“An Incredible Record” — Physical Therapists in the Military

(upbeat music) - Welcome to PTJ Author Interviews. PTJ Editor-in-Chief, Alan Jetty, talks with authors about the most interesting and sometimes surprising aspects of their work. And now, Dr. Jetty. - Well, I'd like to welcome listeners to this latest PTJ podcast. I'm very pleased to have as my guest today, Dr. David Greathouse, who is a colonel in the U.S. Army, retired, but also currently works with Clinical Electrophysiology Services in Texas Physical Therapy Specialist in Texas. Welcome, Dr. Greathouse. - Thank you, good morning. And thank you, Dr. Jetty, for this opportunity. - Well, I'm very pleased that we can talk about your essay, which was entitled, "U.S. Military Physical Therapy, 1970 to 2020." And our listeners should realize that Dr. Greathouse's essay is one of a centennial series that we're publishing in PTJ on various aspects of the history of our profession. So why don't we launch right into it and let me ask you to talk a little bit about your background and your career as a PT in the military and what kind of led you in that direction for your career? - Yes, thank you. I graduated from Marshall University in Huntington, West Virginia in 1968 and went to physical therapy school at D.T. Watson School of Physiatrics in Leedsdale, Pennsylvania, outside of Pittsburgh. And it is now the University of Pittsburgh DPT program, but at the time D.T. Watson was one of the first physical therapy schools in the United States. When I was in physical therapy school for the year and 15 months, Army, Navy and Air Force recruiters came to our campus. The Vietnam War was going on at that time, but the recruiters came and made a presentation to show what military physical therapists were doing, not only in Vietnam, but in their stateside hospitals. And it intrigued me to what they were doing. I really had no plan of where I was gonna go after finishing PT school. So my wife and I decided this would be a good opportunity to try the Army for two years and get some experience and then look for other avenues of work and practice. As it turned out, I came in for two years and stayed 26 years. So it was a very rewarding career for me, both professionally, academically, clinically. I started off, you go to some military schooling and I'll mention that along the way. I went to officer basic school for medical personnel and then went to Walter Reed in Washington, DC for two years from 1970 to 1972. And during that time, I was on the wards, treating patients not only back from Vietnam, but other patients from the military. And then I was in charge of the amputee program for one year from '71 to '72 when I was at Walter Reed. After 1972, I made the decision to stay in for another assignment. We moved to Fort Riley in 1972. We were there through 1975. The Army provided me opportunities in manual therapy, training in EMG and nerve conduction studies and Fort Riley was one of the test sites for the first direct access programs for physical therapists to see patients with neuromuscular skeletal problems without referrals from physicians. And to summarize my career, I had two educational opportunities, University of Kentucky, my master's degree and my PhD in anatomy and cell biology. After finishing my PhD, I went to the Army School at Fort Sam Houston was the director for five years. In 1990, I became the assistant chief of the Army Medical Specialist Corps and director and chief of physical therapy section. And then in 1993, I became the chief of the Army Medical Specialist Corps through 1996. Both of those positions were with the office of the Army Surgeon General. And I believe that PTJ is going to have an essay on Colonel Vogel, Colonel Emma Vogel was our first chief of the Army Medical Specialist Corps in 1947. - It's a remarkable career that you described, Dr. Greathouse. I had no idea of the breath and the complexity. I'd like to take you back now to Fort Riley. You were there when the military began direct access for physical therapy. Can you talk a little bit about how that came about and how widely is it currently being practiced throughout the military? - Thank you. Yes, in the early 1970s, we were starting to bring the Vietnam War to a close. So we still had some activity in Vietnam. But there were a large number of patients with musculoskeletal problems, not necessarily from Vietnam, but from training and exercises and from physical fitness and so forth. At the same time, we were losing a number of physicians because the drafting of physicians was then coming to a close. And so with this large number of problems, physical therapy saw an opportunity to start seeing these patients without the patients have to go to a physician or at the beginning of PA or a nurse practitioner at that time. So it was mostly a large number of patients, a small number of practitioners who could do that. And so we brought up four test sites. One was at Fort Riley, one was at Fort Sill in Oklahoma, one was Fort Hood in Texas, and the other one was Fort Knox in Kentucky. And so we had a number of physical therapists that were trained. We had no training and background in this for PT school. So we had, because we had the opportunity to order imaging, radiographs to start and then CAT scans and MRIs at a later date, we had opportunity to provide some medicines and pharmaceuticals and order lab studies. We also, and I think one of the big things that we were provided was the ability to directly refer patients to specialty clinics, to have them evaluated if we found things. We spent a considerable amount of time on differential diagnosis. We met with the lab folks, the pharmacy folks, the radiology folks and had training in these areas we did not, which now that you see these are common in physical therapy programs across the United States. So we started with these test sites. We soon saw that this was going to be a program that was going to be very effective, very efficient. And then it spread across other clinics in the United States, first in the Army, then the Navy picked it up, the Air Force. And then there were some clinics in the public health that later picked up direct access. And now it is just a primary part of practice. Physical therapists in the military see patients in direct access environment. They also see patients with referrals from nurse practitioners, PAs and physicians. - David, was there much pushback from physicians in the military at the start? - Very interesting question. No, we got tremendous support from the physicians, especially orthopedics because in most hospitals we had orthopedic surgeons there. And they were very supportive of our program because they were then spending more time in their clinics and especially in the surgery. And so they were very supportive throughout. And as we gained momentum with this program as it moved in the '80s and the '90s, we've continued to support the physician community. - Let's talk a little bit about the safety record. What does that look like for PTs in the military functioning in primary care and direct access? - The military physical therapists, as you look through this program starting in the '70s up through just current times because we've just done a study on this just recently, there have been no records of malpractice or any legal issues within the military on physical therapies, practicing in a direct access or primary care environment. We've had no problem. That's not to say that there haven't been some issues with maybe a misdiagnosis or something of that nature. We've never had any legal issues or any serious confrontation from physician groups within the military to our practice of primary care physical therapy and direct access. - You know, that's an incredible record. And it's one that I don't think is widely understood outside of the military. - I think that some of this has to do with the fact that early on we prided ourselves on seeking out additional education and opportunities. And then we also had a very strict continuity quality improvement CQI programs at every place we were doing direct access. So we had peer review and at the early start we had physician review of our records and assessments. As our program progressed and matured, we moved from not having physician oversight. And we still had liaisons with the physicians but we just did peer review and that continues on to our program at present. - Let's talk about the other side of the coin with respect to the positive impact of direct access and primary care by PTs. Is there good evidence with respect to its impact on diagnostic testing, medication use and patient outcomes? - Yes, when you look at how the military model of direct access works, if you look at a typical model, the patient would go to their primary care physician or PA or nurse practitioner. They may be sent to a specialist or they may then be sent to physical therapy. The military model patient comes in with some kind of a musculoskeletal problem. They're seen by at their troop unit and then sent directly to physical therapists. At first our physical therapists were located in our clinics within the hospitals but now our physical therapists are located out in the troop units or the troop medical clinics. And so they have a very short, most patients are seen within one day. And so you take that opportunity for patients to be seen very quickly and having the military P's with physical therapists with the ability to order imaging studies and lab studies and so forth to help make their diagnosis and then plan their interventions. It's very efficient and it's very expedient. So the patient can be seen somewhere between 24 hours to 48 hours of the incident of injury. And we can see from our evidence in just clinical practice, the sooner a PT can look at a problem with musculoskeletal pathology, then the better the outcome's going to be because the interventions can be provided in an earlier day. And I think that having the ability to order imaging and lab studies and in some cases pharmaceuticals, a couple of the other things that PTs can do in the military environment is they can place people on quarters. They can also place and adjust their work schedules, what we call profiles in the military where they can adjust their work environments so they can only lift certain things or not have to run for certain distances so that they can get better treatment for their musculoskeletal problems. - Well, you know, you were on the front lines and lived through this experience. What are some of the lessons that you would take from your experience in the military that might be relevant to civilian practice of physical therapy? Because although it's now legal in most states, if not all, to practice with direct access, it's not the predominant form of practice by any means. What do you see as some lessons from your experience in the military? - One lesson that we have learned that has taken place and I mentioned this already is how what we have done with primary care and direct access and education. If you look at now the DPT programs that are credited by CAPTI, everyone now has courses in pharmacology. They have courses in differential diagnosis. They have courses in radiography and imaging. And we now see that happening. I think that, so the training is placed in civilian PT schools. The opportunity for civilian physical therapy students, what they lack is the opportunity to go to clinical practices that offer direct access or primary care for PT. We see a few more of these occurring in the United States, but the opportunity isn't there for they get to clinical. Whereas the students that go to the military physical therapy school at the Army Baylor doctoral program in physical therapy at Ford Sam, which is Army, Navy and Air Force, therapists get that kind of opportunity, clinical opportunity, as well as Army, Navy and Air Force PTs that come in from either ROTC or direct access or direct commission. They have the opportunity to train and learn in clinical environments for direct access. I think if you look at the failure and some organizations like the VA has moved into some of these areas, some of the licensing boards have allowed direct access. And like you said, in most of the States, the problem is they're not compensation or reimbursement for these services. And until Medicare or Medicaid starts funding, physical therapist doing this in a civilian environment, I doubt it's doubtful the third party payers will jump on board with this. The military model has been proven to be effective. It's just, it takes legislative efforts or efforts by the government insurance agencies to fund and reimburse physical therapists outside the military for their services in direct access. - Yeah, I don't think that experiences as widely appreciated as it should be. Do many civilian PT programs place the students in military PT practices? - Yes, they have the opportunity. The military clinics and hospitals primary responsibility is to support the Army Baylor doctoral program at Fort Sam. But then they do have other limited opportunities. And so I can't give you the number of PT programs that use military facilities, but they have the opportunity, depending on how much clinical education these clinics and hospitals can provide is a case by case basis. But their primary responsibility is to the Army Baylor doctoral program. - Yeah, and that's... - Those students that get that opportunity will, as a part of their rotation or part of their clinical, will have an opportunity to go to a direct access clinic. - Yeah, and I think that would be really very valuable experience for new PTs and PT students. Well, as you think back on your career, would you recommend a military career for PTs and PT students? - Yes, I would. I think it's a kind of practice that when you look at what we're seeing, we're mostly seeing if you could think of an orthopedic or sports environment. Yes, we're seeing all kinds of patients, but the military physical therapist is focused on keeping the soldier, the airman, the Marine, the naval person fit and ready for duty. And so someone coming into the military, you're doing two things. You're going to be a physical therapist, of which you can train through with your program, but you're also going to be a military officer. You're gonna be an Army Navy Air Force officer. And so you're not only have the responsibilities of being a physical therapist, but also a military officer. I think another thing that you have to think about when you want to go into the military is there is always a chance because our primary mission is to support the military fighters. And that means when we deploy, when troops deploy to like recently Iraq in Afghanistan, we had physical therapists in theater, both at the troop units and at clinics and hospitals within the theater of operations. And so you have to think about if you want a military career, even though now deployments are down because of our withdrawal in those countries, we still have the opportunity to be deployed in environment. I think if you look at the height of the Iraq and Afghanistan deployments, we had almost every physical therapist that was on active duty in the Army had a rotation to one of those countries, either with a troop unit, whether they supported or to a hospital or a clinic. So it's a kind of practice that you have an opportunity to practice direct access, which is unique. I think the other opportunity for the military is that those that stay in after their initial assignments have opportunities, we have excellent programs for education. We send at least one military Army physical therapist speak for the Army. We send at least one Army physical therapist a year to a PhD program. We have two of the most outstanding fellowship programs in clinical science, one in sports medicine at West Point in New York and one in orthopedic manual therapy at Fort Sam Houston at BAMC, of which we take three to four residents every year and a half for their fellowship programs, which also get a doctor's science degree in our affiliation with Baylor University. So there's educational opportunities. So I think that, and then continuing education, not only with outside and civilian, but the Army has a number of physical therapy educational opportunities like the CURSI course, which is an advanced a musco-skeletal clinic course for younger officers that have been in for a couple of years and doing direct access to come and train in that environment. You know, your essay focused on the period of the 1970s to the present time, the early 2000s at least, but you mentioned Colonel Emma Vogel in the early days of the military. Could you just talk briefly about her role and the early period of PT in the military and how that developed? - Yes, thank you. I mentioned Colonel Vogel earlier in this discussion. Colonel Vogel, if you look back, military physical therapy would not be where it is today without her efforts. And she started out as you'll see in the essay as a reconstruction aid during the later stages of World War I and trained at Reed College, continued the push at military physical therapy and was at Walter Reed for a long period of time. So not only did she contribute as a clinician and as an educator during World War I, but was very instrumental in keeping physical therapists work at that time, civilians working in the military in pre-World War II and then mobilized the forces of physical therapists and training programs in the United States to support our troops, both in the European theater and Asia. Then following the war, she was instrumental in having the legislation passed that brought Army and Navy and then Air Force, not only physical therapists, but dietitians and occupational therapists into the military as commissioned officers, of which they were during World War II. But then they were formed within the corps, within the Navy and the Air Force and then the Army. They formed the Women's Army Medical Specialist Corps, which was then changed to the Army Medical Specialist Corps in 1955 when they allowed men, officers to be PTs, OTs and dietitians. And then the fourth specialty area within the AMSC came in 1992 when we had the PAs joined the Army Medical Specialist Corps. So Colonel Vogel was the first chief of the Army Medical Specialist Corps at that time. And so she was instrumental in laying the foundations for our corps, then which then continued then into the '60s and the '70s and so forth. - She had a remarkable career. And I would encourage our listeners, if you're interested in learning more, to take a look at that essay in PTJ. Well, Dr. Greathouse, I really wanna thank you for writing that essay, sharing your experience with our listeners today. You really had a remarkable career and impact on the PTs in the military. And I thank you for your service and thank you for your time today. - Alan, thank you, Dr. Jenny. Thank you for this opportunity. Again, I always enjoy talking about military physical therapy. I still continue to support the program teaching as an adjunct faculty down there. And again, as people are listening to this, if you have an interest in military physical therapy, it is a specialty kind of area of practice, but I encourage folks to seek out opportunities in the military for physical therapy. (upbeat music)