APTA Delegate 101

With my new pal Jenny Jordan

I was watching Gilmore Girls re-runs one evening in November 2021 when an email notification popped up on my screen from Dr. Jenny Jordan, Physical Therapist, Professor in the Eastern Washington University PT Program, former Chief and current Delegate for APTA (American Physical Therapy Association) Washington, and - I would soon learn - incredible human being. Jenny's email asked if I would be willing to discuss an appointment to a one-year term as an Alternate Delegate representing APTA Washington.  

With my long-time pal, Maryclaire Capetta

I've been an APTA member since starting PT School in 2011, but despite how much money I've spent on membership, at the time of Jenny's message, I really couldn't explain what the APTA did. I joined as a student when it was compulsory, and I maintained membership because it discounted board certification and allowed me networking opportunities that I occasionally took advantage of.  Also, it felt like it was the right thing to do, supporting the leaders of my profession.  I knew that Delegates existed and that they worked on making changes that impact the physical therapy profession from a nation-wide perspective, but I had never given any thought to being a representative myself.  One of my Professors in PT School, Maryclaire Capetta, now a long-time friend, has been a Delegate in Connecticut for many years. She took me to a Delegation event at CSM in Chicago in 2012, which was my first glance at the politics of PT.  Over my eigght years attending PT Pub Night events living in Seattle, I've gotten to know several of our local Delegates including some who are good friends. All of this to say - I knew Delegates existed.  I did not know how they came to be in their role, what they did, or why I would ever want to be one.

We set up a time to chat and Jenny explained the responsibilities and the time commitment and asked if I wanted to join for a one-year term. Washington had enough elected Delegates to serve two-year terms, but because our group is pretty large, if the time came to vote and someone wasn't available, we needed to have alternates to step in. Our Alternate Delegates participate in all the regular meetings along with the rest of the Delegation and contribute to the discussions and can work on developing policies, but they do not have the ability to vote unless an elected Delegate is unavailable.  The usual process to be chosen for the Alternate Delegate spots is to be the next highest vote getter on the ballot after the votes are counted. Unfortunately, there weren't enough names on the ballot for the 2022 cycle to fill the Alternate slots. I said yes, and after one year of a much deeper dive into what the APTA does, how new policies are formed, and learning about the problems the Association and the Profession faces, I'm here to share some of that with you.

First and foremost, I want to be very clear: I’m really new at this and there are many others who have been working in leadership roles for far longer who know much more about the APTA.  I was just recently elected into a two-year term as a Delegate for the 2023 and 2024 House of Delegates Cycles and have only attended one House of Delegates meeting so far. This is my understanding of things and my experience- it’s true to the best of my knowledge.  If I'm wrong, for sure someone should tell me!  

Let’s talk about Delegations first.

I've come to understand the Delegation to be a little like the US Congress, but instead of two separate chambers, ours are combined.  In US politics, there’s the Senate with two Senators from each state, and the House of Representatives, with number of representatives based on population of the state. In the APTA, all the Academies/Sections (think specialty areas of practice: acute care, pediatrics, geriatrics, orthopedics, etc) have two votes, and the Chapters (each state and Washington DC) have representatives based on the number of APTA members in that state.  Link to see full apportionment list by state, but here's a tiny snapshot of the top of the list:

Just like in American politics, states with more members have a bigger impact on the direction of the profession. States also have Alternates, which was my role, which are included in all the regular meetings, but don’t vote unless one of the elected delegates isn’t available. According to this document, there were 73,525 members in the APTA as of July 2021. This includes professional Physical Therapists and Physical Therapist Assistants, but not our student members, which push our total membership closer to 100,000. I was curious, so I looked for comparisons from other large medical associations and found that the American Medical Association has about 250,000 members, the American Dental Association has about 160,000 members, and AOTA, the American Occupational Therapy Association, lists about 65,000 members. 

Delegates meet with their Delegations throughout the year, led by their Chiefs. Regionally, Chiefs gather at regular intervals to discuss what’s happening across the country and what groups are working on at their local levels. The whole group meets annually at the House of Delegates, led by a Speaker of the House. The purposes of the House of Delegates meetings are 1) to elect new officers to the Board for the APTA, 2) to debate and vote on motions to move the profession forward, 3) for the elected leaders of the Association to have opportunities to meet, network, recognize individuals who have done impactful work, and 4) learn about different topics related to leadership.  This year, House of Delegates was embedded into an entire Leadership Conference, including many students as well as the Delegates. If you want to find out who your Delegates are, you can search the rosters here. 

I've said Delegates too many times already...  So how about some of the work they're doing? How does a motion come to be?  In January, the elected representatives from Washington met for our regularly scheduled monthly meeting to brainstorm ideas for work that we would like to see done by the Association.  We came up with several possible ideas and broke off into smaller groups to do some early research on the topics, come up with basic rationale for why we felt the concepts were important, and then expand the concepts into more detail at subsequent meetings.  The group voted on each idea, deciding which ones we wanted to dedicate our time and effort to, and which ones did not seem to be optimal for continued work.  This year, Washington presented three motion concepts to the House of Delegates and members of our group spent about six months working on them. 

An important piece of motion development is collaboration with other Academies or Chapters.  Consider that priorities around the country differ, payment models are not the same state by state, challenges to patient care practices differ depending on the Academies and variation between settings.  So early on, we identified potential groups that might be helpful as co-makers to the motions, helping to develop statements in support, who would likely want to pursue the same outcomes.  For our three motions, we collaborated with three different Chapters and one Academy as co-makers.  I primarily worked on RC 16-22, APTA as an LGBTQIA+ inclusive organization in collaboration with the Academy of Leadership and Innovation and PT Proud, which ultimately passed by over 90% vote.  

There's a whole process that the Chief facilitates to take the motions and escalate them up the chain of the APTA to be reviewed by a Reference Committee (which I think makes sure we're not going to violate any of our own previous rules and regulations or any laws, and gives input on the language being used) as well as sharing the motions with the rest of the country's delegates for feedback and discussion.  Washington's Chief, Murray Maitland, had to do a lot of work to get our three motions reviewed and heard on the floor. Over time, updated versions are developed and the content and language can change until the minute it is debated on the floor of the House and voted on.  

This year the House had 22 motions up for debate, but did not end up completing the whole list, running out of time.  The whole operation follows Roberts Rules and Parliamentary Procedure and stays on time with an agenda - which can be amended - but which this year's delegation voted not to amend to increase the time.  It was really unfortunate because there are some really important issues that were waiting to be voted upon.  I pretty much live-tweeted the House of Delegates so you can find a barrage of my tweets from August 14th and 15th from me sharing how things were progressing as we worked through debate and voting.  

I could probably write a small book about my experience at the House of Delegates, but since I will

 Bringing RC 16-22 to the floor for vote

now have two more to attend in the future, I think I'll save those for another day.  It was incredibly exciting working on an important motion that will hopefully improve Diversity, Equity, and Inclusion in our profession.  It was amazing meeting the physical therapists who have worked so hard to shape our profession for many years - and who the leaders of tomorrow might be.  I hope this is helpful to anyone who is considering APTA membership. Know that your state IS impacted by your membership and that a small group of new members could influence how many delegates your local group has to vote on issues in the future.  I also hope that it helps more people to understand what APTA Delegates do - so if you have an issue, APTA member or not, find your local Delegates and share your concerns so they can try to help.  Feel free to reach out to me if you're looking for ways to get involved!

AASPT Traveling Fellowship

Fellows @ Cincinnati Football

Long before sunrise on the morning of Thursday, September 12, 2019, I boarded a sleepy airplane lightly coated in the typical Pacific Northwest mist heading towards a career-enhancing expedition.  After a brief pit stop in Denver, I continued on to Cincinnati airport, weirdly located across the Ohio River in Northern Kentucky.  Upon arrival at the CVG baggage claim I met two physical therapists who I would spend the next eleven days learning and observing various topics related to sports physical therapy. Rebecca Troulliet from North Oaks Health System in Louisiana and Patrick Barber from University of Rochester in New York joined me for the American Academy of Sports Physical Therapy (AASPT, formerly known as the Sports Section) Traveling Fellowship.  Sponsored by Kevin Wilk, LightForce and DJO Global/DonJoy. We spent about three days each at University of Cincinnati, Mayo Clinic locations in Minneapolis and Rochester, Minnesota, and The Ohio State University. 

What does it mean to be a Fellow?  According to Wikipedia, "a fellowship is a group of people who work together to pursue mutual knowledge or practice."  Though each of us had individual purposes for participation, we are all physical therapists working with athletes and we were all looking for growth in our careers.  Through observation and lecture attendance with more seasoned clinicians, we had exposure to different techniques and clinical approaches than our usual day-to-day experiences.  Now that I've returned to my usual swing of things and seeing my patients at Seattle Children's Hospital, I'm taking this opportunity to reflect on the experience and share why I chose to pursue this Fellowship along with some highlights from our trip. 

First: Why did I want to complete a Fellowship?
In May 2014, when I was completing PT School at the University of Connecticut, my career aspirations were to serve as a team physical therapist in the WNBA.  I had previously worked in a non-medical capacity for the Connecticut Sun for four seasons, but elevating to this new type of position as a new grad PT didn't seem remotely feasible.  Beyond the fact that I was a new clinician,  WNBA teams didn't have physical therapists, then, so this goal seemed unrealistic. (Most teams still don't, which I wrote about here)  I thought my fastest route to working with professional female athletes was to advance my education from PT School through a Sports PT Residency Program. In 2014 there were about twenty of those programs nation-wide, mostly offering one or two slots. I applied to three, including Ohio State, but was not successful in securing a position.  Now there are almost fifty SCS Residency programs with so many more opportunities nationwide! To search Residency programs in any PT Specialty area, click here.

Fortunately, physical therapists have an alternative route to obtaining board certification and specialization in sports physical therapy that does not require participation in a residency program.  You can find the requirements to do so here. As I pursued the alternative route, I also landed a role with the Seattle Storm, and in March 2019 completed my Board Certification Exam.  In our cohort, Pat also took his exam in March following completion of the University of Rochester Residency program and Becca is currently working through the alternative route requirements to specialize in the future.  So because I did not complete a residency program but did pursue specialization, I felt like I lacked some of the mentorship and on-field hours that a residency would have provided, and this fellowship filled some of that gap.  

Second: What was the Fellowship like? 
Each location was very different from the others which helped us gain a broad spectrum of the possible roles and responsibilities for a sports physical therapist.  

Fellows and PT staff @Cincinnati

At the University of Cincinnati, we were hosted by Bob Mangine and Tim Machan and primarily spent our time in their athletic training room with them and on the sideline.  We had the chance to watch game-time coverage, led by Head Athletic Trainer Aaron Himmler and had a sit-down discussion with their concussion program and vision training expert, neuroscientist Dr. Joe Clark. We attended lectures on a variety of topics by members of their staff including wearable technology, use of the ACL-Return to Sport Index Outcome Measure, Neuroplasticity, Prevention of Catastrophic Injuries, and and we each presented our own lectures. My presentation examined the Impact of Fear Avoidance on Return to Sport, Becca discussed Sudden Cardiac Death and Pat outlined Upper Extremity Return to Sport Tests.  

With Timberwolves Robby Sikka and Matt Duhamel

After exploring Cincinnati, the three of us packed our bags to head to Minneapolis for the first half of our visit to the Mayo Clinic.  Our host in Minnesota was Corey Kunzer who is the coordinator of the Mayo Residency program.  The clinic in Minneapolis serves the community as well as having partnerships with the Minnesota Lynx (WNBA), Minnesota Timberwolves (NBA),  and Minnesota Twins (MLB).  Only days before our arrival, the Seattle Storm had knocked the Lynx out of the WNBA playoffs so I felt a little like I was in enemy territory, but I was glad to finally meet Emily Beyer, Lynx Team Physical Therapist as well as Matt Duhamel, Team Physical Therapist/Director of Athletic Therapy for the Timberwolves and Jeff Lahti, PT for the Twins.  We also met Robby Sikka, Timberwolves VP of Basketball Performance and Technology who uses wearable technology with the basketball players to improve their on-court performance.  Their basketball facilities are fantastic and, according to their staff is considered to be the best training site in the NBA. They have practice basketball courts with athletic training rooms and locker rooms for the teams right next to the medical clinics where they have physical therapists, orthopedic surgeons, physicians, athletic trainers, and other specialties who can thoroughly care for the athletes alongside the general public.  Can you imagine being at your PT session and rehabbing alongside (Lynx superstar) Sylvia Fowles or  (Timberwolf and UConn great) Shabazz Napier?! The Mayo providers collaborate with the team providers in their biomechanics lab which includes force plates and multiple angles of cameras for jump-testing and movement assessment as well as for recommendations for optimal care.  It was a really interesting arrangement for sports medicine for all levels of athlete.

Diagnostic Imaging with Dr. Jay Smith @ Mayo

Then we drove down to Rochester, MN, home of the original Mayo Clinic.  Founded in 1889, the Mayo Clinic is basically the entire town of Rochester and the area is spotted with old historical buildings that contain the most beautiful old libraries and intricate marble ceilings that tell the history of medicine in the US along with more contemporary constructions housing the huge variety of specialties that the Mayo Clinic houses.   We learned about Diagnostic Ultrasound from expert Dr. Jay Smith were taken to the Mayo Clinic Biomechanics lab which houses the machine used by Dr. Tim Hewett to extensively study ACL injury, and participated in a golf biomechanics lab.

Coach Tamika (Williams) Jeter @ OSU

After Minnesota we headed to Columbus, Ohio, home of The Ohio State University Buckeyes.  Our host, John Dewitt took us on a tour of their athletics and training facilities where I ran into former UConn and Connecticut Sun basketball player Tamika Williams for a quick reunion.  We attended a discussion on articular cartilage surgical procedures presented by Caroline Brunst and a lecture presented by Dr. Ken Yeager on Building Resiliency observed the nationally recognized Ohio State Marching Band rehearse, attended the marching band Skull Session pep rally and another football game.  We had the chance to meet many of the Ohio State Physical Therapy Residents studying in a wide variety of specialties including performing arts, oncology, sports, orthopedics, women's health, and neurology.  And I got to see some of my Ohio family living nearby, which was the cherry on top of a really awesome collection of learning experiences.

Fellows with John DeWitt @The Ohio State University

I can't recommend this Fellowship highly enough, and would be happy to connect with anyone considering application for future participation.  I'm sure that if you asked Pat and Becca, they would select different portions of our trip as their highlights or what was most impactful based on the differences between our patient populations and professional goals, but I'm so glad I was able to share this impactful experience with them.  Thank you so much, American Academy of Sports Physical Therapy for this opportunity!

Physical Therapist Board Certification

On a dreary morning in March 2019, shortly after we lost an hour for daylight savings and my internal clock was thrown for a disastrous loop like it does every half-year, I turned off my three alarm clocks which were completely unnecessary because I hadn't slept a wink, crawled out of bed, and drove over to a ProMetrics testing center near my house to complete the Sports Certified Specialist Physical Therapist exam.  I had my photo identification, my registration paperwork, and a list of test day reminders: make sure you remove all jewelry before going through the metal detector, be prepared to pull up your shirt and pants sleeves and have your ears checked, bring water and snacks because your exam is seven hours long but you can have a break in the middle, and a bathroom will be available.

Now, here we are almost the end of June 2019, more than four months later, and today I received the results - I passed my test!  I was walking out of basketball practice with the Storm when I glanced at my phone and saw the email with this report.  Without the Storm, I would not have met the criteria to even take this exam, because you need sideline coverage hours in a contact sport, and lots of them.  I'm so grateful for them.  Per the rules of the examination and ProMetrics, I won't go into any details on the actual content of this test, but I wanted to discuss the preparations I used and what advanced certification as a physical therapist even means.  Fortunately, I wrote many of these thoughts in March, because there's no way I would have remembered them now!  But I couldn't get myself to share it, in case I hadn't actually passed the test!

What does it mean to be a Board Certified Physical Therapist?  Right now, if you go to PT school in the USA, you're going to graduate as a DPT - Doctor of Physical Therapy - but you are a generalist.  You've learned the basics of physical therapy for all the areas of specialty that a physical therapist can work in and you took a big, terrible test that shows you are competent to practice physical therapy.  That test would cover all the different areas of practice and is very broad, covering a lot of topics.  After graduation, a new grad physical therapist will get a job and, with or without intention - begin to specialize.  To some extent, your job may dictate your specialty because that's the area of practice you're going to focus learning about moving forward.   The beauty of this is that you're able to change the area of specialty by working in different settings and pursuing alternative continuing education, but it also means that when we first come out of school - or if we change work settings - we're not very experienced in that care area early on.

When I first graduated, I worked at an adult orthopedic clinic while picking up shifts in a skilled nursing facility.  I focused my learning on orthopedics because it was my interest, but I had to learn the basics of the rehabilitation center because the needs of those patients were different.  Another example - if you came into the rehab gym at Seattle Children's where I work, you would see physical therapists working with children who have developmental conditions, which looks entirely different from what the sports physical therapists, like me are doing.  We're working side by side, all physical therapists, doing entirely different things from the same generalist education. I'm in awe of their work every day... and it's so different!

In some ways, the pathway of a physical therapist mirrors how a physician (MD) completes their schooling.  Any doctor you have seen - your primary care or specialist - went to medical school and graduated as a generalist.  However they can't practice medicine that way.  They are required to continue on their education pathway into a residency, determined by an intense matching program that I'm incredibly thankful I did not have to endure. They will be matched into the field they will pursue and specialize in, like emergency medicine, cardiology, orthopedics, family medicine... that list is super long.  And then, after another several years of working in their specialty while learning on the job, they become a specialized physician and can practice in their field.  But they don't have the wiggle room to wake up in the morning and say - I don't like being a heart doctor anymore, so I'm going to study diabetes and be a doctor for that.  They're a bit more restricted in their careers.

I have read articles recommending that physical therapy transition into the medical school model, requiring residencies to specialize.  This is an option now, but it is not required.  A physical therapist currently has the option to specialize in nine different areas, and this can be done by either completing a residency program and taking a big test, or by meeting a list of requirements and taking the same big test.  This is the test I took earlier this year and have been tortured into waiting four months to get my results. The residency program is meant to give you the hands-on experience and focused training needed to pass the test, but you're able to test without the residency and achieve the same end-goal if you meet specified criteria.

In early 2014 I had applied for residencies in Sports Physical Therapy.  I wanted to work in sports and having had years of experience working with women's basketball and a shortage of physical therapists working with the WNBA, I felt this was the direction I needed to go in.  At the time, I think there were fifteen programs, but only three had options that were not soccer (none had options specific to women's sports) - and those were the programs I decided to apply to.  (No offense soccer, but I'm a fair weather sports girl.  I'll support the USWNT all day long and cheer and attend games when the sun is shining, but a year of sideline coverage in the rain was NOT on my To-Do list.)  And so - I applied to University of Southern California, Ohio State University, and Duke University.  (It would have killed my Husky Heart to be a Blue Devil a little bit, though the education would have been superb at all three institutions).  Needless to say, I was not selected for one of the few slots available, a very sad failure, but a few months later I managed to secure a spot in the WNBA without it, so I took the alternative route. 

The options for physical therapist specialist certification right now are: Cardiovascular/Pulmonary, Clinical Electrophysiology, Geriatrics, Neurology, Oncology, Orthopaedics, Pediatrics, Sports, Wound Management, and Women's Health.  The list of accredited residency programs is here for all the specialties.  A recent presentation I watched discussed focus on making a new specialty for Pain, which has not yet been established, but that seems like an interesting approach to try to advance the use of physical therapists in treating people with persisting pain. Since I've previously written about pain on many occasions, and I work with the Seattle Children's Chronic Pain Team, I'm excited to see if that will be specialty number ten.

A little about preparing for the exam:

The application deadline for the Sports specialty was July 31, 2018 to test in March 2019.  These dates have been consistent annually with all the specialties having application deadlines sometime in July the previous year for a March test date.  That means that if you want to take the test in 2020, you have 1 month to apply - or even less! The application process is pretty complicated for some of the specialties if you haven't completed a residency, so I advise you check it out soon.  All the information you could ever need is right here.

So, once you've applied, the American Board of Physical Therapy Specialties (ABPTS) reviews your qualifications to determine if you're eligible to take the test in your requested area.  That takes about 6 weeks.  I started studying when I applied, but I know others waited to make sure they could even take their exam.  Here's a look at how I prepared.

First, I gathered a bunch of materials to help me determine what content I needed to study.

The materials I used were:
1) The SCS Prep Course from MedBridge Education which has a nice table of contents covering all the content areas on the exam.  They have prep programs specific to many of the specialty areas.
2) I googled "SCS Residency Program Curriculum" on Google.  There are many, but I used this one which outlined a lot of the content topics.
3) I purchased "PT Sports Questions" by Matthew P. Brancaleone PT, DPT, SCS AT, CSCS" a question/answer book off Amazon for $35.
4) I already have my CSCS (Certified Strength and Conditioning Specialist) and the book "Essentials of Strength Training and Conditioning" and the study guide I made when preparing for that test.
5) I borrowed "The Fundamentals of Athletic Training" book from my boss
6) I found my course materials from the Emergency Management Course I took at REI which was a required pre-requisite to take the exam.
7) I borrowed the Manual of Structural Kinesiology from the Seattle Children's Inter Library Loan System for a review of anatomy and biomechanics basics, particularly with regard to the mechanics of the shoulder, and review of throwing motions and gait cycle.  My test was two weeks before giving this presentation at Seattle Children's so I was preparing for both at the same time.
8) Per the recommendations of the curriculum in #2, I secured copies of the National Athletic Training Association Position Statements, all of which are free here as well as many of their consensus statements and several of the APTA Clinical Practice Guidelines here.  The highlight of reading those was seeing how many of my UConn mentors were authors of them, including Lindsay DiStefano, Doug Casa, and Robert Huggins.  Man UConn puts out some amazing stuff!
9) Lastly, and probably most importantly, the Description of Specialty Practice (DSP) for my exam.  The APTA has a breakdown for each exam listing the material that would be covered on it. If you're approved to take the test, they send it to you as part of your application fee.  Or you can buy it before you apply.

Second, I took a practice test.  Right from the start.  The MedBridge Prep Course offered several practice exams that were shorter in duration than the actual test and covered a wide variety of topics.  Based on the results of my first practice test, where some of my outcomes were abysmal, I knew how to prioritize things.

Third, with my current skills clearly identified, and more importantly, my biggest weaknesses, I looked at this ginormous pile of stuff to read and the ~80 hours of online MedBridge videos available, and, I made a study schedule.  This is the same approach I took when studying for the PT licensing exam, so I was optimistic it could be successful again. I tried to cluster things together in a sensible way.  For example, when I read the chapter in the Athletic Training book about weather-related injuries like heat stroke or how to deal with lightning, I also read the NATA position statements related to the chapter, and then watched the Medbridge Video on that same topic.While I was studying the weather-related injuries, two quotes stuck out to me that I had saved for this post  With regard to cold-related illness: "Nobody is dead until they are warm and dead."  So, if you find someone buried in the snow, they're not dead until their body has been warmed up.  And with regard to lightning injuries, "In the contest between people and lightning, lightning always wins." So I got the repetitions for a topics and kept notes on things that I was unfamiliar with or wanted to come back to after I had gone through everything once.  Repetition is helpful for me, but also sometimes felt like I was beating a dead horse by the end of some of the longer (or less interesting) topics.

And then I took my test.  I'll be honest - I was behind on my schedule pretty much from the second week, but I just kept plugging along.  I had an excellent student in the clinic, who I wrote about here and here, and who was treating about half of my case load for several weeks leading up to the test, allowing me more time to devote to reading papers and studying.  I read A LOT of the materials listed above, but found some of it to be too inapplicable to the patient care I typically do, that I decided it was worth leaving out some chapters despite the risk of doing so.  I watched almost every single Medbridge course that was listed in their prep program, several just listening while I was driving, including most of the optional ones.  I was stuck on the Brooklyn Bridge for over an hour in traffic and watched an entire course on nutrition in that time.  And I was certain that I did not pass.  Today's news that I passed was super exciting.  Hopefully writing up my preparations will help someone else on their road to board certification.

Show Me the Money!

I really love being a physical therapist.  It's funny to say that now, because I didn't know this was the right career path for me.  I never said I wanted to be a PT when I was growing up.  I applied to the PT program at UConn as an undergraduate - but was also considering several other options.  When I was accepted, I set up a meeting with the program director and the dean and was told that I could not continue my role as a manager for the UConn Women's Basketball Team if I wanted to be in the PT program - the two were just not compatible.  I withdrew from the PT program.  #BasketballIsLife

Anyways, a few years later, I was again at a cross roads.  My basketball life was going in a direction that didn't really fit me and I felt like I was meant to do more for the athletes than travel arrangements and video taping practices.  There's nothing wrong with those jobs - some people love doing that - it just wasn't what I was meant to do.  So I applied to PT School again.  Got accepted again.  And back to UConn I went.  I didn't know it was the best career decision for me until I started my job at Seattle Children's Hospital.  Now I'm certain it was the right path.  Despite the cost. 

Free photo 3643050 © Melissa Evanko - Dreamstime.com

I work in an office with a lot of younger clinicians balanced by a few more experienced ones who share their experiences and wisdom generously.  Those more experienced clinicians, however, do not typically share the same burden of student loan debt that many of the rest of us face.  I've briefly discussed my student loan payment approach here where I celebrated my achievement of getting my student loan balance under $100,000 from my starting balance around $124,000.  In that November 2018 post, I talked about some of Dave Ramsey's principles that I had applied to my payment plan to try to move the balance down.  That post was six months ago.  I'm currently sitting at a balance of $86,500, and, thanks to Facebook, I recently learned about Fitbux.  

If you're a new graduate physical therapist - I'm going to 100% recommend you reach out to them as soon as you know how much your total debt looks like from school.  You may have accumulated your loans at a much higher rate than you can get by making a change.  I waited almost five years to do this - who knows how much more money I could have saved if I did it sooner.  If  you're not yet done with school or you've been out for a bit longer, I'll also recommend you connect with them, just to see if they have any recommendations.  It only takes 30 minutes.  Here's how it works:

Fitbux is a company run by Joseph Reinke, a CPA (certified public accountant)- who actually was the one that posted a comment on Facebook in response to questions about mountains of student loan debt- and whose wife is a physical therapist.  They've combined their finance knowledge with their knowledge of physical therapy income and high student loan debt and created this company.  Fitbux offers FREE CONSULTATIONS to anyone (physical therapist or other careers) to assess their student loans to make recommendations on payment plans, approach for payment, consolidation, refinancing, and - I'm sure - many other things, though I don't know finance so I probably don't understand those.  

Until now, I had been doing a pretty good job of paying off my student loans and making a dent in them, but I still felt like it was a huge burden and had hoped something could make this a little better.  I had asked my own accountant about recommendations regarding consolidation and refinancing in the past and was advised not to do either.  Perhaps those were the best choices at the time, but my consultation with FitBux showed me that I could lower my average interest rate from 6.73% to a fixed loan at 3.75%.  My FitBux consultant calculated that I could now be done in five years and pay at least $8,000 less than the plan I was previously on.   They even found me a loan company that offers a bigger discount in interest rate to APTA Members! Yes, I'm paying a little bit more money per month than I was previously committed to in order to get that low interest rate, but we're talking a 3% decrease!  If I keep making extra payments like I had been - I could be done even sooner!

I'll repeat here that I'm not advising anyone to refinance or make financial changes without some professional advice.  They explained a lot of things to me that I thought I understood - but now understand much better.  I will advise everyone to take these free consultations.  FitBux explained to me that they get paid if you choose to refinance through one of the companies they point you to - and there are many options.  So, since they advised me to check what rates I would be eligible for through one of the companies they work with, and I then had this new company buy my loans for a new rate - FitBux will get a kick back from this arrangement.  The loan companies pay them so we can have this free service and I didn't have to commit to anything - but FitBux supported me through the entire transition of my loans.  FitBux also offers a tracker that you can purchase which will track your student loan payments to make sure they're being applied to your loans in the way in which you intend them to be paid.  So that's how they can offer this service for free.  

And who doesn't like free stuff?  Check it out.  Worst case scenario - you're already in the best student loan debt situation you can find yourself in and nothing changes.  Best case scenario - you save a boat load of money!

National Physical Therapy Month

October is National Physical Therapy Month!  Wahoo!!!  A whole month to celebrate physical therapists - which means celebrating so many of my friends, my coworkers, the providers who keep me moving when I need some physical help, and my old pals from UConn Physical Therapy!  If you're currently seeing a physical therapist for care, wish them a Happy PT Month!

I frequently get asked about what PTs do. The cool thing is that we can do so many things!  PT school is a little bit like medical school in that when you finish, you're a generalist and basically know enough to not hurt people (hopefully)... while you then continue your education to specialize.  The big difference is that PTs don't (yet) have to complete residencies and fellowships for our specialties - we learn them in our choices of clinical affiliations towards the end of school and then we further learn our practice on the job.  Physicians go into many years of residency to specifically learn the specialty they will practice.  

The current specialties for physical therapists - in which you can become board certified - are: cardiovascular/pulmonary, clinical electrophysiology, oncology, women's health, geriatrics, neurology, orthopedics, pediatrics, and sports.  But this is just areas we can choose to further our knowledge in, take a test, and then get some fancy letters after our names.  (Don't get me wrong, I'm working towards this and think this is great - I'm just pointing out that this is only the start of things PTs can do).  

Physical therapists are considered to be the musculoskeletal experts.  We help people optimize their functional mobility - whether that be rehabilitative (trying to gain a function they used to have but somehow lost) or habilitative (acquiring a new function they haven't previously had). This could include treatment for patients with burns and wounds, care for children born with developmental or congenital conditions, adults who have had a heart attack and are regaining their endurance, children who need help at school... so many things!  We can work in clinics, hospitals, sports venues, athletic training rooms, large corporations, nursing homes, schools, in people's homes, at a horse barn!, in a gym or fitness center, in a doctor's office, in the emergency department.  We can work with old or young people, males and females and those who do not identify with either of those, people who just had surgery or who are trying to prevent it, people with all different sorts of pain, and more!

The best part is - we don't really have to choose just one patient population or one location to work, either!  Personally, I only work as a Sports/Orthopedic Physical Therapist.  My full time job is at Seattle Children's Hospital's North Outpatient Clinic and I treat children between ages 5-21 with sports or musculoskeletal injuries.  The most common conditions I treat there are people with knee pain or who had a knee surgery, ankle sprains, broken arms, and back pain - though I also work with children who have been experiencing chronic pain, concussion symptoms, neck pain, and many other conditions.  The ways these kids get hurt varies considerably, too!  On the side of treating patients, I also participate in research projects around the conditions I'm working with, which helps me learn.  When I'm not at Children's, I also treat athletes in the athletic training room or at the basketball arena as well as at a dance studio.  I get to work in three different settings and find that to be cool  In the past I have treated people in nursing homes - and that setting wasn't for me, but some physical therapists love doing that!  And, if I woke up tomorrow and decided I wanted to start working in a different setting, I could change my continuing education and learn more so that I could transition to a different area of work.

Why am I discussing this?  Well... first of all, because so many people just don't know what we do... and that's partially because we do so many different things based on the environment we're working in.  But also because I've previously written about "What Physical Therapists Do" and those were more from my perspective as a Sports Physical Therapist.  This is one of the recurring themes on my blog - and you can check out "What Do Physical Therapists Do? Installment #1: We Look at Mechanics, here.  Or #2: We Listen. here.  And the third installment: "We Strength Train" here.  But truthfully - we do so much more!

One of the big initiatives the American Physical Therapy Association has been working on is fighting the opioid epidemic in the United States.  This is a target because physical therapists help patients who are experiencing pain to get back to a more functional life. Often times, people experiencing pain use medication to try to get rid of the pain... but pain is a symptom!  Medication can sometimes attack the cause of the underlying problem, but oftentimes - it will only mask the symptom, perpetuating the problem.  I've previously written about chronic pain several times: here, here, here, and here.  PTs are learning more and more about the science of how pain works and can help patients better understand pain so that they can move forward and back to their optimal level of function.

It should be said that not all physical therapists practice the same way.  This has made the general perception of what we do cloudy for many people.  At the end of the day, what should matter most is that you're feeling better and doing more of your favorite activities.  Here are a few things you should consider if you are currently going to physical therapy:

1) Your physical therapist should not be hurting you!  Now - if you just had surgery last week, and we're guiding you with some gentle movement, you may feel some discomfort... but you should only be working within your tolerance and if it's really painful, the PT should stop.  If you don't exercise often and you're starting PT and moving in new ways - your muscles may feel some soreness.  But again, this should remain within your comfort level.  Think about the last time you were having pain.  You tighten up and definitely can't relax. What good is it doing to fight through that?  I can't say this enough... treatment should not be painful.  Nobody should feel like they're receiving torture when they come to PT.  Physical therapy is not the place for cliches like "No pain, No gain." Period.  

2) Your physical therapy treatments should be specifically made to address your issues and goals.  If your goal is to walk without pain - and you're not doing any exercises that look like they're going to get you to your goal, you have the right to ask why you're doing the things you're doing.   Sometimes it's hard to tell how the path you're on may get you to the target destination.  But - in order to run, you must first be able to walk, and to walk, you must first be able to stand up.  When I'm working with patients, I'm breaking down the goal activities into components, and I can explain why I have chosen every single activity.  Healthcare providers should be encouraging their patients to ask questions and understand their own care.  They should also be educating patients/  

3) Physical therapy only works if a) the patient buys into the things the physical therapist is saying and b) the patient commits to doing the program.  You may only spend 1 hour per week with your PT.  That leaves you with a whole lot of time where you're not working with them - but should be working on things to improve yourself.  Take charge of your recovery.  Take charge of your own body! As a patient, it can be hard to understand medical conditions - and that's scary!  Your back hurts and someone you don't know is touching you and then telling you to move in weird ways... you have to feel comfortable and there needs to be a little bit of trust to be successful.  This is really difficult when patients have previously seen a different physical therapist and didn't get better.  Maybe it wasn't the right fit for you... give another PT a try and make sure they treat you differently than the last one.  

4) You have the right to "fire" your physical therapist.  At Seattle Children's, I often share the patients I'm treating with one other physical therapist.  There are pros and cons to sharing a patient - but my favorite pro is this: if you don't like me - see the other therapist!  My feelings won't be hurt... I just want you to get better!  I can promise you we won't do things exactly the same way.  The best way is the one you like most as the patient.  Sometimes I even recommend patients see one of my coworkers because I think they'll be a better fit.  I'm a female... sometimes young male patients just do better with a male physical therapist.  I'm very direct and tend to be pretty loud... sometimes the more shy kids need one of my more gentle or softer spoken coworkers.  Any PT who gets upset that you would prefer to see someone else isn't looking out for your best interests.   

5) If you feel like you've been going to PT for months and not making gains - you should see if you have a better outcome with another PT.  Don't give up hope!  I think - because health insurance often pays the bulk of the costs - and because people are having pain - they forget that their healthcare providers are PROVIDING SERVICES.  We only have jobs because patients find us to be helpful.  You wouldn't use a carpenter to fix your toilet instead of a plumber just because they both know how to use a wrench... don't settle for a physical therapist who isn't fitting your needs.  

Now that you know more about Physical Therapists, make sure you reach out to your favorite PT and let them know that you're celebrating them this October.  If you're experiencing pain or having trouble with one of your favorite activities - sports or otherwise - find a PT near you to get treatment.  Having trouble finding the right fit? I'm happy to help you find someone near you.  Reach out with questions.  And know that the biggest compliment you can ever give to a physical therapist is to send your friends or family members to see them.

Physical Therapist Continuing Education Requirements

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This past week I was on an airplane reading some journal articles included in Mike Reinold’s “Shoulder Seminar” when the gentleman sitting next to me asked if I was still in school. (Yay for still looking young enough to be a student!) We discussed our careers and he explained that he is a home health nurse in Indiana where he is not required to do any continuing education.  Seriously?

I immediately shot off an email to a good friend who is a home health nurse in NY, soon to be in WA, and asked if she had the same requirements.  She told me that in NY State she also has no requirement, which she thinks is because of the administrative burden so many providers doing continuing education would cause on the state health department. As she’s preparing to relocate, however, she knows her requirements will change. Despite not having a requirement, she noted that she has participated in continuing education- some independently and some offered through her job. I didn't ask the gentleman on the plane if he did education even though it wasn't required - because I didn't think I'd like his answer.

This got me wondering about the requirements for continuing education as a Physical Therapist.  I have had a license in Connecticut and currently practice in Washington so I knew they both had requirements (that happen to be fairly similar).  My PT School classmates from UCONN are practicing in New Hampshire, Massachusetts, Rhode Island, New York, Colorado, and Texas (plus me in Washington).  For a class of sixteen people, we've spread out far and wide to be in seven different states! We're about to hit the four year mark out of school and I remember my friend who works in acute care in NYC telling me that she had no requirements for the first three years, but now does.  Thinking back to the past three years, I've probably averaged more than 75 hours per year of continuing education, far more than what was required of me, and can't imagine what it would be like to have not done all that work. 

I wanted to look at each state's requirements and was surprised to find that the APTA website links you to each state's practice act from which you could search for your specific requirements.  It makes sense that this would be the most up-to-date way to get the desired information, but I expected the APTA to have an easier way to look at the information.  Fortunately, WebPT has published a state by state list found here and published in December 2017.   I found several alternative lists of continuing education requirements for physical therapists such as this one from 2005 which only listed 29 states as having  requirements. That was a study examining practitioner opinion and healthcare outcomes along with continuing education and may have had an impact on states developing requirements.

 That paper outlined the following results:

1) "Of respondents from states without mandatory CE, 5.9% reported that they had not attended any CE over the preceding 5 years and 10.8% reported that they had attended, on average, 2 or fewer hours per year over the preceding 5 years"

2) Table 4 interestingly outlined that Washington State (where I live) Physical Therapists participate in 97% more continuing education than the required 40 hours every two years. 

3) "For the overall sample, respondents reporting membership in APTA participated in more CE than those who did not report membership in APTA."

4) "The overwhelming majority of all respondents, 96.2% (95.6% of therapists from states with a mandate and 97.2% of therapists from states without a mandate), believed that they improved as physical therapists from their participation in CE."

I went through WebPT's list and found that only Maine, Massachusetts, and South Dakota do not currently require continuing education for Physical Therapists. While each state varies, the average per year seemed to be between 10-20 hours of continuing education. Some states were very specific and others more vague regarding certain content and means of participation such as online versus in person course work. For example, in Washington, physical therapists must complete a three hour course for suicide prevention.  Many of the states also listed PTA requirements for continuing education which had a few more states that did not require hours.  

I wondered if any research has been done on the impact of continuing education requirements on patient outcomes. That search was a bit of a bust.  There were almost no articles that specifically examined physical therapists' education with patient outcomes. I did come across this paper which assessed patient outcomes following physical therapists completing a 2-day course for neck pain with minimal impact on their patients.  According to this 2010 paper from the Journal of the American Medical Association which looked at continuing education for physicians, the evidence for improving patient outcomes was not strong.  There isn't a strong body of evidence to support participation in continuing education, and what I could find showed minimal improvement in patient outcomes at best.  Both papers suggest that new ways of participating in continuing education may need to be developed and bigger sample sizes may also be beneficial.  More research on the topic is needed.

Regardless of these two papers, I'm not planning to stop my continuing education efforts any time soon.  I'll continue to pursue a variety of course topics and presentation methods including video presentations, in-person learning workshops and conferences, and self study, so that I can try to achieve optimal outcomes.  Also, in the future, when I'm the patient, I'm going to ask my providers what type of continuing education they've recently done because it shows a dedication to growth, and I want to be treated by practitioners who also value learning. Watch out Dr. Knudson - I'm asking you at my teeth cleaning next week!