2019 Presidential Address
APTA President Sharon L. Dunn, PT, PhD, Board-Certified Orthopaedic Clinical Specialist, addressed the House of Delegates, June 10, 2019.
I want to begin tonight's remarks with a question.
If I asked you, right this very moment, to tell me the height of the west antenna on the Willis Tower here in Chicago, what would you do?
Pretty easy, right? You'd get out your phone, do a quick search, and have the answer for me in less than a minute.
The answer is 294 feet, 5 inches, by the way. So you can put your device away.
But here's the more interesting question: when did this happen? When was the exact point at which we began to instinctive reach for our smartphones to satisfy our curiosity, or to navigate from one place to another, or to entertain ourselves the instant we get bored?
Most likely, there was no exact point. To borrow a line from Ernest Hemingway's The Sun Also Rises, it's something that happened gradually, then suddenly.
A few decades ago, the idea of carrying around a supercomputer thinner than a deck of cards was the stuff of science fiction. Then, incrementally, things changed. Technology improved. Our behaviors evolved. And here we are.
This phenomenon is all around us. For example, when did we come to expect a Starbucks on every corner? Wi-fi in every room? And fresh headlines, photos, and messages behind every swipe of our thumb? (Or maybe even a date?)
Of course the answer is, we didn't. Not in any single moment. Nobody flips the "change" switch-not individuals, and not any "powers that be."
This is even true of change we remember as happening in a specific time and place. Yes, we can say the Berlin Wall fell in November of 1991, but that was decades in the making. We can say that the 19th Amendment to the US Constitution, the amendment giving women the right to vote, was passed by Congress 100 years ago last week—but we know that change was the culmination of years of sometimes-incremental advances.
Or, in our own history, we can say that Congress eliminated the hard cap on physical therapy services under Medicare on February 9, 2018, but that leaves out 20 years of hard-fought short-term fixes to avoid the cap's impact.
Change is rarely instantaneous.
Why am I bringing this up here, at the 75th APTA House of Delegates?
Because over the past few years we have been going through our own momentous yet incremental change. We have been transforming this association into one that's more outward-facing and collaborative.
This body helped trigger that evolution by adopting our vision statement in 2013. And our approaching centennial has compelled us to think a lot about where we've been, and where we're going.
That mind-set is reflected in the motions you'll be considering at this House. And as we're thinking about the future, we must remember the words of poet Emily Dickinson, who observed that "Forever is composed of Nows."
History is being made, all around us, this very minute.
History is of course defined by the actions we take. And, just as significantly, it's defined by the actions we don't take—the challenges we ignore, the problematic realities we don't look squarely in the eye, and the status quo we accept because, well, it's just the way things are.
The good news is, this association is acting with urgency. Powered by improved self-confidence, we are playing more offense than defense.
For example, our profession is looking beyond traditional settings. We're exploring ways to bring our expertise to community and population health, and to increase our impact in the areas of prevention and wellness.
We're embracing collaboration—not just within the profession but across disciplines. And we're attempting to improve evidence-based practice by improving the base of evidence itself through the Physical Therapy Outcomes Registry.
We aren't waiting for the future. We're building our forever, now.
In this address back in 2017, I talked about making bold moves. Now many of those bold moves are reflected in our association's three-year strategic plan, which has themes of relevance, stewardship, quality, and value.
Our strategic plan is about our focus now. It's about trying to accelerate change so that it is noticeable. But that doesn't mean it won't take time.
For instance, one of the objectives is the implementation of an integrated brand strategy across the association. It's a project that challenges us to be coordinated and consistent.
Sticking with the status quo is tempting—particularly for those of us who helped establish it. But it's time to embrace change and imagine something different.
To look at our vast landscape of uniquely branded products, events, services, and even components is to behold an association that is fragmented and complex. It suggests to our community that association membership should come with a tour guide and a translator.
Aligning our dozens of brands won't be easy, but the result will be a more accessible association. A unified brand strategy makes it easier for our community to engage, and it strengthens our collective voice. It's yet another chance for us to be better together.
So, over the next few months and years, we'll need to demonstrate the fortitude to push through some predictable growing pains, confident that a coordinated and connected association can be much more effective than a disjointed one.
Like so many bold moves in our association's history—and in our nation's history—once we complete this transition it will lead us to a brighter future that will seem obvious in retrospect.
But creating a brighter future isn't just about making the good better. Sometimes, it's about recognizing when we're heading down a path that is unsustainable, or counter to our association values, and then working to set things right.
This is the less enjoyable side of living out our future. But it's every bit as necessary.
In my opinion, the biggest issue we need to tackle is the cost of physical therapy education, which has become a crisis that is plaguing our present and threatening our future.
The cost of a DPT degree is an almost insurmountable barrier that challenges the ability of recent graduates to achieve basic financial stability. It's a barrier to participation in our association. And it's a barrier to increasing our profession's diversity.
It's a barrier we must dismantle. Now.
Awareness of the problem is not the problem. The House of Delegates has discussed the problem. Many of you are personally affected by the problem. But let's add some data to this discussion.
A survey of DPT program graduates between 2013 and 2015 found that for the 87%—87%—of graduates who had student loan debt, their average debt was $107,000. For those who also had debt from undergraduate school, that average rose to $124,000. Meanwhile, the median income for an entry-level position is around $70,000.
In those same surveys, 66% of PTs said they would not be pursuing residencies, citing student debt as the top reason for their decision. And while PTA students have a lesser cost burden, student debt concern was second on the list of reasons why 89% of physical therapist assistants surveyed said they may not pursue APTA's advance proficiency pathways program.
We should continue to advocate for better payment, consistent with our knowledge and expertise, yes. But that doesn't mean education couldn't get more affordable.
CAPTE, the Commission on Accreditation in Physical Therapy Education, requires physical therapist students to receive 90 credit hours to graduate. But just last year in 2018, there were no 90-hour accredited programs available. The lowest number of credits offered by any DPT program in this country was 94. The highest was 173. The average was just shy of 120.
That discrepancy is just one example of the problem.
In clinical practice, we are learning to measure our value through outcomes, which involves making an honest assessment of the amount of time and money it takes to produce a particular result.
If our academic programs are teaching our future practitioners to get the best results as efficiently as possible, it stands to reason that these programs should operate with that same philosophy.
Given the degree to which CAPTE's minimum standards are being exceeded, the evidence suggests at least a complacency about how much students are being asked to pay in order to achieve their desired outcome.
In pointing that out, I do not mean to imply that time is being wasted, or that programs aren't striving to produce the most skilled graduates possible. I'm arguing that they are exceeding their obligation.
Now, before any of you are tempted to pull out your device and check LSU's credits. Ours is at 116. We, too, have some considerations to make here!
Our profession has never assumed that PTs and PTAs are finished products the day they graduate.
Upon leaving school, it's the responsibility of each practitioner to remain dedicated to ongoing career development, both formal and informal, to ensure they are the best they can be. But when new graduates are saddled with debt from the day they enter the workforce, what are the odds that they'll feel capable of reinvesting in themselves moving forward?
Today the cost of education isn't just creating financial instability. It's dissuading an entire generation from a culture of lifelong learning.
That's bad for our profession and our patients and clients, but it's also bad for our association. Because even those who prioritize APTA membership despite their debt, or who have their membership fees supported by an employer, even those will find participation in our association to be a serious challenge.
I'm talking about section membership and conference attendance, sure. But I'm talking about something even more basic than that. Because when we're putting graduates into the world who are putting off buying homes or starting families, and who are adding side hustles to help pay the bills, how much emotion, thought, or even basic attention can we expect them to invest in APTA?
Who's to blame for this? At this point, does that question even matter?
Like the examples I used at the start of this address, the reality we find ourselves in now isn't the responsibility of one entity. It's about the interplay of multiple factors.
If there is an original sin in this story, it's our collective unwillingness to acknowledge—let alone address—discouraging trends when they first began to appear. That's a human condition from which our community is not immune.
We can spend time pointing fingers and getting to the bottom of how we got here, but with each passing moment the situation deteriorates. Besides, what will we have gained?
Regardless of how we got here, the simple truth is that student debt is creating a future that will hurt the profession, unfairly penalize those who seek to pursue it, and ultimately deprive our expertise for the people who need it.
We cannot stand for that. Not as an association. Not as individuals.
So what can we do?
I believe the first step is to take ownership of the problem. We must face up to the fact that the cost of higher education is crippling entire generations of physical therapists. And we must acknowledge that—however necessary and helpful—debt consolidation plans, financial literacy curricula, and even loan forgiveness opportunities do not solve the problem. They just make its effects potentially less devastating.
Our ownership needs to go further than that. We, particularly those among us in academic settings, need to speak up. We need to talk about this as a genuine threat to the sustainability of our profession, because it is nothing short of that.
We must not let institutions balance their bottom line on the backs of our students.
Students must get the education they need, not shore up sagging revenues or bankroll ambition.
We were drawn to the physical therapy profession because of our compassion and our belief that there is no higher calling than to help those in need. Right here, right now, the future of our profession needs us. We have an obligation to respond.
There is no switch to flip to make this go away. But that doesn't mean we simply throw up our hands and hope for the best. If we wait for a policy change or some other outwardly generated solution to make it all better, we will squander our future.
Instead, we must do what we've always done as a profession: we must empower transformation.
We can do this through our individual voices. We can do this through advocacy—in our institutions, and at the state and federal levels. We can do this by expanding and rethinking our own assumptions about education in our profession. We can do this by understanding that each one of us has a leadership role to play in creating change.
Some 21 years ago, Jules Rothstein, one of the great leaders of our profession, and, in my opinion, a true visionary, was wrestling with a different issue in educational programs. Jules and many others felt that physical therapy programs were not being rigorous enough in their pursuit and publication of solid research to support evidence-based practice.
As the editor in chief of the Physical Therapy journal, Jules had a front row seat to see the manuscripts being submitted. And as an educator he witnessed what he worried was a drift away from academic professionalism in physical therapy. He saw a dark future for the profession unless something changed.
As many of you know, Jules had a way with words. And he wasn't afraid to challenge assumptions, and occasionally do or say something completely outrageous to make his point. And he had a lot of points to make.
Sadly, we lost Jules in 2005. But his words live on.
In a 1998 editorial for PTJ, Jules called for improvements to the academic profile of physical therapy programs and faculty, and I want you to listen to his words in the context of the cost-of-education crisis we're facing today. Because there is truth in these quotes that transcends issues.
Jules wrote: "At its best, leadership is an invitation from a visionary for others to join in a crusade-a crusade to foster the common good, not just enhance the status of the leader. Leadership involves thinking beyond the narrow confines of one's own institution and one's self interests and working toward improving the education enterprise for the benefit of us all. This requires courage, knowledge, and risk-taking. Leadership involves, but is not synonymous with, power. Real power is directed toward achieving a collective vision."
Jules wrapped up his editorial with this: "In contemporary physical therapy terms, this means leaders that can call forth from their followers a willingness to transform our education enterprise from 'just acceptable' to a shining achievement that makes our profession viable in the year 2000 and indispensable beyond."
Our physical therapy education programs are indeed shining achievements. But if we cannot reduce the financial burden placed on our graduates, the cost of those programs threatens our profession's ability to be indispensable beyond.
I am the president of APTA, and just this month I became the Dean of School of Allied Health Professions at Louisiana State University in Shreveport. I have been on the faculty there for 24 years. No one has more skin in the game on this issue than I do, and we do as academic professionals. My sense of personal responsibility—my determination to walk the walk—is enormous.
But fixing this problem is bigger than me. It's time for all of us to speak up, whether you're within education or you just know people who are.
And, oh by the way: let's not pretend that student loan debt is the only thing keeping our graduates from generating momentum in their careers. Too often our early career practitioners face employer productivity models that run counter to the very heart of our profession.
I admit I'm not standing before you with hard data on this one. I'm guessing you know a colleague who's struggling with productivity demands, or you're struggling with them yourself.
You have seen the way these models make it difficult for PTs and PTAs to live out the very values that drew them to our profession in the first place.
Too many of our peers experience a disconnect: after investing in a career, both financially and emotionally, they find that the reality of their day-to-day experience prevents them from doing the only thing they want to do: connecting with people in a true partnership to improve their lives.
I'm sure all of us know employers, and it's time for honest conversations about the value of productivity quotas that threaten what makes our profession special for the provider and the consumer: a human connection that cares for the person in front of us, not just the condition.
We cannot simply accept this as the new normal.
If you think those two issues are enough, I'm not done yet.
A similar all-hands-on-deck approach is required to tackle one of our other strategic plan objectives: making APTA an inclusive organization that reflects the diversity of the society the profession serves.
The cost of education affects that objective, of course. But let's be honest: the cost of leadership within this association affects diversity, equity, and inclusion, too. Evidence of the latter is all around this room. And it's standing here at the lectern.
For a long time, our association leadership has looked a lot like me: same general age, same skin color, often hailing from the halls of education, as I do.
Our association hasn't actively sought this pattern. But the pattern is unmistakable. And in the least it suggests that leadership is more accessible to people like me-and that's an inequity we must address, because if APTA is more inclusive of me, then it's less inclusive of someone else.
Many of you have likely heard the expression, "diversity is being invited to the party; inclusion is being asked to dance."
Sure, one way each of us can advance diversity, equity, and inclusion is to invite people to the dance floor who have never been there before. But we can't stop there. We also need to examine the dance itself-because we aren't being truly inclusive when doing the APTA hokey pokey requires the expertise and flexibility of a Julliard ballerina.
So let's face it: participation in association leadership is far more demanding than it has to be. We are tied to our phones 24/7, and yet this technology has not reduced our face-to-face time or the volume of our work.
In my four years as president, I travel approximately 123 days per year. Don't get me wrong, I'm honored and privileged to represent APTA. I signed up for this. But how many people in our association feel they could aspire to serve as president if that's the expectation? How many could fulfill even half of that?
Association leadership should be a privilege, yes, but it should not be limited to a privileged few.
The same goes for the House of Delegates. Even leaving out all the time you dedicate to House activities before you arrive-time spent on motion development, keeping up on the discussions in the online community, and so on-how many of your peers could dedicate four days a year to this physical gathering?
Is that underlying requirement the best way to be inclusive, to gain a representative sample of our membership? I don't think so.
I am not questioning our desire. But sometimes our systems are not as inclusive as the values of the people within them.
So it's time we ask ourselves, does this seem sustainable? Is this what association leadership and governance will look like a century from now? And if the answer is no, if change is inevitable, isn't it our responsibility to run toward that challenge and address it now?
Our customs must be as inclusive as our hearts, and today they don't appear to be.
I have two years remaining as president. I don't believe we can change our entire culture in that time, but this is not something I want to leave to the next leader. My hope is that we can identify noteworthy reform of Board and House service within the remainder of my term.
Great leaders prepare to replace themselves. If we cannot demonstrate the professional will to challenge our traditions, if we cannot relax our grip on control, if we cannot accept that our current trajectory is complex and burdensome, then leadership in this association will increasingly represent the few and not the many.
And I believe we can do better.
I began this address talking about the ways change can sneak up on us. We go about our lives, day after day, year after year, and then one day we find ourselves looking at our reflection in a rearview mirror of a self-driving car. And we briefly emerge from our fog and we ask ourselves, "How did I get here?"
That's one way change can happen. But here's another path.
It's the path we take when we embrace the idea that every day deserves our heartfelt best effort-not just to live that day to the fullest but to shape the future more than it shapes us. Because we want to pay it forward. Because we demand that we leave something better than we had for ourselves.
Pick your professional hero-Mary McMillan. Catherine Worthingham. Helen Hislop. Charles Magistro. Lynda Woodruff. Ted Corbin. Steve Levine. Our heroes never reined in their dreams and never backed away from a challenge.
What might they say about the student loan indebtedness, current practice productivity trends, or building an inclusive organization? Can you hear them?
We owe them our gratitude. But we also owe them a legacy. We owe them what I believe each would've wanted more than anything-to know that their love for our profession has been passed on to us, and to know that we'll do the same as they did for future generations. We honor the past by attending to the future in what we do right here, right now.
Last year, I ended my address by saying "we must move." Well guess what? We're moving. And most importantly-we're moving together. But we are still climbing. We have not yet reached the summit of our potential.
In his 2001 McMillan Lecture, Jules Rothstein said this:
"I am here today... to invite you to join me on a journey beyond the horizon, a journey to find the soul of this profession, a journey that began with people like Mary McMillan in the aftermath of a war. This will be a journey we can never complete, but one that will always be redeeming."
And again in a statement that sounds like it was made yesterday, Jules said this:
"The debt I believe we all owe this profession means that when necessary we must make personal sacrifices. Ask yourself what you can do to make certain we are on the right track. The leadership of a select few will help, but what really matters is the willingness of each of us to do the right thing on behalf of our profession, even when that may mean putting our self-interests on hold."
We are on a journey. We do need to lead. We must be ready to do what's right, every day, to shape our future and honor our past.
I've learned much as your president. Some of the lessons I've learned have been hard ones, but I'm grateful that much of what I've learned has confirmed what I've felt about our profession ever since I joined physical therapy school: We are passionate. We are fearless. And once we sink our teeth into something, we don't let go.
As this association moves toward its future I urge you to embrace those qualities-to approach that future with passion, with fearlessness, with tenacity, but also with kindness, tolerance, and inclusion.
We are in this together, and we must be accountable to each other and to the generations who will shape our next 100 years.
There is no room for complacency, because our transformative journey is and always will be a shared effort-the effort of our community to make a positive impact on society.
So let's put our self-interests aside and do the right thing, even when it's the hard thing.
We owe that to our past, and we must invest it in our future.
Our moment is now.
Notes From the Field: MIPS, Quality Improvement, and the Physical Therapy Outcomes Registry
Like many physical therapy clinics, Columbus Orthopaedic Clinic and Outpatient Center in Columbus, Mississippi, has had to make difficult decisions regarding whether—and how—to include physical therapists in the Merit-based Incentive Payment System (MIPS). Columbus is a multispecialty practice focusing on orthopedic surgery, sports medicine, and rehabilitation, employing 11 PTs and 6 PTAs between 2 clinical sites.
#PTTransforms Blog spoke with staff physical therapist Peyton Fandel, PT, DPT, who played a key role in evaluating the potential benefits of MIPS and enrollment in the APTA Physical Therapy Outcomes Registry.
#PTTRANSFORMS:What was the genesis of Columbus Ortho's participation in MIPS and the APTA Physical Therapy Outcomes Registry?
Peyton Fandel: Angela Pendas, our CEO, had already been working with MIPS with Columbus Ortho's physicians, who were required to participate. In 2018, she tasked me with finding out what would be happening with MIPS with regard to PTs. I looked for MIPS information from APTA, which led me to the Registry.
#PTTRANSFORMS:Were you required to participate in MIPS?
PF: In 2018 we were not, but we did so voluntarily, because the incentive payment was attractive. If our data looked good, we could get up to a 7% increase in reimbursement from Medicare. We also were thinking about what MIPS might look like in 2019.
#PTTRANSFORMS:Why did you decide to enroll in APTA's Registry?
PF: To participate in MIPS, we needed to track data and make sure we were reporting things directly to CMS with as little work as possible. We asked ourselves, was it necessary that we find a registry? And if we did, which registry do we need to be a part of? There weren't very many when we first started the process.
What distinguished the Physical Therapy Outcomes Registry was APTA's voice as the national association representing physical therapy, whether in Washington or on the state level. APTA always seems to get new information first and relay that as quickly as they can. We knew that APTA would have a leg up on anybody else. We were comfortable knowing that if APTA is going to be doing it, they're going to be doing it right.
#PTTRANSFORMS:Was it an easy process getting clinician buy-in with the Registry?
PF: It was an easy process for us. Once everybody saw the different benefits, they were really on board with it.
For anybody who's having trouble getting their clinics to buy in, I think there are some important benefits to consider. From a data collection standpoint, the Registry helps save time and energy. From a business standpoint, it's good to be able to objectively look at your patient care and compare it with other clinics. For example, we can look at outcomes clinic by clinic, or therapist by therapist. We can find out where we need to improve in order to excel. The Registry also helps to direct certain patients with a particular condition, like a shoulder injury, to a certain therapist who, according to their outcomes data, is really good at shoulder rehab.
I think marketing to patients and payers is where you're going to see a lot of help from the Registry. We can show patients how we're performing, because we've got it on paper. Patients will appreciate it, as well as insurance companies and other third-party payers.
#PTTRANSFORMS:What were your outcomes like for MIPS activities for 2018? Were you surprised?
PF: In 2018, our quality measures were really good, although that year was a learning process. In the first 2 quarters we were still trying to figure out what we needed to report, and how the Registry worked. Once we enrolled in the Registry, we started getting a little bit more clarity as to where our documentation needed to improve. It helped us get all of our therapists at the 2 different locations on the same page.
In quarters 3 and 4, our quality measures were much better. It was fun to see the transformation from having somewhat of an idea of what we're supposed to do, but not really knowing how to do it, to saying, "We've got this figured out."
I wasn't surprised at our final outcomes, because I think our PTs are some of the best, but it was comforting to see on paper that we are doing things correctly.
#PTTRANSFORMS:Did your use of APTA's Registry affect or change the way you treat patients?
PF: We've always tried to get patients better faster, in a manner that is effective and promotes patient independence. From what we learned through the Registry, we've changed our patient education to explain not just what you, the patient, need to do, but why you need to do it. It helps patients understand their injuries and communicate better with PTs about specific trouble they are having.
Better communication also builds their trust. In return, we get not just better objective outcomes, but also better subjective outcomes. The Registry helps us say, this is what they said they want, and this is what they said they have trouble with. It helps both patients and payers see that we're treating the patient, not just the problem.
#PTTRANSFORMS:What is the business value of the APTA Physical Therapy Outcomes Registry, from your perspective?
PF: Once you start collecting a lot of data, it helps set your therapists apart. The Registry helps you see objectively where you might be lacking and where you might excel. Sometimes I think we can get blinded—we all think that our way's the right way and that we've gotten every patient better. I think it benefits us to see that there may be a different way. A therapist might be doing something different that might help our outcomes.
Sometimes we need to take a step back and look at things from above the ground and see that one therapist over here seems to be getting patients a little bit better, a little bit quicker, or that another therapist is really good with low backs, or that I may not be as good as others at treating shoulder problems. The data that the Registry will collect will help us better direct patient care, as well as identify continuing education needs.
As more practices participate, this will be the case on a broader level. Competition drives success. We all strive for perfection, and anytime you see that somebody may be outdoing you, you try to do better. I think that's good.
I'm a Mississippi state fan, so it's not fun to watch Alabama win national championships, but that's okay. That means we keep on striving, right?
#PTTRANSFORMS:Looking ahead, do you have any thoughts on business planning and implementing technology like APTA's Registry?
PF: The way health care is moving more to a data-oriented reimbursement model, I would look very hard at using an EHR. More and more documentation is going to be necessary. Practices need a secure and efficient way to collect and transcribe patient data, and an EHR is probably the best tool for that. Obviously, it's easier for the Registry to integrate with an EHR because it's pulling from there.
Our EHR was not associated with the Registry at first, and the Registry did a good job of integrating with our EHR even though it was a little bit complicated. Our therapy documentation is on one system that then gets integrated into the EHR, which is a separate system, and then transferred to the Registry. A couple of times we had some trouble with data pulling from our EHR over to the Registry. Everyone that's involved in the Registry at APTA has been open and honest, and has been on top of making sure they get things correct. Anytime a group takes each person seriously and tries to fix everybody's problems, I think that's huge.
#PTTRANSFORMS:What would you tell someone who is on the fence about joining the APTA Physical Therapy Outcomes Registry?
PF: If someone is questioning whether or not to join a registry or specifically APTA's Registry, just know that it is a great source of information, and that you become part of another community—not just within your region or your profession, but in a community as a whole where everybody's striving for the same goal. That helps to improve and advance the physical therapy profession within health care more broadly.
For more information about the Merit-based Incentive Payment System (MIPS), check out APTA's previous blog posts on key MIPS deadlines and answers to common MIPS questions. For more information about enrolling in the Physical Therapy Outcomes Registry, contact email@example.com.