School-Based Physical Therapy in the Age of - COVID-19 - APTA
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Embedded PTs: Changing the
Face of Physical Therapy
A Virtual Success: NEXT 2020
Students’ Privacy Rights
September 2020 Vol. 12 No. 8 The Signature Membership Publication of the American Physical Therapy Association
School-Based
Physical Therapy
in the Age of
COVID-19
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I N F O @ C E D A R O N . C O M | W W W. C E D A R O N . C O M / T E L E H E A LT H
IN THIS ISSUE September 2020 Vol. 12 No. 8
COLUMNS
10
Compliance Matters
Protecting students’
privacy under health care
and education law.
16
Ethics In Practice
Silence isn’t always golden,
but finding one’s voice
in the moment can be
difficult.
62
28 Defining Moment
When it comes to dressing
School-Based
for safety, sweat equity
pays off.
Physical Therapy
in the Age of
COVID-19 DEPARTMENTS
PTs have learned from their experiences with
4
remote service provision and are prepared for a
variety of scenarios in the new school year. Quoted
6
Viewpoints
Forum
Opinion
APTA Asks
52
Professional Pulse
Health Care Headlines
APTA Leading The Way
PTJ’s Editor’s Choice
20 40 Student Focus
APTA Member Value
Embedded PTs: A Virtual Success: 60
Changing the Face NEXT 2020 Marketplace
of Physical Therapy It wasn’t in person, but the Career Opportunities
conference delivered. Continuing Education
Physical therapists who treat
Products
specific populations on-site likely
will play a large part in the future 61
of physical therapy.
Advertiser Index
2 APTA.ORG/APTA-MAGAZINE
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QUOTED ©2020 by the American Physical
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Dan Mills, PT, MPT DISCLAIMER: The ideas and opin-
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weapons and objects
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Charles D. Ciccone, PT, PhD, FAPTA American Physical Therapy Asso-
Gordon Eiland, PT, MA, ATC ciation. APTA prohibits preferential
of abuse. A cane, for
or adverse discrimination on the
Chris Hughes, PT, PhD
basis of race, creed, color, gender,
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Robert Latz, PT, DPT
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status in all areas including, but
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Alan Chong W. Lee, PT, DPT, PhD
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to the ethical standards of APTA.
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Changing the Face Lois Douthitt, Publisher
of Physical Therapy” Jason Bellamy, Executive Vice President,
Strategic Communications
on page 20.
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VIEWPOINTS
APTA welcomes
your opinions and
encourages diverse
Forum
voices.
I SEPTEMBER 2017 (IN PT IN MOTION MAGAZINE)
The Real Story About Chronic
Fatigue Syndrome
Chronic fatigue is not curable. It’s like a cancer
that doesn’t kill you quickly. It just takes you
down slowly. I have had CFS for 31 years with
no option but pacing, accepting the disease,
and hoping for the day that the Lord will wipe
Facebook away our tears and pain. Thanks for trying to
facebook.com/ I MARCH 2020 (IN PT IN MOTION MAGAZINE)
explain it, but only if you have lived it can you
AmericanPhysical
TherapyAssociation
ever, ever “get it.” Designing for the Future
Twitter AMY LAYFIELD In response to the Viewpoint questions about
@APTAtweets the article, “Designing for the Future,” speaking
I MAY 2015 (IN PT IN MOTION MAGAZINE) only for the buildings that we have designed
and built for our practice:
Embezzlement? That Could Never 1. All of the buildings were built prepandemic.
Happen in My Practice The commenter’s perspectives benefit from
Former employers who were subject to embez- a postpandemic world and are enlightened
APTA, 1111 North zlement should be encouraged to tell the truth accordingly.
Fairfax St.
about the employee who committed the em- 2. Our buildings progressively were
Alexandria, VA
22314-1488
bezzlement when that employee applies for a designed for more square feet per PT. The
aptamag@apta.org job with new company. Background checks are 4,250-square-foot building we constructed
good, but what if the embezzler has no criminal in 2009 was designed for eight therapists.
history and is a so-called “trusted employee” Our 2014 building with 5,000 square
who has worked elsewhere for several years? feet was designed for seven therapists.
I am disgusted that these criminals aren’t suffi- The 2019 structure comprising 10,000
ciently punished. Just because they have prob- square feet envisioned five therapists.
lems — who doesn’t? — doesn’t mean they are We increasingly are better positioned for
APTA Engage
engage.apta.org allowed to bite the hand that feeds them and physical or social distancing measures.
get away with it. Mandatory jail time should be Clearly, this was not in mind when the
imposed rather than the usual slap on a wrist. buildings were designed.
We will consider
BEVERLY RYDER 3. We strongly believe that maximizing the
letters, email, patient/customer experience with space is
and social media
a superior model that affords PTs optimal
posts that relate I CORRECTION
to magazine utilization as movement scientists.
articles or are of In the July feature article “Aiding the Olympic
While maximizing short-term return on invest-
general interest Dream,” Arnold Bell was identified as having
ment may be facilitated by higher patient and
to the profession. received his physical therapy certificate from
Responses may be therapist density, this strategy may not be op-
Columbia University. He earned the certificate
edited for clarity, timal for outcomes, value-based experiences,
style, and space, and from New York University. APTA Magazine
and safe communities. In the end, those may
do not necessarily regrets the error.
yield greater results in long-term ROI. We have
reflect the positions
placed our money and bricks in the latter.
or opinions of APTA
Magazine or the MIKE STUDER, PT, MHS, FAPTA
American Physical PRESIDENT, NORTHWEST REHABILITATION
Therapy Association. ASSOCIATES INC.
6 APTA.ORG/APTA-MAGAZINE
VIEWPOINTS
Opinion
cular strength through therapeutic exercise (Sun, 2018).
Physical Therapy, Studies have shown an association between increased
Reduced Opioid Use, muscular strength and decreased pain (Shakoor, 2008).
Similarly, and equally important, exercise can decrease an
and COVID-19 individual’s perception of pain (Koltyn, 1998).
PTs are highly qualified in prescribing and teaching appro-
Opioid abuse is a widely recognized public health crisis priate exercises for their patients. They also are experts at
in the United States, and the detrimental effects are educating patients on proper movement patterns and body
wide-ranging and severe (Hagemeier, 2018). Research mechanics, thereby decreasing pain and reducing the risk of
shows that individuals in pain, especially chronic pain, are injury (Langevin, 2006).
more likely to use opioids (Denenberg, 2016). But it doesn’t
Effective treatment involves understanding the patient’s
have to be that way. Physical therapy can create a path for
thoughts and fears related to their pain response. Knowl-
reduced opioid use.
edge of the patient’s mental state allows the PT to use
The disruption to daily life and the resulting economic appropriate manual therapy and introduce therapeutic
decline due to COVID-19 has the potential to cause an exercise and activity at the most opportune time. Under-
increase in opioid use. In turn, research suggests that standing the patient’s pain response allows the PT to
opioid use can exacerbate chronic pain and induce mood better educate the patient.
disorders such as anxiety and depression (Revadigar,
Promising research indicates that if patients with pain are
2020). This catch-22 between chronic pain and mental
educated on the cause of their pain, they experience less
health issues illuminates one reason opioids should be
anxiety about movement and about their pain in general
prescribed with caution.
(Louw, 2011).
Opioid use that exacerbates chronic pain is known as
Physicians with chronic pain patients in their care should
opioid-induced hyperalgesia, or OIH. While the exact mech-
strongly consider educating themselves on various nonphar-
anisms of OIH are still being researched, it is generally
macological methods available for treating chronic pain. In
accepted that prolonged use of opioids has the potential
general, education on pain management is sorely lacking in
to decrease the body’s ability to deal with pain naturally
medical school, and studies have found that many physi-
and increases the sensitivity of the body’s pain receptors
cians report feeling underprepared when dealing with chron-
(Yi, 2015). This creates a scenario in which opioid dosage
ic pain patients and opioid management (Chiasson, 2020).
must increase to maintain a level of pain relief, creating a
bidirectional recipe for increases in opioid use. Patients with chronic pain should be encouraged to take
an active role in their recovery. Research has shown that
Physical therapy has been shown to be effective at con-
trolling pain and decreasing opioid use by increasing mus- »
SEPTEMBER 2020 7
VIEWPOINTS
APTA Asks
patients who advocate for themselves and collaborate
on their care enjoy better outcomes (Hibbard, 2004).
Patients with chronic pain should be encouraged to
educate themselves about their condition and the full
biopsychosocial spectrum of treatments available.
FRANCIS STENEK, PTA
What trait, quality, or skill
CLINICAL CONSULTANT FOR BARDAVON HEALTH INNOVATIONS do you most look for when
References
hiring a PT or PTA?
Chiasson AM, Brooks AJ, Ricker M, et al. Educating Curiosity and someone who asks
physicians in family medicine residencies about
nonpharmacologic approaches to pain: results of an
questions. Someone with these
online integrative course. Fam Med. 2020;52(3):189- Volunteer service and traits will be a lifelong learner.
197. https://doi.org/10.22454/FamMed.2020.865003.
involvement in profes- LAURA COVILL, PT, DPT
Denenberg R, Curtiss CP. Appropriate use of opioids in sional development.
managing chronic pain. Am J Nurs. 2016:116(7):26-38.
doi:10.1097/01.NAJ.0000484931.50778.6f. RUSSELL STOWERS, PTA, EDD
Hagemeier NE. Introduction to the opioid epidemic: the
economic burden on the healthcare system and impact
on quality of life. Am J Manag Care Supplement.
2018:24(10):S201-S206.
Hibbard JH, Stockard J, Mahoney ER, et al. Development of Social skills and
the patient activation measure (PAM): conceptualizing
and measuring activation in patients and consumers. adaptability.
Health Serv Res. 2004;39(4 Pt 1):1005-1026. doi:10.111
GARRICK JONES, PT, DPT
1/j.1475-6773.2004.00269.
Koltyn KF, Arbogast RW. Perception of pain after resistance
exercise. Br J Sports Med. 1998;32:20-24. http://bjsm.
bmj.com.
Langevin HM, Sherman KJ. Pathophysiological model for Empathy makes
chronic low back pain integrating connective tissue and for a great physical
nervous system mechanisms. Medical Hypotheses. therapist.
2006. doi:10.1016/j.mehy.2006.06.033.
Louw A, Diener I, Butler DS, Puentedura EJ. The effect of ANUJ SHAH, PT, MA
neuroscience education on pain, disability, anxiety, and
stress in chronic musculoskeletal pain. Arch Phys Med
Rehabil. 2011;92:2041-2056. http://www.archives-pmr.
org/article/S0003-9993(11)00670-8/pdf.
Revadigar N, Gupta V. Substance induced mood disorders.
[Updated 2020 Mar 9]. StatPearls [Internet]. January
2020. http://www.ncbi.nlm.nih.gov/books/NBK555887.
Shakoor N, Furmanov S, Nelson DE, et al. Pain and its
relationship with muscle strength and proprioception in
knee OA: results of an 8-week home exercise pilot study.
J Musculoskelet Neuronal Interact. 2008;8(1):35-42.
http://www.ismni.org/jmni/pdf/31/16SHAKOOR.pdf.
Sun E, Moshfegh J, Rishel CA, et al. Association of early
physical therapy with long-term opioid use among
opioid-naive patients with musculoskeletal pain.
JAMA Netw Open. 2018;1(8):e185909. doi:10.1001/
jamanetworkopen.2018.5909.
Yi P, Pryzbylkowski P. Opioid induced hyperalgesia. Pain
Med 2015:16, Issue suppl_1, 1 October 2015:S32–S36. APTA encourages diverse voices. “APTA Asks …” poses questions that all
https://doi.org/10.1111/pme.12914.
members are invited to address, and we’ll publish selected answers. To
[For more information on physical therapy and participate, log in to the APTA Engage volunteer platform at engage.
apta.org, find the APTA National — APTA Magazine Member Input
opioids, go to www.apta.org and search “opioids.”
opportunity, and click the Apply Today! button for a list of questions.
Among the association’s resources is its 2018 “White Answer as many as you want. Responses may be edited for clarity, style,
Paper: Beyond Opioids: How Physical Therapy Can and space, and do not necessarily reflect the positions or opinions of
Transform Pain Management to Improve Health.”] APTA Magazine or the American Physical Therapy Association.
8 APTA.ORG/APTA-MAGAZINEVIEWPOINTS
I have not been included in the Flexibility is important in today’s
hiring process at any of my places ever-changing rehab world. If you
of employment, but I can speak are set in your own ways, it will
from comments that employers be harder for you, your patients,
expressed when they interviewed and your team to move in the right
me for positions. One, a positive direction. Being flexible will allow
personality brings energy that they you to apply new evidence-based
want to see in the workplace. Some approaches. After all, if we had
employers will overlook shortcom- not been flexible in accepting
ings of experience and skill if some- newer interventions, we would still
one is coachable and a pleasure to be drilling holes in skulls to treat
be around. Two, employers want movement disorders. We’ve evolved
someone who exhibits knowledge because of the work of PTs who
and tact when negotiating chal- were flexible in their thinking.
lenges in the treatment setting and
AMUTHA DESILVA, PT, DPT, MS
offers good conflict resolutions.
SONYA NEWLAND, PT
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SEPTEMBER 2020 9COMPLIANCE MATTERS By Kate W. Gilliard, JD
Familiarize
yourself with these
protections — and
know your ethical
responsibilities.
Students’ Privacy
Rights: Where
HIPAA and FERPA
Intersect
As current and future health care providers, PTs, HIPAA
PTAs, and students of physical therapy are bom-
If you aren’t sufficiently familiar with HIPAA,
barded with warnings and guidance on the Health
check out the February 2019 Compliance Matters
Insurance Portability and Accountability Act
column, “Are You Hip to HIPAA?” as a refresher
and its underlying rules on privacy and security.
course on the basics. (See Resources on page 14.)
It’s a complicated and sometimes burdensome
In short, HIPAA requires covered entities (provid-
Kate W. Gilliard, JD, law that’s nevertheless necessary to safeguard
ers, health plans, and health care clearinghouses)
is a senior regulatory patients’ protected health information.
affairs specialist to implement reasonable safeguards for PHI. The
at APTA. For PTs and PTAs working in schools and relat- U.S. Department of Health and Human Services
ed educational facilities, the regulatory hurdles administers and enforces HIPAA and promulgates
potentially are twofold, as both health care and rules intended to clarify and implement the law.
educational law come into play. The HIPAA-related rules most familiar to health
care providers are the Privacy Rule, which sets
10 APTA.ORG/APTA-MAGAZINEnational standards for the protection of individual- that receive no federal funds, such as many private
ly identifiable health information, and the Security schools, are not subject to FERPA.
Rule, which sets national standards for safeguard-
Rights granted by FERPA are to the parent until the
ing the confidentiality, integrity, and availability of
student either reaches the age of 18 or, at any age,
electronic PHI.
attends a postsecondary institution. Once either
condition is met, rights to access, amend, or con-
FERPA
sent to disclosure of educational records belong to
The Family Educational Rights and Privacy Act is students themselves.
a federal law that protects the privacy of student
education records. FERPA is administered and IDEA
enforced by the U.S. Department of Education and
Health and education law intersect in the provi-
applies to educational agencies and institutions
sions of the Individuals with Disabilities Education
that receive federal funds under any program ad-
Act, which requires schools and school districts
ministered by that department. Therefore, schools
SEPTEMBER 2020 11COMPLIANCE MATTERS
to provide a free appropriate public education to
eligible children with disabilities, and ensures
The Family Educational Rights and
special education and related services to those
Privacy Act (FERPA) is a federal
children. Physical therapy is a critical feature
law enacted in 1974 that protects
of special education and related services under
the privacy of student education
IDEA. Special education and related services are
records.
needed to ensure that children with disabilities
can access a free appropriate public education. The Act serves two primary
Because of the nature of related services, many purposes:
of which require a medical license, providers 1. It gives parents or eligible
of these services often sit at the intersection of students more control of their
HIPAA and FERPA. educational records.
Which Law Applies? 2. It prohibits educational
institutions from disclosing
What happens, then, when PTs or PTAs pro- "personally identifiable
vide related services within a school? They are information in education
handling PHI and thus seemingly are subject records" without written
to HIPAA’s Privacy Rule. But the services that consent.
the PT or PTA provides typically are mandated
by IDEA as part of the child’s Individualized
Education Program, making the PHI part of an
education record.
The Health Insurance Portability
Elementary and secondary schools. HHS has
and Accountability Act (HIPAA) is
made clear that elementary and secondary
a national standard that protects
schools probably are not subject to the HIPAA
sensitive patient health information
Privacy Rule for two reasons. First, schools are
from being disclosed without the
not typical HIPAA-covered entities, which usually
patient's consent or knowledge.
are described as health plans, health care clear-
Via the Privacy Rule, the main goal
inghouses, and health care providers who trans-
is to ensure that individuals' health
mit health information electronically. Covered
information is properly protected
transactions under the Privacy Rule are those
while allowing the flow of health
for which HHS has adopted a standard, such as
information needed to provide and
health care claims submitted to a health plan. A
promote high quality health care and
school that employs a health care provider such
to protect the public's health and
as a PT or PTA wouldn’t be subject to the Privacy
well-being.
Rule unless those employed providers submit
electronic claims to health plans.
Many schools do submit claims to health plans —
especially to Medicaid or its Children’s Health In-
surance Program. This would seem to make them
covered entities under the Privacy Rule. HHS
has indicated, however, that such schools still
are exempt from the rule because the records in
question, although medical in nature, are part of
the student’s educational record.
HHS states in its “FAQs for Professionals”:
“For example, if a public high school employs a
health care provider who bills Medicaid elec-
12 APTA.ORG/APTA-MAGAZINEWho Must Comply? Protected Information Permitted Disclosures1
• Any public or private Student Education Record: • School officials.
school: Records that contain • Schools to which a student is transferring.
• Elementary. information directly • Specified officials for audit or evaluation
related to a student and
• Secondary. purposes.
are maintained by an
• Post-secondary. educational agency or • Appropriate parties in connection with
institution or by a party financial aid to a student.
• Any state or local
education agency. acting for the agency or • Organizations conducting certain studies for
institution. or on behalf of the school.
Any of the above must
receive funds under an • Accrediting organizations.
applicable program of • Appropriate officials in cases of health and
the U.S. Department of safety emergencies.
Education.
• State and local authorities, within a juvenile
justice system, pursuant to specific state law.
• In compliance with a judicial order or lawfully
issued subpoena.
• Every health care Protected health • To the individual.
provider who Information2: • Treatment, payment, and health care
electronically transmits Individually identifiable operations.
health information in health information
connection with certain • Uses and disclosures with opportunity to
that is transmitted or
transactions. agree or object by asking the individual or
maintained in any form or giving opportunity to agree or object.
• Health plans. medium (electronic, oral,
or paper) by a covered • Incident to an otherwise permitted use and
• Health care
entity or its business disclosure.
clearinghouses.
associates, excluding • Public interest and benefit activities (e.g.,
• Business associates certain educational and public health activities, victims of abuse
that act on behalf employment records. or neglect, decedents, research, law
of a covered entity, enforcement purposes, serious threat to
including claims health and safety).
processing, data
analysis, utilization • Limited dataset for the purposes of research,
review, and billing. public health, or health care operations.
1. Permitted disclosures mean the information can be, but is not required to be, shared without individual authorization.
2. Protected health information or individual identifiable health information includes demographic information collected from the individual
and 1) is created or received by a health care provider, health plan, employer, or health care clearinghouse and 2) relates to the past, present,
or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future
payment for the provision of health care to an individual; and
(i) That identifies the individual, or
(ii) With respect to which there is a reasonable basis to believe the information can be used to identify the individual.
For more information, visit the Department of Health and Human Services' HIPAA website and the Department of Education’s FERPA website.
SEPTEMBER 2020 13COMPLIANCE MATTERS
itself, so telehealth is not an electronic transaction
for the purposes of HIPAA.
Resources
The same can be said for health care provid-
APTA ers who are not direct employees of the school.
Code of Ethics for the Physical Therapist | apta.org/your- HHS has stated that if a person is acting on the
practice-ethics-and-professionalism school’s behalf, such as when a provider is con-
tracted with the school or the school district, that
Standards of Ethical Conduct for the Physical individual’s records should be maintained as if
Therapist Assistant | apta.org/your-practice-ethics-and- they were directly controlled by the school itself.
professionalism This applies whether or not records are stored on
school grounds. Because the contracted provider is
HHS and ED essentially an agent of the school, that individual is
subject to the same rules as is the school.
Joint Guidance on the Application of the Family
Educational Rights and Privacy Act and the Health Contracted providers also should look closely at
Insurance Portability and Accountability Act of 1996 to their contract with the school or school district to
Student Health Records (December 2019 update, first determine if it dictates any standards not included
issued November 2008) | studentprivacy.ed.gov by federal law.
Because public schools are subject to FERPA and
HIPAA for Professionals Webpage (resources include thus exempt from HIPAA, it logically follows that
a link to a FERPA and HIPAA FAQ) | hhs.gov/hipaa/for- schools that are exempt from FERPA are subject
professionals to HIPAA. HHS confirms this, stating that because
private schools typically don’t received funding
FERPA Webpage | ed.gov/policy/gen/guid/fpco/ferpa
from the Department of Education they are not
Understanding the Confidentiality Requirements subject to FERPA — and they accordingly must
Applicable to IDEA Early Childhood Programs FAQ | comply with the HIPAA Privacy Rule with respect
studentprivacy.ed.gov to any individually identifiable health information
they have about students and others to whom they
provide health services.
However, if a private school accepts a student on
tronically for services provided to a student under behalf of the school district — an exceptional but
IDEA, the school is a HIPAA-covered entity subject occasional situation — that student’s records are
to HIPAA requirements regarding transactions. If, subject to FERPA. Similarly, publicly funded charter
however, the school’s provider maintains health schools are subject to the same rules as are tradi-
information only in what are education records tional public schools.
under FERPA, the school is not required to comply Keep in mind that IDEA has its own set of confiden-
with the HIPAA Privacy Rule. Rather, the school tiality requirements that apply to the records of stu-
must comply with FERPA’s privacy requirements dents receiving services under it. These regulations
with respect to its education records, including the generally are broader than are those under FERPA,
requirement to obtain parental consent (34 CFR § so they entail additional requirements. IDEA Part C
99.30) to disclose to Medicaid billing information regulations identify confidentiality requirements
about a service provided to a student.” that apply to infants and toddlers with disabilities
So, schools and the providers they employ are not and their families. IDEA Part B regulations apply to
subject to HIPAA’s Privacy Rule, but they do need to children ages 3 through 21.
comply with FERPA. Also, under HIPAA, a trans- Postsecondary institutions. Things get more
action is an electronic exchange of information complex for providers at postsecondary institu-
between two parties to carry out financial or admin- tions. The operative rule to apply depends largely
istrative activities related to health care, such as on the specific type of facility and the population
claims submission. It is not delivery of health care it serves. For example, a university clinic that
14 APTA.ORG/APTA-MAGAZINEprovides health care services to its students
is subject to FERPA alone for the purposes Regardless of what HIPAA or
of students’ medical records, as these are
protected by FERPA as “treatment records,”
FERPA dictates, PTs and PTAs
and HHS has excluded from its compliance
all records covered by FERPA. However, if
always are subject respectively to
the clinic also serves nonstudents, those in-
dividuals’ records are not subject to FERPA
the Code of Ethics for the Physical
and therefore are subject to HIPAA.
Therapist and Standards of
In some cases, students receiving treatment
from a postsecondary institution are not Ethical Conduct for the Physical
covered by FERPA. This mostly occurs at
university hospitals. Because these intu- Therapist Assistant.
itions are providing services without regard
to the recipient’s status as a student, patient
records maintained by a hospital affiliated
with a university that is subject to FERPA are
not considered “education records”
or “treatment records” under FERPA,
and therefore are subject to HIPAA.
Non-educational providers. What if
you have no affiliation with any edu-
cational institution but are asked to
provide your patients’ records to an
educational facility? In other words,
you are not subject to FERPA, but you
are being asked by a FERPA entity
to provide records. HIPAA address-
es this instance. A HIPAA-covered
entity, such as an outpatient PT, is
permitted to provide PHI to schools
and their health care providers for
treatment purposes, sometimes with-
out the authorization of the student or
student’s parent.
The Ethical Imperative
Regardless of what HIPAA or FERPA
dictates, PTs and PTAs always are
subject respectively to the Code of Empower your patients & increase compliance
Ethics for the Physical Therapist and
with comfortable and stylish medical
Standards of Ethical Conduct for the
Physical Therapist Assistant. Those
graduated compression garments.
documents require PTs and PTAs
to protect confidential patient and Request a free sample:
client information, and direct them to www.lymphedivas.com/APTA
disclose confidential information to
appropriate authorities only when per-
mitted or required to do so by law.
SEPTEMBER 2020 15ETHICS IN PRACTICE By Nancy R. Kirsch, PT, DPT, PhD, FAPTA
Silence isn’t always
golden. But find-
ing one’s voice in
the moment can
be difficult.
The
Power of
Speech
Nancy R. Kirsch,
PT, DPT, PhD,
FAPTA, a former
member of APTA’s
Ethics and Judicial
Committee, is the
program director
and a professor of
physical therapy at
Rutgers University
in Newark. She also
practices in northern
New Jersey.
16 APTA.ORG/APTA-MAGAZINEThe United States and the world ress in the time since has been slow positive for COVID-19, experienced
have been rocked in recent months — possibly, Mitch thinks, because mild to moderate symptoms, and
by a pandemic and a racial reckon- the peripatetic business owner has soon recovered.
ing. The first has drastically altered been testing the limits of physical
“It’s not a hoax,” Bob had responded,
our daily lives. The second has activity while his dealership has
“but it’s way overblown. Just look at
caused many of us to reconsider been closed. Bob has denied that
my cousin — he’s fine!” Mitch was
and reevaluate roles in helping to during their telehealth visits.
tempted to ask him what he made of
perpetuate a morally unacceptable
“I need to be in good shape now that the many thousands of COVID-19-
status quo. Consider the following
car dealerships have been given the related deaths in the United States,
scenario — a “small” story with
go-ahead to reopen soon,” Bob told but he chose not to go there.
broader implications.
Mitch recently. “You think I’m stupid
That conversation got Mitch to won-
enough to sabotage my own recov-
Corrosive Comments dering how compliant Bob will be
ery? Wait, don’t answer that!” he had
with the health and safety require-
After months of providing services added with a laugh.
ments to reopen his dealership. On
exclusively via telehealth due to the
Although Mitch scrupulously avoids another occasion the car dealer had
COVID-19 pandemic, Excel Physical
talking about politics, religion, and stated defiantly, “A firm handshake
Therapy is offering some in-person
other potentially controversial sub- and a slap on the back are big parts
appointments. Mitch, a PT who’s
jects with patients and clients, Bob’s of what got me where I am.”
been working there for five years,
made no secret of his disdain for
still is seeing most patients and Bob’s appointment at Excel gets off
all the health and safety measures
clients remotely but welcomes the to a shaky start when, before Mitch
endorsed by the CDC and backed by
chance to return to the clinic two even gets to the front desk area, he
lawmakers as conditions of reopen-
days a week under its stringent safe- can hear his patient arguing with
ing businesses.
ty protocols. Lisa, the receptionist.
“You don’t think the virus that laid
Among the first returning patients is “No, I didn’t bring a mask with me,
up your own cousin is a hoax, do
Bob, who’s well-known in the small and I don’t see why I should have to
you?” Mitch once had playfully chid-
Midwestern town as the owner of wear this one,” he’s nearly shout-
ed the businessman, referencing
Junction Motors, a used car dealer- ing as Mitch enters the room. Lisa
one of Bob’s relatives who had tested
ship known for its radio catchphrase is holding one of the masks Excel
“There are no jalopies at Junction!”
Mitch has seen Bob a number of
times over the years because the
latter, an outdoors enthusiast, has Resources at apta.org
sustained a number of hiking- and
climbing-related injuries. Bob also
APTA Coronavirus Webpage
has run unsuccessfully for a variety • Links to continuously updated official guidance for the
of local offices. He’s opinionated and physical therapy profession, best practices, and resources.
loud, and he rubs some people the
wrong way. Mitch likes him, though APTA Ethics and Professionalism Webpage
— especially the way he doesn’t take
• Core ethics documents (including the Code of Ethics for the
himself too seriously. About his
Physical Therapist and Standards of Ethical Conduct for the
repeated failures at the polls, for
Physical Therapist Assistant).
example, Bob’s standard line is, “I’ve
never had any problems getting peo-
APTA Cultural Competence Webpage
ple to buy what I’m selling — except
at the ballot box!” • Links to suggested activities to achieve cultural competence;
APTA’s initiatives toward diversity, equity, and inclusion; the
Bob tore an Achilles tendon just as
House of Delegates position statement; and more.
therapy clinics were closing their
doors throughout the area. His prog-
SEPTEMBER 2020 17ETHICS IN PRACTICE
provides for the patients and clients he snaps, referencing the black face says in a kidding tone, electing not
who lack one. covering on the African American to directly challenge a patient with
woman’s face, “but I’d prefer to wear whom he’s built a relationship of
“We all just need to stay safe,” Lisa
freedom on my mug.” trust and positive outcomes. Bob’s
responds with a warm smile.
expression immediately lightens
Lisa’s mouth is agape as Mitch
Both the receptionist and Mitch are upon seeing the PT.
intervenes from behind the angry
taken aback by what Bob says next.
businessman. “Please just humor us,” Mitch urges.
“Maybe you feel like you’re making “Nobody’s crazy about any of this,
“I see that quarantine has done
a fashion statement because that but, hey, these are the conditions of
wonders for your disposition!” Mitch
thing matches your complexion,” doing business right now. Our clin-
ic’s got bills to pay, just like you do.”
“I get that, doc,” Bob responds, “but
that doesn’t mean I have to like it.”
Bob grudgingly puts on the mask.
Considerations and Ethical Decision-Making
Once the PT and patient are alone
Our ethical principles as PTs and standards of ethical conduct as PTAs direct
in a treatment room, they quickly
us to consider not only the best interests of specific patients and clients, but
fall into their usual roles. Bob is
also of patients and clients as a whole, as well as of our colleagues in the
compliant and attentive, although
profession and the society in which all of us live. In situations in which all of
he twice asks Mitch if he can remove
those interests come into play, the best ethical decision can be made only by
his mask, and Mitch twice says no.
factoring these needs together and determining the optimal course of action.
The second time, the PT adds, “If
Realm. At play here are both the individual realm — concerned with rights, you think I enjoy wearing mine for
duties, relationships, and behaviors between individuals — and the societal hours on end, you’ve got another
realm. The latter is concerned with the common good and addresses social think coming. But, knock on wood,
responsibility. COVID-19 hasn’t entered this clinic
Individual process. Mitch is struggling to summon the moral courage to take yet as far as anyone knows. I’m not
an ethical action that likely will cause conflict with Bob. about to give it an opening.”
Ethical situation. Mitch faces moral temptation to doing nothing and “keep the Bob doesn’t mention masks again
peace.” The resulting moral silence will not, however, address the best inter- after that. As the session draws to
ests of anyone other than Bob and, arguably, of Mitch himself. a close, the two men make a bit of
small talk about the TV shows and
Ethical principles. The following principles of the Code of Ethics for the
movies they’ve been watching in
Physical Therapist provide guidance to Mitch:
quarantine, and they also commis-
• Principle 1. Physical therapists shall respect the inherent dignity and rights erate about technical issues they’ve
of all individuals. been having with streaming video
• Principle 2A. Physical therapists shall adhere to the core values of the and Zoom calls.
profession and shall act in the best interests of patients/clients over the Bob opens the door to the hallway
interests of the physical therapist. just as Raj, one of Mitch’s PT col-
• Principle 3D. Physical therapists shall not engage in conflicts of interest leagues, is passing the room. “Hey!”
that interfere with professional judgment. Bob calls out. “Doc and I here need
some tech support! I imagine you’ve
• Principle 5F. Physical therapists shall provide notice and information about got a big family back in Bombay.
alternatives for obtaining care in the event the physical therapist terminates Maybe one of your relatives can give
the provider relationship while the patient or client continues to need us a hand!”
physical therapist services.
The car dealer laughs heartily. But
• Principle 7. Physical therapists shall promote organizational behaviors he’s the only one cracking so much
and business practices that benefit patients and clients and society. as a grin. Raj regards Bob stonily
and shakes his head in disbelief
18 APTA.ORG/APTA-MAGAZINEbefore continuing down the hall.
Mitch is stunned to silence, thinking At a time when the nation is engaged
simultaneously about the offensive-
ness of the remark, the facts that
in a national conversation about race,
Raj grew up in the state capital and
comes from a small family, and the
baked-in prejudices, and the dangers
strangeness of hearing the word
“Bombay” when the city long has
of “business as usual” regarding
been known as Mumbai.
treatment of minorities, should Mitch
The PT wonders if he should take
the opportunity to talk with Bob have tried to engage Bob in the
about the corrosiveness of miscon-
ceptions, biases, and stereotypes. uncomfortable dialog?
Perhaps this is just months of
quarantine speaking, Mitch reasons,
and Bob is coming from a place of
fear and insecurity. Maybe he could
introduce the conversation that
way, by giving Bob the benefit of the
the dangers of “business as usual” For Follow-up
doubt and saying he imagines the
regarding treatment of minorities,
businessman didn’t mean to offend If you’d like to share your thoughts
should Mitch have tried to engage
Lisa and Raj. But Mitch also wonders on this scenario, and/or recount a
Bob in the uncomfortable dialog?
now if he missed past signs. Has similar experience and how you re-
What might that have accomplished?
Bob similarly offended other staff sponded, I encourage you to contact
Did Mitch owe it to his colleagues
and fellow patients? The thought me at kirschna@shp.rutgers.edu.
and the other patients with whom
troubles the PT. If you are reading the print version
Bob might interact to at least attempt
In the end, though, Mitch elects not such a discussion? Were that talk to of this column, go online to apta.org/
to stir up a potential can of worms. be unsuccessful, should Mitch go so apta-magazine and find this column
As Bob prepares to reenter the front far as to consider terminating the in the September 2020 issue. Look
desk area, the car dealer asks, “See therapy relationship? for the heading “Author Afternote,”
you on the computer next Monday, which features a summary of reader
On the other hand, Mitch asks him-
and back here on Wednesday?” responses to the scenario, as well as
self, what are his responsibilities
Mitch nods and responds, simply, my views on how the situation might
to Bob, a patient with whom he’s
“Monday.” be handled. If you are reading Ethics
built a longstanding and heretofore
in Practice online, simply scroll
With Bob finally out of the clinic, productive relationship?
down to “Author Afternote.”
Mitch approaches Lisa to see how
she is doing. “I’m sorry about Bob’s For Reflection Be aware, however, that it gener-
comments; they were out of line.” ally takes a few weeks after initial
All PTs, PTAs, and students of phys-
Lisa responds, “It’s fine. I’ve heard publication for feedback to achieve
ical therapy face situations in which
worse, so don’t worry about it.” sufficient volume to generate this
they must consider and weigh their
online-only feature.
But the PT does worry about it. A responsibilities to individual pa-
similar apology to Raj results in a tients, all patients, their colleagues,
shrugged “Whatever” response. themselves, and wider society. How
Mitch is left feeling regretful and serious — or benign — do you deem
wondering if he should have spoken Bob’s behavior to be? What would
up to Bob. At a time when the nation you have done, or might you con-
is engaged in a national conversation sider yet doing, were you in Mitch’s
about race, baked-in prejudices, and position — and why?
SEPTEMBER 2020 19Embedded PTs:
Changing the Face
of Physical Therapy
Embedded physical therapists, who treat specific
populations on-site, likely will play a large part in the
future of physical therapy.
By Michele Wojciechowski
20 APTA.ORG/APTA-MAGAZINERetired Lt. Col. Drew Contreras, PT, DPT, says one he had to figure out what needed to be done. But he
reason for his successful career is that he does his also knew when to refer a patient to a specialist.
best to treat every patient the same.
“A mistake that some people make is not know-
That skill especially helped him not to be starstruck ing their own limits. Saying that you need to get
when he served from 2010 to 2017 at the White more help for a patient can be very intimidating,
House as the first embedded PT in its medical unit. because you’re basically saying, ‘I can’t do this.’ As
In addition to serving as President Barack Obama’s an embed, you’re making yourself professionally Damien Avery
PT (a role he still fills for the now ex-president), vulnerable, which many people are not comfortable
Contreras treated members of Obama’s cabinet, with,” he notes. “But if you’re clearly there to serve
senior White House officials, Secret Service agents, the best interests of those around you, you need to
and the entire resident staff — including chefs, be okay with it.”
groundskeepers, and repair personnel.
Practicing at the White House, Contreras says
“I chose to be the first embedded PT because he was always on call — including weekends and
there was a clear need and — in the interest of the holidays. “Some people are fine with that and some
patients — it was better for me to operate out of the aren’t. That’s a challenge an embedded PT may
facility than to have them leave the White House to have to deal with.” Stephanie Bream
come to me,” says Contreras.
If you work as an embedded PT for famous people
He sometimes was asked if his being at the White such as politicians, athletes, or actors, Contreras
House was truly time and money well-spent. What says, you need to realize that you’re working for
about his idle time while he wasn’t needed? them. You’re not their friend. “People ask me if I’m
friends with President Obama. He’s friends with
“I would answer, ‘What do you think an hour of
Bruce Springsteen and Tom Hanks. We’re friendly.
these people’s time is worth?’” Contreras says. He
He’s polite and nice. We’ve gotten to know each
notes that when high-ranking people must leave
other . But I’m not inviting him to my home for a
the White House, there are scheduling and secu-
barbecue. Don’t be weird to them. They have enough Drew Contreras
rity concerns — all of which cost time and money.
weirdness in their lives,” Contreras says.
Imagine that happening eight to 10 times a day.
In addition to cost savings and convenience, Working in Corrections
there’s another consideration: “I was a vetted,
trusted agent. They knew I wasn’t going to run off Capt. Damien Avery, PT, DPT, has spent a lot of
and tell the Washington Post who I’d treated, or time behind bars in the past 20 years. But it’s
write a book to make money off someone’s health all because of his work as a PT at the Federal
care issues.” Correctional Complex in Butner, North Carolina,
and as a captain in the United States Public Health
Contreras says his role was not only professionally Service detailed to the Federal Bureau of Prisons. Jason Hause
rewarding but also professionally stressful.
Avery is an embedded PT assigned to the ortho-
“It was rewarding because I was practicing at the pedic team, which additionally consists of an
top of my license and skillset,” Contreras says. “I orthopedic surgeon and two orthopedic physician
was the one PT there, and a lot of responsibility assistants. “I have privileges as an advanced prac-
comes with that. My decisions really impacted tice physical therapist, much like our sister-service
people, and if I were to do something wrong there PTs in the Army, Air Force, and Navy,” Avery notes.
was no other PT there to help.” “I can order imaging and lab testing. I cannot order
medications and rely on my PA teammates for
While he says that a few support staff such as
help with that. My role,” he explains, “is more of Mike Kelly
licensed practical nurses and medics were present,
an orthopedic surgeon extender, in that I run and
for the most part they were doing their jobs at other
schedule clinics, and triage orthopedic consults
locations in the White House. “The problem with
and patients. I am the primary liaison between
being an embed is that I didn’t have a cohort of
orthopedics and the rehabilitation department,
colleagues to consult with,” Contreras says. He also
which consists of PTs, occupational therapists, and
needed to be a jack-of-all-trades. “I couldn’t say, ‘I’m
wound care nurses.”
the knee guy’ or ‘I’m the spine guy,’” he points out.
The benefits of the prison system having an
For example, on one occasion a repairman caught
embedded PT are threefold, Avery says: safety,
his finger in a fan while fixing an air conditioning
cost, and continuity of care. Ivan Matsui
unit. Although hand therapy isn’t Contreras’ focus,
SEPTEMBER 2020 21A PT inside the prison system must recognize the
practical limitations of this environment. “For exam-
ple,” he says, “a home traction device, or even an
exercise band in some instances, could be used by
an inmate-patient as a makeshift ligature. We also
have to recognize the risks of prescribing assistive
devices or adaptive equipment, and their poten-
tial as weapons and objects of abuse. A cane, for
instance, can be used as a weapon against another
inmate or staff member, and a TENs unit can be
used to fabricate a tattoo device. We are very careful
to issue equipment based on calculated need and are
quick to confiscate items when they are abused.”
Despite these risks, Avery enjoys his practice setting.
“I get a deep sense of satisfaction from problem-
solving and helping my patients,” says Avery.
“Other health care practitioners welcome and
respect my perspective when I acknowledge my
role as being complementary to theirs, and express
that I’m ready to fully collaborate on achieving an
optimal patient outcome.”
Primary Care Team Member
Although Ivan Matsui, PT, is an embedded PT who
practices in a health care system, unlike many
of the PTs profiled here, he practices in the same
exam room alongside the patients’ primary care
“Every patient who is seen on-site physicians.
decreases risk of escape to the As assistant director of rehabilitation services at
Kaiser Permanente Medical Group, Greater Southern
community during a trip into town. Alameda Area, California, Matsui says the biggest
reward of working directly with physicians is the
Also, most inmates require an mutual respect. “None of us knew what each other
did in our own patient exam rooms, so we learned a
escort of two correctional officers lot and gained more respect for one another,” he says.
That’s not the only benefit, though.
— sometimes three — which has an “Patients see us much more quickly,” he adds.
inherent cost attached.” Matsui explains that patients get to see a PT
immediately while they are visiting their primary
— Damien Avery care provider. Embedded PTs in the Kaiser system
primarily manage musculoskeletal issues for
patients of all ages, including those following motor
Capt. Damien Avery, “Every patient who is seen on-site decreases risk of vehicle accidents and those related to low back pain,
PT, DPT, a member of
escape to the community during a trip into town. shoulder limitations, spinal conditions, and knee,
the U.S. Public Health
Service, is detailed to Also, most inmates require an escort of two correc- hip, and ankle/foot/hand limitations.
the Federal Bureau of tional officers — sometimes three — which has an
Prisons.
inherent cost attached. Often, treatment in the com- If the patient doesn’t need additional physical
munity requires multiple town trips for follow-up, therapist interventions following the primary care
which multiplies the cost,” explains Avery. Being visit, there’s no additional cost, as physical therapy
inside the prison addresses both issues, allowing is included within the PCP visit, explains Matsui.
for better continuity of care. He adds that physical therapist evaluations are not
conducted during the initial visit — just a determi-
One challenge, however, is the potential repurposing nation whether the patient needs to receive physical
of rehabilitation equipment for undesirable uses. therapist management.
22 APTA.ORG/APTA-MAGAZINEYou can also read
