PT Practice to the Top of the License
“Practicing to the Top of the License” is a catch-phrase alternative to buzzwords. It represents wildly different themes to different professionals. In 2010, an article (1) on the American Sentinel University blog site – the Sentinel Watch, cites an Institute of Medicine (IOM) article(2) that talks of encouraging nurses practicing to the top of their license. We often hear colleagues & other professionals advocating that every healthcare worker should “practice at the top of their license”. But what is the reality out there?
As of today, a simple Google query “practice to the top of physical therapy license” fails to demonstrate s single link that addresses this matter. Indeed, while it is a buzzword, and another holy grail after the advent of “direct-access”, it remains mired in a veritable haze for the profession.
Much has been said, written, debated, and hashed-out by physical therapy profession about the paradigm of state-level direct-access practice. And certainly, that was an idealistic goal that has been fought for, and eventually attained. But, is that truly the “top of the license?” Maybe for outpatient level practice. But, I would hazard that the top of the license represents the full potential that a “doctoral” title should confer. And that requires additional knowledge, and training that is requisite to performing crucial differential diagnosis that forms the basis of custom-tailored solutions to the movement dysfunctions that therapists encounter in their acute care practice.
Top of the license for acute care practice requires beyond competence in procedural physical therapy. It is common knowledge that the majority of patients in the hospitals are not in the ICUs or in boutique ambulatory procedure beds. The bulk of the patients in the hospital setting arrive for care of their symptoms, & signs, that may be multifactorial, or not. Movement dysfunctions do not just occur from neuro-musculoskeletal dysfunctions, as is commonly assessed. There are myriads of pathophysiological processes, often more complex than that meets the eye, that may influence a patient’s movement dysfunction.
Consider a patient who is admitted for shortness of breath, with a background of congestive heart failure, recurrent ascites, recurrent pleural effusion, idiopathic lung fibrosis, and severe pulmonary hypertension, among other things. The exercise intolerance of such individuals must be carefully considered and evaluated for remediability by exercise, or physical maneuvers alone. This is not entry-level practice. Indeed, even experts dither on how to rationalize and deliver care for such instances & individuals.
The current paradigm of so called “tailored approach” to acute care patients that encourage another buzz word “early mobility”, and the ubiquitous “bed mobility, transfer training, gait training”, needs to be abolished in favor of deep introspection and analysis of benefit vs. harm considerations.
The clinicians-at-large out there seem oblivious to such analytical approach. The challenge remains, “…what the mind does not know, the eyes cannot see…“. This has to change. With advent of Doctor of Physical Therapy degree, there has never been a better time. But our curricular push to reduce instruction time, and no availability of mandatory bedside internship, such an art is relegated to textbook preparation which is fallacious for training the highest rigor of science.
With a doctoral degree standard in physical therapy, it is up to the newly minted professionals, as well as established career-tracks to seek guidance and training, especially when foraying beyond the comfort areas of niche practice to acute care. The guiding authority of speciality practice, the American Board of Physical Therapy Residencies & Fellowship Education (ABPTRFE) , has not yet mandated the differential diagnosis & triage of movement dysfunction as a requirement of training yet. And this update remains elusive in the absence of a true Descriptions of Specialty Practice in Acute Care Physical Therapy as of today. The current standards of practice in acute care physical therapy are still being derived from the somewhat long-in-the-tooth practice analysis done by Gorman et al, 2010 (3), and the acute care residencies being designed off the model of The Johns Hopkins Hospital Acute Care Physical Therapy Residency Petition, both of which no longer serve the next holy grail in “top of the license” practice in acute care physical therapy.
Until the resistance breaks, we are not yet practicing uniformly at the top of our license. Think about that.
Reference:
- Garner C. IOM Issues Recommendations for Transforming Nursing Practice. Sentinel Watch. Dec. 2010. Available at: https://www.americansentinel.edu/blog/2010/12/29/iom-issues-recommendations-for-transforming-nursing-practice/
- Institute of Medicine (US) Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine (Eds): The Future of Nursing: Leading Change, Advancing Health. Washington (DC): National Academies Press (US); 2011. Available at: https://www.ncbi.nlm.nih.gov/pubmed/24983041.
- Gorman SL, Hakim EW, Johnson W, Bose S, Harris KS, Crist MH, Holtgrefe K, Ryan JM, Simpson, MS, Coe JB. Nationwide acute care physical therapist practice analysis identifies knowledge, skills, and behaviors that reflect acute care practice. Physical Therapy. 2010; 90(10): 1453-1467. Available at: https://mds.marshall.edu/physical_therapy_faculty/28/.