was really there!

So what did I hear most about as an observer from afar?

I heard things like:
  • Advocacy
  • Passion
  • Value
  • #CashPT
  • Physical Therapists in the Emergency Department
  • Transforming Society
  • Getting real about "evidence"
  • A need for a change in teaching paradigms
  • Leadership
  • The social aspect of CSM (which I feel I missed out most on)
  • The many students who wish they could have gone
  • Fellow PTs SHAMED for NOT taking the stairs.....
  • #PelvicMafia
  • Empowering Women!
  • And generally, colleagues having WAY too much fun without me!
This was up through Friday night. All in all, I hoped to see more about marketing, branding our profession, consumer focus, disruptive innovation, and data strategies -- I was happy to see some mention of a collaborative data registry. This could be interesting if not powerful if leveraged correctly. Most importantly, if the data was cultivated into smart data, meaningful to both end-user and payer.

And then, on Saturday morning, a veritable storm of #CashPT tweets came through along with management and organizational change content! ...I smiled.

And so, having watched CSM 2015 as a distant observer, I have three lofty, pipe dream goals for CSM in 2016:

After some thought, the idea of sponsoring a student really got me going. Doing something like this invests in the professional (not to mention colleague) of the future. When they get a glimpse into where the passion is, where the possibilities are, and where the profession could actually be. We can protect them from the common burn out at risk when getting into a local workplace which couldn't value them less for being "new grads" and offer them every opportunity at success!

By the way, if you want strategies on new grad career paths and approaching student loans, check these posts out HERE (new grad) and HERE (student debt).

So where do we go from here?

The challenge with anything like CSM is  that mountain top experience. The high we get typically means we have to revert back to the low -- the regression toward the mean is something that no one can escape. The solution? CHANGE THE MEAN.

I exhort all who brought the passion of CSM back home with them to do three things:
  1. Share it in an official capacity (ie. in-service, class report, staff meeting). When you share, recruit. Get someone to join the ranks, officially!
  2. Get one colleague, just one! To sign up for and use Twitter as a mode of connecting with each other and advocating for both our profession and our consumers. Oh, and have them tweet me so I can welcome them!
  3. Commit yourself to checking your passion levels one month, three months, and six months from today. Re-commit yourself to the ideals and the hope you came home with. If you're experiencing discouragement, burn out, or barriers to pushing toward the future, let me know! I'll be happy to help in any way I can.

What's coming down the line from my side?
  • I'm expecting my very first collaborative post to be published here on this very website! I'm quite excited about this as I've decided to slowly introduce some outside content directly promoted here on this blog.
  • I'm almost done putting together all the elements of a branding webinar for the Private Practice Section of the APTA. It is titled: "Advanced Branding Concepts for Physical Therapy."
  • Unless there's some random event to bar me from doing so, I'm planning on launching my book about achieving success in mid-late Spring / early Summer 2015. Keep your eyes peeled!

Until next time, I remain humbly yours,