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Re: DC: Crossing the Line??
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Re: DC: Crossing the Line?? - May 11, 2003 7:52:00 PM
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coloradojulie
Posts: 413
Joined: November 10, 2002
From: colorado usa
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I have to support Dr. Wagner in much of what he says. I personally feel that PTs are the best rehab providers, bar none. That is our specialty. But to start thinking that we can take on the added knowledge base or responsiblity to evaluate deeper issues is over the top. Screening know how is one thing, and a definite necessity. But if I as a practitioner begin focusing the little extracirricular/non-clinical time I have to learn about pharmacology or radiology...I feel I will be a weaker PT, not a stronger PT. My specialty is rehab...I have no problem calling on other allied professionals to answer questions or share information. I call the local pharmacist, the doctor etc. and it is no sweat off my brow or a reflection of being an inadequate practitioner. In fact, it generates greater respect.
As a MD, those guys have gone through hell, and they do know alot of stuff we don't know, or need to know to be great PTs. We are such a paranoid profession...we want to expand our scope, and hold on to our roots. We don't want other allied fields stealing our "material" and claiming it for their own, yet we don't claim it for our own either.
In school, the rehab classes were always referred to as "doctor wanna-bees" and judging by alot of this discussion it is true in many cases.
I know alot about being a PT. That makes me successful. It has created a practice that is successful and highly respected. I am amazed constantly about how highly our office and my therapists are spoken of. It has nothing to do with reading x-rays, or debating the effects of beta blockers...it has everything to do with our expertise as PTs.
Respect is gained through practice and results. Not letters or nomeclature. If you want to be a doctor and have all the rights and privelages they have earned, go to med school. But if you are happy being a PT, put your energy into promoting what is really great about us, setting standards of practice...not into expanding us into undeserved and unnecessary avenues of medicine...
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Re: DC: Crossing the Line?? - May 12, 2003 2:58:00 AM
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Andrew M. Ball PT PhD
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From: Charlotte, NC
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How can you be an autonomous PT WITHOUT the skills that you listed above? You may be a stonger PT TECHNICIAN without them assuming that re-allocate your con ed time to other worthwhile activities, but odds are that you self-censor yourself from being a PT PROFESSIONAL.
That's not to say that you're unprofessional, but being a professional is more than simply acting professionally toward patients.
I want PT to emerge as a true profession, and wish that others would stand in that march and quit draggin' the heels of physical therapy!
Drew
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Re: DC: Crossing the Line?? - May 12, 2003 4:32:00 AM
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Andrew M. Ball PT PhD
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From: Charlotte, NC
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I didn't call ColJulie a technician. You're reading too much into what I said.
Being a profession is much, much more than simply following current standards of practice. I am currently writing an article on the subject of professionalism along with Bob Kizlik, PhD and Erin Midkiff, DPT.
We are developing a working model, based upon the published works of others, by which to evaluate the robustness of profession to which those claiming to be professionals have achieved.
The working model is that for the APTA's definition of a physical therapist professional to be valid, it must comply with what published authors have defined as a "healthcare profession," and that in order for it to be a profession, it must first comply with what it means to be a profession (as defined by Bob's doctoral work).
Failure to conduct and/or read x-ray images, or diff. Dx any patient who walks into our clinic off of the street prevents us as a group from being able to act in a RESPONSIBLE autonomous manner from evaluation and diagnostics through intervention. Without the ability to practice safely in this regard, how do you even expect to justify direct access and direct reimburement? Failure to act in a safe and responsible manner prevents physical therapists from being professional on several grounds including the inabilty to put patient safety above professional renumeration (due to ignorance of the tools to do so), and in so doing lends support to those fighting against direct access and direct reimburesment for physical therapists --- this level of autonomy being a critical component of emerging as professionals.
In that vein, I don't apologize for what I said. Those who speak out against the value of DPT's and DScPT's being able to read x-rays and diff. dx, in my opinion, are dragging physical therapy down into technical entropy and disallow physical therapy's emergence into being a profession --- to say nothing of being a healthcare profession.
It is not enough to act in an ethical manner that complies with current standars of practice. If that's all you're doing, you're a nice person to be sure, but not a professional in the objectively published, peer-reviewed, and defined sense of the word.
If you're defining technician as a profession, and have seen a level of ethics and cohesion lesser than even than the definition of profession refered to here . . . God save physical therapy.
Drew
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Re: DC: Crossing the Line?? - May 12, 2003 7:38:00 AM
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coloradojulie
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From: colorado usa
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Drew,
I agree that there are definitely individuals out there who administer cook book physical therapy, and are truly technicians. However there are other, and hopefully the majority, of physical therapists who practice as professionals, in autonomous ways. For example, if a family practitioner refers a client to an orthopedic surgeon, do we begin to think that this makes the surgeon less autonomous? Or if the orthopedic surgeon refers a client to a neurologist that the neurologist is simply a technician? No. They are mutually respected and complimentary specialists who are adding there expertise to a particular patient problem, just as physical therapists currently do. We are professionals. Specialists, working within the medical community, treating a certain set of patient problems. Just like any other specialist we will have a mix of direct access clients, but the majority will come from other health care practitioners who currently recognize and utilize our services.
The majority of physician referrals state "eval and treat". This gives the therapist the impression that the doctor understands their expertise and allows the physical therapist to manage the patient using their discretion and specialized knowledge.
As far as dragging the heels of the profession, I am all for promotion and development of our field. I simply feel that the current direction of effort is not the most important one, nor do I feel we will advance the profession as significantly as you profess. I think there are many other issues that need to be addressed that currently bog down the reputation of physical therapy, and that is what I mean when I say "practice standards". For example, clinics that see numerous clients per day. If you can step back and look at this through the eyes of referring physicians and clients, the majority, in my opinion, would observe this as abuse, and "factory" care. Clients and doctors have used this word, not myself. This is the feedback I consistently get. From this, the physicians are fearful that PTs will over utilize with seemingly cook book, technician approaches. They may get feedback from their clients that PT was not helpful, and they felt confused and ignored at times due to the hecticness of the environment and the different things they were told by different therapists. We must protect the first impression of our profession, by examining effective treatment practices, and look at utilization related to direct therapist contact. I would be happy to compare our clinic to one of these clinics per diagnosis and see if we are indeed doing a disservice to our clients by increasing volume.
Also, I think if we are fearful of technician status, we should monitor or evaluate the use of "technicians" such as aids and ATCs in the busier clinics. Does not this arrangement promote a cook book approach? When instructions are given to a technician regarding patient care, how complex can we really be with the aids? For complex patients, doesn't that then force us to simplify treatment plans and establish routines of care that the technicians can manage without increasing the time we spend educating them? So wouldn't it become "Put Mrs. X on a hot pack and then have her ride the bike 15 minutes and use the UBE for 5 minutes?" That certainly is impressive physical therapy! In an environment such as this, it wouldn't matter if you were at PT, a DPT or a PTA, you would all give the impression of doing the same thing, technicians if you will.
I am consistently frustrated by patients who have been in the health care system for some time, and have even had physical therapy intervention, and yet have not had the simplist musculo-skeletal issues addressed correctly, nor have they been assessed thoroughly. I feel that in these situations a standardized level of practice, and expertise would prevent clients from seeing unskilled therapists, and therefore develop the impression that this therapist was representative of the field of physical therapy. Wouldn't it be more useful to establish this through practical and written examination? Having written both the US and Canadian national examinations, I think we can all attest that in no way do they adequately assess our clinical skill. Perhaps this is a better aspect of professional development than moving into new territories when we lack control over our current ones.
Stepping back again from the profession and looking at it objectively, imagine how our DPT program must look to medical doctors. Wouldn't they have the very same impression that we do when we see personal trainers, or athletic trainers attempting to expand their roles into the realm of physical therapy? And even if the ATCs added a class on functional rehabilitation, wouldn't we still feel this training is inadequate to justify their expanded role?
If you are practicing within the scope of physical therapy practice, your skills of assessment and symptom recognization, will alert you to possible underlying pathologies that are not musculo-skeletal in origin. I have identified skin cancer and a psoas abcess on clients simply by recognizing unusual symptoms that don't match my knowledge of musculo-skeletal diagnosis.
My personal opinion of practicing medicine or physical therapy is that if you ever believe you know everything, or that your training prepares you for every eventuality, you are a self limiting practitioner. Meaning that the more you learn, you will hopefully realize how little you know. With the DPT training, hopefully practitioners would come out of it with greater respect of the skill of MDs and realize that their surface knowledge of these topics in no way prepares them to practice them autonomously.
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Re: DC: Crossing the Line?? - May 12, 2003 7:43:00 AM
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coloradojulie
Posts: 413
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From: colorado usa
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By the way, SJBird, thank you for the compliment.
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Re: DC: Crossing the Line?? - May 12, 2003 11:04:00 AM
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mcap56
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From: New York, NY
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I think a lot of you don't fully appreciate the argument that Drew and others are trying to make.....
-No one is talking about walking around the hospital calling oneself "doctor"
-No one is talking about taking the place of primary care physicians.
However, if we want to practice autonomously we do need additional skills and competancies. We need to know when to refer on.......that is the most important issue. If we don't discuss medications, radiology and other pertienent aspects of a patients condition in a professional and knowledgable way, then we won't be able to instill confidence or even know when to refer on correctly.
Colorado......PT is hurt by many of the things you mention and there are certainly other issues. However, one of the biggest impediments to competant care is a system in which PTs get scripts and do what the script says. Unless we have more responsibility we will not take the initiative to move forward.
One may counter by arguing that they deviate from the script, (with authorization) when necessary, they get general scrips and/or they don't provide cookbook therapy. However, many of the techniques and nuances that PTs feel make them special and set them apart (much of our manual care for example) may not be worth that much in the long run. How are we ever going to address these issues under the current system. How many times to I hear how different or special a PT is because of their manual care. Well......what happens if manual care doesn't amount to all that much after a closer look? What do we have then?
I have a STRONG word of caution for all of you clinic owners and managers out there that are happy with the presesnt arrangement......IT WONT LAST!!!
I have a colleague who owns clinics. This person is a great community member and the clinics give very high quality care (2 pts/hr, 1 hr eval). There was a steady referral source from local physicians who had a great deal of respect for this person.
These physicians have recently decided to open up there own clinic and employ their own therapists. They will use new grad PTs or other less experienced personell. The PTs are "employees" of the physician clinic so it is not a case of self referral......legally anyway. There will be no more referrals for the PT owned clinic and rehab will now take place in house. The physicians are interested in "making the most money possible." The quote was from them.......not from the PT and they don't particularly care what kind of PTs will go into the clinic. This act will be comingn soon to a practice near you.
How could you ever do anything about this without direct access?
NO profession has ever survived without moving forward. For some on this board, dicomfort with new ideas amounts to a comfort zone that has been established and in come cases, complacency. The system will change whether you like it or not. I think we should start deciding how we want that change to be.
Respectfully,
mcap
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Re: DC: Crossing the Line?? - May 12, 2003 11:56:00 AM
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Bournephysio
Posts: 585
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From: Calgary
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Coloradojulie;
Your last two paragraphs seem to contradict one another. One seems to say you recognize patients who are outside your scope the other says you can¡¦t practice autonomously. If you can recognize the people you need to refer on, why can¡¦t you practice autonomously? Were you not trained as a PCP (practitioner not physician) at Mac? Maybe we don¡¦t agree on the meaning of a primary care practitioner.
To me, being an autonomous primary care practitioner does not mean being able to diagnose SARS, or a kidney problem. It does mean being able to see anyone off the street and being able to asses them and treat them safely. Having practiced as a PCP for the past five years, I have not had any problems. If a patient is outside your scope you refer on. If someone may benefit from the services of another practitioner be they a GP, OT, Kinesiologist, etc, you refer on. No big deal. Nothing magical or mysterious about it.
The biggest problem with PT in the states is that MDs can prescribe treatment. That fosters PTs to turn into technicians instead of professionals. You shouldn¡¦t be pleased or proud that most of your referrals are eval and treat. It should be expected. It should be the law.
Direct access has definite benefits to health care. Patients get access to the professional who can help them faster. Health care is spared the unnecessary cost of a physician¡¦s visit. The physician is freed to see patients who are more suited to their skills.
The next logical step is to see where we can further relieve pressure off of physicians. Limited prescription rights is one way. And yes limited prescription rights is a reality. Anybody can walk into a drug store and buy ibuprofen or acetaminophen and self-medicate. We already get a course in pharmacology in PT. I don¡¦t know how much more they get in a DPT but I don¡¦t think it would take much more education to be able to prescribe certain anti-inflammatories in simple cases (no you don¡¦t need to know how to pump someone¡¦s stomach to prescribe medication. Just send them to Wags if they need it ƒº)
The ability to order and look at imaging studies is even closer to our abilities and strengths. We already have a greater knowledge of when studies are appropriate than most GPs do. More importantly, we have a better idea of what the studies mean. The ability to read x-rays, mri etc would not be wasted time even if we never get to actually read them. Time spent studying xrays and mri would improve our understanding of anatomy even further (you can never get too much anatomy). I also think that we would have very important influence in imaging. I don¡¦t think that current imaging protocols are even close to optimal and could use a PT mind to improve.
Finally, without the extra pharmacology and imaging I think that our profession is still deserving of a clinical doctorate. Our abilities and knowledge base have reached this point. I am not equating a DPT to an MD. They are totally different philosophies. An MD has a very general education in medicine before they specialize in a long residency. A PT is a very specialized program. Both philosophies have their advantages and disadvantages. The major advantage of the PT/PharmD/OD philosophy is that you become a specialist in a much shorter time period. The major disadvantage of the MD philosophy is cost. I don¡¦t think that health care is sustainable as a completely MD system. I think that the system still needs to be MD centered but responsibilities need to be delegated as appropriate.
Doug
Ps. Mcap: have you changed your email address? I tried to email you the other day but my email was rejected.
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Re: DC: Crossing the Line?? - May 12, 2003 12:06:00 PM
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mcap56
Posts: 619
Joined: October 26, 2002
From: New York, NY
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Doug.....
Very well stated!! I couldn't agree more.
Try this email....... mcam54@hotmail.com. If it doesn't work, then I can give you another.
Best,
mcap
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Re: DC: Crossing the Line?? - May 12, 2003 1:05:00 PM
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coloradojulie
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From: colorado usa
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I think you both misunderstood me...I believe that I do practice autonomously...I just don't believe a DPT will enhance that or change the way I practice. I also support direct access, however I don't feel that if I recieve a referral as a specialist, that this somehow compromises my autonomy or makes me any less professional.
As far as manual therapy, I have to say I do less and less of this. In many cases I use it to facilitate some changes we are trying to make. And as far as complancancy, I am hardly complacent. I learn at least one new thing a day, I constantly evaluate what I do as a therapist and develop new treatments based on outcomes on a regular basis. I would like to see change in our profession, but I would rather see it in quality not nomenclature. If anyone as a practitioner possesses critical appraisal or life long learning skills, they can self direct themselves to any amount of information regarding practice (pharmacology, radiology etc). There are numerous post graduate courses etc.
My opinion is simply that we do not need to change our designation. If you think that changing your title to a DPT will create improved quality care or prevent doctors from opening clinics or gain more respect, you are mistaken.
The docs can go ahead and open a practice in our area, in fact they did...and it didn't change a thing...because we already have respect and patients always have a choice with direct access or not.
As far as radiology and pharm go, again I feel their are professional resources aplenty with the skills and training necessary to answer any questions I might have. I don't feel any less capable because I ask a question or look something up. The information already exists in the system...why duplicate services?
Again, the basic pharm, radiology etc. is sufficient to give us the tools we need to refer out as needed. A close working relationship with referring providers is key to differential diagnosis and prevention of malpractice.
Take Drew for example...in a recent post from Dr. Wagner about meds, he sure sounded knowledgeable and we wasn't even a DPT!! Where did he get that information? His degree study and the independent ability to look it up! Fabulous!
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Re: DC: Crossing the Line?? - May 12, 2003 2:34:00 PM
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Bournephysio
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From: Calgary
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Of course receiving a referral doesn't make you any less of a professional. Being told what to do does.
I am not clear on what point of wagner's you agree with. You realize he thought PTs were good at exercise prescription and manual treatment not diagnosis and assessment?
Your points against the DPT seem to be that it won't necessarily change anything and not that there is something inherently wrong with it. Is that correct?
Just trying to clarify. I am always intrigued by the strength of opinions for and against DPTs.
Doug
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Re: DC: Crossing the Line?? - May 12, 2003 8:22:00 PM
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coloradojulie
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From: colorado usa
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I agree that PTs are specialists of rehab.
I don't think the DPT will benefit the profession, or change our status in a variety of issues (direct access etc.)
The points of Dr. Wagners I agree with are that PTs should not expand their scope of practice to include ordering of imaging studies, prescribing meds, differential diagnosis (as a primary care giver).
I agree that we should develop our professional strengths within our current scope of practice through standardized care. Meaning weed out the bad.
I believe PTs are professional and autonomous.
I hope that clarifies it...
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Re: DC: Crossing the Line?? - May 12, 2003 10:24:00 PM
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Bournephysio
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From: Calgary
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If you are being told what to do, I don't know how you could consider yourself a professional.
SJ as for your other points:
1: I don't see a problem with this either
2: It is completely unacceptable to have a professional who is not an expert dictate treatment. Period. If they are experts then they have no need of my expertise. There are obviously times when treatment is going to be decided as a team (ie post-op rehab) but treatment should never be dictated. You shouldn't have to phone the doctor to change the treatment. I struggled with that for eight months in michigan. I have to say patient care suffered. You can only spend so much time hunting down doctors and trying to change attitudes, many physicians will not even talk to you. This was one of the biggest reasons that I moved back to Canada so quickly.
3.It is probably very difficult to do this properly but I suppose it is possible.
4.Obviously it is not possible to be completely autonomous or you wouldn't have patients. As for the “captain” of the team it is going to depend on the situation. Sometimes it should be you, sometimes it should be the gp, sometimes the rheumatologist, sometimes the patient etc. It may (should) change during the course of treatment. I often treat patients without the GP being involved at all. Kind of hard for him/her to be the captain then. Why shouldn't we be captain of the team?
5.I don't know who is driving the DPT. In Canada faculty are almost completely hired based on research ability and almost nothing on teaching ability. Pay has nothing to do with students.
Doug
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Re: DC: Crossing the Line?? - May 13, 2003 3:30:00 AM
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Sebastian Asselbergs
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From: Barrie, Canada
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As always, an interesting subject! Good points made by all - having been in PT for over 20 years in a few different cultures, I think both "camps" here make valid, and not mutually exclusive points.
I agree 100% with direct access (10 years now here and it's working smoothly), but it has also allowed a alarmingly large number of PTs to be employed in (or even own) assembly-line clinics. This greatly undermines our status as "professionals". History is also a factor: PT has been a "support profession" for so long that we are still facing an uphill climb with regards to the perception of some patients and doctors. This IS getting better.
Change needs to occur on all levels - a "DPT" may help, strict rules on ownership of PT-clinics, protection of the terms "physical therapy" and "physiotherapy", enforced standards of practice, education of the public accross the board, etc etc.
I think that limited presciption rights have great benefits, as would imaging prescription. These would take a lot of time to establish safely and prudently - at this time in our province, the MDs are the gate keepers and cost guardians of diagnostic imaging. I am sure that as a profession we need significant education on the cost factors and economics of the health care system we are part of. That is one aspect I find sorely missing in the education of PTs here.
One thing is sure for me, in the long run the status quo HAS to change, and I see it as a combination of public education ("marketing"), professional development and professional identity - aided by DPT. If we do not keep moving forward on many levels, we will be left in the wake of more pro-active and aggressive professions.
BTW, I would caution that it is very UNprofessional to question each other's level of professionalism and dedication to PT on discussion sites as this: there is no pratical reason to do so, and too little information on the participants to justify it.
Thanks for making it this far....
Sebastian
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Re: DC: Crossing the Line?? - May 13, 2003 7:38:00 AM
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Bournephysio
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From: Calgary
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Thanks for the comments Sebastian. I didn't realize that my comments may directly be questioning posters' professionalism. I don't have reason to question anyone's professionalism on this list. I do however know enough about SJ to know that it would be completely unfounded to question her professionalism. I apologize if my comments were taken that way.
I guess I am wrong about it being part of the definition of professionalism as well since nurses take orders from physicians.
I very strongly believe that pt prescriptions (not referrals!) are the biggest problem facing PTs in the states. I challenge everyone in the states to try to change this even if your current situation seems acceptable.
Doug
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Re: DC: Crossing the Line?? - May 13, 2003 5:33:00 PM
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dr. frankenstein
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[QUOTE]The ability to order and look at imaging studies is even closer to our abilities and strengths. We already have a greater knowledge of when studies are appropriate than most GPs do. [/QUOTE]
thats not true at all.
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Re: DC: Crossing the Line?? - May 13, 2003 5:36:00 PM
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dr. frankenstein
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[QUOTE]The next logical step is to see where we can further relieve pressure off of physicians. [/QUOTE]
there's no reason that PTs should have prescription rights. You make it sound as if MDs are way too busy to do the meds. Thats not true at all.
I think you are being disingenuous when you frame this in a "we want to help relieve phyisicians" attitude. You've got ulterior motives, you dont really care about physicians you are just trying to expand your scope of practice.
"Relieving physicians" is not a good justification for expanding practice scope. If it was, then hell we would just let any health tech do meds.
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