When Health Decisions Aren’t a Matter of Choice: Addressing Social Determinants of Health
Physical therapists (PTs) and physical therapist assistants (PTAs) focus on both restoring movement in those with decreased function and promoting healthy behaviors to prevent health problems such as obesity or high blood pressure. But in doing so, they also must consider how social determinants of health—economics, education, neighborhood, and other factors—influence the lifestyle choices patients and clients make.
Zachary D. Rethorn, PT, DPT, a home health PT, board-certified orthopaedic clinical specialist, doctoral student in health promotion and wellness, and adjunct professor at the University of Tennessee at Chattanooga, has been giving these ideas careful thought and incorporating them into his practice. In 2018, he co-presented on the topic of social determinants of health at APTA's NEXT Conference and Exposition, and earlier this year he published a blog post that further explored the topic. In the post, he writes:
. . .the narrative in our country is one in which personal responsibility is emphasized so much that we can forget we live in communities and systems which influence the choices we make. Say you have a prized rose bush (like I do). If it doesn't bloom this year am I going to uproot it, chuck it out, and get a new one? Of course not! When a flower doesn't bloom you fix the environment in which it grows. Not the flower.
#PTTransforms interviewed Rethorn to learn how PTs and PTAs can incorporate these concepts at the point of care.
#PTTRANSFORMS:
In your blog post, you write about the 5 areas of social determinants of health: economic stability, education, social and community context, health and health care, and neighborhood and built environment. Most of these areas pertain to things that neither the patient nor the provider can change, for the most part. You can't change the fact that your neighborhood isn't safe for you to get more physical activity, for example. How can a clinician use this information? Should we be screening for social needs?
ZR: The first question we have to ask ourselves is are we a profession which delivers health services? Or are we a profession that promotes the health of our neighborhoods, communities, cities, and states? If we believe that our role is to advocate for and improve the health of those we serve, then a good place to start is by considering the social and environmental context in which our patients live.
Screening for social needs can be very different from our typical medical or health screening tools. I want to caution readers that screening must be linked to the ability to provide appropriate referrals and treatment. Screening without the capacity to assist is ineffective and potentially unethical.
To mitigate negative unintended consequences of screening, here are 5 tips:
- Be patient-/family-centered in screening.
- Integrate screening with referral and linkage to community-based resources.
- Perform screening within the context of a comprehensive system that supports early detection.
- Acknowledge and build on strengths of patients, families, and communities.
- Engage the entire practice population, rather than targeted subgroups.
#PTTRANSFORMS:
How can a clinician evaluate this information and use it to help with shared decision making to improve the patient's health?
ZR: There are a number of evidence-based toolkits that clinicians and health systems can use to screen for social needs, including HealthLeads, PRAPARE, HealthBegins, and the Accountable Health Communities Screening Tool. These tools all provide a starting point with recommended core domains such as food insecurity, housing instability, utility needs, and financial resource strain. Based on a community's needs, additional domains such as child care and social isolation may be added.
Whatever tool you choose to use:
- Make it short and simple—no more than 12 questions, written at a fifth-grade reading level, translated into appropriate languages.
- Choose clinically validated questions designed to open a conversation.
- Integrate the tool into clinical workflows.
- Elicit patient feedback to prioritize screening items.
- Pilot before scaling.
Once a clinician has gathered information about an individual's social context, it is essential to open a conversation with that individual regarding what he or she wants and believes will be most helpful. This is place where the clinician can provide advice and not only refer the individual to other services, but also facilitate access to those services in a sensitive, culturally acceptable, and caring way.
#PTTRANSFORMS:
What modifications can a PT make to account for, say, a neighborhood where a patient feels unsafe? Or lack of access to fresh fruits and vegetables?
ZR: The first step to take if individuals are saying that a neighborhood is dangerous or there is no access to fresh fruits and vegetables is to understand what local resources are available. Often, there are resources available that the person may not be aware of.
For the first few years of my practice, I worked in a neighborhood where many of my patients felt unsafe going outside. But as I got to know the neighborhood better, I realized there were opportunities for physical activity outside but perhaps in ways different from what I first envisioned. Instead of coaching individuals to take walks by themselves, I started walking groups. Suddenly, this became a feasible way for many of the older adults I worked with to feel safe and be more social in their neighborhood.
If a creative solution is truly unavailable, this is where advocacy comes into play. My clinic was located in a food desert, where the closest grocery store with fresh produce was 2 miles—but 3 bus changes and 50 minutes—away. As I heard more and more that lack of access to healthy food was a perceived need in my population, I took this to a local farming nonprofit that agreed to begin hosting a mobile market in the neighborhood 2 afternoons per week.
These examples are not extraordinary. They come from carefully listening to the individuals I serve and reimagining my role as a PT from one who simply delivers interventions to one who is invested in and cares about the health of my patients. Caring about the health of my patients necessarily means that I care about the social and environmental context they live in, because the context is what shapes their health behaviors and choices.
#PTTRANSFORMS:
When working with a patient, how do you balance empowering the individual to make healthy choices with the knowledge that some things you just cannot control?
ZR: When I work with a patient, I am considering health influences at multiple levels. At purely an individual level, I am examining their health behaviors such as physical activity, diet, stress, and sleep. During my history taking, I will ask about these factors and coach the patient to change their health behaviors based on their desires and resources.
At a wider level, I am cataloguing the individual and systemic barriers that individuals are relating to me. Perhaps a number of individuals are telling me that the sidewalks in their neighborhood are in disrepair. At this point, I can gather more information from a neighborhood association, search for data related to sidewalks in the city, or go to a city councilor to bring up the need related to sidewalk repair.
The goal is to find pain points where social and economic factors present barriers to individuals' ability to engage in health behaviors. From there I can use clinical experience and research evidence to advocate for social change which will improve the health of the population I serve.
#PTTRANSFORMS:
Is there a danger of implicit bias here? How can clinicians avoid making assumptions about the relationship between a patient's health and these 5 areas? Or do social determinants of health help us respect the personal, economic, and cultural circumstances our patients face?
ZR: Current data suggest that, first, implicit bias is a real phenomenon. We all hold underlying attitudes and stereotypes toward members of other groups. But not only is it real, health care providers exhibit the same amount as the general population. This bias is shown in positive attitudes toward Whites and negative attitudes toward people of color. Further, this implicit bias may impact the clinical decision making of health care providers toward their patients.
Addressing implicit bias must be a conscious decision. One way to avoid making assumptions is to commit to screening for social determinants of health across your entire patient population and not just for select subgroups. If you target only demographic variables such as age, education, residence, underrepresented minority status—it may reinforce stereotypes and prejudicial presumptions and could stigmatize the screening process.
Another strategy is to improve your understanding of health disparities and bias in health care. Once I understood the daily challenges that my population faced, I became more empathetic and better equipped to facilitate positive changes in the community.
#PTTRANSFORMS:
Do you see social determinants of health taking a larger role in health research in the future? How so?
ZR: Research on the social determinants of health is already robust. The influence that the social and environmental context plays on individuals' and populations' health is clear. The question is: Do we have the social will to take what we already know and implement it? Are we willing to address health where it starts, not just where it ends? Can we make the healthy choice the easy choice in culturally sensitive and appropriate ways from neighborhood to neighborhood and city to city?
Primary Care and the Physical Therapist: Lessons From the Military
By Jason Silvernail, PT, DPT, DSc
If you keep up with the news, you may have seen headlines like these: "Doctor shortage may reach 120,000 by 2030," "How can we remedy the shortage of health care providers?" and "US faces looming shortage of primary care physicians."
Given the importance of primary care, this isn't good news. To address this shortage, medical schools have increased enrollment, hoping to graduate more primary care physicians. But there are other ways to meet the demand for primary care than just producing more medical doctors, as the US military can teach us.
Several times in its history, the US military has experienced critical shortages of physicians. As a result, after the Vietnam War the military had to develop models of health care that can be an example for a civilian practice environment facing the same problem. Surely if these approaches—validated through reviews of military medicine by organizations such as The Joint Commission and the National Committee for Quality Assurance—are successful for our men and women in the military, they should be considered seriously as options to improve the supply of civilian primary care providers!
Primary health care teams in military medicine are constructed with a basic set of capabilities in mind and can include physicians, nurse practitioners, physician assistants, physical therapists (PTs), and behavioral health care providers such as psychologists and social workers. This "capabilities model" allows these licensed independent providers to work at their full level of training, share responsibilities, and help get the right patient to the right provider in a timely manner to provide effective care.
The military's health care teams often rely on what's known as "capabilities-based assessment": it determines what functions (capabilities) need to be present for success and then identifies resources to provide those functions. Instead of relying on old models and assumptions of how things have always been done, teams develop new solutions that are matched to the details of the problem.
There may be barriers to translating such a model to civilian care, such as high copays and Medicare not recognizing PTs as primary care practitioners, but such barriers are based on health policy, not on medical necessity or appropriateness. After all, PTs aren't seeking to replace primary care physicians but to provide primary health care within the scope of their training and expertise—care that is low-cost, low-risk, and proven effective for many common medical conditions that bring patients to primary care providers.
Primary care providers in team settings need to be able to evaluate and manage a wide variety of injuries, illnesses, and disorders—and no one profession can do it all. An ideal primary care team will be able to triage and direct the patient to the right team member. For example, the patient with the acute sports injury to the physical therapist, the cough and fever to the nurse practitioner, and the acute anxiety reaction to the psychologist.
PTs in the US military are right now stationed all over the country and around the world working in primary care teams managing acute sports injuries, dizziness and balance problems, pelvic pain, nerve injuries, wound care, and of other illnesses, injuries, and disorders well suited to their expertise. Easy access to PTs allows military members and their families to get rapid access to low-cost, low-risk, high-quality care. Using a team-based model in primary care helps foster trust and teamwork as different providers learn to share the overall workload while matching patients to the right provider.
No single provider can do it all—that's why you need a team. PTs are ready now to take on this team role, if we are willing to confront the policy obstacles that stand between Americans and the quality care provided by doctors of physical therapy as part of primary health care teams.
Jason Silvernail is a career Army officer and works in hospital leadership in the Washington DC area. Statements appearing here are Dr Silvernail's personal opinions and commentary and do not reflect the official policy or position of the United States Army, the Department of Defense, or the US Government.
Editor's note: Are you practicing as a primary care PT or working in primary care? APTA wants to hear from you! Contact Hadiya Green Guerrero at hadiyaguerrero@apta.org or Jeannie Bryan Coe at jbryancoe@mindspring.com for your personal survey link.
What Is the PROMISe of Global Outcome Measures? 3 Things You Need to Know
By Jeff Houck, PT, PhD
As health care providers, we often indirectly gauge patient outcomes by quantifying process measures such as number of visits per episode, cost per visit, and compliance with standardized guidelines. These variables can answer important questions: Are we wasting resources? Do we have unwarranted variation in care within our facility? Are treatments consistent with published clinical practice guidelines? But process measures do not place the patient's voice at the center of their care.
Patient-reported outcome measures (PROMs) are pivotal to assessing and achieving high-quality care. Patient-reported outcomes represent the only direct input of health status from the patient, unfiltered by a provider. Patient advocates and agencies such as the Centers for Medicare and Medicaid Services (CMS) see patient-reported outcomes as a key avenue to give patients a voice in their health care.
Global (as opposed to condition- or disease-specific) outcome measures, such as the Patient Reported Outcome Measurement Information System (PROMIS) scales, use the newest approaches to outcomes assessment (computer-adaptive testing and item-response theory) to capture a patient's overall health and compare it with the national average. Measures such as PROMIS allow physical therapists to hear their patients' voices relative to overall health during rehabilitation and to champion wellness programs.
Physical therapists were leaders in adopting condition- and disease-specific outcome measures, so it's natural for us to do the same with global outcome measures.
1. Global measures change the assessment paradigm from disease-specific effects to holistic health assessment that includes the patient's perspective.
Global measures offer distinct advantages over condition- or disease-specific measures. In contrast to such measures, which target a diagnosis, global measures target a health domain independent of diagnosis. The goal is to capture a patient's overall health status. PROMIS, for example, includes over 300 different health domains assessing symptoms and physical, mental, and social health traits. The scales are designed to accurately measure health domains such as pain interference, physical function, fatigue, self-efficacy, or social isolation across a population.
The main benefit of global measures is that they combine different health domains to obtain an accurate picture of a patient's perceived overall (physical, mental, and social) health. For wellness and for patients with comorbidities—which are the majority of patients—global measures help clinicians determine when treating a local problem may have strong effects on overall health and, vice versa, when costly interventions that remedy a local problem have no influence on overall health.
Let's consider a fictional patient, Mary, who had a total knee replacement due to knee osteoarthritis.
Because of Mary's previous longstanding chronic knee pain, she had gained weight and now fatigues easily. Many patients do not increase physical activity after knee joint replacement and are therefore unable to correct these primary health concerns.
A condition-specific measure such as the Knee Injury and Osteoarthritis Outcomes Score (KOOS) would assess Mary's opinions about her pain, ADL function, sports, recreation, and quality of life specific to her knee. In contrast, the PROMIS physical function and pain interference scales would measure Mary's overall physical function and pain.
Fear of doing too much after the surgery and low endurance are not routinely detected using condition-specific assessments such as the KOOS, while the efficiency of PROMIS computer-adaptive scales (1-minute per health domain) allows for additional health domains to be assessed that are important to the patient or provider without burdening the patient.
In Mary's case, the PROMIS physical function and pain interference scales detected deficits similar to the KOOS. However, the addition of the fatigue and self-efficacy scales also detected Mary's low energy and low confidence in her ability to manage her health, which her physical therapist addressed.
By following her plan of care, Mary has lost weight and improved her cardiovascular fitness, in addition to experiencing improvement in physical function and pain interference.
2. Condition- and disease-specific measures are still valuable for some populations, but global measures often perform just as well.
An important issue for the switch to value-based care is documenting change. In statistical terms, a measure needs to be valid and responsive to be effective clinically. There may be some very specific problems, such as carpal tunnel syndrome, where global measures are not as responsive and may require the continuation of disease-specific measures in some specialty practice areas. However, for most conditions, from anterior cruciate ligament reconstruction to geriatric assessment, the PROMIS scales are performing as well or better than disease-specific scales.
(See the PROMIS Health Organization's website for published papers on validity and responsiveness of PROMIS scales.)
3. Global measures present opportunities for PTs to expand their role in the broader health care ecosystem.
Global assessments are agnostic to disease, so scales can be applied successfully across diagnoses and shared easily across multiple types of providers. Everyone speaks the same language! This frees up time for physical therapists and focuses outcomes on a common goal of improved overall patient health. For example, patients with abnormally low physical function may be flagged for physical therapist services such as fall prevention or presurgical screening.
Global measures also support the philosophy of value-based care, which is one reason that APTA's Physical Therapy Outcomes Registry—also rooted in the pursuit of value-based care—has integrated measures like PROMIS. They allow the Registry to develop quality measures that demonstrate value to the patient and multiple types of clinicians, as well as across episodes and provider types.
Wide-scale integration of global measures in electronic medical records has been implemented at major medical systems such as the University of Utah and University of Rochester. PROMIS also is available as an iPad app for users with less technical support or in a private practice setting who want to use computer-adaptive tests rather than long or short forms.
This places highly accurate, state-of-the-art assessment of over 300 health domains at the fingertips of clinicians working in both small practices and large-scale health systems. Patients and providers can easily understand and apply the scores to their clinical decision making. The health care ecosystem is ready to respond to new health care challenges based not on process outcomes but on the voice of patients who are seeking improved overall health.
Jeff Houck is director of research in the physical therapy program at George Fox University.
It's Not About Going and Leaving, It's About Leaving Something Behind
PTs, PTAs, and Students Transforming Society Beyond Borders
To fulfill the APTA mission of "building a community that advances the profession of physical therapy to improve the health of society," said APTA President Sharon Dunn, PT, PhD, at her APTA House of Delegates Presidential Address, the physical therapy community "must get involved—with open arms and open minds—not only as a community, but as individuals."
For quite a few physical therapists (PTs), physical therapist assistants, and students, this responsibility takes the form of global service. APTA recently partnered with Move Together, a nonprofit organization founded by members Efosa Guobadia, PT, DPT, and Josh D'Angelo, PT, DPT, to establish a physical therapy clinic in San Pedro Sacatepequez, a rural town in Guatemala.
APTA staff members Amelia Sullivan and Katy Neas participated in this effort, seeing firsthand how service, in partnership with local communities, can leave a lasting, tangible impact on people's lives. "The contribution of this profession to people's health and well-being is profound, and if we can leverage the strength and capacity we have in the United States to help build the capacity and partner with other communities that don't have the same level of resources, that's an honor and an obligation," says Neas. "People have every right to live without pain."
In addition to helping with construction, Sullivan and Neas interviewed Move Together patients and team members about their experiences and observations. These are their stories.
PTs as Partners
"Something I have loved about [Move Together] projects is that we invite the community to build with us," said Stephanie Irwin, PT, DPT. "This is yours. This is your space. We are not just coming in and [building clinics], we're partnering with local students, local clinicians, and asking them, ‘What are you struggling with? What do you see? What do you know?' We're learning from each other."
Maddie Patterson, PTA, told APTA, "I came on this trip because I'm really interested in how to set up physical therapy clinics in other countries, and how to create sustainable physical therapist practice in another country. I'm hoping to…equip [the local community] with the tools and knowledge they need to continue on when we're gone."
The partnership extends to individual patients as well. April Fajardo, PT, DPT, has participated in multiple Move Together projects in Guatemala. "What keeps bringing me back," said Fajardo, "is the relationships" she's built with the Move Together team, the local Guatemalan physical therapists, and the Guatemalan community—"all working together toward a unified purpose of increasing access to rehabilitative medicine." Fajardo hopes the people of San Pedro Sacatepequez "will take ownership of the clinic as their own."
A Tangible Impact
Irwin has seen the effect of previous Move Together projects. Getting ready to build the new clinic, she said, "I see the potential of what can be…. With the models we have developed, the people we are partnering with, and the municipalities, what we begin to create tomorrow is just the beginning to growing a lasting impact on the community."
In the clinics Move Together built in San Pedro Sacatepequez and Villa Nueva, PTs saw patients with a variety of conditions, from multiple sclerosis to pain after surgery. One patient, Adele, began coming to the clinic after a wrist surgery and improperly positioned cast left her with nerve damage and pain in her elbow and fingers. She said, through an interpreter, her fingers "were like wood," and she experienced tingling in her hand and arm. She had extremely limited mobility and pain from her shoulder to her fingers and couldn't wash dishes, dress herself, or perform other daily activities without help. Her PT in Villa Nueva has worked to increase her range of motion, increase her grip and arm strength, and recover her ability to pick up paper or a small ball.
Projects like this not only improve the health of the community; they also improve the local economy and provide jobs for PTs. Ismael Ubaldo Uz Gutierrez, architect of the San Pedro Sacatepequez clinic, said, "To have a space for physical therapy would be a great benefit for the community. There are a few places in the municipality for physical therapy, but it costs a lot. We are going to receive…an economic benefit as well, not just from therapy, because we don't have to pay money. It's going to help us in other ways."
Ariana Paz, a physical therapy and occupational therapy student in Guatemala, is one example. Three years ago, she told APTA, her mother had a spinal cord injury and lost the use of her legs. That inspired her to help people like her mother and to help her mom improve her life and her movement.
Increasing Access to Care
Jorge Medida, who teaches English for the municipality of Villa Nueva, said, "Helping with translation, I have seen a lot of patients; for example, children who were injured playing soccer. If they don't get proper treatment, their careers might be in danger. I see people getting to do what they want to do, living fuller lives, by getting [physical therapist] treatment."
"I have also seen a lot of older people [with issues like] diabetes or other issues that require physical therapy. So I've seen a lot of improvement there. People who regularly come to these clinics—of course there is improvement," he said, but also hope for people who otherwise wouldn't have access to physical therapy.
Several of the PTs who traveled to Guatemala with Move Together described their commitment to improving unequal access to health care, both at home and abroad. Much of "access" to health care is "structural," Guobadia told Sullivan. "It's not about going and leaving, it's about leaving something behind."
Gabi Borin, PT, DPT, who is originally from Brazil, said that "knowing that in Guatemala there are excellent physical therapists and students with a great passion to learn and provide the best care for their patients encourages us to continue to build connections with people in many other countries. I hope that this experience helps me to continue promoting changes to the lives of those who need the most, trying to build together a world with less inequalities."
Service Starts at Home
Service does not need to be global to change the world. The "best place to start is where you are," said Irwin. "Look to understand the needs in your community, or partner with local organizations."
Guobadia wholeheartedly agrees. One aspect of APTA's vision and mission, he said, is to "change communities, at the local level, the national level, and also the global level."
"I'm a strong believer that a strong profession around the world is a strong profession at home," Guobadia said. "And a strong profession at home is a strong profession around the world."
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.
Teachable Moments
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.