Journal of Orthopaedic & Sports Physical Therapy

Official Publication of the Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association

Advancing Physical Therapy Practice:

The Accountable Practitioner
John D. Childs, PT, PhD, MBA, OCS, FAAOMPT 1
Julie M. Whitman, PT, DSc, OCS, FAAOMPT 2

W
e are excited to introduce 2 special issues in the Journal that feature articles
relevant to direct access physical therapist practice. The rationale for covering
these topics in the physical therapy literature is clear: the American Physical
Therapy Association’s (APTA’s) Vision 2020 states that, ‘‘By 2020, physical
therapy will be provided by physical therapists who are doctors of physical
therapy, recognized by consumers and other health care professionals as the practitioners of
choice to whom consumers have direct access for the diagnosis of, interventions for, and
prevention of impairments, functional limitations, and disabilities related to movement,
function, and health.’’1 To achieve this goal, APTA’s Board of Directors suggests that we
should focus our efforts on 5 key areas: professionalism, direct access, the doctor of physical
therapy, evidence-based practice, and practitioner of choice.5 Because a majority of first
professional degree programs have now transitioned to the professional doctoral degree and
physical therapists can provide direct access care in 39 states, it is clear that we are quickly
moving toward the Vision 2020. However, it would be helpful to reflect on where we are as a
profession and what it is, exactly, that we want in our journey toward the goals set forth by
our national organization.

Since the inception of our profession, we have been transitioning from the ‘‘art’’ of physical
therapy toward the ‘‘profession’’ of physical therapy, with a more recent national emphasis on
‘‘autonomous’’ or ‘‘direct access’’ physical therapist practice. According to the Webster’s
dictionary, autonomy can be defined as ‘‘having the right or power of self-government;
undertaken or carried on without outside control; self-contained; existing or capable of
existing independently; responding, reacting, or developing independently of the whole.’’ If
the view of professional autonomy is in concert with this definition, some may argue that
physical therapy could be likened to an art, where practitioners are free to design unique
diagnostic and therapeutic regimens for each individual patient, drawing on clinical
knowledge and experience, without distractions, regulations, or oversight. Proponents of this
type of system believe that practitioners intuitively know the best way to manage individual
patients, that the purity of practitioners’ motives will insure optimal patient care, and that the
personal competency of practitioners will result in quality health care.7 Unless this was the
intended interpretation, we likely chose the wrong term altogether to describe what we should
be seeking. In fact, if the perspective of professional autonomy focuses on the attributes of
professionalism, an expanded and almost contrary model emerges. In this model, the
profession holds a specialized body of knowledge. It is self-regulating, members are free to
provide care within the profession’s scope of practice, and the expectation is that
performance should be consistent with the best scientific evidence available. Members of the
group are responsible for the integrity and expansion of the profession’s knowledge base and
are accountable for their actions. Proponents of this type of system believe that compliance or

1
Assistant Professor and Director of Research, US Army-Baylor University Doctoral Program in Physical Therapy, San Antonio, TX.
2
Assistant Professor, Regis University, Denver, CO.
The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as
reflecting the views of the US Air Force, US Army, or Department of Defense.

624 Journal of Orthopaedic & Sports Physical Therapy

 conformity to standards of best or evidence-based practice will ensure optimal patient
outcome, reduce utilization of resources, and allow practitioners to control and regulate their
own health care delivery. Herein lies the ‘‘paradox of autonomy’’7: to become more
autonomous as a profession, individual practitioners must become less independent and more

GUEST
accountable to the profession. So, you be the judge. Did we pick the right term?

The profession of physical therapy is not the only health care profession to struggle with the
balance between professional and individual autonomy. As discussed by Reinertsen, the
medical profession has also been faced with the paradox of autonomy, as well as the impact of
their actions on both patient outcomes and health care utilization.7 Physicians achieved

EDITORIAL
unprecedented autonomy in the 20th century, largely attributed to scientific advances during
this period that rapidly improved the effectiveness of medical practice.7 However, this
‘‘honeymoon period’’ was gradually overshadowed in the late 20th century by increased
scrutiny and oversight among third-party payers and growing consumer distrust because of
wide variations in the quality of care, differing levels of integrating scientific advances into
practice, and the rise in medical errors.4 Based on this experience, Reinertsen proposed that
there are 3 ways to lose your autonomy: (1) create a culture that tolerates mistakes and does
not deal effectively with colleagues who fail to fulfill their professional obligations; (2) don’t
follow the evidence; and (3) permit unwarranted practice variation.7 In the spirit of learning
from history, and from the lessons learned from other professions that have undergone
similar transition periods, we propose that these same principles apply to our profession of
physical therapy, representing ways that we will lose, or never gain, legitimate professional
autonomy.

With a focus more solely on the first premise about ways to lose autonomy, one may ask ‘‘How
is this done’’? Historically, licensure boards and legal systems have dealt with egregious
mistakes performed by physical therapists. However, to optimize the likelihood that the
paradigm shift toward Vision 2020 will be realized and that physical therapists achieve a level
of professional autonomy similar to that of other medical disciplines, individual members of
our profession must ultimately be responsible for policing the profession. Additionally, the
members of our profession must ensure that they are continuing to update their knowledge
base and use the current best evidence that is applicable to their respective patient
populations.

One approach of moving in the direction of policing ourselves is through benchmarking.

First, we must determine where we stand in various areas of physical therapist practice,
analyze and benchmark our performance, and implement changes or improvements in the
process to produce better outcomes of care. With this idea in mind, we pursued assessment of
student and practicing physical therapist knowledge in musculoskeletal medicine. As many of
you may be aware, Freedman and Bernstein3 assessed knowledge in basic nonsurgical
musculoskeletal medicine among 85 physicians during their first week of their internship
following graduation from medical school, using a standardized examination. The mean score
was just under 60%, with only 18% of physicians scoring above a level determined by
orthopaedic program directors as the minimum threshold necessary to establish competency
in musculoskeletal medicine in the primary care setting.3 Matzkin et al6 recently demon-
strated similar suboptimal levels of knowledge in musculoskeletal medicine among medical
students, residents, and virtually all physician specialists except for orthopaedists. Our
question was, ‘‘How does physical therapists’ knowledge in musculoskeletal medicine compare
to that of physicians?’’ With our rapid progress toward having direct access in all states, and
given the frequency of musculoskeletal conditions encountered in physical therapist practice,
we thought this was a particularly relevant question.

To answer our question regarding physical therapists’ knowledge relative to physicians, we

replicated the Freedman and Bernstein study among both first professional degree physical
therapist students nearing graduation and practicing physical therapists. The results, are
reported elsewhere in detail.2 Briefly, 174 physical therapist students from 12 randomly
selected educational programs and 182 practicing physical therapists completed the same
examination administered by Freedman and Bernstein3 and Matzkin,6 assessing knowledge in

J Orthop Sports Phys Ther • Volume 35 • Number 10 • October 2005 625

 managing musculoskeletal conditions. As with most data, the results are mixed. Practicing
physical therapists demonstrated higher levels of knowledge in managing musculoskeletal
conditions than medical students, physician interns and residents, and all physician specialists
except for orthopaedic surgeons. Furthermore, practicing physical therapists who were board
certified in orthopaedic or sports physical therapy achieved significantly higher scores and
passing rates than their non–board-certified colleagues.2 Although physical therapy students
performed better than all physician groups except orthopaedists, they did not perform as well
as we expected. Only 24% achieved the passing score established by Freedman and Bernstein,
compared to a 19% passing rate among physician interns3 and a more favorable 67% pass
rate among practicing physical therapists. Interestingly, first professional degree students
enrolled in doctoral degree educational programs achieved significantly higher scores than
their peers enrolled in master’s degree programs, providing at least preliminary evidence for
an increased focus on the diagnosis of commonly encountered musculoskeletal conditions
and orthopaedic emergencies in the curricula of doctoral level physical therapy programs.

Based on the results of this recent study, how do you answer the question, ‘‘Do physical
therapists have the requisite knowledge necessary to manage musculoskeletal conditions in a
direct access setting?’’ Furthermore, how can we apply our findings to the concept of creating
‘‘a culture that doesn’t tolerate mistakes, and one that deals effectively with colleagues who
fail to fulfill professional obligations’’? Perhaps professional obligations should be extended to
our accrediting bodies and professional associations in conjunction with individual clinicians.
On one hand, all physical therapists, regardless of board certification, degree status, and
experience, performed at least as well as physicians, who are presumed to be competent to
provide direct access care for patients with musculoskeletal conditions upon graduation from
medical school. If we set our sights on performance as good as that of primary care
physicians, then we can rest comfortably and convince ourselves that we’re doing fine. On the
other hand, are we missing the point if we settle for substandard performance? If we are
striving to become the musculoskeletal providers of choice with direct access for patient care,
and acknowledge that most physical therapists don’t have an array of imaging and lab tests at
their immediate disposal to assist in clinical decision making, is the passing rate of our
students and practicing clinicians really good enough, or should we strive to be better? Given
the emphasis on musculoskeletal conditions in the curricula of physical therapist educational
programs, all of us thought that our graduates’ performance would have been better. We were
unfortunately mistaken. This study exposed the ‘‘emperor with no clothes.’’

So, in the big picture, where do we go from here? It appears that perhaps we are not as well
prepared in musculoskeletal medicine as we would like to be. Ultimately, we would like to see
information regarding actual outcomes of care for patients treated by our students and recent
graduates, but at this time this information may be the best evidence we have regarding
student preparation in musculoskeletal diagnostic arena. Based on this, we must face the fact
that there is room for improvement and move forward. We propose that there are 3 ways to
respond to this information. One option is to ‘‘shoot the messenger.’’ Individuals and
organizations with a low tolerance for disappointing news will gladly join in the fray. Another
option is blissful ignorance, in which we bury our heads under the pillow and hope it goes
away. A third option—the only viable path in our opinion—is to take action as accountable
practitioners supported by accountable national professional organizations. We should
embrace a healthy debate at the forefront of our profession’s consciousness regarding how we
can do better. For example, we should strive toward outcomes-based evaluation criteria, in
which data regarding outcomes of care for patients treated by our students and recent
graduates are reported in a standardized manner. We should responsibly engage members of
the education community, current clinicians, the Commission on Accreditation of Physical
Therapist Education, various health care delivery systems, and other stakeholders, allowing
data to inform a meaningful dialogue regarding needed competencies for musculoskeletal
direct access care. From a more global perspective, we must take a leadership role in raising
the level of musculoskeletal care in the entire health care system. This requires both an
inward focus on our own profession and an outward commitment to work with our primary
care colleagues. If we pursue this path, we will find solutions that propel us toward rapid

626 J Orthop Sports Phys Ther • Volume 35 • Number 10 • October 2005

 advancement of physical therapist practice and the achievement of Vision 2020 well before
2020. The vast majority of states have approved direct access legislation; therefore, the
proverbial train has left the station. We are all responsible for shaping our arrival at the final
destination. Stay tuned next month for a discussion on the remaining 2 ways to lose your

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autonomy (or never get it): (1) don’t follow (or teach) the evidence and (2) permit
unwarranted practice variation.

REFERENCES

EDITORIAL
1. American Physical Therapy Association House of Delegates. Vision 2020. HOD 06-00-24-35. 2000.
Alexandria, VA: American Physical Therapy Association; 2000.
2. Childs JD, Whitman JM, Sizer PS, Pugia ML, Flynn TW, Delitto A. A description of physical therapists’
knowledge in managing musculoskeletal conditions. BMC Musculoskelet Disord. 2005;6:32.
3. Freedman KB, Bernstein J. The adequacy of medical school education in musculoskeletal medicine.
J Bone Joint Surg Am. 1998;80:1421-1427.
4. Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington,
DC: Institute of Medicine, National Academy Press; 1999.
5. Massey BF, Jr. Making vision 2020 a reality. Phys Ther. 2003;83:1023-1026.
6. Matzkin E, Smith EL, Freccero D, Richardson AB. Adequacy of education in musculoskeletal
medicine. J Bone Joint Surg Am. 2005;87:310-314.
7. Reinertsen JL. Zen and the art of physician autonomy maintenance. Ann Intern Med. 2003;138:992-
995.

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