I want to push back on something I’ve seen gaining traction in our profession: the idea that “practice model” isn’t particularly important in physical therapy.

The argument, as I understand it, goes something like this — because there is no single perfect model, and because time with patients isn’t the intrinsic motivator that drives job satisfaction, the specifics of how we deliver care don’t carry much weight. I understand the nuance. But I think it leads us somewhere our profession should not go.

I also want to be clear about something before I go further: I don’t believe most practice owners, managers, or therapists working inside any particular model are indifferent to their patients. Most of the people I know in this profession genuinely care. The challenge is that caring about patients and structuring a practice around patient outcomes are not always the same thing — especially when practices operate inside larger health systems, private equity-backed organizations, or corporate structures where financial metrics carry significant weight. Good people can work inside systems that quietly prioritize margin over quality. That doesn’t make them bad clinicians. It makes the conversation about “practice model” more important, not less.

What “One-on-One Time” Actually Means

One of the most common features of larger PT practices is a model where a patient is scheduled in a 30-minute slot with their clinician but spends a significant portion of their treatment time with a PT tech, rehabilitation aide, or exercise specialist who guides them through exercises or activities.

On paper, the patient has received a substantial amount of clinical time. In practice, the time with someone who can apply genuine clinical judgment — who can progress and regress activities to optimize movement, or catch something the patient mentioned offhandedly that changes the entire session plan — is compressed and frequently divided. That same therapist is often managing another patient simultaneously, which means even that compressed time isn’t fully theirs.

This is the crux of it: physical therapy is not the delivery of a standardized exercise protocol. It is the moment-to-moment application of clinical reasoning. I say this not to disparage those who practice differently — many skilled clinicians work within these structures and do meaningful work — but to be honest about what is lost when clinical judgment is rationed. Knowing when to progress, when to regress, when today’s conversation changes everything you planned — that belongs to a Doctor of Physical Therapy or a licensed PTA. Not to an aide, regardless of how hardworking or well-intentioned they are.

In our practice, every patient receives 40 minutes of undivided, one-on-one time with a licensed clinician. We don’t use aides to perform patient care. We train students and interns — they are a valued part of our clinical culture — but every patient interaction involving a student occurs under direct therapist supervision. That is a structural commitment we made deliberately, and one we reaffirm every day.

Double Booking: Who Actually Benefits?

Let me say plainly what our profession often dances around: double booking patients benefits one party — the practice.

The patient’s direct time with their therapist is split. The clinician is managing two presentations simultaneously, pulled in two directions, unable to sustain the focused attention either patient deserves. The research on divided attention is not ambiguous — performance degrades when attention is fragmented. Physical therapy is not exempt from that reality.

The practice sees increased throughput and higher revenue per hour. That is a legitimate business interest, and I’m not pretending otherwise. But it should not be repackaged as being good for patients simply because the practice is able to help more people. When a practice tells itself — or its patients — that double booking doesn’t compromise care quality, it’s having the wrong conversation.

We do not double book. Not because it wouldn’t help our bottom line — it would — but because it conflicts with what we’re trying to build.

The Three Pillars We’re Actually Trying to Balance

This is where I want to offer something beyond critique, because criticism without a framework isn’t leadership.

I see physical therapy practice as resting on three pillars: Quality Care, Clinician Satisfaction,and Business Health. Every decision we make as practice owners lives somewhere inside that triangle. And here is the honest truth: striking the right balance among all three is genuinely hard. It is also, for me, the most compelling part of running a practice.

A model that chases Business Health at the expense of the other two produces burnout, high turnover, and — eventually — eroding outcomes. We see this playing out across the profession right now.

A model that ignores Business Health in favor of pure idealism doesn’t survive long enough to help anyone.

The goal is not to maximize any one pillar. It’s to make deliberate, honest decisions about where you’re willing to compromise and where you’re not — and to be transparent with your team and your patients about those choices. For us, double booking and aide-delivered care are lines we don’t cross. Those decisions cost us some revenue. They also define who we are.

What separates a patient-centered practice from one that has drifted toward margin isn’t the absence of financial pressure — every practice feels that. It’s whether the clinical decisions are still being made by clinicians, for clinical reasons.

The Questions Worth Sitting With

If you are a therapist or practice owner thinking carefully about how your model reflects your values, I’d invite you to sit honestly with these:

• Who is in the room with your patients — and are they the right person to be making clinical decisions in that moment?
• Do your scheduling practices allow your clinicians to be fully present, or do they structurally guarantee divided attention?
• Are you balancing all three pillars — or quietly sacrificing two of them to shore up one?

There are no perfect answers. But asking the questions — and being honest about what the answers reveal — is how a profession moves forward.

If you believe that practice model matters, and that how we deliver care is not a footnote to clinical work but the foundation of it, I’d love to hear from you. This conversation needs to happen louder, in more rooms, across our field. The status quo is not inevitable. It is a set of choices. And we can choose differently.