I’m a big believer in periodic reflection as a useful and honest guide for all kinds of decision making. Stopping to notice your own thoughts can solidify your existing beliefs or force you to acknowledge uncertainties. For me, the challenge of making reflection useful is evaluating choices in a vacuum. It’s easy enough to answer questions in absolute terms, like whether or not you enjoy your daily experiences or if you view the overall role of your work as something genuinely meaningful; it’s tougher (maybe impossible) to answer those questions relative to every alternative. Like anything else, career fulfillment seems to lie at an intersection of compromise. Without launching into a philosophical discourse, I’m going to use this post to reflect on a few of my own experiences in detail, on the sum of my observations of our healthcare system, and on how my feelings about PT have evolved in my first year of practice. I hope this will be useful for new grads mapping their next experiences and for practicing clinicians interested in discussing health policy and defining our roles more clearly.

Briefly, I’ve been working with acutely ill patients at a community hospital of about 250 beds. I’ve treated patients with general medical complaints, following orthopedic surgery, immediately after a stroke, dealing with cardiac disease, and some with less-common conditions. Challenges have included understanding the role of rehab services in the acute setting, reconciling clinical decision making with non-clinical pressures, and working to enhance dated perceptions of PT as a component of the medical model. I learned how to be a PT in acute rehab, both as an aide and as a clinical student, and was sometimes intimidated by patients’ acuity. Gaining experience at an acute hospital seemed like a solution, and I’m glad I made the choice I did. I received a lot of support easing into the setting, I’ve grown as a clinician, and am fortunate to have a huge amount of freedom to explore different practice areas.

Besides treating patients on the medical floors, I’ve spent time in the Emergency Room, which is itself a fairly new area of PT practice, and I’ve also seen some patients in the ICU. I believe strongly in PT utilization in the ER as a cost-saver for the healthcare system and as an opportunity to improve the experience of being an ER patient. I think the growing body of literature supporting early ICU mobility speaks for itself, and that clinicians in other practice areas should be strongly motivated to follow suit and share the financial data supporting their work.

So far, a highly comprehensive and rewarding utilization of the whole PT skill set has been assisting in the diagnosis of Normal Pressure Hydrocephalus (NPH). Briefly, patients with NPH present with a triad of clinical symptoms: sudden change in mentation, new incontinence, and Parkinsonian gait disturbance. In NPH, the brain doesn’t absorb cerebrospinal fluid properly, and diagnosis is confirmed by an improvement in physical symptoms after a lumbar puncture to drain excess CSF. Physical therapy assessment is critical because if lumbar puncture leads to significant improvement, patients will undergo surgical placement of a device that shunts fluid from the brain. The evaluation requires highly detailed gait analysis and specific, quantified measurements, which combines my favorite diagnostic tool (gait analysis) and interest in measuring health metrics creatively.

I’ve learned more about common medical conditions than I expected, and used skills unique to PT as a discipline less so. Initially I was resistant to this and concerned that I’d lose many of the tools I had just recently become comfortable with, but I think the scope of what we do is so large that this isn’t necessarily problematic. If you can maintain a set of outpatient skills while learning acute practice, I think you can easily carve out a rewarding opportunity to practice at a high level. Therapists who treat outpatients as well as inpatients can offer a huge amount of value to hospital networks if they’re utilized well, cheaply diagnosing certain injuries and helping manage straightforward conditions in the hospital setting where things that might be obvious to skilled outpatient therapists go undiagnosed or misdiagnosed. But these opportunities are few, and I feel this is largely related to the amount of confusion about what our profession actually does. ‘Physical Therapy’ is a muddled, to some extent inadequate description for the current state of our practice. A hospital physician may view PT as the generator of discharge recommendations. A primary care might be surprised PTs practice in the acute setting at all. Many patients would be puzzled about what a physical therapist could be doing in the emergency room, and rightly so. But per the APTA, we see ourselves as providers of choice for musculoskeletal injuries, as the most skilled at diagnosing movement disorders, and as having the education to support that assertion, regardless of setting. Therapists can specialize in neurology, cardiac rehab, women’s health, and other areas. This is not a small discrepancy, it’s a fundamental miscommunication of our role if we really believe what the APTA is saying on our behalf.

To me, PT is a highly cost-effective component of the medical model, too often perceived as an ancillary service. I got into PT because I think there’s a massive and untapped value in movement as medicine. I thought and still think that I could do the most good for the most people by spreading this idea. I believe strongly in individuals’ abilities to solve many of their own problems, and I view the idea of movement as medicine as an extension of that. I think a lot of our culture allows too little accountability and encourages patients to assume passive roles in maintaining their own health and wellness. I’m not anti-pharmacy or anti-surgery, but I think that both of those services are over-utilized to the detriment of some patients and to the healthcare economy. I predict that the near-to-moderate future will see a shift away from those as default treatment strategies, placing greater emphasis on nutrition, activity, patient-driven care, and legitimate education strategies.

As a whole, healthcare providers have not done enough to educate our patients, and that might prove an expensive shortcoming. Before considering even the most basic health literacy, consider that navigating the health system alone is overwhelming for many older adults. If they don’t know where to go, who to call, or when to seek assistance, they show up at the emergency room. At a time where providers are so focused on guidelines and algorithms, we should be providing better instructions for our patients along every node of the health network. Similarly, we continue to view the obesity problem in the wrong way. We haven’t yet had success with prevention, but our programs have stagnated in their implementation. Prevention is too valuable a strategy for us to not be continually refining our recommendations and the methods we use to spread them. It’s wasteful to not put more effort into prevention.

As we’re all seeing, there’s a lot of waste in the current system. It’s also much more complicated than I realized before I worked in this setting. Mismanagement of simple conditions leading to extended hospital courses and surgical procedures not supported by evidence are just some sources of wasteful spending. I don’t view this as the fault of clinicians at any level, but rather as natural failure points of a highly inefficient system. To focus on a trouble area specific to PT, many patients end up functionally worse off when they leave the hospital than they were on admission. Of course, the priority in dealing with acutely ill patients is to address their medical needs first, and even a large calorie deficit or period of inactivity isn’t as dangerous to a patient as the actual reason for admission. But we as a community understand that nutrition and activity are critical, and still a large part of patients’ recoveries are spent in bed, while we allow poor nutritional choices through it all. We cut a very small cost rather than spend a few man-hours to prevent functional deterioration during a hospital stay, while the burden on the healthcare system of sending so many patients to short term rehab is enormous. I suspect the optimal ratio of full time therapists to hospital beds is significantly greater than the amount actually employed on average, and that very clear cost savings could be demonstrated if disease burden were examined on the scale of the entire system rather than on each facility. Until the Accountable Care Organization model is implemented, this problem will go unresolved because the incentives aren’t there at the level of the individual facility.

I think PTs can help solve a lot of these problems, and that one of our largest obstacles can also become a real strength in this regard. What we do is misunderstood because we practice throughout the entire healthcare system, and our capacities differ so much between settings. But we know when a patient leaves the hospital for a SNF whether their acute course will mean a greater length of stay at the next facility, or whether their participation has been enough to maintain functional capacity. We possess uniquely direct contact with the effect that’s going to have on the entire healthcare system in terms of total expenditure. We know the value of early mobility in the management of acute illness: fundamentally it compares well to the prevention of obesity before a patient develops the many associated comorbidities. Meaningful change in healthcare is effected on the policy level, and PTs are absent from policy-shaping roles. Right now, that position might be justified: systemic change depends on economies of scale, and PT just doesn’t scale very well as it’s used today. We need to prove our value through cultivation of strong objective data that support our work. We can help prevent or shorten costly SNF courses by working with patients during acute stays, and a therapist is extremely cheap compared to a day in a SNF. Accountable Care Organizations are only a few years away, and we are very well-positioned to meet a need that they’ll bring with them, but we have to prepare for it.

As always, thanks for reading. My hope is that I’ve encouraged you to consider acute care if you haven’t experienced it, and motivated you to prove how cost-effective your practice is regardless of setting.