We Are Our Own Worst Enemy (as Told at the 2020 Graham Sessions)

According to one 2020 Graham Sessions attendee, the PT field is facing a pretty grim future. “We have a pretty dire landscape,” he said. “It costs more to earn less.” PTs struggle, he argued, because we know what we’re worth—but that value is totally at odds with how the market values us. PTs are worried—and can you blame us? We’re worried about the future of our profession—about our jobs, our incomes, and our families. We’re facing a heap of problems that we can’t continue to shove under the rug—but we also don’t seem to know how to solve them. And it’s not for lack of awareness; another seasoned Graham Sessions attendee pointed out that some of these issues are not new. We, as a profession, have not managed to—or have simply chosen not to—solve them.

Stuck in this dour mindset, it’s easy for us to point fingers at payers (especially CMS), the APTA, or even our competitors. It’s easy to blame them for our financial woes and our struggle to attract and retain patients. It’s easy for us to gripe about health and wellness businesses that steal our patients—or young therapists who are apathetic about APTA membership and PT advocacy efforts. But, it's even more difficult to have the humility to realize and accept that we are at least partially to blame for many of our own problems.

All that said, I left the 2020 Graham Sessions with one overarching takeaway about PT professionals: we are our own worst enemy, and before we defeat ourselves, we must figure out how to come together as a profession so we can achieve our prime objective of successfully transforming society. 

We still cannot figure out how to define our value—and we are not built to scale. 

What’s cool about the Graham Sessions’ open forum setup is that, by the end of the conference, you’ve heard (and perhaps even voiced) a great number of perspectives about a great number of topics. What’s even cooler is that this setup helps us identify industry sore spots, because some ideas continue to poke their head up—no matter the topic. And this year, despite covering a lot of conversational ground (think everything from “Medicare for All” to competency assessments), attendees often returned to one singular point: PTs are stuck at an impasse. We can’t make progress or stride forward as an industry, because we can’t collectively define our value. 

The PT brand identity crisis is fueled by our inability to function—and grow—as a unit. 

The physical therapy brand crisis is a perennial problem for our industry. It has cropped up at the Graham Sessions year after year after year—and yet, we’re no closer to solving it. We know that we heal through movement, but beyond that, the title of “physical therapist”—and the value of our services—remains undefined to the general public.

Part of the problem is that the title “PT” encompasses countless specialties. And because each specialty—and all the providers therein—is so unique, each individual group of therapists has its own set of wants and needs. Not surprisingly, this often puts us at odds with each other. A regulation that might be great for inpatient therapists could be equally detrimental for outpatient clinics. A win for pediatrics may come at the expense of geriatrics. 

We’re dreaming too big. 

I think another big part of the problem is that we spend too much of our time trying to be everything to everyone. We want to be patients’ health coaches and their primary providers; we want to be the alternative to surgery—while continuing to be a post-op go-to. We want to provide wellness services that promote optimal sports performance or overall health, assist with fall prevention for elderly patients, eliminate (or at least reduce) back pain, and become health care’s first line of defense—and offense, for that matter—for musculoskeletal issues.

All of these goals fall well within our scope of practice—but the reality is that they’re scattered; they all serve different purposes for different patient populations. We can’t seem to fit our services under a single umbrella—and as a result, we don’t have a unified brand. Without a unified brand, we can’t execute a unified marketing strategy, which means the wider patient population (and even other providers) have no idea about the amazing things we’re capable of accomplishing. We are the profession that’s an inch deep and a mile wide.

The opioid crisis could become our uniting banner. 

That’s why I’ve said time and time again that this is the perfect opportunity to push physical therapy as the universal solution to the opioid crisis. Everyone—from payers to employers to patients—is paying attention to this conversation, and it’s our time to shine, because those who are affected are spread across our entire spectrum of specialties. We can use the inherent power of inspirational patient stories to capture the public’s eye and make waves—especially during this election season. We must help elect officials who understand the power of physical therapy and who are willing to support us with their legislative efforts.

Most importantly, we need to remember that a rising tide raises all boats. We cannot let our segmentation prevent us from supporting each other—even when it doesn’t directly benefit us as individuals. A big legislative win for one specialty may not immediately help another, but it’s our duty to support PT wins wherever we can find them. There’s strength in numbers, and we will be at our strongest when we work together and help each other climb the ladder. 

We have not tended to our patients’ social needs—often to their detriment. 

I’d bet big money that most therapists (and healthcare providers in general) do everything in their power to steer clear of tense, hot-button conversations about social issues with their patients—and not without reason. In today’s political climate, conversations about social issues and personal beliefs too often devolve into shouting matches, and that’s not the best look when we’re trying to create raving fans of physical therapy. But, avoiding tough conversations within our internal governing bodies (like the APTA house of delegates) about social status, economic disparity, and internalized discrimination has done a disservice to our patients—because these social issues are proven to affect health and outcomes.

We have a moral and clinical responsibility to address our patients’ social needs. 

The sad truth is that, despite our best intentions, health care—in terms of both quality and quantity—is not distributed evenly across our country. There are literal geographic gaps in care (dubbed Health Professional Shortage Areas [HPSAs] by CMS), where patients do not have the freedom to choose their providers—if they have access to a provider at all. And even if a patient does have access to a PT clinic, there’s no guarantee it’ll be well-run, because PTs haven’t developed uniform clinical standards to ensure that all clinics provide equally excellent care. During this year’s meeting, we discussed how inequity in access and quality can, and often does, impact population health. For instance, ample research has proven that “blacks and minority groups in the U.S. experience more illness, worse outcomes, and premature death compared with whites.”

Obviously, there is no easy fix to these problems. The best we can do is make an effort to support all of our patients—including our underprivileged and minority patients. We can educate ourselves, diversify our industry, and support initiatives (whether grassroots or legislative) intended to create better access to care—and we must make an effort to recognize and shelve our inherent biases.

Our expertise can shape legislative conversations that affect our patients’ health.

One of the topics we discussed this year is whether or not the APTA should insert itself in the national political arena and take strong public stances on widely recognized social issues like gun control. I’m not going to pretend like I know whether or not it’s a good idea for the APTA to take on strong political stances, but I did think the discussion raised some interesting points about how we view population health. 

Usually, when we talk about improving the health of populations, we focus on how we can actively encourage healthy lifestyles and promote preventive care. But, that only scrapes the surface of good health. If you shift your perspective just the slightest bit, population health encompasses mental health, public safety, affordable housing, general accessibility, food and water quality—really anything that affects the well-being of your patients. 

It may be worthwhile to take a look at social issues that heavily affect the well-being of your patients and decide whether or not they fall under your expertise. If they do, perhaps there is an opportunity for advocacy; your expertise as a healthcare provider could be valuable to the conversation. Just be careful not to overextend yourself. “No organization can throw resources at every topic,” one Graham Sessions attendee said. “We have to prioritize to be successful and sustainable.” 

Our new grads are plagued with uncertainty. 

Many new grads are entering the rehab therapy industry wondering if they made a huge mistake—and frankly, I don’t blame them. We have not set up our new grads for success. They are entering the field feeling overburdened by debt, limited by skill deficits, and isolated by the very people who are supposed to mentor them.

Many Graham Sessions attendees came to the conclusion that we’ve overdeveloped our new grads’ clinical skills. In theory, that sounds like a great problem to have. A more knowledgeable provider sounds great, right? But the time spent developing these clinical skills comes at the expense of time spent developing personal, interpersonal, and communication skills. These are often referred to as “soft skills,” but one attendee pointed out that “soft skills” is kind of a misnomer—at least in our field. “Calling soft skills ‘soft’ implies that they’re ‘nice-to-haves,’” she said. But the truth is that these skills are mission-critical. Our best work happens when there is a strong alliance between a PT and his or her patient—and that cannot happen without strong personal, interpersonal, and communication skills. 

Many attendees brought up their experiences with new grads who have deficits in these areas, saying that, while these graduates are whip-smart and wholly knowledgeable about the human body, they seem to lack a personal touch. Therapists must cultivate strong, trusting relationships between themselves and their patients; otherwise, the patient-provider therapeutic alliance crumbles.  

Experienced PTs need to reach out to students. 

New grads are our future, so if they’re starting to feel desperate about their prospects in this field (especially when it comes to their debt), then the next generation of therapists may be sparse. We can take more steps to ensure that our profession will thrive for many years to come. It’s our duty to prepare new grads for the trials and tribulations they will face in a PT career. If our new-grad PTs feel unsteady on their feet—which, by all accounts, they do—then we are failing them. And let’s face it: a lot of training happens on the job during clinicals. It’s on all of us to take this opportunity to coach them—to mentor them—and ensure they have all the skills they need to succeed. 

We can talk all day about why PT schools should teach so-called “soft skills”—but that won’t mean anything if we don’t reinforce those skills in the clinic. We should be modeling these behaviors to our new grads. We, as employers, need to listen to them—and, when appropriate, reach out a hand to help them. If that means mentoring our young PTs in leadership skills, then so be it. It all comes back to company and industry culture. We need to ask ourselves what our profession stands for.

We need to assist the APTA in reaching out to disaffected PTs (including new grads). 

It is our job to safeguard our future—and I also think it’s on the APTA to do a little more safeguarding, too. Our association should be striving to bring fresh PTs into the fold by any means possible—not ostracizing or criticizing them when they speak out against the organization. One Graham Sessions speaker encouraged everyone to reach out to non-APTA members (especially new grads!), seek their input, and be welcoming. “‘My voice doesn’t matter,’ is a damaging thought to cultivate in this climate,” she said—and I couldn’t agree more. That’s especially true considering that one of the best ways to advocate on behalf of our profession is to pledge membership to our professional association.

We are only as strong as our weakest link, and our chain is fractured in a million different places. Our PT voice is not united—partially because only 30% of all physical therapists are members of the APTA, which means we’re missing out on valuable input from those outside of the association. I don’t want to see us become an insular echo chamber; we can only grow and evolve if we’re willing to listen to new input and consider change—even if it makes us uncomfortable.

PTs may be facing an uphill battle, but the future is not all doom and gloom. We can fix the problems in our industry, but we have to be willing to check our egos at the door and look critically at ourselves. We have so much potential, but we’re getting in our own way. 

I’ll leave you with one last quote from the Graham Sessions: “We need to collectively get it together, and we need to go out and show people what we do because we change lives every day…People are desperate for us.” Let’s do this!