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Re: DC: Crossing the Line??
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Re: DC: Crossing the Line?? - May 13, 2003 5:39:00 PM
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dr. frankenstein
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[QUOTE]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.
[/QUOTE]
PTs arent trained to read images. Radiologists spend at least 5 years in residency learning how to do it.
And to suggest that you know of ways to improve imaging protocols is laughable.
Do you have a degree in physics? why dont you try to explain how T1/T2 image weighting occurs and how an echo planar scan is different from a gradient echo.
If you want to prescribe meds and interpret films, then there's a clear route to achieve both. Its called medical school.
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Re: DC: Crossing the Line?? - May 13, 2003 6:31:00 PM
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Andrew M. Ball PT PhD
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You mean a T1/T2 water weighted imaging? The kind used to detect the HIZ (high intensity zone), which has a co-relation with respect to low back pain that runs about 80% (whereas the standard x-ray is only about 20%)?
Oh that? Never heard of it. Never used it in completion of my MS thesis in physical therapy school 10 years ago.
Are you serious with this? And what, pray tell, is your background, Dr. Anon?
Drew
[This message has been edited by Andrew M. Ball PT PhD (edited May 13, 2003).]
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Re: DC: Crossing the Line?? - May 13, 2003 6:36:00 PM
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Sebastian Asselbergs
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Doug, I did not suggest you accused anyone of a lack of professionalism....You're fine!It was suggested in previous posts in this thread.
Dr. Frankenstein (a reflexion of your practice-style?):
Please do not use with arguments such as "go to med school" - this could turn into a slinging contest: "MDs should NOT prescribe PT - let them go to PT school" "MDs should NOT counsel nutrition - let them become nutritionists" etc etc.
I would love to have you sit with me and a couple of general practitioners and a emerg specialist (MD-friends) when we look at x-rays, MRIs and CTscans - there's ONE who can actually read them as well as I do: - I need to study a lot more to even come close to what the radiologists can see. However, for my scope of practice, I have more than adequate training. Do not forget that any imaging still gets read by radiologists - no matter who orders.
With regards to meds - yes, many of my patients have no GP (a shortage of 18-20 here!!), are forced to go to walk-in clinics and rely on MDs who are very limited when they see the patient for only 5 minutes and then only once - they have to do anassessment of a back/shoulder or neck or whatever injured part, and prescribe in the same time! Come on.
I am often forced to call any doc in walk-in clinics, tell them what I found in my eval, then send the patient over (I often even do this with with patients who do have a family MD) - just to pick a prescription! Meds or imaging!
You'll have to come up with a heck of a lot better arguments than "it's not true" or "go to medschool".
Sebastian
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Re: DC: Crossing the Line?? - May 13, 2003 6:39:00 PM
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dr. frankenstein
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andrew,
t1/t2 is a LOT more than just water weighting...
can you even define what a t1/t2 relaxation time is?
At any rate, the stuff you mentioned is simple clinical analysis. Thats a far, far different cry from the claim that was made that PTs have enough knowledge to design their own scan protocols.
Hell, even MDs dont design the protocols, they rely on medical physicists to do it.
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Re: DC: Crossing the Line?? - May 13, 2003 6:47:00 PM
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dr. frankenstein
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[QUOTE]I would love to have you sit with me and a couple of general practitioners and a emerg specialist (MD-friends) when we look at x-rays, MRIs and CTscans - there's ONE who can actually read them as well as I do[/QUOTE]
first off, you could be flat out lying as far as I know.
But lets assume you are telling the truth. A sample size of a "couple" means that PTs are better at interpreting films than MD/DOs?
You might be able to get away with claiming that you are better at it than every doc you know (which is very hard to believe). However, extrapolating your experiences to MDs vs PTs as a whole is something you have no data for.
[This message has been edited by dr. frankenstein (edited May 13, 2003).]
[This message has been edited by dr. frankenstein (edited May 13, 2003).]
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Re: DC: Crossing the Line?? - May 13, 2003 7:02:00 PM
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flexion
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Not sure how this discussion turned to radiology but here are some thoughts:
- an MD radiologist is da' bomb for anything out of the ordinary in imaging.
- when a GP MD reads imaging they look for a Fx so they can make a timely intervention otherwise the films go the radiologist if something else is there. They don't make more complex radiographic calls.
- a DPT trained at looking for NMS problems on imaging will be better than a GP MD.
So yes a DPT is better at reading imaging in the NMS arena compared to a GP MD. But here is the thing... the GP MD has this extension of him/herself who is the radiologist who looks at anything beyond a Fx which the PT doesn't necessarily have access to. The bottom line being that GP MD via his/her resources is better able to deal with imaging compared to a DPT.
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Re: DC: Crossing the Line?? - May 14, 2003 2:49:00 AM
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Andrew M. Ball PT PhD
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Flexion,
Point taken, I agree.
However, like a DC, don' you think that DPT's are well equipted to pick up on radiographic red flags and refer along?
Drew
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Re: DC: Crossing the Line?? - May 14, 2003 6:58:00 AM
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Sebastian Asselbergs
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Yes, i could be lying. If you insist on reading posts with that attitude, I guess you'll always be "right", and anything I say will be a "lie".
However, twist your mind into unusual terrain here: assume I am not lying. You bring up "sample size" - if you call my example that, fine. I never meant it as that. But still vastly better than your "it's not true"
- where's your data?
I was NOT speaking about general MDs or DOs - you may want to look at the original quote from Doug
"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. "
See? "GPs" meaning general practitioners - family physicians.
My claim was based on my personal experience with friends - not a statement suggesting I extrapolate that to all docs. It is very clear I expressed a personal experience - if you have trouble believing, not my problem - yours.
Further: You state that we "arent trained to read images" - now that is a flat out blooper - do you have any idea what imaging courses PTs take?
Last, I just realize you could be ....not a doctor! We only have your word for that, don't we?
Sebastian
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Re: DC: Crossing the Line?? - May 14, 2003 9:14:00 AM
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dr. frankenstein
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no i'm not a doctor...
but i deal with them everyday.
I know how radiology works, and the claim that PTs can design their own scan protocols is flat out laughable. Even the MD radiologists cant do that, much less PTs.
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Re: DC: Crossing the Line?? - May 14, 2003 3:56:00 PM
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flexion
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Drew:
Sure a DPT could pick up on a flag as well as anyone else. I really have no need to do imaging myself. My view is a bit different than most DCs as I send every patient that needs imaging directly to a radiologist and get the read back in less than 24 hours.
Doing the imaging myself makes me no money and interpretation to a clinical impression does take some time if you want to be thorough. Could I do it all related to NMS - sure. Just seems like a lot of work when a system already is in place ya' know?
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Re: DC: Crossing the Line?? - May 14, 2003 9:14:00 PM
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Bournephysio
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I am never disingenuous. I am always upfront and to the point. Yes I do care about physicians and more importantly I care about the public and our health care system. The current system is unsustainable.
I strongly think that we should have the right to order imaging and I think that it would be beneficial for PTs to have limited prescription rights. Since neither are currently in our scope of practice, it is pretty obvious that I am trying to increase our scope. As I said I believe that this would be in the best interest of patients, the health care system (and thus physicians), and my profession.
I have never suggested that PT ordered imaging would not be read by a radiologist.
No I don’t have a physics degree, but my current masters thesis has been called an engineering thesis by engineering friends of mine. I am currently looking at 3d motion analysis and it looks like I may be getting into 3d image processing. One of the faculty members in my lab does 3d motion analysis using mri and besides the typical PT courses I’ve done a course in brain imaging techniques including PET and fmri.
Your choice of the word laughable shows just how necessary our input is. We are one of the few professions which treat musculoskeletal injuries with any formal training in biomechanics. Almost all currently used imaging techniques are static. Most do not place injured structures under load and almost none are functional. There is more to protocols than positioning, scan techniques and contrasts. New scanning protocols are useless if they don’t have clinical significance thus medical physicists are not enough. And yes, I have ideas about scanning protocols as well.
Laughable doesn’t really sound like a good description, does it?
Doug
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Re: DC: Crossing the Line?? - May 15, 2003 3:31:00 AM
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Andrew M. Ball PT PhD
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FYI,
PT's in the military do have imaging rights, shouldn't we make sure they're trained in school for the task?
drew
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Re: DC: Crossing the Line?? - May 15, 2003 7:17:00 PM
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johnjfraser
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Just a couple of comments:
1. No referring MD dictates my treatment (even though some physiatrists like to think so when you have the recipe list on the referral). I am the professional and I base my interventions on experience and the evidence that is out there in literature. Minor exception: if a surgeon has a protocol in regards to a specific procedure, I will base my interventions around the principles of the protocol. I am not a technician, and if the MD is so adamant regarding the specific interventions, let them carry out the treatment themselves (or find a PT technician that will).
2. I think that PT should indeed be able to order imaging studies, but with the radiologist (who is the expert in this domain) interpreting the films and listing the impairments. The PT can integrate these findings and more effectively intervene in the management of these pts.
3. I think that PTs should be able to Rx certain meds (m. relaxers, NSAIDS), but in only in close collaboration with an MD and a PharmD.
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Re: DC: Crossing the Line?? - May 15, 2003 7:19:00 PM
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johnjfraser
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Oops, forgot topicals for ionto.
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Re: DC: Crossing the Line?? - May 17, 2003 6:19:00 AM
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Dr.Wagner
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It really sounds, that as many have you aged in your practices...your idealism has turned into what is truly Osteopathic Philosophy.
Though I don't agree with PTs having prescription rights, and I don't believe you should order basic imaging without being able to read them, I still love the field of PT. Some of my basic observations (as I have said in the past) are that PT's of today are acting like the chiropractors of the present and past, and somewhat oblivious of their new attitudes which they themselves shunned (likely) when they graduated. Also, one of the strangest things is that with EVERY PT I have spoken with during the past month...none share your opinions. Sure this poll is not scientific, but it goes to show you that a few people can really "make some noise".
I did have one question...if a PT wants to prescribe a "muscle relaxant"...then what is a muscle relaxant...since drugs like skelaxin doesn't work directly on muscles (more like a side effect than anything else)...diazepam (valium) is a FAR FAR better muscle relaxant than skelaxin or flexeril or norflex...does that mean you want prescription rights for benzodiazepines?? And why oh why would you want the hastle of drug licensure and renewal or even having your eval come down to your patient just wanting more "relaxants", and wasting your time. Is that why you went to school? I went to PT school to learn rehabilitation and exercise not to prescribe...that was a reason I went BACK to school.
Ok, one more question...what is the utility of a PT ordering radiographic studies? Truly. Modern practice dictates referal to PT after ruling out fracture, and if this is followed, why does a PT need to order ANY type of xray? And where would you read your films? And if you can't read them, why order them? Why also would you want the extra liability of radiographs?? You miss a fracture you are big trouble. And what if you are woried about "AC seperation" and you want a picture of the AC joint...well to do that, you need a chest xray...and therefore you are now held liable for anything on the chest film (yes including the lung fields). And let me tell you gentlemen, it is not school that prepares one for radiographic interpretation, but residency. And even in medschool I saw far far far more films than ANY PT did. So why open yourself up for litigation or mistakes in a field that you certainly are not trained for? Having a radiologist interpret your films is like walking into a room and saying "well, I know the heart is there, but I don't need to listen because he has a cardiologist"...bad logic. Clinical correlation plus radiographic interpretation goes together...if you are gonna order them, you gotta read them.
Really this debate is best done in person not on the world wide web..any way, you guys have a good day and take it easy.
[This message has been edited by Dr.Wagner (edited May 17, 2003).]
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Re: DC: Crossing the Line?? - May 17, 2003 10:05:00 AM
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DocZon
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The PT's who want to prescribe and order imaging studies could always go to school and become a PA (physician Assistant) and work within a medical facility and then you could prescribe under the docotr's supervision. I agree with Dr. Wagner though, that is not why you went to PT school.
Physical therapy can do things that medicine cannot. Medicine is so limited in their ability to treat NMS type conditions. Take away the prescription aspect and they have very little to offer. An MD is not going to rehab a shoulder, they don't want to. Give the patient the appropriate meds and send them to PT or chiro. That's what makes the system work.
If PTs get prescriptions rights patients will bypass the contact with their specialist or PCP. It could divide PT and medicine and completely backfire.
An another thing, I am sure you could call the referring MD and tell him/her that their is in a lot of pain and may need some pain management or anti-inflammatory. I do it all the time. They even ask ME what they should prescribe.
DocZon
Winchester Hospital Chiropractic Dept.
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Re: DC: Crossing the Line?? - May 17, 2003 11:32:00 AM
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mcap56
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I think everyone is getting far too caught up in the medication, imaging and titles debate.
The ability to prescribe and order imaging are useful things to consider and they are not out of the scope of the vision we have for the field. The issues are certainly worth debate.
But they are not the main issues. A new vision of practice can be acheived without either. The real issue is the ability to practice independantly and to see patients directly when and where appropriate. Right now....PT isn't practiced in this way and it holds us back.
For everyone who comes on here and claims to treat every patient exactly as they see fit, there are 100s or even 1000s who work in hospital outpatient departments and tightly managed clinics who spend their days performing techniques aimed at satifying the patient (short term) and the referral source.
One of the issues from previous posts was what are PTs truly experts at. The answer from several was exercise prescription and manual care. As others have mentioned.....the jury is still very much out on most of our manual care. The research is quite underwhelming....and at the end of the day....I don't think it is going to prove that useful except for the short term. In fact, most of the research we have on manual care and LBP comes from chiropractic research. Much of it is very sound methodologically - very high level research.....but it really hasn't shown much more than short term benefit.
This leaves us with exercise presciption. If it is done correctly and by great PTs it is a critical skill. But somehow I don't see insurance always viewing it as such. When expert task forces repeatedly come out and say that exercise....ANY exercise is best for chronic LBP.....it doesn't leave us with much ammunition. I have seen studies with much better results from specific exercise. But what are we to do when many PTs, comfortable with their positions in the physician driven system are unaware of the research.
If an insurance company knew that a patient with an uncomplicated Musculoskeletal disorder could visit a PT and be unlikely to have the expense of an MD visit unless warrented, unlikely to have expensive tests or X-Rays completed and was unlikely to have an excessive number of visits......PT would be something worth compensating.
That is how I would like to see the field. Still working with very closely with physicians when and where appopriate - we don't wish to sever those relationships. The current system however, has produced generations of substandard clinicians who are using techniques invented a long time ago, still awaiting validation. Not acceptable and I don't think the current reimbursement system will sustain it without change. The DPT is part of this process, although it is certainly not a panacea.
Respectfully,
mcap
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Re: DC: Crossing the Line?? - May 17, 2003 12:01:00 PM
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Dr.Wagner
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Interestingly enough, we discuss money saving issues...which is absolutely false. Many, many times we (orthos and SM docs) halt therapy because much of it can be done by the patient at home or in a gym (I now KNOW what patients tell doctors is MUCH different than what they tell their therapist ..."we ain't doin nuthin" etc etc) so the one visit to the doctors office saves 3 (or what ever) to the therapist...becuase the VAST majority of PT's and clinics are gonna use ALL the visits they can for the patient. It is a business. I really don't see the money saving argument at ALL.
The real beef is NOT direct access and it isn't practice rights... it is getting FULLY reimbursed for your charges!! It is widespread in medicine. REIMBURSEMENT is the issue and the end of corporate PT clinics...
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Re: DC: Crossing the Line?? - May 17, 2003 12:48:00 PM
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PTstud
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Doc Wagner,
You keep stating how you "love PT" but at the same time you seem to want to keep a foot on our necks. Perhaps because you are out of the field and now a "doctor" you feel like we should not want to persue ANYTHING that closely resembles the rights of a physician. With direct access, I believe x-ray rights would be beneficial, to save a trip to a PCP for only x-rays when the PT can do them himself. As far as meds, I do agree that PTs arent ready for and maybe shouldnt have even limited rights, after all PTs are PTs because we do PHYSICAL rehab. I totally respect you and your opinions, but it seems like you want to keep the PT field from having any ambition or aspirations.
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Re: DC: Crossing the Line?? - May 18, 2003 8:43:00 AM
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mcap56
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Dr. Wagner:
If anecdote was insufficient justification for a previous point....it shouldn't be adequate here. I can give you just as many examples of when PTs are forced to complete visits because the referring physician insists or because the patient asks and the physician acquiesces. In many hospitals, the PTs have virtually no say on how long patients remain in PT....which is by the way......ethically wrong. In my previous situation, PT was almost always over prescribed. We held our ground and did not overtreat as best we could but it was difficult to dissuade patients from using visits once they were on the script.
If a PT is in a different situation and has full responsibility for the case, we can shift from treatment to management. This should reduce the number of visits for those PTs. There will always be clinic owners, hosptial departments, and independant workers who abuse the system and seek to use as many visits as possible. They will have employees that feel compeled to go along with it even though they shouldn't.
The incentive to do more/treat more/order more is always there in any healthcare setting. If it is about money all the time, what exactly is it that stops a physican from performing procedures when they are uncessary? Are you saying that they are capable of holding the line on tests and procedures but that PTs can not be trusted to hold the line on visits?
Where direct access has been studied carefully, the results indicated fewer PT treatments and reduced costs.
mcap
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