physical therapists can alleviate the primary care shortage in...

Running head: PHYSICAL THERAPY CAN ALLEVIATE PRIMARY CARE SHORTAGE 1

Physical Therapists Can Alleviate the Primary Care Shortage in the United States

T. Marc Skinner

Student, US Army-Baylor Graduate Program in Health and Business Administration

PHYSICAL THERAPY CAN ALLEVIATE PRIMARY CARE SHORTAGE 2

Abstract

The United States health care system is currently experiencing a shortage of providers in primary

care. Experts expect this shortage will persist beyond the year 2025. Musculoskeletal conditions

are a leading cause for primary care visits. Despite this, non-orthopedic physicians, nurse

practitioners, and physician assistants, as groups, fail to achieve a mean passing score on a

survey validated by orthopedic surgeons to assess musculoskeletal medicine knowledge.

Physical therapists have demonstrated their knowledge and ability to manage musculoskeletal

conditions. Direct access to a physical therapist is both safe for the patient and cost effective for

the organization and health care system as a whole. Health care administrators and policy

makers should consider physical therapists taking a larger role in primary care.

Keywords: primary care, shortage, physical therapist, musculoskeletal


Physical Therapists Can Alleviate the Primary Care Shortage in the United States

The United States health care system is currently experiencing a shortage of primary care

providers (Cherry, Hing, Woodwell, & Rechtsteiner, 2008). Despite regulatory incentives to

encourage physicians to enter primary care, and the proliferation of non-physician providers in

primary care, experts predict the shortage will persist beyond the year 2025 (Petterson, et al.,

2012). Musculoskeletal disorders are growing in proportion as precipitating factors for primary

care visits (American Association of Orthopedic Surgeons, 2008). However, physicians have

documented the lack of education and training among all non-orthopedic physicians in

musculoskeletal medicine (Freedman & Bernstein, 1998). This lack of education has also been

demonstrated in nurse practitioners (Benham & Geier, 2014) and physician assistants (Grunfeld,

et al., 2012), many of whom are working in primary care. Compounding the shortage of primary

care providers poorly educated to deal with musculoskeletal conditions, is the fact that

musculoskeletal conditions are a leading cause for health care visits (American Association of

Orthopedic Surgeons, 2008). The US health care system is therefore facing a significant three-

tiered challenge: there is a lack of primary care providers; current primary care providers are

inadequately educated and trained to effectively manage musculoskeletal conditions; and

musculoskeletal conditions are the leading cause for a primary care encounter.

Researchers have demonstrated physical therapists’ knowledge of musculoskeletal

medicine; physical therapists are the only health care professionals, aside from orthopedic

surgeons, reported to achieve a mean passing score on a survey used to assess musculoskeletal

medicine knowledge (Childs, et al., 2005). Physical therapists have worked in a direct access

capacity for more than 48 years in the US military, with well-documented benefits to the patient

and decreased costs to the health care system (Moore, et al., 2013). Patients seeking care from


physical therapists practicing in a direct access capacity are safe, with one study reporting 100%

physician agreement with treat or refer decisions made by physical therapists (Boissonnault,

Badke, & Powers, 2010), and another reporting physical therapists as the public consumer’s

provider of choice (Snow, Shamus, & Hill, 2001).

Proposed regulatory initiatives of the Affordable Care Act will not solve the problem of

getting sufficient numbers of physicians, nurse practitioners, and physician assistants adequately

educated to manage the leading patient conditions in a timely manner (U.S. Department of

Health and Human Services, Health Resources and Services Administration, National Center for

Health Workforce Analysis, 2013; Petterson, et al., 2012). The current primary care situation

affords health care administrators, policy makers, and health care providers the opportunity to

seek alternate solutions, as opposed to business as usual. Physical therapists possess the

knowledge to effectively manage the leading cause for health care visits (Moore, et al., 2013),

and should be more fully incorporated into the primary health care delivery system to meet the

current and growing demand. The remainder of this paper will explore the following: the

primary care provider shortage; the scope and cost of musculoskeletal conditions to the US

health care system; the education and demonstrated musculoskeletal medicine knowledge of

health care providers; and the qualifications of physical therapists to address those needs at the

primary care level.

Methods

Google scholar, PubMed, and CINAHL were searched, using the following terms:

primary care, physician, nurse practitioner, physician assistant, physical therapy, physical

therapist, education, training, outcomes, safety, diagnosis, musculoskeletal, and management.

Searches were limited from 1995 to 2014. Results were limited to English-language, full text


articles, and were sorted by relevance. Google scholar returned 12,800 results, PubMed returned

269,654 results, and CINAHL returned 608 results. The first 100 results were screened by title

and abstract review. References from selected articles were used to identify additional source

articles. A qualitative review of selected articles was conducted and synthesized into a topical

review with a solution proposed to the problem.

Primary Care Provider Shortage

The shortage of primary care providers in the United States health care system continues

to grow, despite concerted efforts to increase supply (U.S. Department of Health and Human

Services, Health Resources and Services Administration, National Center for Health Workforce

Analysis, 2013). Shi and Singh expect the situation to worsen due to the increase in the number

of individuals able to purchase insurance because of the individual mandate of the Affordable

Care Act (2015). The reason for the primary care provider shortage is complex and

multifactorial, with lower income, growth of technology, less prestige among their peers, and

less predictable work hours cited as potential reasons (Shi & Singh, 2015, p. 134). Historically,

the number of physicians entering the workforce as primary care providers has been decreasing

since 1949; however, with the aging population and now expanded access to primary care via the

Affordable Care Act, experts anticipate the need for primary care to grow (Shi & Singh, 2015).

The US health care system has undergone reform to help fill the primary care provider

shortage, with the proliferation of non-physician providers (nurse practitioners and physician

assistants). One provision of the Affordable Care Act designed to help alleviate the primary care

provider shortage is the investment of $230 million to increase the number of physicians and

non-physician primary care providers (Shi & Singh, 2015). Despite these efforts, researchers

expect the primary care provider shortage to persist through the foreseeable long-term (see Table


1). Petterson and colleagues estimate the shortage of physicians in primary care to be 52,000 in

2025 due to the provisions of the Affordable Care Act, with demand projected to be 260,687 and

the supply projected to be 208,807 physicians (2012). The US Department of Health and Human

Services projects the physician shortage to be approximately 20,400 full time equivalents by

2020 (2013). These models take into account the use of non-physician providers in primary care.

Even with the Affordable Care Act provisions to increase primary care, the US

Government expects supply will increase by only eight percent, compared to an expected 14%

increase in demand (U.S. Department of Health and Human Services, Health Resources and

Services Administration, National Center for Health Workforce Analysis, 2013). Integrating

nurse practitioners and physician assistants into primary care still leaves Americans with a

shortage of 6,400 primary care providers by 2020. (U.S. Department of Health and Human

Services, Health Resources and Services Administration, National Center for Health Workforce

Analysis, 2013). Given the fact that the Affordable Care Act provides new emphasis on primary

care, and the continued projected shortage of primary care providers in spite of regulatory

incentives, American health care consumers need an expanded model of primary care provision

to fulfill their needs.

Scope of Musculoskeletal Conditions on the US Health Care System

The utilization and costs of medical interventions for musculoskeletal disorders has been

increasing over time (American Association of Orthopedic Surgeons, 2008). The American

Association of Orthopedic Surgeons estimates the prevalence of musculoskeletal disorders

among Americans to be 30% of the population (see Figure 1), with costs at 4.5% of the US gross

domestic product (see Figure 2). Musculoskeletal disorders account for six visits per person per

year, with growth attributed to an increase in the number of people with a musculoskeletal


condition, not an increase in the number of visits (American Association of Orthopedic

Surgeons, 2008). Since insured people seek health care at a rate of two to three times more than

the uninsured, it is prudent to expect that utilization of health care for musculoskeletal conditions

will likely increase dramatically with full implementation of the Affordable Care Act (Shi &

Singh, 2015). The soaring prevalence and costs associated with musculoskeletal disorders is not

unique to the American public; Canadians estimate the prevalence of musculoskeletal disorders

to be 36% with costs at 2.5% of their gross domestic product (MacKay, Canizares, Davis, &

Badley, 2010).

Health care utilization patterns in the United States have trended away from inpatient

care to increased ambulatory care (Shi & Singh, 2015). Over the period 1995 to 2005,

ambulatory care for musculoskeletal disorders increased by 21%, while inpatient care dropped

9% (Decker, Schappert, & Sisk, 2009). Most significantly, utilization did not change for heart

disease, cerebrovascular disease, or for cancer (Decker, Schappert, & Sisk, 2009). This reflects

the aging of the US population, the increasing prevalence of musculoskeletal conditions, and the

inability of the US health care system to react to the scope of musculoskeletal conditions.

Health care utilization for musculoskeletal conditions in the US armed forces is also

increasing (see Figure 3), and represented the leading cause for a health care visit in 2013

(Armed Forces Health Surveillance Center, 2014). One study reported that musculoskeletal

conditions accounted for 49% of all outpatient visits (Jones, Canham-Chervak, Canada,

Mitchener, & Moore, 2010), while another reported that musculoskeletal conditions accounted

for the majority – three of the top five – of all health care encounters (Armed Forces Health

Surveillance Center, 2014). Musculoskeletal conditions accounted for 10% of all lost workdays

(130,000+ in 2013) in the armed forces, highlighting one of the indirect costs associated with


musculoskeletal conditions (Armed Forces Health Surveillance Center, 2014). Experts estimate

the incidence of musculoskeletal conditions, acute and chronic, among members of the armed

forces to be 1.6 million per year (Hauret, Jones, Bullock, Canham-Chervak, & Canada, 2010).

Musculoskeletal conditions do more than hinder the armed force’s ability to accomplish its

mission, as disabilities eventually force members out of the armed forces into the civilian

economy.

Further underscoring the importance of musculoskeletal health care delivery,

musculoskeletal disorders account for a large proportion of all disability claims against the

federal government. Musculoskeletal conditions account for 64% of all disability claims

(Patzkowski, Rivera, Ficke, & Wenke, 2012). Songer and LaPorte report that 53.1% of all

disability claims in the Army, and 63% in the Navy, are due to musculoskeletal conditions, at an

estimated cost of $1.5 billion annually (2000). Clearly musculoskeletal conditions are a growing

cause for health care utilization; however, as will be shown, the education for the majority of

health care providers to diagnose or manage these costly conditions is inadequate.

Education and Training in Musculoskeletal Conditions

Medical school educators, primarily orthopedists, have long decried the lack of sufficient

education and training in musculoskeletal conditions (Freedman & Bernstein, 1998). Multiple

researchers have repeated their landmark study in a variety of locations, and across health care

disciplines, with consistent results (see Figure 4). The next sections of this paper will investigate

the education and training of physicians, then non-physician providers, finally concluding with

the education and training of physical therapists in musculoskeletal medicine.


Physician Education and Training

Freedman and Bernstein first researched physician education and training for

musculoskeletal conditions (1998). Skelley and colleagues have compared their results to the

Flexner Report (1910), due to the parallel findings of inadequate education and training (2012).

Orthopedic residency program chairpersons (124 out of 185) validated the 25-question survey,

and determined a passing score to be 73.1% or greater (Freedman & Bernstein, 1998). The mean

score for the chief orthopedic residents was 98.5%, compared to 59.6% of medical school

graduates; 82% of the medical school graduates failed a validated assessment of their

musculoskeletal knowledge (Freedman & Bernstein, 1998).

Other studies have found similar results regarding physician education for

musculoskeletal conditions (Skelley, Tanaka, Skelley, & LaPorte, 2012; Matzkin, Smith,

Freccerio, & Richardson, 2005). Matzkin and colleagues reported similar results to the

Freedman and Bernstein study (see Figure 4), with orthopedic residents attaining a mean score of

94%, while all other physician specialties failed to achieve a mean passing score (Matzkin,

Smith, Freccerio, & Richardson, 2005). Skelley and colleagues also investigated the self-

perceived confidence of their subjects, with only 15% of fourth year medical school students

reporting high confidence in their ability to diagnose and manage musculoskeletal conditions

(2012).

Due to the large proportion of allopathic medical schools, researchers hypothesized that

osteopathic schools of medicine, with their emphasis on the musculoskeletal system, would

produce physicians with better musculoskeletal knowledge. However, when the same Freedman

and Bernstein survey was administered to new graduates of allopathic and osteopathic medical

schools, 70.4% of the allopathic physicians failed to achieve a passing score, and 65.6% of the


osteopathic physicians failed to achieve a passing score (Stockard & Allen, 2006). It is fair to

characterize allopathic and osteopathic medical school education curricula as lacking in

musculoskeletal emphasis (Freedman & Bernstein, 1998; Matzkin, Smith, Freccerio, &

Richardson, 2005; Skelley, Tanaka, Skelley, & LaPorte, 2012; Stockard & Allen, 2006).

Non-Physician Provider Education and Training

Researchers have not investigated the musculoskeletal medicine education for nurse

practitioners and physician assistants as extensively as with physicians. In a pre-press pilot

study, Benham and Geier reported that none of the nurse practitioner respondents were able to

pass the Freedman and Bernstein survey (2014). Note that this was a pilot study, and was

therefore lacking in statistical power, meaning we cannot infer meaningful conclusions from the

data. Given the limited exposure to musculoskeletal medicine during graduate training to

become a nurse practitioner, the results of the Benham and Geier study (2014) are consistent

with the Freedman and Bernstein study (1998): There is a lack of sufficient emphasis during

didactic and practical educational experiences on musculoskeletal medicine for nurse

practitioners.

Grunfeld and colleagues compared graduating medical school students and physician

assistant students on the students’ musculoskeletal knowledge (2012). They did not use the

Freedman and Bernstein survey, opting instead to use the National Board of Medical Examiners

Musculoskeletal Subject Examination. The mean score for the medical school students was

73.8%, compared to 62.3% for the physician assistant students; the difference in means was

statistically significant (Grunfeld, et al., 2012). The authors also investigated the number of

hours devoted to musculoskeletal education, with the physician assistants having significantly

fewer hours compared to medical school students (Grunfeld, et al., 2012). As with physicians


and nurse practitioners, there is a lack of sufficient emphasis during didactic and practical

educational experiences on musculoskeletal medicine for physician assistants.

This paper has established the evidence regarding the knowledge of physicians, nurse

practitioners, and physician assistants in musculoskeletal medicine. The data supports the

general lack of knowledge for diagnosis and management of musculoskeletal conditions for the

majority of health care providers working in primary care (Freedman & Bernstein, 1998;

Benham & Geier, 2014; Matzkin, Smith, Freccerio, & Richardson, 2005; Skelley, Tanaka,

Skelley, & LaPorte, 2012; Grunfeld, et al., 2012). The next section will examine the education

and training of physical therapists.

Physical Therapist Education and Training

Childs and colleagues conducted a study investigating the knowledge of musculoskeletal

condition management of physical therapists compared to physicians (2005). They used the

Freedman and Bernstein survey (1998), a validated measure used to assess musculoskeletal

medicine knowledge for physicians (students, interns, and residents). Physical therapists

achieved a statistically significant higher score compared to all physician specialties, with the

sole exception of orthopedics, and were the only subgroup other than orthopedic physicians that

achieved a mean passing score (Childs, et al., 2005). In another study, Moore and colleagues

reported that physical therapists’ percent agreement for clinical diagnostic accuracy of

musculoskeletal conditions compared to MRI findings was not statistically different compared to

orthopedic surgeons; the difference between physical therapists and non-orthopedic providers

was statistically significant (2005).

Despite the demonstrated knowledge of physical therapists in managing non-surgical

musculoskeletal conditions, participation in a primary care role in the United States is rare


outside of the federal systems (military and veteran’s administration); however, some non-

federal health care organizations have expanded the role of physical therapists to realize cost

savings (Boissonnault, Badke, & Powers, 2010; Murphy, Greathouse, & Matsui, 2005). The

condensed and simplified arguments against physical therapists practicing in a direct access or

primary care role are cost containment and patient safety arguments.

Cost containment. Provider-induced demand has been cited as an argument against

physical therapists working in a direct access (without a physician referral) capacity (Mitchell &

de Lissovoy, 1997). However, when physical therapists practice with direct access, researchers

have reported anywhere from 2.3 fewer visits per patient (Leemrijse, Swinkels, & Veenhof,

2008) to 4.6 fewer visits per patient compared to physician-referral episodes of care (Mitchell &

de Lissovoy, 1997). This translates to a savings of more than $1,200 per patient episode

(Mitchell & de Lissovoy, 1997).

Physical therapists tend to order fewer diagnostic imaging tests, with uninvestigated

second- and third-order effects to the health care system (e.g., unnecessary specialty referral).

Ojha and colleagues reported a statistically significant 6-8% decrease in diagnostic imaging

orders, and 12% decrease in medications prescribed, for physical therapists compared to

physicians (2014). In a study conducted in the United Kingdom, an orthopedic clinic compared

junior orthopedic physicians with physiotherapists; the physiotherapists ordered statistically

significant fewer diagnostic images (with concomitant decreased costs) with no differences in

patient outcomes (Daker-White, et al., 1999). Finally, in the US military, physical therapists

have decreased costs by limiting unnecessary medical evacuations from combat theaters of

action (Moore, et al., 2013) and by returning soldiers to duty at a rate 50% greater compared to


primary care providers (McGill, 2013), as well as with decreased diagnostic imaging and

medications ordered.

Patient safety. Research on treatments for patients who sought physical therapy care

without a physician referral demonstrates the safety of physical therapists. The University of

Wisconsin Hospital System conducted a study in which physical therapists worked with direct

access capability (Boissonnault, Badke, & Powers, 2010). Physicians determined that 100% of

the referral or treat decisions made by physical therapists were appropriate (Boissonnault, Badke,

& Powers, 2010). Moore and colleagues reported on a 40-month period, with 472,013 physical

therapy encounters; 50,799 of which were new patients seeking care without physician referral

(2005). Over the 40-month period, there were no reported credentials modifications, revocations

of state licensure, or litigation cases brought against the US Government (Moore, McMillian,

Rosenthal, & Weishaar, 2005).

Conclusion

The United States health care system is currently experiencing a shortage of primary care

providers (Shi & Singh, 2015). Experts expect this shortage to persist through 2025, even with

the current emphasis and provisions of the Affordable Care Act (Petterson, et al., 2012).

Musculoskeletal conditions, increasingly recognized as a growing “burden” to the health care

system, have total direct costs to treat these conditions of approximately 4.5% of the US gross

domestic product (American Association of Orthopedic Surgeons, 2008). The training and

education of physicians, with the exception of orthopedic surgeons, in musculoskeletal medicine,

does not meet the minimum standards as determined by both orthopedic surgeons and internal

medicine physicians (Freedman & Bernstein, 1998). Non-physician provider training is

consistent with that found in medical schools: Education and training in musculoskeletal


medicine does not adequately prepare providers for the most common conditions precipitating a

primary care visit (Benham & Geier, 2014; Grunfeld, et al., 2012).

Physical therapist education and training in musculoskeletal medicine exceeds a

minimum standard as determined by orthopedic surgeons and internal medicine physicians

(Childs, et al., 2005). Physical therapists order diagnostic imaging studies more appropriately

compared to non-orthopedic providers, as determined by both radiologists and orthopedic

surgeons (Moore, et al., 2005). Physical therapists practicing in a direct access capacity achieve

high quality, patient-centered outcomes in fewer visits and with lower costs (Mitchell & de

Lissovoy, 1997).

The US health care system has arrived at a critical point in health care delivery, where

administrators and policy makers have an opportunity to recognize the benefits of seeking an

alternate solution rather than a version of business as usual. The challenge is three-tiered: there

is a shortage of primary care providers; the education and training of current primary care

providers lacks sufficient emphasis on management of musculoskeletal conditions; and

musculoskeletal conditions are the leading cause for a primary care encounter. Physical

therapists represent a trained and ready pool of qualified health care professionals to help fill this

shortage. Models exist demonstrating the safe and effective use of physical therapists in a

primary care role. Health care administrators and policy makers should consider physical

therapists taking a larger role in primary care.


References

American Association of Orthopedic Surgeons. (2008). Burden of musculoskeletal diseases in

the United States: prevalence, societal and economic cost. New York, NY: American

Academy of Orthopaedic Surgeons. Retrieved from http://www.boneandjointburden.org

Armed Forces Health Surveillance Center. (2014). Annual summary issue. Medical Surveillance

Monthly Report, 21(4), 1-32.

Benham, A. J., & Geier, K. A. (2014). Preparing nurse practitioners to provide orthopedic

primary care. The Journal for Nurse Practitioners, 1-4. doi:10.1016/j.nurpra.2014.04.015

Boissonnault, W. G., Badke, M. B., & Powers, J. M. (2010). Pursuit and implementation of

hospital-based outpatient direct access to physical therapy services: an administrative

case report. Physical Therapy, 90(1), 100-109. doi:10.2522/ptj.20080244

Cherry, D. K., Hing, E., Woodwell, D. A., & Rechtsteiner, E. A. (2008, August 6). National

ambulatory medical care survey: 2006 summary. National Health Statistics Reports, 3, 1-

40. Retrieved from Center for Disease Control and Prevention:

http://www.cdc.gov/nchs/data/nhsr/nhsr003.pdf

Childs, J. D., Whitman, J. M., Sizer, P. S., Pugia, M. L., Flynn, T. W., & Delitto, A. (2005). A

description of physical therapists' knowledge in managing musculoskeletal conditions.

BMC Musculoskeletal Disorders, 6, 32-38. doi:10.1186/1471-2474-6-32

Daker-White, G., Carr, A. J., Harvey, I., Woolhead, G., Bannister, G., Nelson, I., & Kammerling,

M. (1999). A randomised controlled trial. Shifting boundaries of doctors and

physiotherapists in orthopaedic outpatient departments. Journal of Epidemiology and

Community Health, 53, 643-650.


Decker, S. L., Schappert, S. M., & Sisk, J. E. (2009). Use of medical care for chronic conditions.

Health Affairs, 28(1), 26-35. doi:10.1377/hlthaff.28.1.26

Flexner, A. (1910). Medical education in the United States and Canada: a report to the Carnegie

Foundation for the Advancement of Teaching. Boston: Merrymount Press.

Freedman, K. B., & Bernstein, J. (1998). The adequacy of medical school education in

musculoskeletal medicine. The Journal of Bone and Joint Surgery (American), 80(10),

1421-1427.

Grunfeld, R., Banks, S., Fox, E., Levy, B. A., Craig, C., & Black, K. (2012). An assessment of

musculoskeletal knowledge in graduating medical and physician assistant students and

implications for musculoskeletal care providers. Journal of Bone and Joint Surgery

(American), 94(4), 343-348. doi:10.2106/JBJS.J.00417

Hauret, K. G., Jones, B. H., Bullock, S. H., Canham-Chervak, M., & Canada, S. (2010).

Musculoskeletal injuries: description of an under-recognized injury problem among

military personnel. American Journal of Preventive Medicine, 38(1S), S61-S70.

doi:10.1016/j.amepre.2009.10.021

Jones, B. H., Canham-Chervak, M., Canada, S., Mitchener, T. A., & Moore, S. (2010). Medical

surveillance of injuries in the U.S. military: descriptive epidemiology and

recommendations for improvement. American Journal of Preventive Medicine, 38(1S),

S42-S60. doi:10.1016/j.amepre.2009.10.014

Leemrijse, C. J., Swinkels, I. C., & Veenhof, C. (2008). Direct access to physical therapy in the

Netherlands: results from the first year in community-based physical therapy. Physical

Therapy, 88(8), 936-946. doi:10.2522/ptj.20070308


MacKay, C., Canizares, M., Davis, A. M., & Badley, E. M. (2010). Health care utilization for

musculoskeletal disorders. Arthritis Care & Research, 62(2), 161-169.

doi:10.1002/acr.20064

Matzkin, E., Smith, E. L., Freccerio, D., & Richardson, A. B. (2005). Adequacy of education in

musculoskeletal medicine. Journal of Bone and Joint Surgery (American), 87(2), 310-

314.

McGill, T. (2013). Effectiveness of physical therapists serving as primary care musculoskeletal

providers in a deployed combat location: a retrospective medical chart review. Military

Medicine, 178(10), 1115-1120. doi:10.7205/MILMED-D-13-00066

Mitchell, J. M., & de Lissovoy, G. (1997). A comparison of resource use and cost in direct

access versus physician referral episodes of physical therapy. Physical Therapy, 77(1),

10-18. Retrieved from http://ptjournal.apta.org/content/77/1/10

Moore, J. H., Goffar, S. L., Teyhen, D. S., Pendergrass, T. L., Childs, J. D., & Ficke, J. R.

(2013). The role of US military physical therapists during recent combat campaigns.

Physical Therapy, 93(9), 1268-1275. doi:10.2522/ptj.20120136

Moore, J. H., Goss, D. L., Baxter, R. E., DeBerardino, T. M., Mansfield, L. T., Fellows, D. W.,

& Taylor, D. C. (2005). Clinical diagnostic accuracy and magnetic resonance imaging of

patients referred by physical therapists, orthopaedic surgeons, and nonorthopaedic

providers. Journal of Orthopaedic & Sports Physical Therapy, 35(2), 67-71.

Moore, J. H., McMillian, D. J., Rosenthal, M. D., & Weishaar, M. D. (2005). Risk determination

for patients with direct access to physical therapy in military health care facilities.

Journal of Orthopaedic & Sports Physical Therapy, 35(10), 674-678.


Murphy, B. P., Greathouse, D., & Matsui, I. (2005). Primary care physical therapy practice

models. Journal of Orthopaedic & Sports Physical Therapy, 35(11), 699-707.

Ojha, H. A., Snyder, R. S., & Davenport, T. E. (2014). Direct access compared with referred

physical therapy episodes of care: a systematic review. Physical Therapy, 94(1), 14-30.

doi:10.2522/ptj.20130096

Patzkowski, J. C., Rivera, J. C., Ficke, J. R., & Wenke, J. C. (2012). The changing face of

disability in the US army: the operation enduring freedom and operation Iraqi freedom

effect. Journal of the American Academy of Orthopaedic Surgeons, 20(suppl 1), S23-

S30. doi:10.5435/JAAOS-20-08-S23

Petterson, S. M., Liaw, W. R., Phillips, R. L., Rabin, D. L., Meyers, D. S., & Bazemore, A. W.

(2012). Projecting US primary care physician workforce needs: 2010-2025. Annals of

Family Medicine, 10(6), 503-509. doi:10.1370/afm.1431

Shi, L., & Singh, D. A. (2015). Delivering health care in America: a systems approach (6th ed.).

Burlington, MA: Jones & Bartlett Learning.

Skelley, N. W., Tanaka, M. J., Skelley, L., & LaPorte, D. M. (2012). Medical student

musculoskeletal training: an institutional survey. Journal of Bone and Joint Surgery

(American), 94(19), e146(1-7). doi:10.2106/JBJS.K.01286

Snow, B. L., Shamus, E., & Hill, C. (2001). Physical therapy as primary health care: public

perceptions. Journal of Allied Health, 30(1), 35-38.

Songer, T. J., & LaPorte, R. E. (2000). Disabilities due to injury in the military. American

Journal of Preventive Medicine, 18(3S), 33-40.


Stockard, A. R., & Allen, T. W. (2006). Competence levels in musculoskeletal medicine:

comparison of osteopathic and allopathic medical graduates. Journal of the American

Osteopathic Association, 106(6), 350-355.

U.S. Department of Health and Human Services, Health Resources and Services Administration,

National Center for Health Workforce Analysis. (2013). Projecting the supply and

demand for primary care practitioners through 2020. Rockville, MD: U.S. Department

of Health and Human Services.


Table 1

Projected Primary Care Physician Demand Under Various Conditions by Year.

Condition 2015 2020 2025

Baseline 209,662 209,662 209,662

Aging of Population 2,693 6,246 9,894

Population Growth 11,201 21,952 32,852

Affordable Care Act

Coverage

7,104 8,097 8,279

Total 230,660 245,975 260,687

Table showing the total projected number of primary care physicians needed through the year

2025. This table was adapted from the Petterson and colleagues study (2012, p. 507). The actual

number of physicians expected in the workforce by 2025 is 208,807 (Petterson, et al., 2012, p.

506).


Figure 1. This figure shows the prevalence of musculoskeletal conditions among the US

population from 1996 to 2006. Note that data smoothing occurs over a three-year period (shared

two year period between each successive bar). This figure reproduced from the American

Academy of Orthopedic Surgeons’ study (2008, p. 219).


Figure 2. This figure shows the cost of musculoskeletal conditions as a proportion of the gross

domestic product of the United States in 2006. The line demonstrates a generally upward trend

in the combined direct and indirect health care costs associated with musculoskeletal conditions.

All dollars adjusted to 2006 value. This figure was adapted from data in the study conducted by

the American Academy of Orthopedic Surgeons (2008, p. 250).

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

9.00%

year 1998 1999 2000 2001 2002 2003 2004 2005


Figure 3. This figure shows the raw number of ambulatory visits in relation to reported

dispositions, by diagnostic category, among members of the US Armed Forces in 2013.

Musculoskeletal conditions are the leading reason for a health care visit during the year 2013 in

the US Armed Forces (Armed Forces Health Surveillance Center, 2014, p. 20). Note that the

categories “Signs/symptoms/ill-defined” and “Injury/poisoning” both likely report reasons for a

visit that are musculoskeletal in nature that were not included in the “Musculoskeletal/

connective” category.


Figure 4. This figure shows the mean passing scores comparing physicians by specialty and

physical therapists. PT (OCS/SCS) signifies physical therapists who are board certified in

orthopedic physical therapy (OCS) or sports physical therapy (SCS). PT (no OCS/SCS) signifies

physical therapists who have either not taken or not passed a board certification examination.

Mean passing score set by orthopedists = 73.1% (Freedman & Bernstein, 1998). This figure was

adapted from the Childs and colleagues study (2005).

94

81

74

61 59 58 54

48

0

10

20

30

40

50

60

70

80

90

100

Mean passing score, percent

physical therapists can alleviate the primary care shortage in...

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