Certifiably Certified

I stared at the place on my intake form for new patients, the line that requests "occupation." The new patient had written: PT-A-A. "I'm sorry, I don't know what those letters mean," I admitted. She proudly explained, "It means I am an assistant to the physical therapy assistant."

I had never heard of such a position. I said: "I know there is a certification program for physical therapy assistants, who apparently support the duties of a physical therapist, but an assistant to the assistant is foreign to me. Tell me about it."

The very young woman worked in a large rehab clinic. This clinic included the MD specialists known as physiatrists, many occupational therapists (OTs), lots of physical therapists ( PTs), and some "PT-A"s, which I believe is the official certification notation for physical therapy assistants. But my patient said she was being "certified" as a PT-A-A. She told me, "I will be certified after I work for three months carrying towels, changing sheets, and stuff like that!"

So, who or what is the certifying body for this PT-A-A? It turns out it is the very corporation that owns the rehab clinic which employs her, as well as numerous clinics around the country. There is no nationally recognized organization that certifies an "assistant to the physical therapy assistant" or even an "assistant to the physician's assistant". The value or necessity of a PT-A-A seems to me to be about the same as having a remote control for your television's remote control. (Nod to The Onion magazine, February 1997.)

This encounter perked my interest in the Zen of Certification. If a tree falls in the forest and there is not a certified forest ranger witnessing the fall, did it really fall? In the history of health care of any kind, this idea of certification is based on the "authority" of the credentialing body. Paul Starr's book The Social Transformation of American Medicine makes this very clear: There must be criteria that is measured by a recognized authoritative source to validate any degree or certification.

In my opinion, the physical therapists are a good case study in how a professional inferiority complex can lead to educational inflation. The PT degree now requires a master's degree, and some strive for the DPT, Doctor of Physical Therapy. So, how do the insurance companies reward this doctorate expansion? They don't. They reimburse the efforts of the standard PT exactly the same as the DPT. What might be a remedy for status dissatisfaction may not be a good business decision.

Chiropractic has all kinds of certifications, most of which are sensible. I went on a manic 10-year-long postgraduate education spree in the '90s, and my wife and children have finally forgiven me for all the weekends I spent in the process. But there are venerable organizations that measured and credentialed my efforts, and I feel validated by their "authority." That is why I am not impressed by some of the "certifications" offered in popular advertising.

For example, years ago some DCs started putting hospital beds in their offices. This fad was called "inpatient" or "day" care by some, and was designed to provide intensive treatment leading to better outcomes. One of the chiropractic colleges actually offered a certification in "day care." But how hard could this have been? Just put the patient in bed and smother them in ultrasound and adjustments! The fad has faded, but the certifications are still out there.

Then there is the story of a chiropractor in California who claimed he could detect the personality of a patient by looking at their full-spine X-rays. So he certified himself to teach this magic power to other chiropractors. I have always considered this as a good example of an attempt to certify the uncertifiable.

I understand that there are only a few "real" naturopathic colleges, meaning those that are recognized by appropriate federal credentialing agencies. But there are still a few "diploma mills" out there, offering ND or PhD degrees for a substantial "tuition." When I was in chiropractic school, a student came to class one day with a beautifully framed diploma from one of these mills. It was big, multicolored and certainly more impressive looking than the diploma we would receive upon our graduation. I wonder sometimes if he actually hung it in his office.

Chiropractic is synonymous with manual techniques, and certifications abound. I surprised myself by not writing about them, which was my original intent. It would have been like hunting fire ants with a small water pistol. As humorous as it might have been, the amount of e-mails from ticked-off DCs probably would have been impossible to field. Now don't go messing with a chiropractor's technique – certified or not.