Proposed changes to OCS eligibility...pathway to Physical Therapist vs. physical therapy

The Orthopaedic Section recently announced proposed changes to the eligibility criteria necessary to sit for the OCS board-certification exam. I suspect it will generate much discussion and debate in the coming months. Please take the time to respond should you be invited to complete the survey that is mentioned.

It's past time for us to take the next big step towards incentivizing residency training post graduation from PT school. Our current criteria of 2000 hours of general practice in an orthopaedic setting are insufficient to establish any degree of face validity in our health care system that equates board certification as being something achieved post residency training (translated...tough, lots of sweat, late nights and weekends, stressful board exams, etc.). We know that we will have matured as a profession when 95% of our graduates complete residency training similar to medicine. It's clearly must be the "next big thing" in a post DPT world, a rapidly evolving profession, and skyrocketing demand for our services.

By the way, please don't ask whether completing residency training will immediately translate into higher compensation. Our value in the health care system is determined by fee schedules, which is largely driven by our brand and the relative perceived value of our services as determined by 3rd party payers (currently PT = black hole of disparate services provided with complete inconsistency). Therefore, none of this will lead to immediate changes in compensation, nor does having a DPT or residency training itself make you immediately deserving of a high salary. However, standardizing our training around a medical model with legitimate post graduate residency training that is so common you wouldn't seriously consider practicing as a physical therapist without it (and no consumer would want to see a non board certified PT), will go a long ways in improving our brand, differentiating physical therapists as experts in managing patients with musculoskeletal conditions. PT compensation will adjust upwards once we lay claim to our brand and become recognized as legitimate health care providers (think "Physical Therapist", not "physical therapy") that deliver value for improving health.

If you're in doubt, just ask yourself when was the last time you got referred for "medicine", "dentistry", or "optometry"? No, you get referred to a physician, a dentist, or an optometrist. We can mark our arrival when patients are referred (or better yet think to see their physical therapist instead of a primary care provider or physician specialist) to a physical therapist vs. physical therapy. Residency training is an important step forward to that end. Looking forward to everyone's thoughts.

John

Comments

[John Ware]

I just commented on this topic on Tim's original thread, but John has struck a chord, so I'm going to chime in here as well.

We just lost our latest battle for direct access here in Indiana because the chiro lobby got a state senator to add an amendment to a perfectly good bill that would require PT have 400 additional hours of classroom instruction spinal manipulation and 800 hours of experience performing spinal manipulation (residency training?) in order to perform it on a patient.

Of course, they pulled these ridiculous number out of thin air, but the legislators somehow saw it as a reasonable requirement to perform this procedure.

I would argue that if 95% of PTs had residency training that the whole point of additional training to perform spinal maninpulation would be moot, and the chiros wouldn't have an argument (despite their vast amounts of lobbying dollars).

APTA needs to move forward with the PT programs and CAPTE to make residency training a requirement of graduation from PT school.

[Todd Watson]

I think it's a great idea to incetivize residency training as the APTA is proposing. In fact, I think it's a great next step and one I think is overdue. I'm really not sure if it will work, however as there is simply no major incentive for the masses of PTs out there to obtain board certification in the first place. How many PTs are not board certified in a specialty - something like 85-90%?

John's third paragraph basically sustains this position we find ourselves in. Physicians go through residency not to sit for board certification so they can put it on their resume or for practice marketing, but because without it (board certification) they are unable to practice in that specialty.

That would be quite a bit more of a stretch for our position for our position, one that many would think impossible. That would be the ultimate emulation of the medical training model. What do some of you think? Would you see this as absolutely unattainable, extremely difficult or a distant possibility for PT practice (Vision 2040)? I would like to hear from some of you out there regarding this.
Todd

[Derek Dalton]

Man this is a tough subject for me - let me try to explain.

I believe residency training is a great, great thing. I know as a soon-to-be graduate, the experience of working with a mentor who is specialty certified would be so valuable. I've spoken with several residency coordinators and given tremendous thought about attending a residency post-graduation, but here's my issue.

I'm 26 years old and have a family including a wife and 2 small children. The orthopedic residency programs (currently accredited) are spread all over the country with only a couple in the eastern United States. Of these, the salary is greatly reduced and the cost of living is higher.

Raising a family of four on 23,000 dollars isn't easy -- and quite frankly isn't realistic where many of the residencies are located.

I'm all for making residencies required, but there are issues that have to be addressed first. Can something be required when there is not enough spaces for everyone to complete it?

There's no doubt residencies are the right route, but are we as a profession ready to do that?

[John Childs]

Derek:

Very valid points that are commonly raised (and legitimately I might add). The problem is that you are being financially "raped" during your final year of PT school when you are serving as cheap labor (likely so cheap you were free!)to a PT practice providing your clinical education, while you pay premium tuition dollars to a university that is providing you absolutely no service about right now (other than the every so often phone call from the DCE/ACCE...an expensive hourly rate, huh!!!). So, the issue is bigger than just adding residency training on top of a broken clinical education system (my opinion, others disagree strongly on silly grounds like the fact that we don't see widespread malpractice in PT means that all can't be that bad). However, we need full scale re-vamping of clinical education where we graduate mostly incompetent PTs (same as docs after 4 years of med school). This cuts out your final year of paying tuition and allows you to complete a longer residency program and actually get paid a residency stipend (still meager but more than you're getting now...goose egg)!!! In fact, much like a doc, you would recognize your utter incompetence and not dare practice PT without residency training, never mind the fact that the public wouldn't want to see you anyways because they know that residency training + board certification = assurance of at least some level of quality.

So, are we ready? I don't really know, but I seriously doubt that educational programs are going to take the lead. Employers have power if they would just exert it uniformly across the clinical education system and demand longer term clinical residencies (at least 1 year) rather than these ridiculous 8-week affiliations where you get just competent enough to be of use to the employer, only to be yanked out of that setting to start another.

It's time for radical change...who will lead???

Passionate PTs like you.

John

[Dave]

I think we are using the assumption that the residency is the best model. Just because it is the system that is used by physicians doesn't make it the best model. However, it would be better than the current system of clinical education. In the medical model, there appears to be a more equatable distribution across specialties. In physical therapy, the vast majority is in orthopedics. How will you find the large number of residencies needed to fill the need?

We have been attempting to start a residency program. The most challenging problem is funding the resident to make it appealing to the resident but provide the needed mentorship at the same time. Employers have to pay both the resident and the mentor for unproductive hours. A tough sell.

With all schools transitioning to DPT model, the wages haven't keep up with the education level of the students. With an added residency, the expectations is the fair wage for a doctoring profession. But if the 3rd party payers aren't buying into, then the employers can't pay the therapist a fair wage based on the increased knowledge. So then it is tough to sell it to the new graduate that needs to start paying off those student loans.

However, I don't see the current system changing unless there is a major incident that would percipitate change. It may sound silly but for many employers, that is reality.

[Derek Dalton]

Thanks for the reply Dr. Childs.

There are, to say the least, flaws with the way current clincial education is handled. I in no way want to be negative because I've been fortunate to have pretty good affiliations (especially my current one).

But you are right - many of these affiliations allow you to become comfortable with one facilities ways (billing, documentation, etc) only to move on to the next set of methods.

I believe having some exposure to all settings is good, but I believe programs should foster and focus more on student strengths and interests than they currently do. For instance, I'm extremely interested and motivated in the orthopedic realm of physical therapy. Wouldn't I (and my patients) be better off if I were completing advanced training in exactly that?

I think we'd all agree that is probably true.

Tying the residency into the last year of the PT program is an interesting idea that makes sense. Reduced, yet resonable pay for you services as a student/resident, while at the same time advancing practice and the profession.

I could have probably talked the wife into that idea. :)

[Johnny May]

A structured residency model for the final year of PT clinical education is just the type modification the current clinical education models needs. Otherwise, we are thrown to the wolves, as I've posted about (http://physicaltherapistrover.blogspot.com/2008/01/physical-therapist-clinical-education.html.) Dave-The assumption isn’t that the residency model is the best, the assumption is a model that resembles a medical residency model is a whole lot better than the current state of clinical education.

[Johnny May]

edit- Dave is correct in stating that a resembled medical residency model is better that our current state of PT education.

[John Ware]

I think the "major incident" that Dave is referring to would have to include the complete collapse of our current cost-containment/procedure-based reimbursement system.
Under the current system, the lack of quality is directly attributable to the lack of results-based incentives.

As the reimbursement squeeze on private practice PTs continues, the farthest thing from the minds of practice owners is participating in a residency program that is going to reduce the billable time of their staff. We all want what's best for the profession, but to expect practice owners to take it on the chin in a shrinking reimbursement environment is unrealistic.

I think the PT programs need to re-think their clinical affiliation structures, and as John suggested, provide some real incentive to practice owners to participate, rather than just grab the tuition money and then send the students off to their clinicals.

[Carina Lowry]

Interesting discussion here, and I was just speaking with a junior colleague last night about the exact same issue. He has been out of school for 2 years now in orthopedics and taken further manips courses offered here in Chicago for post-doc credit. He wanted to know if I thought he should go into a residency or sit for the OCS. Basically I told him that the OCS is quite worthless and he could likely take it tomorrow and pass it. Admittedly I studied for a year for it but I am a slow learner and take a bit to absorb everything. However I was disappointed in the knowledge level needed to pass this test. So as it is set up right now, the OCS designation is not really akin to the specialist certification of a spine specialist MD (who I would hope could do more than pass a test if I were going to see him).

I believe the model that we are going to here at UIC is a longer clinical model in fewer settings. We have our students for at least 4 months or so before they move on. Everyone (including fellows in training such as myself) assists with mentoring the students in the clinic in advanced skills such as cervical manips, etc. I do believe that offering the student a stipend to perform a 6 month clinical is more appropriate than the current system. It would give the student approximately half their hours for certification and valuable experience in the setting of choice. I am not sure that the clinics should be the ones paying the stipend, but possibly a collaboration between the clinical site and the PT school.

[Paul]

What precipitated the movement from MPT to DPT?

The answer will be vague, but will mimic the answer to why we need residency programs.

So now we have a beginning of a critical mass of DPTs.

Why did the profession begin the process of specialty certification?

Again, a vague answer will mimic the answer currently granted to the residency program.

When residency programs fail to deliver a final solution to a never ending problem, what will be next?

My credentials on this issue are clear. I bought into the idea of a DPT, got a certification from one of those ‘institutes’ and passed the OCS. Now, as a father of 3, there is a proposed new standard? It just seems to me like it is never ending.

I also wonder what happened _before_ the introduction of the MPT. Probably more of the same issues, probably the same debate, different credentials, same answer.

[John Ware]

Paul,
I understand and empathize with your frustration, but I think it's misplaced.

The lack of value we receive from 3rd party payers-the "black hole" that has been referred to in another thread on this blog- is largely driven by practice variability and lack of standards of care in physical therapy. The very succinct answer to why advancement in degree requirements and specialty certification has occured is that the leaders of the profession saw these measures as a means to remedy practice variability.

Have they been successful? It may be too soon to tell. But, like you, I'm not encouraged. It seems like the "black hole" is now where we keep dumping all our time and money in the endless search for professional respect.

On the matter of a residency, though, is where we depart. Paying a PT student in his last year a stipend versus the indentured servitude that is the clinical affiliation would be a marked improvement both in terms of equitability and education. Also, residency would supplant the current OCS process, which I've always seen as a boondoggle to make us appear more doctor-like.

[sean]

Todd,
many Neurologists can practice as just that without "board certification" in Neurology. I'm not sure of the legalities or process but I do know it occurs in this specialty and they still advetise as "neurologists" in Texas.
Derek,
I believe the lack of compensation is ridiculous. The clinics doing these should limit themselves to profitable ones who can afford to pay reasonable wages (45K+) or not do it at all. the 23K salary is a huge obstacle which all but the most affluent of our new grads can afford to participate in.
John Ware,
As I have stated multiple times without response from you is that the few outcomes companies which measure data are completely flawed... unless they've changed in the last 2 years. In addition, nobody I've negotiated a contract with has ever asked for my outcomes.
I recently tried to negotiate a contract with a workers comp network who stated that they held absolutely no value in outcomes measurement for PT.
Regarding your argument for paying a stipend to a PT in residence training, I disagree. Most Pt directors I've met in the large hospital systems rarely practice patient care nor do they have the aptitude to mentor/minimize practice variability. They play politics to get into their positions. The real PT mentors are "staff" PTs who basically commit career advancement and payscale suicide to advance their profession. This is because their bosses are of lower educational advancement in PT and possibly decided to get an advanced business degree like an MBA.
We need to get our APTA leadership, models for practice advancement, and
professional mentors out of the hospial systems altogether. They do nothing to serve us as a profession, besides the occasional APTA dues they pay for their employees.
APTA needs to establish processes for all of the above and figure in checks, balances, and evidence-based meausures of expertise to accredit professionals of higher learning.
there are so many issues to identify and put long-term plans in place to remedy, that it will take until 2020, just to have a good system in place. We need to realize that reimbursement will not improve to the levels we deserve until we have solid data to support all PT's expertise and training in those interventions.
The current specialist certifications and outcomes measurement tools do not provide us with anything valuable to payors in cost-savings or expertise across the nation.

[John Ware]

Sean,
Your last comment is lost on me. I didn't make any reference to outcomes data or the companies that provide outcomes measurement tools in my remarks on this topic. Maybe you're referring to someone elses comments?

I also don't follow you on the politics in the hospital departments as it relates to residency training. I don't disagree with your assessment of what goes on, I just dont' see what it has to do with paying a 3rd year PT student a stipend.

It sounds like we agree on the uselessness of the OCS, though.

[Andrew]

Many great comments and probably the most engaging thread I've read in my blog reviews today. I agree with John Childs(which I do frequently on these type issues) that we need to change it ourselves. Sean, while I can appreciate what good leadership can accomplish, a radical change like this needs to come from inside, not top down. This is a culture change as much as it is a system change. Those of us that have opportunities to influence the culture of our workplace, our patients, and the therapists we work with carry the burden. WE must foster an environment where best practice is expected and anything else is just not good enough. We must be creative in ways to facilitate residencies and ways to minimize the financial roadblocks for our residents AND those in the mentoring role. Not all great PTs are great mentors...we all have seen that in one way or another. But the great mentors are invaluable. Correction, rather they have a real value to the business.

We've discussed several times across this group the idea of establishing a "new" clinical education process. But for it to work it needs to be a win-win-win for new PT, internship site, and PT school. Hmmm..internship.

Think about this from the practice owner standpoint:
Your clinic is staffed by 3 tiers of providers. Interns - they've completed all the didactic, only hurdle left is 6-9 months of supervised patient care in your clinic and to pas the licensure exam (AKA - Not gonna hurt any patients certification).
Residents - post graduate training in the real sense of the word residency. Seeing pts and overseeing the interns are their main priority.
Staff - your residency trained therapists. Perhaps even some are now in their Fellowship training. These are the ones we lean heavily on to shape the practice. To mentor the residents and to run the practice. To monitor payor contracts, visits per eval, SWandB, and of course to model waht patient care should be.

I'm not proclaiming we have the answer. We're trying here in Texas to make a good run at it, though we're ALL building it.

ab

[sean]

John,
In my reference to politics in the workplace I'm speaking of directors who are threatened by more knowledgeable practicianers. They can hold back some of our best and brightest with poor performance reviews etc. Directors need to understand that there is a shared leadership amongst all employees in a successful clinic.
If we don't allow the most qualified PTs to lead, we are dismantling the profession from the inside out.
Paying the students a stipend to cover reasonable living expenses in a hospital system would be very easy to do. However with these non-profit (lmaorof) hospitals putting income in front of patient care, it is a terrible place for our leaders of tomorrow to cut their teeth.
Paying someone 40K to do an internship is easily recoverable in reimbusement and should be looked at as something akin to R&D - banking on future returns, rather than immediate profits.
Sorry about the outcomes thing, it was another guy named John who posts on the blog.

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[San Diego LASIK eye surgery]

There are, to say the least, flaws with the way current clincial education is handled. I in no way want to be negative because I've been fortunate to have pretty good affiliations (especially my current one).