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PT Code of "Non-DC Referral"
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PT Code of "Non-DC Referral" - February 16, 2004 6:07:00 AM
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Scanner
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I am helping spearhead an integrative program next year in a corporate/hospital/wellness type of setting. There will be AT's and PT's vying for my referrals and the other doctor's referrals there.
A colleague of mine has levied the charge that there is an unwritten (or maybe written, who knows) code among PT's of "never refer a pt. to a chiropractor." So, I thought I would come to RehabEdge and hear it from the horses' mouthes.
Is this true? Speaking from personal experience, I have only gotten 2 referrals from a PT in 6 years, and it was one I went to some length to secure a relationship with. I was told the reason why PT's don't refer to DC's is because they operate under a prescription of the MD and don't wish to disrupt that dr./pt. relationship. Seemed logical enough but maybe there is more. After all, Drew is constantly telling me that PT's have direct access anyway.
I'd rather have an honest answer, rather than what I want to hear, as I will have to address this issue if the integrative program is to be functional and work for the patient.
The corporation is attempting to create a Utopia of sorts, something that is surely unacheivable but something to strive towards. . .
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Re: PT Code of "Non-DC Referral" - February 16, 2004 1:40:00 PM
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Scanner
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Alba Longa,
Why do you ask? Do you not know what circumstances to make a good faith referral? Have you never referred to a DC?
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Re: PT Code of "Non-DC Referral" - February 16, 2004 7:19:00 PM
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mcap56
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There may be some legal ramifications to consider. If the patient was referred by a physician then he/she makes the call. If it is a direct access state, then the PT may be able to recommend a D/C but not refer them directly. Most PT patients, even in direct access states come through referral.
Now...for the other reasons........
1. There is no shortage of DCs that spend a fair amount of time disparaging PT. Not all of them, but why take that risk. I have had personal experience with this and on that basis along would never refer to a D/C.
2. There is overlap. Many outpatient PTs know skilled manual therapists who perform manipulation and mobilization. They would be the first choice for referral.
3. I personally don't puch much stock in manipulation. Despite all of the claims and pitches, there isn't much that proves it to be more than a short term benefit. Some of the theories behind it lack validity. There is no validated assessment tool to determine who should get what mob/manipulation (this goes for manual techniques practiced by PTs also).
4. As PT is a referral business, direct access PTs may be saving referrals for MDs who would in turn send patients back.
5. DCs are engaged in attempts to limit our ability to perform manual therapy and our ability to have direct access. They fight on both fronts tooth and nail here in NY. The bill on manipulation, which thankfully has gone nowhere, is so vaguely worded that performing any manual therapy would be difficult if it passed. Why would I refer to a profession that is determined to end my own????
So....there you have it. I would be more open to a relationship in the future. I know my arguments are one sided. However, you wanted to know the thought process. There it is.........
mcap
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Re: PT Code of "Non-DC Referral" - February 17, 2004 7:37:00 AM
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Scanner
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Mcap,
Thanks for your response. I would think your response would be representative. I understand there is much overlap and certainly I don't think any DC would expect a PT to refer x%age of patients to a DC. They were prescribed PT care, after all, and that's what you are there to deliver.
What's confusing this issue, I guess, is the direct access. I am continually educated by Andrew Ball that PT's have direct access. I was once even scolded for using the word "prescribe", saying that I should "refer" my patients to a PT. Very well, I thought, let's be colleagues and I dutifully referred.
I can understand if you are delivering care on a prescription basis. You aren't there to advise the patient, that's the MD's job. You are there to deliver care. In that, I could not expect any referrals.
However, if you do serve in an advisory role on a direct access basis, then what do you do with your fibromyalgia patients, whiplash patients, cervicogenic headache patients who fail to respond to your care? Tell them good luck and give them a kick in the ass? Go for surgery and an epidural? Again, this is very educational, don't take my sarcasm as an insult.
A colleague at the chiropractic forum has charged that there was a thread "Never Refer to a DC" here in the now closed chiropractic forum. I can't investigate it on my own now even though I am **** curious about the psychology that ran in that thread. It seems if there is a "Never Refer to a DC" than there must be a "Always Refer to a MD" type of mentality? Right?
I see you have political reasons (and one clinical - "manipulation doesn't work", LOL)for not referring your patients to a DC.
I am not complaining although it may sound like it. I am really just being educated to your "mass psychology" as I attempt to figure out PT's role among DC's, Athletic trainers, and massage therapists at the new integrative program. So far, it seems the program director wants PT's to serve in a massage therapy role so there is a reimbursement stream for those patients and let the AT's demonstrate exercises and recondition muscles. My practice would anchor the "alternative pod" at the wellness center. Massage therapists will work along side PT's and myself. It doesn't seem quite right to me but that's what is being proposed by the corporation at this time. But there will be a seperate PT center probably handling worker comp. type of work.
I guess the point of all my above rambling is I am testing the waters to see who are going to be the best "integrators"? The profession(s) that don't integrate well, won't do well in this program. It sounds corny but it IS all about the patient, not yourself, in this program. True consumerism, I guess. I don't know who the worst integrator will be - LMT's, PT's, LAc's, nutritionists, MD's, DO's, or maybe myself. I have my own prejudices I will have to lay aside I suppose although DC's have always bridged the gap from alternative to mainstream. I will probably have the easiest time, being the bastard mutt I am, LOL.
Anyway, thanks again.
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Re: PT Code of "Non-DC Referral" - February 17, 2004 8:05:00 AM
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flexion
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Scanner I hear you on many levels and can relate to what you are trying to determine. I think the model that works is the NMS DC gatekeeper role or a NMS DPT role with the other profession working as a subordinate or sorts underneath the global MD gatekeeper. Now determining who is the gatekeeper depends on scope and location.
Finding a situation where the MDs want the NMS gatekeeper to be a PT or DC is also a challenge. Being a DC my bias goes towards a DC gatekeeper because we all order diagnostic tests and make a Dx with a patient. Also, DCs do refer for PT but the converse isn't true.
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Re: PT Code of "Non-DC Referral" - February 17, 2004 10:14:00 AM
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steve
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I actually have referred patients to specific chiropractors on rare occassions. When I have referred it has been through the family physician (Ie. A note stating "Do you think this patient would benefit from a short course of chiro") and knowledge of the chiro's philosiphies (Musculoskeletal training, no monthly maitenance program). The one chiro that I have used tends to be very supportive of the physiotherapy aspect of treatment (Ie telling patients the importance of continuing with exercise) and communicates well with me (Ie. follow-up phone call etc.)
I think the major reasons you dont see more referral for chiro from physios is:
1) GPs involvement as treatment team quarterback.
2) Hesitant to send patients to chiros who treat with maitenance plan/subluxation based.
3) Replication of service - virtually all physios where I practice manipulate.
4) Chiro "Horror stories" - I have had more than one patient who was concurrently attending chiro come back and state the DC had said "Physios are horrible on the joints" or "You need to stop doing the exercises the physio gave you". I dont care who a patient attends, it is inappropriate to bad mouth the other professional, it only undermines the patients confidence in both practicioners.
Hope that helps,
Steve
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Re: PT Code of "Non-DC Referral" - February 17, 2004 11:08:00 AM
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Bournephysio
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Scanner,
If I am not helping a patient I send them to someone else. That is generally another PT. If they think that they could benefit from another professional I refer them on. I have never referred to a chiropractor. I don't see what a chiropractor can provide that I or other PTs can't. I know plenty of amazing manual therapists I can refer to while I don't know any chiropractors. Thats not antichiro. I just refer to people who I know are good.
To me the corporations suggestion of having PTs act as massage therapists shows a complete lack of understanding about what PTs do (and the reasoning of a revenue stream sounds dubious).
If you want to divy up the treatment, the only thing that might work is chiros manip, physios do specific exercise work, education ergo etc, the atcs do more general exercise. I personally wouldn't work in that situation. A better situation would be to have chiros and PTs work side by side with different caseloads. As trust develops you should see more collaboration between them.
The only situations that I would like referals from chiros (or other PTs) are:
1. On a consult basis to see what I think.
2. Provide a specialized service that they can't i.e. manipulation or acupuncture.
3. To treat a completely different area.
4. When a patient can't see the referer because of distance or some other problem.
or
5. To take over treatment.
Doug
ps referral is the correct term. I assess, diagnose, develop a treatment plan, treat, educate and refer as needed. That to me is a referral. A prescription is when you are told what to do or give.
[This message has been edited by Bournephysio (edited February 17, 2004).]
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Re: PT Code of "Non-DC Referral" - February 17, 2004 12:28:00 PM
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FlaDC
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this discussion is getting interesting, and I appreciate the honest answers. Coming from a DC who has on occasion referred patients to a PT when I felt they needed more in the area of physical therapy then I was prepared to offer, I can say this; as PT's wouldn't you think it perhaps a good idea to get a know a DC whom you can trust? the vast majority of us restrict ourselves to NMS care, without resorting to controversial modalities. this is dispite the rantings of the young man who used to post as enlightened. The overwhelming majority of DC's have no axe to grind with anyone. We are simply trying to do the best work for our patients that we can. For every DC "horor story" a PT might hear, a DC can repeat one related to a PT's treatment. It does noone any good to repeat such "highway" horror stories.
By getting to know a few such DC's you can open up your own referral network source that much more.
I have worked hard at establishing a good reputation with several orthopedists in my area, and have received a good amount of post-op knee and shoulder rehab work, as well as WC and PI cases. now before anyone accuses me of "performing PT without a license", in my state I am fully licensed to perform anything a PT does in the area of rehab. I would assume the orthopedists refer patients to me because of several reasons: #1. they are aware of the way I work in my office, #2. they know that they will be referred patients from me to them, #3. I have eatablished a personal relationship with them--seems friends refer work to friends. It's a two way street. One can never have too many friends in this world.
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Re: PT Code of "Non-DC Referral" - February 17, 2004 2:08:00 PM
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Scanner
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Steve,
I don't want to get off on a tangent too much but why the opposition to maintenance care?
What if a person has fibromyalgia or disc degeneration and they receive benefit from periodic spinal manipulation and become less episodic in their pain presentations as a result?
I have known even the strictest of EB DC's, NACM members in fact, to have maintenance patients.
Or should the patient just take Celebrex 2x/day forever?
Or should the patient just visit a pain management doc, a DC, a PT, etc. only when it is a crisis, let's say a 5 or more on a numerical pain scale?
Truthfully, I have asked orthopedists and pain management docs if it is maintenance care that they oppose in chiropractic and so far I haven't found any objection from them.
Maybe they are just being polite though, LOL.
That type of thinking will be the antithesis of this wellness program. Not necessarily wrong but definitely the antithesis.
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Re: PT Code of "Non-DC Referral" - February 18, 2004 2:51:00 AM
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nrl
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"Or should the patient just take Celebrex 2x/day forever?" no. and they should not come for a periodic spinal manipulation. they should be educated and advised on how to take control of their problem, make life styles adjustments specifically a correct exercise routine. this is true and effective " maintenance".this is EBP that is patient oriented.
as for the reasons for referals the only one i believe, which is patient oriented is the first of the three. the others are "practitioner oriented".
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Re: PT Code of "Non-DC Referral" - February 18, 2004 3:06:00 AM
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mato_tom
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PTs aversion to maintenance care is very silly IMO.......if people are willing to pay out of pocket for our skills then givem what they want
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Re: PT Code of "Non-DC Referral" - February 18, 2004 4:54:00 AM
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Scanner
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Enlightened DC
NRL,
If you could please show me where rehabilitation certified chiropractors oppose maintenance care, I would be interested. I don't think that is true at all and I think we have all learned not to accept what you say at face value. I would think a rehab-certified DC would think maintenance care is appropriate for a certain selected groups of patients. Would a rehab-certified DC think it right to put the entire population of America on maintenance care (actually preventive care) like some DC's do? No, I don't think so.
Maintenace care does not equal preventive care.
Of course, lifestyle changes such as encouraging exercise and a non-sedentary life should be a primary form of pain management. If the patient acheives this, then great! PRN care for them.
You don't think that really works 100% of the time, do you? No, of course not. You're being silly.
What about the highly conditioned athlete with chronic pain syndromes that goes to a chiropractor 1x/month? He not exercising enough? Oh, I know, he isn't exercising right.
What about the patient who doesn't comply to an exercise routine?
What about the patient who complies, does their exercises like a good little girl or boy, but still has disc degeneration and chronic pain?
I am surprised you would say this. I thought PT's had a more global view of their patients.
As far as the effects being short-lived, that can vary, Enlightened DC. Sometimes my maintenance patients (maybe 10-20% of my practice) get 3-4 weeks of releif, others get 1 day. If I find out it is only 1 day, then most certainly I say, "I think we are in a rut here" and refer on. At that point, I am not managing them well. Most often, it is probably these "ruts patients" that present to the PT and all of the sudden, you are jumping to conclusions of "maintenance care is invalid" and "DC's are evil." Each person is handled on an individual basis. Yes, running into ruts with maintenance patients is a pitfall DC's have to deal with and be careful of. I know I am not perfect.
From what I can tell, it is the fact the DC is getting the money and not the pharmaceutical company that is upsetting you. You are not as upset about patients taking Celebrex 2x/day forever because I suppose that is a cultural icon that is accepted. After all, the MD who prescribed PT prescribed Celebrex 2x/day as well and you wouldn't be as so bold to speak up even if you harbored such thoughts, would you?
I do agree it is probably more expensive to engage in maintenance care from a DC for pain management vs. Celebrex 2x/day forever.
However, as drug costs grow at 15%+/year, I don't think that will be true for much longer.
As far as the David Seaman Opinion Article, you have opened Pandora's Box.
If he feels that spinal manipulation is powerful enough of a pain management tool to mask pathology, then apparently, IT DOES have a role in monthly pain management. To not employ maintenance care "because you may miss pathology" is silly again. You just have to be aware of their global health (constitutional symptoms, other providers visited, tests ordered) and that again, you don't fall into a "rut" and miss pathology. A definite danger. . .
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Re: PT Code of "Non-DC Referral" - February 18, 2004 5:43:00 AM
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Diane
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I disagree with the concept of "maintenance care" when it consists of manipulation being performed monthly or weekly or whatever periodicity indefinitely. I believe there is a tendency toward addiction here.. where manipulation relieves pain, but at the same time creates a situation where a new pain syndrome actually 'develops' that requires manipulation to relieve IT... just like drug dependency.
I raise this topic, because this situation happened to me personally, about 20 years ago. A (boy)friend of mine used to, every day almost, lift me up in the air, squeeze my back and pop it. It felt kinda good, I kinda liked it, but before too many months went by, I actually needed this, because my back would be sore and this would help.. We parted company after about two years, and you know what? It took about 5 or 6 years to get rid of that grumpy pain in my mid back! I got treated non-manipulatively (a long slow, sustained non-pop direct compression to the spine, with me free to move my shoulder girdle in ways that assisted the effect of relief) .. and my body/brain relearned not to "need" the pop to feel "good" temporarily. It normalized again.
So, that's my case study, on me.. I see manipulation as a real slippery way for practitioners to create a large population of dependent patients (like a herd of milk cows) from whom they can siphon a income forever. "Crack addicts." These can be the most well intentioned practitioners in the whole world. They can delude themselves into believing that they're doing the world a big favor, saving it from unnecessary pain'n'suffering, etc. blah blah, but the fact remains that manipulation like opiate medication is a strong tool that must be used judiciously short term on the appropriate issues in the tissues/pain in the brain. I say, stop entraining peoples' nervous systems to your "technique" to make a living.
Diane
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Re: PT Code of "Non-DC Referral" - February 18, 2004 7:02:00 AM
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mato_tom
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what about a PT maintenance program that does not involve manipulation........periodic visits or PRN
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Re: PT Code of "Non-DC Referral" - February 18, 2004 7:14:00 AM
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steve
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My problems with maitenance programs are two fold. There is no evidence that manipulation provides long term benefit, having said this for acute pain, I think it is a valuable tool. If a patient does get relief from mobilization/manipulation, we should be able to teach them home exercises to self mobilize (I am in no way suggesting self manipulation, rather mobilization exercises with belts, towels etc). Secondly and more importantly, there is increasing evidence that chronic pain has a significant psychosocial element. Dependence on passive treatment creates an external locus of control over the pain. Self management creates an internal locus of control and allows the patient to feel they can control their condition and there is evidence to support this. Just my two cents worth as a clinician.....
Steve
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Re: PT Code of "Non-DC Referral" - February 18, 2004 7:43:00 AM
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Scanner
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Enlightened DC,
I apologize for being rude. I read the article and I think you are overextrapolating.
Dr. Lieberson is merely saying the new trend in rehabilitation is from passive modalities to active care. I am not disagreeing with that - in fact, I agree that a quick introduction of active care is the trend in rehab.
But that is a far cry from saying rehab. DC's think maintenance care is inappropriate in all forms.
How do you rehab. degenerative disc disease anyway? This forum isn't suggesting this condition can be exercised away or merely pain-managed with the instruction of daily exercise all of the time, do you?
As far as manipulation being addictive, well, that is a topic needing exploration. We know there is endorphin release following manipulation. Is that chemical your body produces addictive enough to create a physical dependence? I personally doubt it. I don't have too many patients salivating for manipulations in the waiting room but it is possible.
Enlightened DC has also raised the concern of creating hypermobility. I believe one study with the ankle joint refuted that concern. However, it is still a risk that must be considered because what he says does have face value.
It's all about risks vs. rewards, fellows/gals. This may sound condescending and it isn't meant to be but you have to be put in an authorative/managerial role with the patient to realize this. What you are going to do for the patient depends on the risk of each procedure outweighing the reward. Of course, home exercise is the best risk/reward ratio. It's cheap. It's effective. It's creates self-dependence. If that fails for whatever reason, you have to start to move up the ladder.
But yes, we are guilty of fostering "passive dependence", I suppose, as guilty as the pain management doc is for prescribing Celebrex 2x/day forever as I point out. The question is, back to risk/reward, what is the risk of Celebrex vs. SMT? DocWagner could illuminate me on Cox-2 inhibitors with relation to renal failure, liver disease, ulcer bleeds (I beleive this is very low), etc.
If any of you are interested in really seeing each role a speciality plays in pain management and passive dependence, I suggest exploring the American Academy of Pain Management for credentialing.
[URL=http://www.aapm.org]www.aapm.org[/URL]
I beleive that is the link. DC's, MD's, DO's, PT's, Pharm.'s, RN's, and even ministers are eligible for different levels of membership.
Last year, a DC was President, in fact. Maybe next year, a PT will preside.
Pain management is a Hot Topic among hospital accreditations as it has been pointed out that medicine does a poor job of following up and managing on pain. Hopefully, an integrative approach can change that.
Unfortunately, insurance co.'s are caught up in "acute" pain and limiting physical medicine to that. Something that will hopefully change. . .
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