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ADVANCE Perspective: Physical Therapy & Rehab Medicine

Confronting Clinical Autonomy

Published July 11, 2011 9:49 AM by Lisa Lombardo

In our July 11, 2011 issue, our Management Focus story "A More Direct Approach" by Larry Briand, MS, PT, ATC, and Kevin Svoboda, PT, discussed how practice owners can hone their referral approaches in this new era of direct access for PTs.

They brought up a point that especially got my attention. They stated, "Some hurdles still block the implementation of direct access in the four states that do not fully recognize the professional training and skills of physical therapists. It can be argued that one of the largest hurdles is PTs themselves. Some therapists have become accustomed to the traditional referral source relationship and may be afraid to assert their independence and claim their share of the patient market."

The authors go on to say, "Therapists should recognize that direct access is a great way to grow a PT practice and should work to encourage its implementation. This can help advance the physical therapy discipline and ensure its longevity and recognition of credibility."

It's an interesting notion-therapists almost unwittingly standing in their own way of true clinical autonomy. It struck me after attending a session at PT 2011 last month, "Practice Autonomy: Strategies to Help You Stand and Deliver," presented by Laurita M. Hack, PT, DPT, and Dianne V. Jewell, PT, DPT. They opined that some therapists have gotten wary of the word "autonomy" but that many therapists have the right to use it.

Drs. Hack and Jewell emphasized that they weren't just presenting to merely promote the APTA's policy stance to direct access. They argue that the concept of true autonomy is often tied up with who owns a practice-that ownership is the only true autonomous state.

But ALL therapists can and should exercise clinical autonomy-what they do directly with their patients.

"Clinical autonomy is essential to practice for our responsibility to act solely in the patient's interest," Dr. Hack said. "Therapists need to be able to make informed, uncoerced decisions."

Clinical autonomy is possible in any setting, not merely private practice, said Dr. Jewell. "Therapists need to know the dynamics of where they work and apply it. Autonomy doesn't mean running amok; it's about our context with our patients and their families."

Perhaps the barrier to autonomy exists due to the fact that the traditional medical model still tells therapists the physician is in charge. In addition, clinical autonomy can be hampered by documentation and productivity issues in private clinics. Other barriers include referral relationships-as Briand and Svoboda suggested-staffing issues and third-party payer contracts.

Do you feel like you are free to practice true clinical autonomy? Are there barriers you constantly face to having your own say in how you treat a patient, or do you feel open to make day-to-day decisions on treatments for patients when needed? How has this influenced the setting in which you choose to work?

Lisa Lombardo is editor of ADVANCE and can be reached at


Lisa, you are correct that many therapists stand in their own way. I was having an issue with a herniated C4-5 disc so I went to a colleague who had recently achieved Mckenzie certification as well as her DPT. I asked her to treat me and I would pay out of pocket whatever her fee was. She balked. She wanted me to get an MD referral and go to the private practice that she worked within. I asked her, "isn't this what you just did all this work for?" She treated be at home, I got better, I paid out of pocket because I knew she knew her stuff and I knew I would get better treatment than if I went through my insurance company's approved providers.

It had never occurred to her to seek out private clients, to valuate her own services, or to work outside of the usual norm. I'm happy to have paid her directly, that no money went to the practice owner and that she got the full amount for her services.

How many more PTs need this kind of boost?

Dean Metz July 14, 2011 1:43 PM

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