PT mills – we all know of them and maybe even some of us have worked or are working in one. It’s probably one of the biggest topics I’ve seen debated about in Instagram comments. We’ve largely accepted PT mills as an ugly side of our industry. However, they’re far more detrimental not only to patients, but also to PTs and the profession as a whole than we give them credit for.
No, I will not be calling out any specific companies in this post for two reasons: #1.) I could get sued (your girl doesn’t have enough money for a lawyer) and #2.) the names are different depending on geographical location, but we all know which ones they are in our areas.
Regardless of who or where they are, we need to be aware and speak honestly about how they short-change our patients, worsen the PT workforce, and prevent the advancement of the profession.
Bad for Patients
Let’s start with arguably the most important thing PT mills impact – the patients. The idea we can divide attention between patients for entire sessions while providing skilled and personal care is faulty at best. If we’re bouncing between two or even more patients it’s difficult to provide quality care. The PT-mill business model and the nature of the job just don’t mix well to get the best results for patients. This plays out in so many ways in practice.
I think we’ve all been there when we show a patient an exercise but then when it’s the patient’s turn it looks like a completely different movement than the one we just demoed. If we’re prescribing an exercise to target a specific muscle, it’s likely because we know that muscle is weak. If that muscle is weak, it’s likely the patient is going to make muscle substitutions and compensations to make that exercise easier.
From experience we all know cuing someone for the appropriate corrections just once may not be enough. The patient might make the same compensations over and over again. They may not even realize they’re doing it unless we tell them. Part of what makes us skilled is being able to recognize substitutions, bring them to the patient’s attention, and encourage desired movement patterns or muscle activation. However, it’s hard to do this if our attention is somewhere else. Sure, at some point we may finally realize it and correct them or they may figure it out. Until then though they’re not exactly making big strides towards their goals.
Progression of exercises and patient condition is likely slower within a PT-mill model as well. The PT-mill model is pretty grueling. One way to make it less stressful is sticking with the same exercises patients can do fairly easily. Patients can get started on exercises quicker and do them more independently if we use the same ones. This frees us up to start on our pile of documentation or check on other patients. Not to mention it would be difficult to come up with progressions without a second to even think because we’ve had a slew of patients all day. This means patients probably aren’t getting progressed as soon as they could be. Lack of progression delays improved function, healing, and return to activity.
While we’re talking about freeing ourselves up. I’d be remiss not to mention the lure of modalities and passive treatments in PT-mills. It would be tempting to stick a patient on e-stim for 15 minutes to allow ourselves a break or be able to focus on just one patient for a little. Even just thinking about the caseload of a PT mill is enough to make me tired. The workload would make any of us want to slow the day down with a passive modality or treatment. However, many of these treatments don’t lead to the best results for our patients and just put a band-aid over their symptoms.
HEP compliance is an issue too. One of our biggest complaints as PTs is patients not doing their HEP because we know how important it is for progress! If the patient feels like just a number that’s not likely going to motivate them to do any work outside of the clinic. To be fair, if your doctor didn’t seem to be able to give you the time of day during the appointment would you be willing to do what they suggested? If we can’t give patients our full attention during their appointment, we can’t expect them to take our advice or extra time to do their HEP.
One argument I’ve seen in favor of PT mills is if you’re treating 2 patients with similar conditions or at a similar time in their protocols it’s “totally doable”. While it might be “totally doable”, is it quality care or fair to patients?
Let’s say you have IBS, not a life-threatening condition, but still a problematic one. You go to your GI specialist for an appointment who decides they’re going to see you and another patient who suffers from IBS at the same time. Even though you both have the same condition it’s likely your complaints and concerns vary. At the appointment you both try to communicate your individual needs during your shared slot. By the end of it, the GI doc comes up with one treatment plan. It addresses a hod-podge of each of your concerns, but isn’t specifically tailored to either one of you. You go along with the plan and maybe some of your symptoms get better, maybe they don’t, or maybe they get worse; but hey, I mean you guys were at least similar right?
The scenario above more than likely didn’t lead to the best outcome for you and your IBS. Maybe eventually you get it right if you keep going back. But things likely would’ve been better had you gotten your GI’s full attention from the beginning.
While yes, something like a rotator cuff tear may have similar pain patterns, limitations, and deficits; severity and irritability vary case by case – kinda like IBS. Also like IBS, there’s many different treatment options. One thing that works for one patient might not work for another.
Our patients are trying to get back to living their lives. Most or all are trying to return to work, return to sport, start or return to exercise, play with their kids or grandkids, walk their dog, walk with their spouse, be able to take care of themselves, the list goes on. The deficits are the same – weakness, decreased ROM, decreased endurance, poor balance. . . but the effects on their lives are deeply personal. A common symptom of IBS is constipation. When we see 2 (or more) patients for their musculoskeletal conditions we’re figuratively making them stay constipated in their mobility. To me, that just doesn’t sound fair, ethical. . . or comfortable.
Bad for PTs
So PT mills obviously are not best for patients, but they’re pretty terrible for individual PTs as well. If you read my first article on combating burnout, you know it can lead to us providing worse care. Well I’d say PT mills are doing a great job at contributing to the PT burnout pandemic.
The workload at PT mills is gigantic. Sometimes PT’s wind up seeing 30 patients a day. On social media I’ve seen some PTs report seeing even more than 30 depending how many hours they work. Then there’s the added factor of having to document for all of them. Many PT’s have to bring all their work home to complete documentation on unpaid time. I can’t imagine doing this even one day, much less everyday. These unrealistic expectations wouldn’t be great for anyone’s emotional, physical, or mental health. Honestly many of us would probably feel massively burned out after just one week.
There’s a lot of turnover in PT mills because of the burnout. The job demands are most of the time unsustainable. Even if someone leaves a PT mill, they likely will always have a bit of a bad taste in their mouth. Some of the experiences PT’s have in these kind of work environments can leave them disenchanted with the profession for years.
Oftentimes PT mills recruit poor, unsuspecting new grads who don’t know what kind of situation they’ve gotten themselves into. They lure them in with promises of “an exciting fast-paced environment” or “mentorship”. Maybe this has even happened to you. You’re excited for your first real PT job. Then you’re thrown into an environment where you realize all that matters are the numbers, not the patients getting better and certainly not the well-being of the PTs.
How sad is that? The freshest minds who are ready to practice get their passion deflated right away. All because their first employer wanted them to treat patients like they’re in a factory. Those first experiences can really have a positive or negative affect on the trajectory of a person’s career. Some may think this is just how it is, accept it, and settle for delivering subpar treatment in order to keep their sanity. Others, who could have gone on to be phenomenal therapists, may wind up walking away from the profession altogether.
Want to know the worst part of PT mills? The therapists do all that work and don’t even get paid like it!! I have yet to see or hear of a competitive salary considering the patient load, schedule, and amount of documentation. In many clinics not even the site directors are making substantial money. The patients and the PTs suffer and grind day after day, but most of the profits likely end up going to the salary of the clinic director’s, boss’s, boss’s, boss. So basically some admin bigwig who has probably never treated a patient in their life.
As I said before, mills usually operate several locations in one area. The likelihood we come in contact with one as a student or licensed clinician is pretty good. However, they start to skew our expectations for the worse. We begin to think this is just how things are. Even if we don’t work in a mill we start to say to ourselves “Well at least I don’t see as many patients as in a mill”, “At least I make more or comparable to one of those places”, or “I guess things could be worse.”
These are dangerous thoughts because they lead us as individuals to settle. They encourage us to accept the bare minimum. We settle for constant burnout, mediocre wage for a 6-figure education, and poor workplace conditions. I know for many of us these are things we’d like to change about our profession. A step in the right direction would be to start trying to make PT mills the outliers rather than the standard. We’ve all maybe heard the quote “we accept the love we think we deserve”. Well friends, we need to start expecting much, much more than what PT mills have to offer.
Bad for the Profession
If you were informed your physician would be seeing you and another patient at the same time how happy would you be? It’s likely you’re coming to resolve an issue that’s important to you. You might’ve had to wait awhile for an opening. You might’ve had to take off work to make the appointment and you might’ve had to fork over a copay.
Given this, you wouldn’t be very pleased to realize your time and doctor’s attention would be divided. If it was your first experience with that office or specialty of care you’d probably form an unfavorable opinion about it as a whole. Would you think the clinicians there were caring? Trustworthy? Credible? Or skilled?
Folks we harp about wanting to be treated and paid like doctors. Well, then we need to start practicing like them. You don’t see any other healthcare professionals with doctorate-level degrees treating 2 patients at once. Theoretically, they could. Just like in our IBS example they could do that, but they don’t. We should not be the exception.
The PT-mill model decreases our credibility and skill to other healthcare providers, insurance companies, and patients. Some say “oh patients don’t notice or care”, but they do. I’ve had several patients talk about poor experiences in PT mills or mention how nice it is to be 1-on-1 with their PT.
In regards to those patients that supposedly don’t mind it, it’s probably because they’ve never had different. They think that’s just how PT works. But at the end of the day what’s their overall impression of us? Especially compared to their other healthcare providers. I mean if it looks like we can easily treat two people at once and provide the best possible care, then how hard can it be right? Would the impression be different if they received that skilled 1:1 care where we can analyze, educate, and motivate throughout the course of treatment. I’d like to think so.
Another opinion we need to start caring about is that of insurance companies. I know, I know, I don’t like it either, but it’s the truth if we ever want to achieve higher reimbursement rates and increased salaries. Insurance reimbursement is a convoluted issue. It goes far beyond just PT, but you can’t tell me PT-mills do us any favors.
Insurance companies know PT mills exist. They know mills take advantage of a fee-for-service model and use questionable billing practices. The fact that many mills are chains with multiple locations across the country creates a big problem. Rather than try to crack down and catch these places in the act, it’s much easier for insurance to just decrease reimbursement and we all suffer the consequences. As long as mills stay prevalent, they will continue to be used against us in advocacy for increased reimbursement.
I hate to put pressure on and say there’s a microscope on us, but there is. We’re a profession that recently transitioned to a higher level degree with a higher price tag. As a result of that we’re now asking for increased pay, autonomy, and recognition at organizational, state, and national levels. As we should. What we need to understand though is that legislators, other healthcare providers, and insurance companies are going to do everything they can not to give it to us. PT mills provide perfect arguments for any one of these entities to make their case.
So What Do We Do About Them?
If you are a PT who works in a PT mill my purpose of this post is not to demonize, shame, or guilt you. I don’t want to see any of this in the comments section from others either. What I do hope is you found something that resonated with you. I hope it encourages you to ask for change at an organizational level or make a change on a personal one. The best way to make PT-mills go away is if enough of us quit them or demand change.
If you’re a PT who doesn’t work in a PT mill, great, but your job isn’t done. A patient mentions they’ve been to a mill before? Let them know that’s not the standard of care or what most PT’s believe in. Tell your friends or family if they go to PT and their therapist is dividing their time between them and another patient to seek care elsewhere. Educate doctors you have relationships with to decrease referrals to PT mills to keep patients from walking through those doors in the first place.
If you’re a student about to start looking for that first job, do your homework this one last time for me. Listen to your gut, if it seems too good to be true – it probably is. These places will say anything to make it sound doable and like a great opportunity. Some straight-up lie about how they do their scheduling. Put them to the test. Ask to shadow for an entire day, maybe even multiple days. Ask for a detailed outline or description of their “mentorship program”. If they promise you “advancement opportunities” ask what those opportunities are and average salary. Remember you are interviewing them just a much as they’re interviewing you.
Lastly, if you work in a mill and completely disagree with what I said in this article please at least ask for a damn raise. You’re doing at least double the work non-mill PTs do in a day. You should at least be paid like it.
As always, share your experiences in the comments section and use the links below to share with your co-workers and PT friends! Ever worked for a mill or received care in one? Got other ideas on what to do about them? Let’s chat about it. Get the convo going in the comments and Instagram @the_pt_page. Don’t forget to hit “subscribe” below to get new posts directly to your inbox. Till next time!
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