We Are at a Breaking Point (as Told at the 2023 Graham Sessions)

Last month, the APTA’s Private Practice Section hosted its 16th annual Graham Sessions in the Paris of the South—the one, the only, New Orleans, Louisiana. As if drawing from the city’s eclectic and diverse history, this year’s discussion was energetic, impassioned, and, at times, controversial. But, that’s to be expected. After all, Graham Sessions was created to provide a safe space for rehab therapy professionals to openly discuss the biggest issues impacting our industry—and share their unique views on these matters. There is no pretense, there are no formalities, it’s just good ol’ fashioned debate, which is why Graham Sessions is one of my favorite industry events to attend (besides Ascend, of course). 

But, if I’m being honest, I left this year’s sessions a bit uneasy. There is an undeniable problem with our problems: they haven’t changed. At one point, a presenter pulled a quote from an industry paper printed 50 years ago that directly spoke to a key issue we’re facing today. So, it’s clear we know the problems, we have some solutions, but yet we remain stagnant in many areas. By definition, that could very well be considered insanity.

So, the big question is, why aren’t we pushing harder for reform? Because I fear that if we push any further, we might just break. 

The cracks are showing.

This year’s speakers continued to trod over familiar cracks in our foundation: therapist burnout, PT education vs. reality, crippling student debt—the list of usual suspects continues. But, new to this year’s Graham Sessions party were issues around supply vs. demand. From what I can recall, more than half of the room raised their hands when asked, “Who here currently has a patient waitlist?”

Some of you reading this may view this as a good problem to have—a sign that demand for our unique set of skills is increasing. And it very well could be! After all: 

• Public awareness of PT and its benefits is growing;
• The number of people who will pay for qualified professionals to help them achieve their healthiest life possible is expanding; and
• The rise in Medicare patients due to an aging population has created a greater need for physical therapy services. 

So, yes, waitlists can be a sign of a prosperous industry, and—if efficiently managed—an effective solution to filling scheduling gaps created by patient cancellations. However, we’re seeing the pendulum swing much too far—and into dangerous territory. In recent conversations I’ve had with WebPT Members, I’ve discovered that some currently have a 30-day waitlist for new patients. This isn’t acceptable—and it certainly isn’t sustainable. 

We are in the midst of a crisis.

These inflated waitlists are (at least, in part) a direct result of a much bigger issue we have on our hands that will inevitably impact us all: the PT staffing shortage.

In 2021, we saw 22,032 staff physical therapists leave clinical care. If you compare this with data from the Bureau of Labor Statistics (BLS), that’s nearly 10% of our therapist workforce. This is also corroborated by the 2022 State of Rehab Therapy report, which found that the rehab therapy industry’s 2021 turnover rate average was roughly 9%.

The BLS also predicts that “about 15,400 openings for physical therapists each year, on average, over the next decade.” Comparatively, this PT Progress article and this CAPTE resource estimate that only 10,000-12,000 newly graduated physical therapists enter the workforce every year, respectively. Furthermore, three-quarters of Graham Session attendees indicated that they currently have a PT job opening that have gone unfilled for more than 30 days. These are clear signs that this workforce deficit may very well worsen in the future if we don’t act now.

Times have changed—and we aren’t keeping pace.

As we emerge from the pandemic, people (being people) just want to go back to what’s familiar. However, we’ve experienced so much change in such a short amount of time that there is no going back. And while there are a multitude of factors contributing to the PT staffing crisis, I suspect that the added burden of grappling with our “new normal” is making it all the more difficult to see where the leaks in our talent pool are springing from. So, where to start?

Combining a bit of what I’m seeing play out in the industry with the hot topics from the Graham Sessions, I think we should turn our focus—at least initially—to addressing these key issues:

• Improve employee satisfaction and retention;
• Increase our capacity; and
• Better prepare students for the real world of PT.

1. Show employees just how much you value them.

These past three years have forced practice owners to spend a lot of time on the operational side of their business in order to keep their doors open. Now, as things have begun to restabilize, it’s time to refocus on what I consider to be any business’s greatest asset: employees.

Of the workforce we currently have, 35% have stated that they’re burnt out. While there is no singular answer, there are a number of potential causes for burnout (which I sourced from Mayo Clinic and the nonprofit HelpGuide):

• Poor workplace culture
• Lack of social support
• Perfectionism
• Lack of control
• Feeling overworked 
• Feeling unchallenged
• Unclear job expectations 
• Lack of recognition

Do you see a pattern? All of these factors can be controlled. But it will require a joint effort on both the employer’s and employee’s ends to get to a place of understanding and resolve—and that starts with a conversation.

During the Graham Sessions, it was uplifting to hear how many clinic owners hold regular one-on-ones with their employees and create feedback loops to better understand their core motivations. I can’t stress how valuable these conversations are—especially when you consider the many differing opinions rehab therapists have on big topics like burnout, work-life balance, and workforce expectations. To this end, communication is an important bridge between the generational gaps in our workforce that are often at the root of misaligned expectations and values.

To quote one attendee, “[i]n order to reach the people we’re treating, we need to reach the people we’re employing.” And at the end of the day, people just want to feel as though they’ve been heard and are valued. It really is as simple as that—at least, to begin. It’s up to every clinic leader to take the feedback they’re given and turn it into something that fuels employee happiness. (We’ve got a few ideas on that front.)

2. Utilize innovation to increase capacity.

Speaking of our reach, it was clear from those in the room at the Graham Sessions that we all can agree: we must increase our capacity if we intend to expand the PT footprint and (finally) put a sizable dent in our 90% problem. But how do we do so without heaping more work onto an already burnt out workforce or adding more overhead to paper-thin budgets? The answer is through efficient technology that maximizes staff productivity (without increasing administrative burden) and improves the patient experience.

I know I’ve referenced our 2022 industry report a few times already (what can I say, I’m a sucker for great data), but I think there’s a notable revelation worth mentioning here: “burdensome documentation and regulatory requirements” was listed as the fourth-highest contributor to burnout overall (and was the third-highest among rehab professionals between the ages of 27 and 47—a.k.a. the majority of our workforce). These are strains that the right EMR can easily alleviate—especially if you go the extra mile by pairing it with a rock-solid billing platform.

Circling back to the waitlist discussion above, some of the delay in getting new patients into the clinic could also be chalked up to human error. Clinics are busy, things can get overlooked—it happens. However, having an integrated scheduling software that enables your staff to effortlessly create and manage waitlists—and schedule appointments directly from them—can ease scheduling mixups and missed opportunities.

While I’m at it, let’s discuss digital health.

I’d be remiss if I didn’t discuss the value digital health tools, like telehealth and remote therapeutic monitoring (RTM), have on increasing access to care, expanding provider bandwidth, and extending our sphere of influence—especially in underserved populations. Unfortunately, we have digital health startups breathing down our necks because they’ve also seen the business value in remote care—and that our industry is ripe for disruption in this area. 

Rather than viewing digital health as the enemy to hands-on care, though, I challenge us to embrace a hybrid model that weaves both modalities together. This will require some vulnerability and self-appraisal on our part as we acknowledge the shortcomings in our current practice. As one attendee poignantly stated, “we are not so special that we can transform society by ourselves.” Leaning into the technology that is specifically built to improve patient care and streamline workflows—all while enabling us to collect more and better data that we can leverage to promote our worth—is a win-win for everyone.

3. Provide the next generation with what they need.

What would a PT shortage discussion be if we didn’t discuss the current DPT educational framework—and specifically, whether it’s providing the next generation with what they need to face the realities of our profession? While this topic could be a blog post (or several) unto itself, I’ll try my best to keep it brief.

The big problem with PT clinical education is the same one that plagues our entire industry: a lack of standardization. There is a lot of variability of care protocols based on where students went to PT school or where they did their clinicals. For example, some students may follow the McKenzie school of thought, where extension exercises are the key to treating most all low back pain cases. Others, however, may enter the workforce determined to forgo any semblance of manual therapy in favor of an exercise-only dogma. But who can blame them when the contradictory research being done to support our manual therapy interventions lacks pragmatism for real-world clinical scenarios.

Additionally, the relationship between academic institutions and clinical affiliation sites remains fragmented and at times, vague. To this day, it’s a gamble—students may end up in a clinical rotation with either an awesome, well-respected instructor or a substandard one who didn’t even know they’d been assigned.

It’s also relevant to note that the National Physical Therapy Examination (NPTE) still draws much of its questions from textbook material as opposed to current clinical best practices. And yet, we complain that students aren’t properly prepared for clinical care. As one person duly noted, “We must look for a better system to measure how good PTs are before we change the whole structure.” 

The current education model is financially crippling.

To add insult to injury, today’s students are being buried beneath mountains of student loan debt. Currently, one in two PT students will graduate with more than $70,000 in loan debt. Of this group, 18% of students graduate with more $100,000 in loan debt, and 16% will graduate with more than $150,000 in loan debt. With this in mind, it’s unsurprising that the top reason therapists gave for considering a professional change (in our industry report) was additional compensation.

As Richard Severin, PT, DPT, PhD, CCS, Owner of PT Reviewer, states in our report, “I say this with no exaggeration that the student debt-to-income ratio is one of the most important issues regarding the long-term sustainability of the physical therapy profession. We must accept that if becoming a physical therapist is not financially viable it will lead to the collapse of the profession.”

Quite frankly, we can’t afford collapsing any further. So, it’s heartening to see that accelerated DPT programs are beginning to proliferate—albeit gradually—in an effort to reduce students’ educational debt and solve the provider shortage faster. But we’re nowhere near the finish line when it comes to innovating our curriculum models, and it will take a coordinated, multi-pronged effort from various groups to solve this sprawling problem. I’m working diligently to do my part by providing PT scholarships to BIPOC students who come from disadvantaged backgrounds. Others are beginning to offer student loan payback programs in their clinics. At the minimum, make an effort to educate yourself on this topic to spread awareness and shore up advocates for the cause. Every little bit helps.

It’s well-known among those who’ve attended Graham Sessions that this event’s aim is to explore new ideas without the pressure to act on them. However, if there’s one thing I wish we would do, it’s to agree with one another. This industry is comprised of such intelligent, driven, and inspiring people—but that can also work to our disadvantage when we’re asked to look beneath our hoods and examine practices that may no longer be applicable in today’s PT landscape. It’s less about admitting wrongdoing and more about accepting that times have changed. And we must either get on board with these changes and look for new ways to elevate our profession, lest we risk deteriorating further. 

It’s time to leave our egos at the door—we’ve got work to do.