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Sinusitis and our future
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Sinusitis and our future - January 1, 2001 9:53:00 AM
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mcap
Posts: 652
Joined: February 8, 2000
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Dear Group:
While recovering from my standard end of semester cold I did some research. Since I had sinusitis and I didn't know if it was bacterial or viral, I did a little research on the use of antibiotics in the event that things worsened and I had to go to the doctor.
First I read some books on the subject where the expert ENT doctor went on to describe how sinusitis should be treated aggressively with long courses of strong antibiotics in chronic cases and with decongestants.
Then I did a Medline search to look at the results. The results.....antibiotics have been shown to significantly help sinusitis both in the medium and short term. There was no evidence as of yet, however of any long-term conclusive benefit.
I thought now isn't this funny......Sinusitis, one of the most common reasons for a doctors visit and a growing epidemic that has tremendous cost for the society both interms of medical care and decreased productivity.
Perhaps there is a significant benefit. Perhaps these people do worse over time as the natural bacteria of the body is replaced by fungus. Who knows????? [IMG]http://www.rehabedge.com/forums/confused.gif[/IMG]
But isn't this what we always hear about Physical Therapy?????? Short and medium term benefit only????? The only thing is that whenever a study on P.T. comes out and there is a problem - there is an outcry to reduce or eliminate our usage.
Part of the problem is that we are mostly on the treatment end of things. Even if antibiotics don't work, there is still a purpose in going to the doctor and letting he/she rule out complications or more serious pathology. When you are just treating and the treatments aren't proven, then why bother??
There are other issues as well such as money, public perception, political influence etc.
But I think that unfairly or not, we need to justify what we do, perhaps more than others in the health field. I think that evidence based practice is the only way we are going to secure the future. Of course, you could make the argument the other way by saying evidence based medicine isn't practiced as often as it should be and it still doesn't matter - so why should we??? I disagree but I realize that other side.
Happy New Year All [IMG]http://www.rehabedge.com/forums/biggrin.gif[/IMG]
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Re: Sinusitis and our future - January 2, 2001 1:14:00 AM
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Barrett
Posts: 967
Joined: July 28, 1999
From: Cuyahoga Falls, Ohio
Status: offline
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mcap,
You said: "Part of the problem is that we are mostly on the treatment end of things. Even if antibiotics don't work, there is still a purpose in going to the doctor and letting he/she rule out complications or more serious pathology. When you are just treating and the treatments aren't proven, then why bother??"
Therapy works similarly by treating problems in an effort to discover more about them. The notion that you can know precisely all that is wrong before you begin care is an orthopedic conceit I find unjustified in practice.
Perhaps we don't need to prove that therapy results in resolution, but only that it shortens the recovery period and reduces pain. Before we existed people got better in time, but it was a longer time and I don't think anyone doubts this.
The insurers won't pay us and argue that it's because we lack evidence, but twice each year I walk through the poster presentations at the national meetings and it sure looks like a lot of research is being done, and most of it clinical. The insurers know that 60% of us do not belong to our professional association. They know we're weak, so they don't pay us anymore. It's got nothing to do with evidence, it's politics and power.
And we've lost.
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[This message has been edited by Barrett (edited January 02, 2001).]
[This message has been edited by Barrett (edited January 02, 2001).]
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Re: Sinusitis and our future - January 2, 2001 7:29:00 AM
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mcap
Posts: 652
Joined: February 8, 2000
Status: offline
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Barrett:
I would never underestimate the influence of politics and power. And on that front, I agree, we have lost. But I am not sure that membership in the professional association is the primary reason.
The lack of research, I think, is still a problem. I would readily concede that there is a lot of research out there but where is it?? When there are reviews of effective treatments and guidelines formulated, some of this research doesn't seem to hit the map. Is it a problem of visibility and power, or of research design, or of both???
An additional problem is that no matter how much research is performed, there exists a large proportion of PTs that will go out of their way to ignore it. Even if we have proven, effective treatments (indeed we do), many PTs cling to mystical treatment techniques that have no validation, and no outcomes research.
Maybe insurances would deny payment anyway? But why give them more ammunition. Chiropractors were able to gain footing with reimbursement with not just power and money, it was research. Before the AHCPR came out with it's guidelines, they produced a buch of research showing the benefits of manipulation (albeit short term only). The studies were pretty good. Manipulation has been recommended for short-term pain releif in most reviews since then. And, chiropractors have been able to gain reimbursement in cases where previously they could not.
Until long-term benefit is proven however, they will face increasing scruitiny of their methods. But my point is that the research matters. Maybe it is a subordinate concern to money and power but it is a factor.
mcap
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Re: Sinusitis and our future - January 2, 2001 7:32:00 AM
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mcap
Posts: 652
Joined: February 8, 2000
Status: offline
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Also.......
I would agree with you that it is almost impossible to find out most of factors critical to a disorder or disease in one doctors visit. That is the medical model however, and no one seems to be questioning it for now.
PTs do a great job in making comprehensive evaluations both at the IE and during the course of treatment. But I don't think this is recognized by the 3rd party reimbursement powers that be.
mcap
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Re: Sinusitis and our future - January 2, 2001 6:12:00 PM
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Andrew M. Ball, MS, PT
Posts: 500
Joined: October 8, 1999
From: Chapel Hill, NC, USA
Status: offline
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Wow, what an impressive discussion this is! I don't think that I have anything to add. I agree that many, but not all (and hopefully not the majority of), physical therapists self-censor themselves from current research. There is certainly a greater lag between research discovery and clinical application in PT, OT, and SLP than other fields. Every health profession has these problems, but the allied professions (PT, OT, SLP), seem to have a greater problem with this than others (MD, DO, etc.). Allied health professionals, in general, tend to obtain more information from continuing education than basic science research, and take longer to apply it to clinical practice. I used to think that the 5 year lag between discovery and application in medicine was shocking . . . until finding that the lag in physical therapy was more like 15 to 20 years.
I'd also like to raise a related issue . . . the APTA's apparent position (and someone please correct me if I'm wrong) that the DPT should at some point in the future, be able to diagnose and "gatekeep" neurmusculoskeletal injuries . . . as a discussion point in this thread.
I still have mixed feelings regarding the utility of the physical therapist for this purpose. I agree that we need a more enhanced professional role in the future healthcare environment, but I'm not sure that the general public, nor third party pay sources will ever see the benefit of going to a PT to rule out more serious pathology.
Drew
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Re: Sinusitis and our future - January 3, 2001 3:53:00 AM
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mcap
Posts: 652
Joined: February 8, 2000
Status: offline
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Drew:
Nice addition. As an outpatient ortho type I have mixed feelings about our ability to diagnose as well. I truly beleive that I am often in a better position to make a diagnosis and rule out serious pathology in patients with MSDs than a relatively untrained primary care M.D. But what about the time when I may miss something sinister? Some visceral and oncogenic pathologies behave very much like orthopedic problems.
Furthermore, without the ability (and knowledge) to order imaging and bloodwork I am quite limited. So in cases where the PT is the gate keeper, they will still have to refer to doctors quite often. Although wasn't there some direct access Maryland study where costs were less overall?
But we also have to realize that our ability to help in diagnosis is the result of time. With a forty minute evaluation and with subsequent treatment sessions it is often after the IE when I decide a patient needs a further evaluation. This, while it may be good for the patient, is not something insurance would be ready to recognize. They would like their code after the fifteen minute M.D. evaluation. I don't think that this is going to change. Placing me in that 15 minute pressure cooker is not something I am interested in either [IMG]http://www.rehabedge.com/forums/eek.gif[/IMG]
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