Jill Murphy, DPT, LAT, CSCS
There is much we are concerned about with healthcare in 2012, such as unsustainable increases in health insurance premiums, fraud based on the payment system, and hefty deductibles and out of pocket amounts people are paying to access care across the country in the guise of reducing costs by having your own skin in the game. In the midst of the gloomy debate about healthcare reform, there is one bright shining light that has not dimmed just yet- that being increased consumer choice in healthcare. Instead of being limited to certain providers in one certain area, most of us can now choose our own providers, specialists, and yes, even physical therapists.
Whether you are aware of it or not, when you are referred to a physical therapist, you are not obligated to go to the physical therapist your physician recommends. A physical therapy order is good anywhere you choose for a licensed physical therapist to guide you through the rehabilitation process. Research has shown that physicians tend to refer patients to their own or their affiliated hospital’s physical therapy practice, or simply to the practice that is closest in proximity to you and/or the physician. Sadly, it is very rare that a patient is referred to a physical therapist based on type of treatment they will need matched with the specialties that a therapist provides.
You have one shot at physical therapy. You want it to not simply be okay, but a really great experience! You will benefit from a physical therapist that is empathetic and understanding, encouraging and challenging. So how do you know the difference between a so-so physical therapist and a stand-out physical therapist that is not only knowledgeable and highly skilled, but gladly goes above and beyond the call of duty on your behalf?
Here are several specific and important questions that anyone can ask to help narrow down the choice of the best physical therapist fit for you.
1) How will I be matched to a specific physical therapist?
Skip the large clinic who tells you when you ask on the phone who your physical therapist will be, “All of our therapists are great and specialize in the type of care you need for your diagnosis.” For a few cases this may be true, but quite honestly, this is a line that really means you will be placed with the therapist with the most open schedule that matches yours, not the skills that match your therapy needs. If you settle for this, you’re rolling the dice on your care- it could be great, mediocre, or flat out inadequate.
Solution: Ask what type of skills your physical therapist has, and what diagnoses they see most often. Ask to be placed with the therapist who sees your diagnosis most frequently, but please also read on...
2) Will I be working with the same physical therapist each and every visit?
In many cases, you will work with whoever is available to meet your scheduling needs, whether or not it is with the same therapist. Every physical therapist would agree when asked, that you receive the best care from a single physical therapist that knows you and your case, and follows the exact plan of care he or she wrote specifically for you at your initial evaluation. Of course, physical therapists do go on vacation now and then or call in sick, or go on maternity leave, but for the majority of your visits, your best care will come from your own dedicated physical therapist.
Solution: Ask specifically if you will be working with the same physical therapist on every visit.
3) Will I be given one-on-one care throughout my visit?
This is easy to see once you are attending physical therapy, but it may be hard to find out ahead of time what kind of care is delivered by your physical therapist; or worse yet, if you end up with several physical therapists and/or physical therapist assistants. Hopefully, if you ask straight up before your first visit, you will get a straight up answer. If you are in the middle of your bout of physical therapy before you realize your physical therapist is working with another patient or two in the gym at the same time, and this happens on a regular basis, realize that this is not the type of skilled care your insurance company likes to reimburse (in fact they would consider this fraud), and this is sub-par medical attention that you should not be settling for.
Solution: Run for the hills! You will get better care elsewhere!
4) Has my physical therapist attended continuing education for the type of care he or she will be giving me?
This is a great question, especially for people with low back pain, neck pain, tension headaches, temperomandibular (TMJ) joint pain, and a host of other more complex patient diagnoses to treat. When physical therapists graduate from physical therapy school (myself included), we know enough not to kill someone, and maybe a few other treatment tricks of the trade from our clinical instructors. But quite honestly, the physical therapy education each of us is provided with is really just basic training. We graduate as generalists, and then must choose a specific setting where we begin our careers. It takes a lot of continuing education, mentoring, and experience to truly be a great physical therapist, especially for the complex and/or rare diagnoses in the out-patient orthopedic and sports medicine setting.
Solution: Ask for a bio of your specific physical therapist; this should contain all of the information you need to know. However, figure out what continuing education or years of experience in treating your specific diagnosis that the physical therapist has, not just the things he or she likes to treat. There is a difference.
5) Does it matter if my PT has a BS, MPT, or DPT degree?
Despite what the obvious answer may seem it should be, the answer here is no, with a caveat. Let me explain. The difference in education between a MPT and DPT degree may be as little as 6 college credits. This is equal to two classes, which are likely in subject matters that physical therapist cannot even legally participate in clinical practice at this time (such as ordering medications and diagnostic imaging). On the other hand, if your physical therapist received a BS in the 1970’s and has attended little to no continuing education since, it is doubtful you will find great care here either. In every profession, exceptional care is not always experienced with the most recently educated, or with the most experienced, but somewhere in between in the form of someone who is passionate and takes pride in continually improving practice to truly master their trade.
Solution: Know what degree your physical therapist has, but don’t put all your eggs in this basket. It can be very misleading.
6) Do I want to be treated by a physical therapist assistant?
Just like physical therapists, physical therapist assistants are well trained and talented individuals who deliver the treatments contained in physical therapy plan of care, despite a large difference in formal education and degree. For many simple orthopedic patients, there is little to no benefit in being treated by the same physical therapist who evaluated you and developed your plan of care other than the obvious benefit of maintaining continuity of care. However, for most patients, there is a big difference in the size and complexity of the tools that a physical therapist and physical therapist assistant tend to have. Especially when it comes to manual therapy skills, unfortunately in our profession physical therapist assistants are not even allowed in the door to learn these skills at the best continuing education classes for manual therapy. Some physical therapist assistants have learned some basic manual therapy skills despite their exclusion from the continuing education; however, most will not have the opportunity or desire to seek out a mentor to teach them these skills unless they really are an exceptional physical therapist assistant. If you have a diagnosis that requires a significant amount of manual therapy, such as treatment for back and neck pain, headaches, TMJ dysfunction, adhesive capsulitis (frozen shoulder), post RTC or labral repair of the shoulder, hip pain, knee osteoarthritis, and even total joint replacements and post ACL reconstructions, you will recover faster with the skills of a physical therapist with significant manual therapy skills to mobilize the affected joint itself along with the other, more typical interventions.
Solution: Ask if you will continue your treatment with the same physical therapist to allow for continuity of care, or if the clinic’s policy is to hand off patients to a physical therapist assistant. And remember that this might be okay for you or not, depending on your specific diagnosis and treatment needs and depending on the specific skills of the physical therapist assistant who would be treating you.
How to Tell if You're Receiving Poor Physical Therapy
Finally, I would like to end this article with a number of situations that may indicate you are working with a less than stellar physical therapist or physical therapy practice, and should be searching for an alternative before you use up your annual quota of visits from your insurance company...
- You’re being “shaked and baked.” This refers to the physical therapy you would have received in the 70’s and 80’s, when hot packs, cold packs, ultrasounds, and e-stims were done on every patient, and oddly enough, billed to and fully reimbursed by third party payers. While utilizing treatment via special equipment such as ultrasound or iontophoresis may be beneficial for you, using more than one such modality per treatment can be a red flag.
- You get the same exact treatment every visit, even though you are not getting better for weeks at a time. At some point, your physical therapist should be trying a variety of approaches if you are not responding to the current approach, or you should be sent to another physical therapist with a different set of skills to help you improve.
- Your physical therapist tells you your pain is “in your head” when you are not responding to their care. Sadly, this is a common complaint that I hear from patients, and have even experienced myself when I was a physical therapy patient many years ago. This is a huge red flag for several reasons. First, it means your physical therapist is blaming you for their unsuccessful treatment, which means he or she has run out of tools with which to treat you, but doesn’t have either a clear knowledge of the situation or simply the integrity to tell you this. It also means your physical therapist should have referred you to another physical therapist or specialist elsewhere several visits ago, before their only referral is to a psychologist with your label as a head case. Realize there are some diagnoses that have some aspect of psychosocial influence, in which case a frank discussion about seeing a counselor or psychologist may be fully appropriate as part of a larger physical therapy plan of care. Also realize that some diagnoses do not have a cure at this time, such as multiple sclerosis, Parkinson’s disease, spinal stenosis, and osteoarthritis among others, but this does not mean a physical therapist has no solutions for you. In case you were wondering, you problem is NOT ever solely in your head! Find another physical therapist immediately!
- Your physical therapist is billing you for time he or she is not spending with you in a one-on-one setting with skilled care delivery. You should not simply be performing your home exercise program in the corner of the gym or biking for 30 minutes as the majority of your treatment without any medical interaction or intervention by your physical therapist unless you are not being billed for this time, and you are receiving skilled intervention before or after your work-out.
- You feel like you are getting the same treatment and exercises as everyone else around you in the clinic. Every patient is unique, and your treatment plan should be specifically tailored to you. While exercise programs may be similar if you and another patient share the same diagnosis, chances are you require different tweaks, tips, and exercise cues than the physical therapy patient next door.
- You are just not comfortable with your physical therapist; he or she does not relate well to you. While we are all different people with different perspectives and preferences in life, your physical therapist should empathetic, and have the ability to effectively communicate the plan of care and explain treatments in a way that you can understand. You should be comfortable asking questions and for clarification from your physical therapist when needed. Your questions should be answered fully, in an unhurried fashion, and you should feel listened to and respected at all times. For example, if your physical therapist thinks you are crazy because you run marathons, and their solution is to simply stop running for good, maybe they just don’t relate.
- Your physical therapist never touches you. As odd as this statement may seem, physical therapy is a uniquely hands-on profession. Whether we are evaluating a joint or giving you manual cues to improve muscle activation during an exercise, it should be a red flag if your physical therapist has never laid hands on you in the first two visits in an out-patient orthopedic setting.
- You are having significant difficulties scheduling appointments with your physical therapist. You should be able to be seen for the correct amount of visits per week, with an adequate amount of time devoted to your visit to allow the best chance for your rehabilitation to be successful. If this isn’t happening, try to be more flexible on your part and prioritize your physical therapy appointments in your schedule. If it still isn’t happening despite great flexibility on your part, you should see another physical therapist who can better meet your scheduling needs.
Despite the lengthy list above, know that when you are referred to a physical therapist, we enjoy helping you in part because we feel better at the end of the day when you are successful. Rest assured that you are in great hands with the physical therapy profession. Even though the road to health and healing may seem long and uneven at times, your physical therapist is more than a well-educated medical professional. We are your coach, cheerleader, and teammate working tirelessly to see you reach your every goal. Take some time to choose your coach well, and with your own hard work and perseverance, you just may win your own personal championship as you return to the joy of living!