It’s Time for PT to Work Smarter, Not Harder (As told at the 2024 Graham Sessions)

This year’s Graham Sessions ended just over two weeks ago. It marked the 17th year of this “think tank” style conference that has left me pondering the ideas and topics discussed like the previous nine times I’ve attended. This year we gathered in San Diego at the historic Grant Hotel, which provided a fantastic setting for in-depth discussions on the hot topics affecting our profession today.   

Last year, the consensus was that we were getting close to a breaking point if we did not continue to push for change and, most importantly, embrace change. This year, the theme that emerged was that the profession is tired and that we must embrace new models and technology to start working smarter, not harder. Our profession has undeniably evolved significantly right before our eyes, especially in the past five years. Much of the change can be attributed to the pandemic, but access to technology and a changing consumer (patient) landscape has pushed the market to adapt or die. As much as some might want to put the genie back in the bottle, physical therapy will never be what it was 20-30 years ago. To quote Vivien Greene: “Life isn’t about waiting for the storm to pass. It’s about learning how to dance in the rain.” So, who’s ready to boogie?

AI can help overworked clinicians and staff. 

Talk of artificial intelligence (AI) can generate a lot of reactions from clinicians; some fear that we’re a few years away from being replaced, while others fully embrace technology for the potential of efficiency and most importantly clinical insights for data analysis.

I understand the apprehension around AI—for as much as we’ve heard about it, the imagination can run wild, especially without proper context. Personally, I think AI offers a lot of promise within a PT practice, doing what AI is best suited for: the tedious tasks that PTs don’t have time for, and frankly hate doing. For all the fear of world domination, right now AI is simply the best pattern recognition tool we’ve created to date. It can’t reason critically as clinicians do, but it can assist us with coding and documentation—which is why I think of it as a digital assistant. And, at a time when administrative burden is stated as the biggest driver of clinician burnout, we should take advantage of all the help we can get. 

Machine learning has the biggest opportunity for success in healthcare. The ability to digest and analyze mountains of data to find trends, insights, and clinical decision support will be what drives efficiency in our clinical model.  The biggest hurdle will be to overcome the physical therapists’ resistance to uniformity and standardization of treatment plans of care.

Interoperability is the future of better care

As PTs have fought for recognition among healthcare providers, we’ve been doing so at a disadvantage. The divide between an electronic health record (EHR) and an electronic medical record (EMR) might not get as much attention as some of the other headline-grabbing issues, but it has been brought into the spotlight due to the 2024 MIPS requirements. Even as the founder of what started as an EMR company, I believe interoperability is the path toward a better standard of healthcare delivery—which is why WebPT is evolving to become an EHR with better connectivity standards to share PT treatment and patient data with other healthcare providers and systems. 

As it stands today, approximately 87% of PT practices are using an EMR according to the Office of the National Coordinator of Health IT (ONC). Although the capabilities of an EHR are compelling, there is no standard of requirements for PTs as the current CEHRT (Certification for EHR Technology) requires many elements that do not pertain to our needs, like the transmission of prescriptions, for example.

I admit, I’m a bit biased when it comes to this topic, but I believe interoperability should be focused on improving access to care and improving the provider and patient experience. That is essentially what we’ve aimed to do with PXM–to create an interconnected system that allows providers to share information across multiple platforms to enable the best care and patient outcomes. Shining examples of the opportunity that interoperability and EHR use bring to our profession were shared, but unfortunately, today, it only serves those seeing a large number of Medicare patients and is financially unattainable for the majority of practices in our profession. 

New practice models are the way forward—at least for some.  

The past few years would seem to demonstrate that moving beyond the traditional insurance-based practice model is the only way to survive in the current economic climate PT finds itself in—but the solution isn’t as simple as adding a few cash-pay services to your offerings. 

We need space for continued innovation. 

Direct-to-employer contracting was cited as one option for PTs looking to grow their business, with more employers looking to save on the MSK costs they’re incurring through traditional insurance. However, much of the overall conversation hinged on the inherent conflict between innovation and operations when it comes to practice models. We are currently so mired in patient volumes and insurance payments that most clinicians or clinic owners aren't finding the time to pick their heads up to think outside of the box and try a new technology, or develop a new idea or model that allows for improved economic stability. If we want to move forward, we have to find space for both—our patients and providers are demanding it. That’s why I was so excited to find out about the 1st Annual Shark Tank event that the Academy of Leadership and Innovation is putting on this year with the hope of sparking and funding ideas that can move our profession forward.

A good investment can help you get where you want to go. 

Private equity (PE) may play a part in helping to grow practices, but only if owners are smart about the path they take. Unfortunately, we are severely lacking in business education as PTs and attendees heard some horror stories of mergers and acquisitions, as well as PE deals, gone bad and the subsequent lessons learned. PE has its place in business, and our industry was and is offering what PE looks for in investment opportunities: a large industry made up of disparate practices that lack uniformity and systems to make clinic operations more efficient and more profitable. Not every PE firm is created equal, but, with the right partnership and leadership—the result can be not only lucrative for the executive teams, but also amazing for patients with increased access to care, an improved patient experience, and an opportunity for company growth.  

Many experienced with a PE transaction stated that the relationship was akin to a marriage where you can take advantage of one another’s strengths and that communication was imperative to success. The right PE deal can offer the financial security necessary for growth and expansion but usually comes with a playbook including margin and revenue mandates within a set timeline for meeting those goals.   

While taking on a financial partner is not new, the amount of PE money that has flowed into our industry over the last five years is—although that trend has slowed for the moment. We had started to see the “roll-up” of smaller practices accelerate post-pandemic, but the skyrocketing interest rates over the last year put a damper on M&A activity in almost every sector, not just healthcare. There are still some deals getting done as organizations have money to deploy, but at present, we are in a “cash is king” mode, and PE-backed organizations are being much more selective with the businesses they are willing to acquire. 

Traditional models still serve a purpose. 

Of course, discussing innovation opens the door to questions about what might be left behind when the traditional model gets abandoned. A few people had words of caution about the rapid increase in cash-based practices. While cash-based services are potentially great for the bottom line, they exclude many patients who do not have the discretionary income to afford these services and rely solely on their insurance benefits to get the care they need. This is where innovation and operational efficiency must be a priority as the more traditional insurance-based model reigns supreme as the mechanism to pay for PT services for the majority of patients. The traditional model must improve to become more efficient and profitable for clinics to survive.

We must open the profession to talented, qualified people — and retain them.  

Speaking of exclusion, some of the most interesting conversations happened around the topic of the PT workforce and potential solutions to solve our current shortage. 

Our current educational system isn’t working — for several reasons. 

It’s no secret that we have a student debt problem; the 2023 State of Rehab Therapy report found that more than 25% of students were graduating with over $100,000 of debt. Pile inflation and cost of living expenses on top of that, and many students are opting to skip DPT programs entirely because they simply can’t afford to attend. That problem is particularly acute for students in underserved and underrepresented populations, and while we’ve tried to address the problem at Rizing Tide, it’s going to take a lot more work to solve the workforce shortage issue. Although there has been a lot of scrutiny of DEI and our university systems recently, we must remain focused on expanding the TAM (total addressable market) of our recruiting efforts to fulfill the growing need for PT services. 

Additionally, students who shoulder the burden of six-figure debt aren’t leaving school feeling fully prepared to enter the workforce. Going back to the State of Rehab Therapy report, a significant number of students (roughly between 20% and 40%) felt unprepared in one or more areas upon graduation—with a concerning 23.5% saying they felt least prepared in their clinical skills. That’s an astonishing statistic, and we shouldn’t be surprised when young people enter the profession, get immediately overwhelmed with the workload, and then want to leave for greener pastures.

While it would be easy to engage in some classic grumbling about “kids these days”, there was a recognition among attendees that the educational system has not evolved as the profession has evolved. And, if students aren’t ready after graduation, much of that responsibility lies in the current educational system and structure. The suggestion was made that with a problem this big, everything should be on the table to be examined: the skill of current faculty, the standards set by CAPTE and ACAPT, and how DPT programs could be shaped to fit the needs of today’s students and most importantly, meet the current demands of the industry.

PT extenders can help solve our staffing crisis.  

The place of therapy extenders (PTAs, ATCs, massage therapists, and others) within PT has long been a point of contention, but if the conversations at Graham Sessions are any indication, there’s a growing recognition that their exclusion has come at the cost of a valuable resource. It’s long been said that PTs can be their own worst enemy, and the failure to bring PT extenders more fully into our work has only hurt us in the long run. After all, we’ve fought hard for recognition as experts on par with other primary care providers, and yet we’ve continued to insist that we’re the only ones who can also serve as technicians. Worse yet, insurance companies are happy to pay us as technicians rather than doctors.

One suggestion that I found most interesting, and could potentially improve access to care quickly and relieve the PT shortage problem, is embracing the medical model used by other providers. If we adopt the workflow of a dentist or physician, for example, in which the PT is the evaluator, assessor, and planner, but NOT the executor, we could vastly increase the volume of patients seen in our clinics.  When was the last time you had your dentist complete your teeth cleaning, or had a physician assess your vitals?  Probably never. Then why have we, as PTs, not been able to shed our technician status and practice at the top of our license? Why do we hang onto the notion that we are the best at teaching exercises and continue to roll around on the floor with our patients? If a PT could see six evaluations, a couple of re-evals and perform only the most complicated of hands-on techniques in a day while supervising PTAs, ATCs, and even personal trainers to perform the corrective exercises and teach HEPs with our patients, how many more people could get access to our services?

There was a collective groan in the room at the idea of stepping back, so to speak, as we all have enjoyed the relationship-building and the validation that comes with being the provider who “does it all.” But if we could embrace a change in the culture of who we are and what we do as Doctors of Physical Therapy, I agree that our impact could be even greater than we can imagine for ourselves today. We have to be willing to make bold changes and evolve with the needs of patients if we are going to remain the go-to MSK providers.

With no answer to the waiting lists in many PT practices today, the decreasing pipeline of DPT students, and the growing percentage of therapists leaving the profession for non-clinical work, we must be willing, in collaboration with PT programs, to shake up the current model of education and patient care as it is not financially sustainable for most practices.

Retention efforts require attention. 

Of course, all of these efforts will go to waste if we can’t hold onto the people we recruit. According to a 2023 report from Definitive Healthcare, we had over 15,000 physical therapists leave the workforce between 2021 and 2022—11% of all PTs. Not surprisingly, employee retention was a much-discussed point as we tried to stem the tide of this mass exodus. 

There isn’t a single solution that will fix our problems, but the path to better retention is fairly straightforward: listen to what your employees are telling you via NPS surveys, formal sit-downs, and informal chats. Once you’ve heard them, work to implement those ideas into your practice. 

If you want to retain your teams, start by creating a culture that celebrates the “why” all of us got into the field. Part of that culture means providing transparent and clear communication of goals and expectations, career pathing opportunities, and fair wages with benefits. However, we must also understand that there are differences in the generations and company loyalty is somewhat a thing of the past. Clinics and leaders must have efficient systems in place for recruiting and onboarding to counter the potential loss of providers. I was glad to see that there was less finger-pointing this year discussing retention than in years past, with pragmatism ringing loudly. 

As leaders, we must have great cultures and systems in place for our teams, but also must accept that people will leave and we shouldn’t be surprised when it happens. Building great relationships with your employees will reap the benefits of longer-term employment and the time to prepare for their departure should they decide it's time to move on. Admittedly, that’s all easier said than done sometimes. But, most discussions centered around the importance of communication and the human need to feel heard. Something as simple as re-examining maternity and paternity leave or providing flexibility in work schedules to accommodate therapists becoming parents can be the difference in retaining a previously loyal employee.  It's not rocket science, but it does take intention, time, and willingness to make accommodations or changes to policies that may have been in place for many years.  We do this for our patients all the time - the same care and thoughtfulness should be considered within our workforce.

Graham Sessions is vital as a forum for discussing big ideas in a space where everyone feels safe sharing their opinions, and our profession isn’t short on smart, passionate people with innovative minds wanting to better the physical therapy profession. As a do-er, it can be a bit frustrating discussing the big ideas without specifically hashing out solutions. But, the Graham Session is meant to be the spark for innovation. 

Along with the amazing personal connections made and reinvigorated passion and faith in our profession, this year’s big takeaway from Graham Sessions for me was that we must recognize the need to embrace technology and improved workflows to work smarter. We have worked ourselves into burnout, and it's time to take a page out of the PE playbook and find the operational efficiencies to meet the growing demand for our services. But, we must do it collectively and swiftly as the consumer’s attention span is short and they have and will continue to move on to other providers who are willing to serve their needs. 

I love being a PT, but the education and job duties that I had, especially during the early years of my career, may not be what the future should hold for our new grads moving forward. Let’s all make some time during our week to dedicate ourselves to innovation and forward-thinking—the future of our profession depends on it. Put down those umbrellas and let’s start dancing in the rain.