Transformative Dialogues: The Use of Motivational Interviewing in Physical Therapy
By Rose Pignataro, PT, DPT, PhD
Patient-centered care is the hallmark of physical therapist (PT) practice. Individualized patient and client assessment helps us tailor treatment to support effective self-management and optimal independence. PTs and physical therapist assistants (PTAs) often underestimate the powerful impact of our patient relationships; successful outcomes are largely dependent on the personal investment of both parties. Motivational interviewing (MI) is one strategy to strengthen the therapeutic alliance.
MI is an evidence-based, patient-centered form of communication that has been used effectively to encourage a broad range of healthy behaviors, such as vaccinations, preventive screenings, exercise, weight management, and tobacco cessation. When done effectively, MI fosters rapport, creates transformative dialogues, enhances adherence, and inspires successful lifestyle changes. Ultimately, it can result in better outcomes and long-term wellness.
How Is MI Different From Typical Patient Care?
The approach is very versatile; MI is applicable across practice settings and in diverse populations because it is specifically tailored to the unique needs of the individual. The provider begins by asking open-ended questions to learn why the individual is seeking professional consultation. Using the patient's goals as a starting point helps the provider establish credibility and lays the foundation for a trusting relationship built on a strong sense of collaboration. This is a dramatic shift from traditional models of care that employ a hierarchical, paternalistic approach toward providing advice and presuming patient adherence.
Techniques used in MI often are represented by the acronym OARS:
O: Ask open-ended questions.
A: Use affirmations, or positive statements that demonstrate an authentic interest in the patient's own perspectives.
R: Reflective listening reinforces this interest and offers opportunities to clarify information or make inferences that invite the patient to continue to share his or her thoughts and opinions.
S: The provider can pause the conversation to summarize information, pulling together pieces of the dialogue in a way that inspires action.
For example, home exercise programs are frequently a key component of the physical therapist plan of care. Ideally, the PT selects exercises based on examination findings that reveal impairments in strength, flexibility, endurance, coordination, and/or balance. Hopefully, the provider explains the supporting rationale and expected benefits, but may not totally consider other factors that may affect the likelihood of adherence. Open-ended questions can uncover patients' perceived barriers to exercise. Common issues include time constraints, pain or fear avoidance, and lack of confidence, particularly for individuals with little or no history of regular physical activity. Providers can use affirmations and reflective listening to learn more about these barriers and encourage patients to set small, incremental goals. This often makes larger tasks seem more manageable and also allows patients to build confidence and track their own progress, creating positive outcome expectations and greater willingness to continue working toward success.
Empathy, Not Just Education
It is rarely lack of knowledge that prevents someone from enacting healthy lifestyle changes. For instance, most people who are overweight or obese are aware of the problem and the toll it can have on their health. Excess weight and sedentary lifestyles are chronic issues that develop over time. Often, the person has made multiple attempts to correct the issue, only to fail repeatedly. These past failures slowly erode the belief in one's own capabilities. Advice from a PT or PTA can seem threatening or even judgmental, unless we express empathy and anticipate ambivalence.
A patient may genuinely want to lose weight and establish a regular exercise routine, but for some reason feels that he or she is simply incapable. If the provider challenges this belief, it may lead to patient resistance. It is important to remember that resistance to change is a normal human reaction. Talking it through allows the provider to learn more about the patient's perceptions regarding barriers to weight loss.
Some barriers may be cultural. In this regard, MI provides a helpful tool to enhance cultural competence, since it is impossible for us to be completely familiar with someone else's background and beliefs, even when we share the same racial and ethnic characteristics. For example, a person who is overweight may have grown up in an environment where social events and relationships were closely linked to meals. Certain food choices might provide comfort, or lead to preferences that do not seem compatible with nutritional recommendations. As the patient-provider conversation continues, the patient may learn to identify successful solutions to these challenges. Describing solutions out loud is a powerful form of self-talk. We each pay close attention to our own choice of words, and this alone increases the likelihood of success.
Working together with our patients also can make problems seem less intimidating. For a patient who is significantly overweight, losing 50 pounds may seem impossible. However, losing 10% of body weight is not only manageable but has been shown to significantly reduce metabolic and cardiovascular risk. Smaller weight losses also can improve low back and lower extremity joint pain, as well as energy levels, making the patient more likely to want to continue making changes that support these positive outcomes.
Of course, patients will at times need to lean on our professional expertise. Although MI is patient-centered, there are still opportunities for providers to provide advice and recommendations. Asking permission to share possible strategies and solutions demonstrates respect for patient autonomy. It also allows the provider to select the appropriate "teachable moment." If someone is having a bad day or is particularly emotional, the provider and patient can mutually agree to table the topic of conversation until the patient is ready for further discussion.
It is well recognized that PTs and PTAs are masters of patient education. After all, patient education represents a large portion of what we do when working toward lasting functional improvement. MI fits well with our usual methods of practice and our professional roles. One-on-one contact and regular visits throughout an episode of care provide opportunities for follow-up and establish close relationships that create a deeper level of sharing than what may occur in other health care settings. MI capitalizes on these relationships, using them to optimize treatment outcomes, enhance adherence, and reduce rates of disability. This enables PTs and PTAs to achieve our vision—transforming society—one conversation at a time.
Rose Pignataro is associate professor in the physical therapy program at Adventist University of Health Sciences.
2018 Presidential Address
APTA President Sharon L. Dunn, PT, PhD, addressed the House of Delegates, June 25, 2018.
My fellow members of the American Physical Therapy Association, welcome to the 2018 House of Delegates, and thank you for this opportunity to address you tonight.
Three years ago, this body elected me APTA president—a tremendous honor that opened a door to an even greater privilege. I have always been proud to be a member of APTA, and I have always been fulfilled by opportunities to contribute to this association, but serving as APTA president has been enriching beyond measure.
Tonight we gather together three years removed from our centennial—a milestone that, like being elected president, is less a landing place than a launching pad. Our future awaits, and we have the opportunity, the honor, and the responsibility to shape it.
It's a journey we've already begun.
When our bicentennial arrives in 2121, astute historians will note that in 2013 the House of Delegates foreshadowed a fast-approaching new era for our profession—and hastened its arrival. Five years ago this body propelled us beyond our previously inward-facing Vision 2020 to today's outward-facing Vision Statement for the Physical Therapy Profession: Transforming society by optimizing movement to improve the human experience.
In that truly transformative moment, our profession and association were nudged out of our familial nest and made to spread our wings. And just as birds are meant to fly, as professionals dedicated to serving others, we were meant to look outward all along.
That is not to suggest that we were misguided in the decades spent fighting for our autonomy and ensuring our profession was well positioned to capitalize on hard-earned independence. Most of us in this room wear those battle scars—and quite proudly. But where our past was shaped with sharp elbows, our future must be shaped with open arms. Where our origins situated our profession in recovery and treatment of disorder, our future will be characterized by an increased role in sustaining health and proactively preventing disability and disease. And where previously we have demanded respect in part by staking out turf and occasionally pointing to the shortcomings of others, in our future we will demonstrate our value based on the irrefutable data of our own outcomes and in partnership with our colleagues across disciplines. The health care system and our patients will demand nothing less.
We will not arrive at our centennial fully formed or having conquered all challenges. Traditional payment models do not align with the present day cost of physical therapist education. The rich patient relationships that have been a hallmark of our profession are threatened by misaligned incentives and mounting administrative burdens. Outdated insurance plans and old-fashioned attitudes about the patient journey continue to create financial and behavioral barriers to our services. The fact is, at present, our societal impact is less than we desire, and too many physical therapists feel challenged to provide the kind of care that drew them to this profession in the first place.
For those reasons alone, we all should feel a sense of urgency. But we should approach our future with enthusiasm, not dread, because our profession has never been satisfied with our position within the status quo. Our existence has been one of almost constant self-challenging evolution. Our progress has never been inevitable; it has always been hard-earned. So if we truly desire to not only see society transformed but to shape that transformation, we must not only weather the storm of health care disruption. Instead, as Dr Alan Jette urged in his 2012 Mary McMillan Lecture, we must face into the storm and choose questing over resting.
But let's be clear: simply embracing change does not create change—and it doesn't make change easy.
A few months ago, I was on the phone with my nephew, who is a youth pastor in a large church in Central Texas.
You don't need me to tell you that right now our country at large is struggling for and struggling with change. That environment has created tension within my nephew's experience in ministry—and within my nephew himself. He described his current state as "waking up" to the many challenges of today. As we were talking he asked me, "Aunt Sharon, how can you be so nonjudgmental?"
I told him it's because I have been judged, and I know what that feels like.
Likewise, throughout our history, in ways large and small, our profession has been judged, and we know what that feels like. And we have participated in judgment as well.
Judgment is delivered with folded arms, not open arms. It thrives on bias and stereotypes. It fosters tribalism. It ends conversations rather than starting them. It frequently dismisses nuance and entices us to build narratives around intent and hidden motives that sometimes say more about the judge than those being judged. It shackles us to old attitudes and routines. Perhaps worst of all, it draws us to the margins of the issue rather than the center, making us critics instead of change agents, more interested in tearing-down than building-up.
We cannot transform society through judgment. Our vision charges us not to stand at a distance and point our fingers at our nation's ills but instead to accept a personal responsibility to try to make a difference.
In that conversation with my nephew, he encouraged me to read Dr Martin Luther King's "Letter from Birmingham Jail," written in 1963. Sitting in prison, having been arrested for parading without a permit, Dr King learned of an advertisement placed in the local paper by eight religious leaders he once considered his friends and colleagues in the ministry. The ad labeled him as an "outsider" who was trying to influence change in a place he supposedly didn't belong, and it condemned his nonviolent tactics for inciting hatred and violence.
In his response, Dr King was compelled to point out the idle indifference of his critics, writing: "I am in Birmingham because injustice is here. ... I am cognizant of the interrelatedness of all communities and states. I cannot sit idly by in Atlanta and not be concerned about what happens in Birmingham. Injustice anywhere is a threat to justice everywhere. We are caught in an inescapable network of mutuality, tied in a single garment of destiny. Whatever affects one directly, affects all indirectly. Never again can we afford to live with the narrow, provincial 'outside agitator' idea. Anyone who lives inside the United States can never be considered an outsider anywhere within its bounds."
As an association and profession, we must ensure that no one feels like an outsider anywhere within our bounds. This obligation is spelled out in our recently updated mission statement: Building a community that advances the profession of physical therapy to improve the health of society.
To fulfill our mission, our community must vastly improve our diversity by being intentional about inclusion. We must prioritize listening and learning. We must enable the next generation of physical therapists and physical therapist assistants to transform our association, just as our association must transform society. Most of all we must get involved—with open arms and open minds—not only as a community, but as individuals.
I understand that in today's turbulent climate the problems we face as a nation and profession can seem too complicated and volatile for any one person to make a difference. For our younger members, this might be the first time you have felt this way. But we have been here before.
Fifty years ago, almost to the day, APTA members gathered in Chicago for APTA's annual conference of 1968. Dr King had been assassinated not even three months earlier. Robert Kennedy had been assassinated just over three weeks earlier. And around those tragic deaths there were riots in Chicago, Washington, DC, Baltimore, and other places across the United States. The conference was unfolding in what APTA President Eugene Michels called "trying times."
In his annual member address, President Michels said, "Our journey, both in society and in the world of health care, is beset with difficulties—with wrangling, haranguing, and with conflict between forces. ... We are exposed daily to arguments and counterarguments over whether ours is a sick society or a violent culture."
Sadly, those words ring true today. And it's not the only place in which Michels' 1968 address resonates.
He articulated that "there are disturbances of some human functions which the skilled physical therapist can evaluate more competently than the physician." He noted that physical therapist "'treatments' rarely comprise the total physical therapy program of any one patient." And while advocating for the physical therapist's autonomy, he cautioned against clustering together in specially trained groups and erecting, in his words, "high, surrounding fences with warning signs that say, 'Special Functions-KEEP OUT.'"
Instead of isolation, Michels urged cooperation. That would mean, he said, "sitting down as adults for frank, well-informed, intelligent dialogue in which areas of agreement and disagreement can be mutually explored," and "doing this at all levels, ... for the practice of physical therapy is just as broad as what all of us do, and just as deep as what each of us does."
As Don Berwick, the former administrator of the Centers for Medicare and Medicaid Services, recently described in a keynote lecture, it is time we as health care providers snuggle for survival within a collaborative health delivery system, instead of struggling to survive in isolation.
These conversations are more urgent than ever, and thankfully our profession has never been better equipped to have them, and our association has never been better positioned to lead the way.
APTA is strong. Membership is larger than it's ever been and growing at a rate not seen since the early 1990s. We are months away from breaking ground on a new headquarters in Alexandria, Virginia, having already paid off the land we purchased just one year ago. Our association has benefitted from strong financial stewardship going back at least to the early 1980s when our current headquarters was purchased—an investment we have maximized. But the most valuable asset in our portfolio has always been the engaged member.
When we formally charge APTA to act, or simply daydream about "what APTA should do...," we sometimes behave as if we're writing a check for someone else to cash. But as an individual membership association, we are charging ourselves-we are writing our own to-do list. APTA is not a distant factory that churns out ready-to-order physical therapy progress on a conveyor belt. It's a community of physical therapists, physical therapist assistants, and students. It's our community. We are APTA, and APTA is us. Our association's growth, commitment, and determination cannot outpace our own personal development.
Make no mistake, the disrupted health delivery environment is an opportunity. It's a sign the system is malleable enough to be transformed. Since at least the turn of the century, the health care experience has been dominated by the quick fix and the passive patient experience. The result has been more opioids than are safe, more scans than are necessary, more surgeries than are helpful, and more people who are physically inactive than a healthy society should responsibly accept.
These aren't just trends. They are a genuine societal need that must be addressed. We not only have the ability to be agents of change, but as a health profession we have an obligation to do so. We won't solve these problems alone, but change must begin with individual action.
In the spirit of Dr King, we must follow our dreams with our own footsteps.
If, like I do, you anticipate a day when physical therapists, like dentists, are part of our society's regular health routines, don't just point the way—raise a hand and accept a portion of responsibility to take us there.
If, like I do, you believe that we gain strength not just with increased membership but with greater engagement, find a colleague who isn't as involved and demonstrate the spirit of inclusiveness our community requires.
If, like I do, you believe that the power of our profession is boundless, that it can optimize movement and health in every corner of the world, then dare to look beyond traditional delivery and payment models; our patients and clients are likely just as frustrated by the limitations of the status quo as we are, and they are eager for the precise and personalized service we can provide.
Above all else, if you believe, as I do, that our profession is more educated and skilled than ever before, that our potential is greater than it has ever been, then join me in demanding that we provide only the highest quality of care and that we are immediately accountable when the data suggest our patients and clients deserve something better.
As Eugene Michels said 50 years ago, "We must promise only what we can deliver and we must deliver what we promise. ... As a profession, we need to improve our posture and add one cubit to our stature by tending to some of our own deficiencies. ... As for the signs of professional maturity, these cannot be generated by a committee, legislated by our House of Delegates, or financed and carried out by some program. They are a matter for our collective and individual consciences."
A few months ago, I was reminded what it looks like to deliver on a promise when Lynda Woodruff, a notable member of our community, passed away at the age of 70.
Lynda was a physical therapist and an educator. But more than that she was a trailblazer. She was the first African American to join the faculty in the Division of Physical Therapy at the School of Medicine at the University of North Carolina. She was the founding director of the physical therapy department at North Georgia College. She began the transitional doctor of physical therapy program at Alabama State University. And she was instrumental in establishing APTA's original Advisory Council on Minority Affairs and the Office of Minority Affairs, as well as the Minority Scholarship Fund and the Minority Scholarship Award for Academic Excellence.
Lynda was a doer, never charging others with a task she wouldn't take on herself. She was a mentor, shaping and inspiring her beloved "Woody Babies." She was someone who found people on the outside and brought them into our community. Lynda was a leader in the purest sense of the word.
In 1962, Lynda and a young man named Owen Cardwell became the first black students to attend the all-white E.C. Glass High School in Lynchburg, Virginia. The landmark Brown v Board of Education decision had been established in 1954—but it was Lynda who delivered on what was promised.
What I didn't know until I attended a memorial service for Lynda was that sometime before her first day at E.C. Glass High School, that little 13-year-old girl sat in her living room with her family and talked to a 33-year-old African-American Baptist minister who counseled her about the strength and courage it would require to be a pioneer of integration.
That was roughly a year before he would write his "Letter from Birmingham Jail," but already Dr Martin Luther King realized that he could not sit idly by in Atlanta and not be concerned about what was happening in Lynchburg. He, too, delivered on a promise.
I knew Lynda in life, but hearing friends and family memorialize her showed me I didn't know her well enough. I regret that I never got to hear Lynda tell her whole story. I regret that I missed an opportunity to better understand her experience. But knowing what I know now about Lynda, everything about her makes sense. She was a strong woman and a powerful presence—one who deeply understood the redemptive power of love, and one who had the requisite tenacity to see dreams to fruition and to deliver on promises.
Thanks to trailblazers like Lynda Woodruff, we have unprecedented freedom to pursue a better tomorrow. But time is precious, and we cannot waste it.
When we enter our next century as an association, we must not close the book on our proud history, shaped by those who led by example. That would be both ungrateful and unwise.
Instead, we must strive to match their commitment for progress with our own, fully aware it will lead to a tomorrow much different than today, because the pursuit of anything less would be an injustice, both to those we hope to serve and to those coming behind us.
Our bright future is already shimmering on the horizon, and we don't need to wait until the sun rises on our centennial to begin to realize our potential or accept our responsibility.
At our core, we are healers, and as much as ever our country and our society need healing. It is not enough that we tweet about it in judgment. It is not enough that we adopt policies that articulate our principles. It is not enough that we sit idly by, in the comforts that were afforded by those who forged the path before us.
No, our history tells us that when we stand together and act, we are a force.
The members of the American Physical Therapy Association were bold enough to dream of transforming society. Now we must deliver on that promise by following the most universal piece of advice we provide to our patients and clients: we must move!
APTA President Sharon L. Dunn, PT, PhD, Board-Certified Orthopaedic Clinical Specialist, was reelected to a second 3-year term, June 25, 2018.
Looking Back to the Future: APTA's First National Conference
"Think again and see if you cannot possibly make your vacation include June 27-30 and have Orlando as your objective."
Most of that sentence came directly from a notice in The P.T. Review (now known as PTJ) advertising the First National Convention of the APTA, nearly 96 years ago. The only difference? We changed the date and inserted the upcoming APTA NEXT Conference and Exposition, in Orlando, in place of APTA's first national conference location, the Boston School of Physical Education, held in September 1922.
"The Convention should do much to straighten out some vexing questions as well as give the Association an added impetus," the notice reads. Among the "vexing questions" that were debated by the 63 attendees: Should "qualified" male physical therapists be admitted? Should the APTA constitution define minimum requirements for general education and specialized training?
Highlights of the convention included presentations on electrotherapy, exercise therapy, and hydrotherapy, and even a "paper with lantern slides" on posture training by physical therapist Inga Lohne. (Lohne, incidentally, became APTA's second president the following year.) Physician Frank Granger led clinical observations on muscle reeducation at Boston City Hospital.
While the modern-day NEXT conference is much larger and comprehensive, the collegial atmosphere remains much as described by then-president Mary McMillan in Chapter 3 of Healing the Generations: A History of Physical Therapy and the American Physical Therapy Association: "We shall endeavor to be as informal and homelike in our meetings as possible, in order that we shall be able to get close to one another in understanding."
And was the convention a success? Here's what The P.T. Review had to say about it afterwards.
10 Tips for Maximizing Your Experience at NEXT 2018
APTA's NEXT Conference & Exposition is coming up quick! If you didn't make it in time for advance registration, you can still register online or onsite in Orlando. Plus, we have daily rates if you can't make the whole conference.
Whether it's your first conference or your twentieth, here are some helpful tips for connecting with fellow conference-goers and making the most of your time in Orlando.
Make plans ahead of time to meet up with people you know will be attending. Your former classmates, professors, and coworkers can introduce you to their networks. Rather than feeling overwhelmed by so many attendees you've never met, you'll be exchanging ideas and building your professional networks.
Maybe you see a speaker on the NEXT app with whom you'd really like to get in touch. Contact them and see if they might have a few minutes during conference to answer some questions in person.
Learn your way around the NEXT app. Seriously, the app is a time-saver. It contains all session descriptions, locations, and times, as well as a scheduling feature to keep track of the sessions you are most interested in. You can search for sessions by day or by speaker. It also has exhibitor info and maps.
Outline your goals and plan your schedule. Write down your top 3 goals for NEXT, and then use the app to find ways to achieve them. Want to learn about a topic outside your current focus? There's likely a session on that. Want to find a mentor? Plan to attend the Oxford Debate, daily networking coffees, or receptions. APTA staff also has put together some handy highlights for early-career PTs, mid-career PTs, and PTAs.
Pack comfortable shoes to wear—and some to give. As PTs and PTAs, comfortable shoes should be a no-brainer. But if you've never been to a conference, trust us. Your back will thank you for some arch support and cushioned soles.
Shoes4Kids will thank you, too, for a donation of children's athletic shoes and socks. In the spirit of service, APTA is once again collaborating with the nonprofit to collect and distribute shoes to area children in need. Attendees can bring brand-new children's athletic shoes and socks to conference or make a monetary donation. Check out requested shoe and sock sizes.
Get inspired. NEXT signature events such as the McMillan Lecture, the Opening Ceremony (this year with Gabby Reece!), the Rothstein Roundtable, and the Maley Lecture can open your mind to new possibilities for the profession and your career trajectory, while the Oxford Debate is a good way to have fun while tackling a two-sided topic.
Connect with attendees who practice in specialties other than yours. Just because you mainly practice in orthopedics doesn't mean you can't learn from peers in pediatrics or women's health. The same is true for clinicians and academics. You never know—you might end up switching career paths, or think of new ways to collaborate in the clinic.
Get social! You have colleagues or friends who won't be attending, so don't forget to share video clips, photos, and hot tips from speakers on your topic of interest. Make sure to get a photo with friends at the selfie station in the exhibit hall. Use hashtag #APTANEXT, and follow @APTANEXT on Twitter and Facebook.
Have some after-hours fun. Once sessions are over for the day, take some time to get outside and decompress. NEXT attendees have access to specially priced, after-2 pm tickets to Universal Studio's Florida™ or Universal's Islands of Adventure™. The ticket also includes select live entertainment venues of Universal CityWalk™. There are general discounts on Orlando attractions available through the Convention and Visitors Bureau site.
Follow up with new connections. After you return home, send an email note to a speaker, and establish LinkedIn and social media connections with new acquaintances. Sharing information and advice can continue long after the conference is over.
After NEXT ends, be proud. You made it through a tsunami of information, expanded your network, and hopefully made some lifelong friends. As a profession, we're #BetterTogether.
Enjoy the conference!
Yes, We Should: 5 Ways to Transform Your Mindset to Improve the Health of Society
By Todd E. Davenport, PT, DPT, MPH
Valerie Rucker, PT, DPT, is right: "Yes, we can" be leaders in improving the health of our communities. As she pointed out in her recent #PTTransforms blog post, our Millennial colleagues are our profession's future. But I don't think we should just leave it to a new generation of physical therapists to transform how we think about health and health care. This Gen X-er is here to tell you that all physical therapists and physical therapist assistants have an important role to play.
The United States is home to some of the most advanced and abundant medical care. Our medical technology, research and development, and per-capita number of specialist physicians are among the best in the world. We spend 17.2% of our gross domestic product on medical care, which is the highest in the world by almost 5%, and amounts to over $3 trillion per year.
If US medical care is so advanced and we spend so much money on it, then our health outcomes must be at or near the top in the world, right? Not necessarily. Just look at the stats related to medical process and outcomes. We have higher rates of overall mortality, premature death, and preventable deaths than comparable countries, on average.
It's now clear we have a health problem in the United States.
It's also now clear that health care and medical care aren't the same thing, and that we aren't going to treat our way out of poor health using our old ways of thinking and doing.
I believe these 2 ideas should inform how we operationalize our new American Physical Therapy Association mission statement: "Building a community that advances the profession of physical therapy to improve the health of society." In turn, our efforts at community building will propel us toward realizing our professional vision: "Transforming society by optimizing movement to improve the human experience."
So, how do we start thinking about society so we can transform it?
And how do we start talking about communities so we can build them?
The answers to these questions are simple, but they're not necessarily easy to do.
Our mission and vision statements invite a fundamental change in how we see ourselves as PTs and PTAs, from expert and caring practitioners who provide care within the confines of a clinic to population health change agents.
Does that sound like a lot? It is! And that's what makes the challenge interesting and exciting.
Here are 5 places to start:
Find your tribe. Find a group of people with whom to share, collaborate, learn, and act. There are PTs and PTAs who are actively involved in population health activities. Check out APTA's Council on Prevention, Health Promotion, and Wellness. The council already has assembled some great resources on the APTA (members-only) Hub, and they have organized some great conference programming to help you get started. Also, the Academy of Prevention and Health Promotion Therapies is an organization that cooperates with APTA and has some fantastic materials and collaborative tools to help clinicians of all backgrounds.
Get to know what your community needs. You might know the needs of your own patients very well. However, your caseload might not reflect the broader community and might be skewed by case mix, insurance, referral sources, and geography. A good place to find more information about your community's needs would be your state or local public health department or nonprofit hospital system. These organizations often produce community health needs assessments that can help you get to know your community in a new way. Public data also can help you understand your community's health needs.
Do a little asking around. Find agencies that align with critical community health needs, and ask how you can help. For example, local opioid safety coalitions have been organized in California to address the unique social, cultural, and political underpinnings of the opioid crisis. These organizations can coordinate with other stakeholders in providing services that can mitigate the incidence and prevalence of opioid use disorder in our communities, including addiction treatment programs, prescribers and pharmacists, school representatives, city and county officials, and public health officers. This model could be extended to other coalitions organized around active transportation, healthy aging in place, and other community health needs.
Find new income sources. Funding for population health initiatives will require us to "add by subtracting." That is to say, every dollar of savings on lost productivity and medical care that we provide to an organization can become our dollar of income. This way of thinking will require us to get outside our predominant habit of fee-for-service medical billing. Direct-to-employer contracts and community benefit funding are just a couple of examples of income sources to cover your costs while improving the health of your community.
Direct-to-consumer wellness arrangements also might be designed to address community health needs. Be aware that these types of cash-based services will be directed to people who can afford your services out of pocket, which might lead you to unintentionally widen existing wealth-based health disparities in your community.
Advocate for a healthier society.
Sixty percent of the variance in premature deaths is attributable to an individual's behaviors and social factors. Social and environmental contexts often influence whether an individual practices healthy behaviors. These social determinants of health are group characteristics that, in turn, predict an individual's health and access to health care. They include race, gender and sexual identity, occupation, education, wealth, built environment, and geography. In other words, your health depends in large part on who you are, where you live, what you do, and who you're attracted to and partner with.
Physical therapists and physical therapist assistants should be active in advocating for a society in which people can be healthy where they live, work, play, learn, and worship. Part of advocating for a healthier society will necessitate that our profession addresses health and health care inequities that exist based on our communities' relative social vulnerability.
So, I add a hearty "Yes, we should" to Valeria Rucker's "Yes, we can." By building healthier communities, we can ensure that the physical therapy profession remains vibrant, engaging, and dynamic in responding to our public's changing health needs now and in the future.
Todd E. Davenport is professor and director of the physical therapy program at University of the Pacific.
Keeping It Real: Finding the Missing Link Between Our Patients and Research
By Christine McDonough, PT, PhD
If consumers are going to "#ChoosePT" to address their movement disorders and functional limitations, they need to perceive physical therapists (PTs) as the preeminent experts in conditions that affect movement, pain, and quality of life. Potential patients and clients look for a strong recommendation from their family, friends, or peers, and perhaps a referral from their treating physician. Physicians and payers—both public and private—want to know that science informs our practice and that our interventions will result in tangible improvements in patient outcomes.
Patient clinical data registries such as the Physical Therapy Outcomes Registry have the power to use large amounts of outcomes data to evaluate outcomes of a given intervention for a specific condition in a specific population—for example, the effects of resistance training on falls in older, community-dwelling women.
This real-world evidence is important, because to provide the best possible patient care and transform the health of our communities, you need to know:
- How to classify patients for accurate clinical decision making
- What interventions work for a particular patient under specific circumstances
- What the prognosis is for patients who undergo treatment
- What kind of home exercise program or behavior changes are necessary to optimize outcomes
Randomized controlled trials (RCTs) are the "gold standard" for establishing the effectiveness of treatments, but their role is changing, as clinical registries enable researchers to understand real-world impacts from patient outcomes data. Evidence developed from clinical data registries such as APTA’s Physical Therapy Outcomes Registry—with their power to use large amounts of data to evaluate outcomes of specific interventions for specific conditions and populations—will fill important gaps in knowledge that will serve PTs and meet the needs of our consumers.
RCTs Are Important but Have Limitations
While RCTs aren’t going away any time soon—and shouldn’t—they are very expensive, and they often take a long time to plan and to complete. It simply is not feasible to conduct RCTs on every intervention available.
Because of the way they are designed, both efficacy and effectiveness RCTs have built-in limitations in determining whether a given intervention will work for the patients you see every day.
Efficacy trials answer the question: "Does the treatment work better than placebo?" If the results of an efficacy trial are positive, researchers can investigate additional questions in subsequent trials. But if the results are negative, the intervention may be abandoned altogether.
These high stakes have an impact on the design of efficacy studies. Because a negative result may mean abandoning a potential intervention after significant financial resources have been devoted to a trial, they are often designed to optimize the possibility of detecting a treatment effect. This is done by designing the trial to answer a focused question, such as "Is this treatment better than no treatment under ideal circumstances?" The studies often include patients with similar characteristics that make them the most likely to benefit, and they exclude more complex patients that might muddy the waters of interpretation.
Effectiveness trials answer the questions: "Is the treatment better than existing treatment?" or "Does the treatment work better when combined with existing treatment?" As with efficacy trials, in order to avoid abandoning effective treatments trial design must balance broad inclusion with detection of treatment effect. Clinical trials are now being designed to more closely represent the real-world environment. These "pragmatic trials" include a broader range of providers and patients, and provide support more aligned with what would occur in real-world implementation.
The Real World Is Not the Ideal World
The effects found in early efficacy and effectiveness studies are not always the same as the effects found in real-world circumstances. There are several important reasons for the differences, including:
- The providers delivering interventions in clinical studies often are different from those providing treatment in the community.
- The patients receiving interventions are more complex than those in clinical studies.
- The range of activities and support provided in clinical trials are not available in actual practice.
So clinical trials are now being designed to more closely represent the real-world environment. These "pragmatic trials" include a broader range of providers and patients, and provide support more aligned with what would occur in real-world implementation.
In a recent blog post on medical registries, Dr Caroline Fife highlighted 10 goals that many registries share. Among them, 6 will be of critical importance to the future of physical therapist practice.
Provide evidence to support value of interventions and services to stakeholders. The Physical Therapy Outcomes Registry will provide direct evidence of the results of real-world PT services that can be used to communicate our value to clients, patients, payers, and policy makers.
Submit quality reporting data to CMS (eg, MIPS). For future quality data required of PTs, the Registry can streamline the process.
Provide benchmarking data to users. Including your data in the Registry will allow you to get real-time feedback to inform and improve clinical decision making and outcomes. High performers can share their success, and everyone will benefit.
Support quality improvement. Registry data can be used to identify improvement opportunities and to measure the success of quality improvement initiatives.
Support development of classification and risk stratification tools to improve clinical decision making. As we identify the characteristics that predict response to treatment, we can improve our outcomes and the value of our services
Provide real-world data for research to fill gaps not covered by traditional research.
There is wide recognition of the value of using data to improve patient care—as it is actually delivered—and help bridge the gap between what is learned in clinical trials and what we need to know. Registries provide this missing link by collecting standardized outcomes data from real-world patients, with all their complexities.
PTs across the country are participating in APTA’s Physical Therapy Outcomes Registry to help bridge the gap. They are pioneering the way for the future of our profession and the future of health care. Visit www.ptoutcomes.com/ to learn more.
Christine McDonough, PT, PhD, is assistant professor in the departments of physical therapy and orthopaedic surgery at the University of Pittsburgh. She also is a member of the Physical Therapy Outcomes Registry Scientific Advisory Panel.
Yes, We Can: How a Millennial Mindset Can Help PTs Improve the Health of Society
By Valerie M. Rucker, PT, DPT
As a Millennial, sometimes I joke that I was born in the wrong decade because of my affinity for Marvin Gaye and Frankie Beverly band, Maze. As with generations before mine, the younger generations tend to get a bad rap: Critics contend that Millennials are entitled, too fast-paced, transient, and lazy, and they scoff at our participation trophies.
But Millennials are undoubtedly key contributors in the workforce, across all disciplines and fields. Studies have shown that we are helpers, doers, activists, tech-literate, collaborative, and left-brain dominant. We give back to the community just as older generations have done, but rather than donating to institutions we are more likely to support causes we are passionate about. According to the Millennial Impact Project, health care is among the top 5 issues we care about, along with civil rights, climate change, education, employment, and immigration.
With all of this collective energy and interest igniting our generation, Millennials have a unique opportunity to impact health care, specifically the physical therapy profession, in a meaningful way. And the beautiful part is that you don't have to be a Millennial to adopt this mindset!
I began noticing the ways in which the Millennial mindset could change the game in health care as I sat in the first lecture of my first conference as a new graduate, at CSM 2018 in New Orleans. The conversation was about the term population health. Mike Eisenhart and his copresenters, Todd Davenport and Dawn Magnusson, explained that population health is broadly about identifying the problem, creating a service appraisal to address the needs of the community, and then using that program or project within the population being addressed.
Sounds simple, right? But the driving component of why this works is applying a patient narrative to a larger population. With its goal of keeping people healthy and out of formal care, population health introduces the concept of social determinants of health—linked to many of the issues my Millennial peers care about deeply. Population health is a way we as PTs can manage the needs of underserved communities.
I considered a then-current patient on my caseload. "Mrs Jones" is a middle-aged, cisgender, African American woman who had experienced chronic low back pain since 2008. That diagnosis in itself does not scream "unique," as this is a common diagnosis in America, but her narrative does.
Mrs Jones lost children to neighborhood violence within the past 8 years, lost her job because of her back pain, and missed appointments after shootings in her apartment building led to an abrupt move. Along with a host of cardiovascular and pulmonary diagnoses, other musculoskeletal issues limited Mrs Jones in most activities of daily living and decreased her quality of life.
Jumping back and forth between listening and contemplating, I gathered from Eisenhart's lecture that Mrs Jones' social determinants of health included (1) being part of a vulnerable and underserved population, (2) living a sedentary lifestyle, (3) living in an unstable, variable environment, and (4) lacking access to quality health care.
The wheels in my Millennial mind turned, as I questioned how I could take this narrative and apply it to the bigger picture. What population shares this story? What are the barriers to addressing the disparities within that population? As PTs, we see our patients more often than do many other health care providers and, as such, can capture our patient's stories.
Snapchat, a social media app-based company developed by Millennials, is marketed as a way for people to share their stories via photos and short videos. One picture conveys one moment, but a story emerges in viewing a user's "snaps" over time. That concept can be used to develop sustainable solutions to population health problems, by capturing patients' stories and looking at them as a whole to get a more complete picture of entire populations and the challenges they face.
At the end of the lecture, instead of feeling helpless I felt energized; not only did I have the desire to help, but I now knew of a concrete way to do so, through research and implementation of the population health model. Even small amounts of collaboration and creativity across health care disciplines can effect a ripple of change throughout a community, thereby impacting the triple aim of health care: lowering health care costs, improving the patient experience, and improving the health of populations.
Why can't PTs be leaders in population health? We are an integral part of the interdisciplinary team, thereby fostering vital relationships with other health care providers. We attend conferences such as CSM, which spark interests and start conversations about topics that can impact whole communities and patient populations. We have a powerful platform via APTA, upon which we can make our—and, more important, our patients'—voices heard. We already provide patient education regarding lifestyle modifications and techniques for a better future. We also can impact the health of society by adopting the Millennial mindset: one that sees the need, addresses it with creativity, and attacks challenges without fear of failure.
After reading this post, you might ask, "Millennial, what makes you think you can fix everybody?" And to that I might reply, "What makes you think we can't?"
Valerie Rucker is a licensed physical therapist. She currently works within an outpatient department in Washington, DC, and is a member of the DC Physical Therapy Assocation.