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Toni Talks about PT Today

The Skilled Nursing Facility Conundrum
by Toni Patt

Last week I was involved in a discussion regarding membership in the APTA. For once the topic wasn't new graduates but therapists who were members but no longer are. The question was, what would it take to bring them back in? What do they value? I responded by describing how a SNF functions. Fix that chaos and they'll return.

SNFs are unique. Their purpose is to provide rehab for patients who can't tolerate three hours of therapy and can't return home. They are usually part of a nursing home because those patients also require nursing. The crux of this dilemma is for those patients, therapy is a priority and reimbursement is based on therapy.

Maybe in the beginning it worked. Now we have the bare minimum of staff doing the best they can to provide quality care. SNFs are staffed heavily with PTAs. The PT primarily does evals, re-evals and therapist summary notes. Productivity requirements hover around 90%. That doesn't leave adequate time for documentation.

Some facilities do point-of-service charting, which basically means spending time inputting data into a device rather than with the patient. Some payers don't want point-of-service documentation because they are paying for therapy time, not documentation time. I worked, briefly, at one place where the only way to meet the various demands was to work off the clock, which is illegal. Thus why I say I only worked there briefly.

Equipment in SNFs is limited. There is little capital budget for purchases. If something breaks, there often isn't money to replace it. DME for patients is also problematic. If the patient's insurance can't be billed, the patient will either receive something off the shelf or have to wait until going onto Medicare part B. No facility wants to pay for DME or equipment out of their reimbursement.

SNFs do not pay staff well. This is true of both nursing and therapy, although therapy fares a little better. Lower salaries aren't going to attract quality workers. Nursing care suffers. Medicine and medical supply levels are strictly monitored.

Changing this means changing legislation. The APTA would have to lobby, and lobby hard, for those changes and that costs money. Currently those lobbyists and that money are focused elsewhere.

The problem is SNFs are only one piece of the puzzle. Similar issues exist for home health, pediatrics, inpatient rehab and everywhere else PTs work. Thus we have one very large reason PTs and PTAs drop their membership in the APTA. They don't see any value.

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Facilities Don't Want to Pay for PT Experience
by Toni Patt

Previously I've written about the financial burden on newly graduated DPTs. If undergraduate costs are included, a new graduate could be as much as $100,000 in debt. The debt is driving decisions about jobs, salaries and benefits. Until last week, I hadn't considered the effect this is having on more experienced therapists.

A friend of mine from another state called me. She lost her job. She wanted advice. She has been filling out applications and sending out resumes. She's had a few interviews but says they didn't go well. She put on her best face but felt like the facilities weren't really interested in her as much as going through the motions. One sent her an email the next day stating another candidate had been selected. The rest haven't contacted her.

She lost her job because the facility downsized. It was losing money and had been for a while, so they cut staff to reduce the cost of salaries. She thinks she was laid off because she had the highest salary of everyone in the department. I'm not sure if that is legal but she is probably right. Salaries are one of the biggest expenses in healthcare.

Facilities don't want to pay for experience. It's been a long time since experience mattered. Everyone wants a revolving door of new grads. Hire a new grad and replace him with another when he moves on. If the same position is constantly held by PTs with little or no experience, the salary remains near the bottom of scale. Even at prn rates, the facilities save money.

This means those of us from back in the day are at a disadvantage. Changing jobs becomes problematic. It might mean staying in a job you hate just to have a job. Or accepting another job you don't really want with a pay cut for the same reason. Or you could work prn at several places and make more money but lack benefits.

This truly concerns me. There is no hope the situation will change in the near future. I just have to hope that I don't experience it.

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Why Nothing Will Change at the APTA
by Toni Patt

In my last blog, I described my concerns that nothing will change with the APTA, expensive consultant group or not. I expect them to continue with the same message but repackage with new words. I see subtlety in their future. The reason I don't expect change is simple. The same people will still be in charge.

No one is stepping down from a leadership position. No one with new ideas is coming into the fold. Therefore the ideas haven't changed. APTA leadership has an agenda. That agenda hasn't changed and won't. The approach might be different but the goal is the same. It might work for a little while.

All we'll have to do is follow the money. It will go to the same places through the same people. I've heard enough updates from those people to know the general strategy. They get limited face time with lawmakers so keep to the talking points. Those talking points aren't going to be any different. They could bring up other issues but won't.

What those leaders fail to realize is even if they got everything immediately, nothing would change. It wouldn't be a reimbursement issue or a practice act issue. It wouldn't be conflict with physicians. It is our consumers. Consumers of therapy services don't see the value of therapy. They go because the physician tells them to go. If they're in a facility, they're a captive audience.

I've worked in numerous facilities. Most of the patients don't really want to go to therapy, or if they do, only on their terms. Yesterday I overheard one woman complaining that therapy comes whenever they want and takes you away. You can't watch your TV shows. You can't take a nap. You miss your physicians when they come.

If the general public thought physical therapy was valuable and started demanding better access, better reimbursement and coverage for equipment, more time in rehab facilities, then things would change. If all the lobbying groups for seniors got together and pushed for those things, there would be changes. It doesn't happen because no one sees the value of doing so.

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Is the APTA Repackaging an Old Message?
by Toni Patt

I've spent more time thinking about the "new" APTA. This could be a golden opportunity for the APTA to reinvent itself and address the needs of its current non-members. By asking questions and actually listening to the answers, its membership might grow and it could become a true association of the profession.

Alas, I just don't think so. I expect something along the lines of reshaping the message to fit the needs. Yes, they're going to listen to what we say. They're going to ask what keeps us up at night. Then the old message will be repackaged to appear to address these needs. Call me a cynic.

Vision 2020 has been scrapped. The new vision statement is more vague and ambiguous. There are lots of different interpretations possible. That was deliberate. Even the goals are vaguer. They want to improve society, the association and the profession. Direct access is written into the profession goal and implied in the society one.

I agree patients need easier access to our services but not at the expense of the profession. The Texas Physical Therapy Association didn't listen to what I had to say. I gave them some answers to their burning question about being up at night. What I said didn't fit into their vision of what the answers should be, so I was ignored.

Maybe they thought I didn't know. Let's consider my sources. I write this blog and get regular feedback from readers. I teach a continuing education course that requires me to travel around the country. I get to talk to a variety of other therapists. If this were research, that would be a good sample. I hear the same things everywhere. Yet, apparently this isn't enough to be considered as feedback.

Instead of making significant changes, I think the goal isn't to change the message but to change the form of the message. The message will be phrased to appeal to the masses without a change in substance.

That isn't going to work. We're not stupid. It wouldn't surprise me at all if we're having the same conversation in a year or two. Then the APTA will be wondering why the new message didn't work. It would never occur to them they are focusing on the wrong message and goals.

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A Glimmer of Hope for the PT Profession
by Toni Patt

Last weekend I attended a Texas Physical Therapy Association (TPTA) meeting. The purpose was to rethink our strategy for the next few years. It seems the American Physical Therapy Association (APTA) has been researching why its message isn't being received. Thousands of dollars were spent on consultants to tell them why this has been happening. The answer was simple.

The APTA is getting the message out but members perceive this as being shouted at and aren't responding. As a result, the APTA is working on changing both the message and how it is delivered, starting with a new vision statement.

The consultants also told the APTA that concentrating on direct access has alienated therapists. The perception is that direct access only affects a portion of practicing PTs and by focusing on it, the remainder are feeling ignored. I could have told them that for a lot less money. Now the APTA, and by extension, the TPTA are switching gears and focusing on listening to members. They want to learn what keeps the average therapist up at night.

I think we've been expressing ourselves clearly. We don't agree with the message and aren't joining the APTA. Nor are we giving money to the APTA PAC. I think this very clearly says we don't agree with what is being done and how the money is being spent. We aren't going to support those actions. Grassroots therapists are putting their money where their mouths are, so to speak.

To me the remainder of the meeting was an exercise in frustration. I can give them some reasons why we aren't engaging. I can give them some examples of what keeps PTs up at night. I tried to do that and discovered that while we are now asking the questions, no one is listening to the answers. I was actually told I was wrong.

While this is a step in the right direction, more is needed. Those in leadership positions need to let go of their preconceived notions. Our leadership seems to have already decided why we're not listening. Nothing I offered was taken seriously. Finally I just sat back and watched.

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Texas Is Getting Another PT School
by Toni Patt

I recently learned Houston is getting another PT school. It's still in the planning stages. They are looking for individuals to develop and open the school. I'm not sure how long that takes but I would guess it will be a few years before the first class is accepted.

I find this unbelievable. Texas has more PT schools than almost any other state. We have two in Houston and five or six in surrounding cities. Houston also boasts three PTA programs. It isn't that I think we have too many schools. No, my concern is where are these new graduates going to work?

Over the past several weeks, I've been writing about the problems facing physical therapy as a profession and new graduates in particular. Furthermore there is no reason to believe the economy is going to improve or that reimbursement for our services will increase. If anything, the trend appears to be the opposite. There will be fewer jobs with lower salaries.

We don't need more new graduate DPTs. We already have an excess of new graduates awash in debt with limited employment options. Adding more graduates to this pool will mean more people are competing for the same number of jobs. An excess of applicants will help keep salaries suppressed.

Yes, I know PT school is difficult to get into but that may change as fewer people choose the profession. I see great irony in the deterioration of the profession being caused by direct access, which is touted as the end-all for physical therapy. How nobody even thought of this is beyond me.

The one thing we don't need is another PT school. We need to start addressing all the other problems facing the profession.

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What Can We Do About the Problems Facing Physical Therapy?
by Toni Patt

For the past few weeks, I've been blogging about problems within the profession of physical therapy and our frustrations over them. Everyone agrees on the problems. There is probably some disagreement on which ones should be addressed first. After all, they are interdependent. Attempting to improve any of them would be a step in the right direction.

There is another thing we all agree on. The APTA isn't doing much of anything about what we're complaining about. No one is even talking about these issues. Everything is focused on direct access. I've seen previous budgets for the Texas Physical Therapy Association. All of the PAC money is earmarked to promote direct access. I've heard legislative reports. The hot topics are direct access and preserving our piece of the outpatient billing pie.

I think by now I can make another general statement. We are starting to believe no one is going to address these problems. At least no one will until direct access is fully achieved. Should that happen, emphasis will then switch to getting reimbursed for that practice. The rest of us will just have to wait. The dire predictions we've been making will have plenty of time to come into being.

I don't remember when the APTA narrowed its focus to the special interests of a select group. In the earlier years, I don't remember it standing for much of anything. It was supposed to be for everyone and maybe it was. Not anymore.

The changes of the last few years aren't helping the profession. Maybe the DPT was the right way to go but implemented poorly. Direct access needs to be addressed but not instead of everything else. Most of us would just like job security, yearly salary increases and adequate staff to treat our patients.

The real losers here are the patients. No matter what level of care our patients are in, they are not getting the care they deserve. We're so overworked we can barely spend the minimum of time with anyone. Our equipment is inadequate or dated or both. Support staff is limited to barely enough to manage the paperwork. When we complain, the answer is the same everywhere. There is no money in the budget.

I could go on and on about the numerous ways lack of funding is affecting our patients. There is no money for equipment. There is no money for DME. There is no money for orthotics. There is no money for adaptive equipment. No one gets enough therapy. For most of us, new technologies are something to be admired at the Combined Sections Meeting. Many of us from back in the day are trapped in jobs we don't like because there are no other opportunities.

But we have to have direct access. We have to be DPTs.

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The Future of the Physical Therapy Profession?
by Toni Patt

As I read the responses to my latest blog on the ADVANCE website and Facebook page, I noticed a couple trends. First, why would the APTA push the DPT without consideration of the economic consequences for new graduates and the profession in general? Second, many of us are encouraging others to enter the profession as PTAs instead of PTs. The two go hand-in-hand.

We have the DPT because the APTA wants practice without referral. They created the DPT to make it happen. It had to be the entry-level degree to avoid confusion over who could and who couldn't practice without referral. If everyone is a DPT, anyone could practice without referral. If the degree was optional, it would create numerous problems.

Among the unintended consequences are the situations we have now. No one saw the salary situation because no one seriously thought about it. Why anyone would think salaries would be adjusted upward because of an arbitrary decision that had nothing to do with the realities of reimbursement and healthcare economics is unfathomable.

More people will be entering PTA programs. Competition for those slots will become more intense. That opens up all kinds of new considerations for the future.

Meanwhile, PTs and DPTs will be in less demand because they want more money. The way we practice is going to change. The model will shift toward one or two PTs with numerous PTAs. This is already happening in SNFs and home health. In turn, that trend is going to impact DPT programs, salaries etc.

I think the trend will be toward using more prn DPTs. Full-time benefited DPT positions are going to be more difficult to find. Those available will not have salary increases. Facilities would rather have prn employees because they don't have to pay for benefits. New grads will take those prn spots to get the higher salaries. For the most part it will work.

This is not a good time for our profession. I've heard several vision statements for beyond 2020. None of them address these issues. The APTA needs to recognize it has a problem. When practicing PTs are discouraging others from entering the profession, it is a problem.

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Who Will Want to Be a PT?
by Toni Patt

I've been reading the feedback on last week's blog. Everyone recognizes the problem. It costs more to go to PT school than the salary will support. I suspect many people saw this coming. I did. I'm kind of amazed the people who crafted this grand scheme didn't consider a serious consequence.

If I wanted to go to PT school today, I couldn't afford it. I wouldn't even be able to consider it as a career. I put myself through college. Under those same circumstances today, I would spend the majority of my career paying off that debt. If I did consider grad school it would be for something different.

In the past year, I have discouraged four people from PT school. I didn't tell them it was a bad career. I explained the financial side of the equation. Instead I pointed them toward being a PTA, a PA, nurse, or OT. The amount of schooling varies with these professions but the debt is less.

As more and more potential PTs decide on something else there are going to be consequences. We will lose the best candidates to other professions. There will probably be fewer PTs graduating but more PTAs will be entering the field.

Practicing PTs will spend more time evaluating and re-evaluating than treating. That's already becoming a trend. Staffing models are changing to several PTAs and fewer PTs. Salaries aren't going to change. If current trends continue, salaries will be stagnant at best. A new grad might get raises the first few years but will hit the ceiling sooner and at a lower rate. Even if reimbursement improves, PT salaries aren't going to be a priority.

Ironically, increasing our salaries is the one thing that would probably boost support for the APTA. I have yet to see them address it except for the outpatient world. Several years ago, when the DPT wasn't a reality, I read salaries were expected to rise to meet the demands of the newly graduated DPTs. Otherwise they wouldn't be able to employ them. Obviously that isn't happening.

Experienced PTs are also going to feel this. It is less expensive to hire a new grad than an experienced PT. Retention has become less important. That may change if the only way to hire new grads is to pay them prn rates or bring them in higher on the pay scale. Any potential savings will be lost. I guess I'll still have a job for a while.

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When a Physical Therapist Position Doesn't Pay Enough
by Toni Patt

We recently hired a new graduate as a prn therapist. We offered him a full-time position. He turned it down because it didn't pay enough. He gave the same response to three other facilities when they offered him positions. None of them paid enough. He now works as a prn therapist at two or three facilities.

All three of the facilities offered similar salaries and benefits. The only differences were location and setting. His wife works full-time. He gets his insurance through her employer. He isn't eligible to participate in retirement planning or other services at my facility. I don't know about the others. Those things aren't as important to him as making more money.

I don't know how much debt he has. His wife worked full-time while he was in school. I assume he has some loans since the cost of his DPT is more than $20,000. That's a lot of money on top of supporting a family on one income.

He is probably a typical new graduate, or maybe a little ahead of the rest since he had a spouse working while in school. He has debt that he must pay off but the majority of employment opportunities aren't offering salaries that allow him to do so. His goal is to work prn for a few years until he has some experience. Then he believes a full-time position will pay enough.

I'm not sure that will happen. I make the same thing I made more than four years ago. Given our current environment, I don't see much increase in salaries for anyone. Nonetheless this is the situation faced by new graduate DPTs. The salaries offered don't pay enough to earn a living and pay back loans.

I know of three people who've decided against physical therapy as a profession for that very reason. I think we'll see more of that over the next few years. The question is, what will that leave? Will PT school be limited to those who can afford it without debt? Or will the most capable choose other careers to avoid the debt? Both? We'll have to wait and see.

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My Patients Are Sicker Than Ever
by Toni Patt

We're all well aware of the fattening of our patients. Years ago facilities rented bariatric equipment. Now they own it. Obesity compounds other medical problems as well as interfering with mobilization, and the trend continues. I've noticed another trend that doesn't seem to be getting attention. Our patients are sicker than they've ever been.

My facility has always been known for accepting critically ill patients. But the ones we get now are more dead than alive. It isn't that they're acutely ill. Acuity doesn't always correlate with severity of illness. Some of them have been chronically ill for years. The severity of how ill they are has changed.

Even our "better" patients are in bad shape. Our liaisons aren't going out of their way to find these patients. This is what is in our hospitals. This is what is being discharged. The less severely ill are being sent home.

Nursing homes are also feeling it. I've heard several complaints on the weekends of how the admissions aren't as good as they used to be. Trach patients are much more common.

We can blame our reimbursement structure for some of this problem. In an LTAC, the sicker the patient is, the higher the reimbursement for care we receive. The same is true of DRGs. On the flip side, payers limit the length of stay so the less sick are sent home to be cared for by home health.

The other piece of this puzzle is that patients are living longer and developing more chronic diseases. Combinations of DM, HTN, renal failure and CHF pack quite a wallop, especially if they're not well controlled. I can't remember the last evaluation I did that didn't list something in the past medical history as out of control.

It isn't going to get better. It is the way things are now.

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The Patient Is Always Right No Matter What
by Toni Patt

My facility has instituted a new policy: Keep the patient happy no matter what. Staff has been instructed to think of patients and their families as clients. Happy clients tell friends about their experiences. We want those friends to choose our facility if they ever need long-term care. That way we can maintain our financial goals.

Nothing is more important than achieving that goal. Patients and families who complain are termed priority patients and must be kept happy. For example, a Spanish-speaking family complained that not everyone caring for their mother spoke Spanish. As a result, we now have a contract with a telephone translation service, with the number posted in every room. A formal letter of apology was given to the family.

Our liaisons are telling outright lies to potential admissions. They have been told to promise anything. It will be provided once the patient is admitted. Needless to say, staff isn't very happy about this. It falls to us to meet these outrageous demands and keep the unhappy happy.

So far, rehab has escaped the worst of this. Administration has already decided to remake all departments in the image of nursing. Thus all departments will be expected to respond to demands in the manner of nursing. It won't work but until it fails horribly, the expectation will be there.

What administration fails to understand is there are some people who will never be happy. The more they accommodate, the more those people will demand. Staff will be the ones caught in the middle. I wonder how many good workers are going to leave as a result. Meanwhile those people will still be unhappy.

There are so many other things that could be stressed that would have a positive impact on the facility. Keeping staff happy should the priority. They are the ones who do the work. All I can do is watch this play out.

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When a Patient Refuses a Bedside Commode
by Toni Patt

"I'm not sitting on that."

This week I have a patient who refuses to use a bedside commode. He refuses to allow us to position the BSC over the toilet to increase the height. He refuses to do anything but use the toilet in his room. Many people feel the same way, although the BSC is considered an improvement over a bedpan.

There is just one problem. The patient in question has an incomplete spinal cord injury and has been chronically ill the past few months. The only way he can use the toilet is if someone lifts him on and off of it. He can walk to the bathroom. He can do a pivot. What he can't do is the sit-stand from the toilet. Between his spinal cord injury and multiple orthopedic injuries, he lacks adequate flexion in the necessary joints.

The simple solution is to put the BSC over the toilet, which would compensate for the ROM restrictions. He won't let us do it. He wants to use the toilet and expects someone to be available as a human lifting service. Worse, he complains if the person isn't available on demand because he doesn't want to have to wait.

Bedside commodes aren't known for comfort. They're designed to allow people with weakness and joint restrictions, just as this gentleman, to use a toilet with minimal assist. All I can do is shake my head. Because he requires assist to get on and off the toilet, he ends up sitting there waiting for the one person who can perform the transfer.

Sitting that long on a toilet can't be any more comfortable than sitting on a BSC for any length of time. I don't understand the logic. Is it that important to say, "I was able to use the toilet, not a bedside commode," to go through all this?

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Treating a Difficult Patient
by Toni Patt

"I'm paying to be here and be taken care of. You will do what I tell you."

It's bad enough we struggle for respect from physicians and occasionally other disciplines. I would say the majority of the population doesn't know what we do or the amount of education required to be a therapist. Usually if we work hard and prove ourselves, the respect follows. Or we generate recognition that what we do requires skill and training.

That wasn't true of a woman I attempted to work with last weekend. She had just arrived to the SNF and wanted to go to the bathroom. When I arrived, she was still on the gurney demanding a RW be given to her so she could walk to the bathroom. When I told her I wouldn't do that, I got the response quoted above. She seemed to think I was a servant, not a trained and skilled therapist.

At that point, I knew nothing about her because I'd been called to the room without explanation of what was needed. The only information in the old chart was her diagnosis of THR and ambulation of 15 feet with moderate assist. That's not a lot of information, certainly not enough for me to plop a RW in front of her and let her be off to the bathroom.

I tried to explain the process to her. This resulted in being told I was rude by both her and her son. Her son pulled me into the hall and threatened to have me fired on the spot as well as have my license removed. He actually behaved worse than that. Meanwhile his mother was still demanding to go to the bathroom very loudly. They both believed I should just deliver the RW and let her be.

The EMT person made things worse by saying the patient did it at the hospital. Yes, but did she do it correctly? The EMT had no way of knowing.

I was the bad guy because I wouldn't simply put the RW in front of the patient, but actually wanted to do an assessment and make sure everything was done safely and properly. The patient, her family, the EMT and nursing didn't seem to think any of that was necessary. The woman said she could do it. That was enough for them.

No one seemed to understand that PT is a skilled service. A PT can't just deliver a RW because the patient wants one; much less leave it in the room without assessing the patient. I made everyone angry because I wanted to do things the right way. The patient's demand was more important than using clinical judgment and making sure everything was safe.

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APTA Membership: Cost vs. Benefit
by Toni Patt

I've been reading the responses to my various blogs over the past few weeks. The responses seem to be echoing what I've been saying. Hardly anyone has had anything to say in support of the APTA. Many explain why they don't belong.

The general consensus is the APTA doesn't represent the majority of PTs and PTAs. No one wrote in support of its current focus on direct access. While no one specifically said it, there continue to be negative feelings about moving to a DPT. Concerns were voiced about cost, additional years of school and stagnant salaries that aren't enough to pay back school loans.

Many writers had other suggestions for the APTA on where to direct its attention and money. I can think of only two people I know who contribute to the APTA and TPTA. I've contributed to the TPTA but will not give the APTA anything. No one is going to donate money toward something they don't believe in. I wonder if it has occurred to anyone at the APTA that this might be a reason for the difficulty in raising funds.

The only positive comments I read were for the chapters and sections. Several people would join at the state level. In order to address the cost issue of membership, the APTA has developed some payment options. But I don't think cost of membership is the problem so much as the belief there is no benefit to membership. What are we really getting for that money? The majority of work is done by volunteers. If you're an elected official of the APTA or a section, you get some money toward expenses to attend CSM. Where does the rest go?

I make the same amount of money now that I did four years ago. That doesn't seem to concern the APTA. I've heard nothing from them addressing PT salaries. APTA membership is very low on the priority list for expenses. Of course that also goes back to the perceived value of membership.

I'm not encouraging anyone to belong. The sad truth is unless you work in outpatient, you don't seem to matter. That seems to be the image the APTA is creating for us. But then look at our leaders, who are either outpatient orthopedic, private practice or both. It shouldn't really surprise us. Even if someone with a different agenda made it to elected office, I doubt it would do much good. They would be one vote against everyone else.

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