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Re: Direct Access to PT's - What's it like?
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Re: Direct Access to PT's - What's it like? - October 17, 2003 9:18:00 AM
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mcap56
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In the absense of a neurological deficit, why would anyone sue for an HNP? I clearly tell my patients (or at least I used to) that the pain could result from an HNP. However, without a neurological deficit and/or severe functional limitation, there really is no reason to dx an HNP. It could be a false positive. Also, the size and nature of the HNP often bears little relationship to the clinical picture. A minor internal derangement can debilitate someone and a very large extrusion or sequestered fragment can cause very little to no symptoms. All varies depending on the patient.
Furthermore, even in cases of neurological deficit, the 10 year outcomes appear to be even, surgery or not........cauda equina and progressive deficit excepted.
mcap
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Re: Direct Access to PT's - What's it like? - October 17, 2003 10:05:00 AM
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OAK
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Scanner wrote:
"I have admitted, that if it weren't for an x-ray, I could have very easily missed this. In this case, the exam confirmed musculoskeletal pathology. If it weren't for me just saying to myself, "Oh well, there is some chronic pain there - better look out for degenerative conditions" I would have missed it."
Scanner also wrote:
"I don't x-ray everyone"
So basically you are saying that you only order diagnostic imaging if you have some "sneaking suspicion" that the patient needs an x-ray.
Unless you x-ray every patient that walks in your door you have, AT BEST, the same chances at picking up a serious pathology as any PT with direct access.
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Re: Direct Access to PT's - What's it like? - October 17, 2003 1:19:00 PM
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Andrew M. Ball PT PhD
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No, not quite. What a PT misses, unless they are in the military and order/read x-rays rountinely, is the ability to catch a serious incidental finding such as a tumor.
As such, the PT isn't expected to find said incidental finding and while just as likely to be sued, may be less likely to be held accountable . . . maybe.
Drew
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Re: Direct Access to PT's - What's it like? - October 17, 2003 3:08:00 PM
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touchiba
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The number one reason for DCs being sued is sexual misconduct I believe.
It's not that it happens a lot, I think it's more due to the lack of any other kinds of claims.
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Re: Direct Access to PT's - What's it like? - October 18, 2003 5:45:00 AM
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Scanner
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Don't quote me. This is my understanding of law:
#1 Reason a DC is sued: Missed pathology
#2 Reason a DC is sued: Claimed we herniated a disc.
#3 Reason a DC is sued: broken rib
For all it's hype, stroke is rare, however, it will produce a huge settlement award for obvious reasons.
Despite above, my malpractice is $1500/year.
Sexual harrassment is a criminal and/or civil misconduct, not a case of malpractice (my limited understanding of law).
[This message has been edited by Scanner (edited October 18, 2003).]
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Re: Direct Access to PT's - What's it like? - October 18, 2003 6:03:00 AM
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Scanner
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MCAP,
[QUOTE]In the absense of a neurological deficit, why would anyone sue for an HNP? [/QUOTE]
Oh, I don't know - because the MRI says and the orthopod says it's a HNP and my back hurts a lot or I need the money because I was at the casino's a lot last month or I got a bill from the PT for $400 and who does he think he is, he makes more money than me?
[QUOTE] I clearly tell my patients (or at least I used to) that the pain could result from an HNP. However, without a neurological deficit and/or severe functional limitation, there really is no reason to dx an HNP. [/QUOTE]
Yeah, a lot of DC's say this too. And it is good risk management. However, take it from me, without the imaging, it can still bite you in the rear. Patients want their problem investigated to the fullest when there is retrospective analysis. They don't want a "clinical diagnosis."
So, if a round of PT or chiropractic fails, often they are in the neurosurgeons or orthopods office, who doesn't think twice about spending health care dollars to get an MRI. Then the patient is wondering why he has a bill from the PT center and why he wasted his time with you.
Do you see the psychology?
[QUOTE] It could be a false positive. [/QUOTE]
In my experience, orthopods (not neurosurgeons) don't beleive in MRI false positives. If the radiologist says it's a disc, they read it to the patient verbatim.
The patient believes them. They come back to me and say, "Dr. Orthopod says it's a disc".
Now, I know it ain't a disc, you know it ain't a disc, but the orthopod has to make a livin', right?
[QUOTE] Also, the size and nature of the HNP often bears little relationship to the clinical picture. A minor internal derangement can debilitate someone and a very large extrusion or sequestered fragment can cause very little to no symptoms. All varies depending on the patient. [/QUOTE]
Yes, this will be your defense in court.
Unless the attorney wants to settle. . .
[QUOTE]
Furthermore, even in cases of neurological deficit, the 10 year outcomes appear to be even, surgery or not........cauda equina and progressive deficit excepted.
[/QUOTE]
"Ladies and Gentleman of the Jury, in conclusion, we know this to be a fact:
MCAP claims he told the patient she may have had a herniated disc. Of course, the patient doesn't remember this - all she remembers is getting some exercises and then placed on a traction table that pulled the spine apart with what was it? 100 or more pounds of pressure?
Meanwhile, her back started to deteriorate and eventually she had to go through painful, invasive surgery and months of rehab at a different rehab center. She can't garden. She can't go dancing. She can't please her husband sexually anymore.
Now, we have heard the testimony of several expert witnesses that that traction device produces enough force to herniate a disc. Now, maybe that HNP was there before, maybe it wasn't.
Truth is *looking annoyed and poised* - we'll never know, will we, ladies and gentelmen of the jury?
*pointing to MCAP*
Because MCAP, failed to uphold the standards of health care, tried to play coctor, when he is a therapist, and failed to diagnose this condition and appropriately refer.
So, I ask you to find a verdict of guilty so this patient can take care of her bad back the rest of her life."
Do you think your attorney is going to let it go this far?
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Re: Direct Access to PT's - What's it like? - October 18, 2003 7:37:00 AM
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mcap56
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An interesting/entertaining courtroom vignette!!!! Sounds like I am headed up the river.
Scanner, I know this patient. We have all had the experience of the patient whose pain probably did not come from a disc yet returns to your office MRI in hand with angry accusations. You missed my disc!!!!
I would also agree that it is often specialists and radiologists who really do a disservice to the patient and the rehab clinician by playing into this game.
Perhaps I am naive. Perhaps I spent too much time in a setting where we worked hand and hand with the physicians and MRIs were given sparingly. However, I will say that if you take the time to explain everything to the patient and present the evidence, in a lot of cases, the kind of situation you described can be avoided.
I don't know how much time the typical DC spends with each patient. But I can tell you, in spending 1/2 hour with each patient, one on one during treatment, the coversations would progress to a point where patients would realize that I knew what I was talking about. I knew the studies. I knew the research. I could comment on IDET. I had read Sarno's book and had an educated opinion about it. And yes...I would even comment somewhat evenly on the strengths and weaknesses of chiropractic. To further get the message accross, I referred them to my website where everything was explained quite clearly.
It is only through the depth of relationship that you have any chance of getting the message accross. There are many patients who trust their PTs more than their physicians. PTs often misuse this relationship in my opinion by spending their time trying to please the patient and take away pain at all costs. They also don't keep up their end of the bargain by reading the research. For the rare PT who uses this relationship effectively - it's a great thing.
There are people that want to find the "cause" of their pain at all costs. They are difficult to treat and I have no easy answers on that one. It's going to take a wholesale change throughout the medical community, MDs especially. When the true economic costs of LBP (by some estimates up to 2% of GDP) are realized, perhaps we will get somewhere.
mcap
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Re: Direct Access to PT's - What's it like? - October 18, 2003 7:40:00 AM
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mcap56
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One more point......not only does it do a disservice to these patients to dx and run but it makes rehab really difficult. These are often the patients that have fear avoidance problems and actually need to work into a fair amount of pain to recover. However, I will freely admit that I sometimes don't push like I would like to becuase I am afraid they will go running back to the orthopod.
Again, in many cases, education and appopriate provider relationships can mitigate this.
mcap
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Re: Direct Access to PT's - What's it like? - October 18, 2003 9:37:00 PM
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Sam B
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[QUOTE]Originally posted by Andrew M. Ball PT PhD:
No, not quite. What a PT misses, unless they are in the military and order/read x-rays rountinely, is the ability to catch a serious incidental finding such as a tumor.
Drew[/QUOTE]
Ditto that Drew....
Scanner is right on the money here. We need to stop being so defensive and get real here. I am a very skilled PT, but I know what I don't know....All the red flags, yellow flags, skills/ training and accurate history taking will not change the fact that our lack of access to X-ray diagnostics will limit us as complete diagnosticians, and we WILL miss these rare problems. It is inevitable, but a part of having direct access.
PT's have direct access in every other major country in the world, so direct access works, and these PT's are not a threat to the public what-so-ever.. The problem is that U.S society is litigious by nature and does not take responsibility for their own actions ( e.g, the driver of the winnebago who sued for millions, because the cruise control did not stop him from crashing his vehicle, while he made a sandwich in the back compartment. He won the suit, because the manufacturer did not warn drivers in their owners manual of the fact that their cruise control was not an "auto-pilot" system)
My other main concern is that most U.S trained PT's are not skilled enough to screen for pathologies and are not competent or responsible enough for direct access. This is changing quickly, so I know it will improve as the door opens.
The problem in the U.S programs lies in the baccalaureate set-up, leaving you with only 2-3 years training in actual P.T, after you get your gen-ed requirements. I had 4 years of nothing but PT, and my last 2 years were only spent in clinical training. The DPT just adds more years to the training, so now U.S PT's will be similar to their foreign counter parts with only BHSC degrees. Look at PT students in Australia, NZ, Canada, England and you will not believe the level of competency compared to US grads. I have seen both, and the difference is routinely STRIKING. Changing the PT educational model at the ground level is needed, but, seems like we will now just be expanding the time frame of study, without adding clinical training of appropriate rigor and duration.
My opinions only.....
Sam
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Re: Direct Access to PT's - What's it like? - October 20, 2003 3:40:00 AM
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Sebastian Asselbergs
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Quick note: here in Ontario, Canada, we have had direct access since December 1993, and our liability rates are about CAN$ 180.00. That would be US$ 133.00.
Our judicial system does not allow as much frivolous litigation as in the US (we have some doozies though!), which could explain the low rate. It is through a group plan - individually negotiated policies have been quoted as high as CAN$ 1,600.00.
I have yet to see a case of patient suing a PT here - in ten years.
Sebastian
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Re: Direct Access to PT's - What's it like? - October 20, 2003 6:12:00 PM
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veghed
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Isn't there always the possibility that we will all miss something? In this case of"catching the suspicious case of blastic mets", it doesn't sound like it would have been caught if the woman hadn't reported chronic pain. If it weren't caught, but was truly asymptomatic, no one missed anything. Granted, someone could still sue, but how could anything else have been done---if there are no red, yellow or any color flags at all? This woman just happened to come in with back pain, and got lucky. If she didn't have back pain, she'd still be clueless, We don't just routinely order x-rays on seemingly healthy people on the street!
Anyway, being able to order tests is irrelevant. Every PT still has the opportunity to request an MD (or other) to order tests, or in many cases just refer the patient to be seen by the appropriate professional. It just potentially makes things a little more challenging, but not necessarily less safe for the patient. As has been argued before, if we have 1/2 to 1 hour with a patient, the increased time we have increased the liklihood of picking up some potential problems. It all comes down to each professional and his ablility and training to assess each situation.
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Re: Direct Access to PT's - What's it like? - October 21, 2003 4:41:00 PM
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Andrew M. Ball PT PhD
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I fail to see what the issue is anyway. When patients go to see a dentist (DDS), optomotrist (OD), psychologist, (PsyD), or audiologist (AuD), (all of whom have direct-access in most states) no one is expecting them to diagnose medical conditions outside of their scope. Doctors of physical therapy are no different.
The argument, in my opinion, is a non-issue. It's one cooked up by DC's and a handful of MD's (mostly those who are ill informed about what direct-access means in the first place) to justify limiting the profession of physical therapy's progress toward direct access. As for the chiropractors, the only reason that they are legally held to this standard is because too many of them try to play medical physician, physical therapist, athletic trainer, nutritionist, etc. instead of sticking to the spine where they belong (and in some cases, at least in my experience, they overstep their bounds there too).
Physical therapists aren't that stupid to bring this standard on to themselves through delusions of gradeur. Either that or they simply aren't organized enough as a group to truly wreck havoc upon themselves as a profession . . .
Drew
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Re: Direct Access to PT's - What's it like? - October 22, 2003 5:03:00 AM
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Scanner
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Drew,
Optometrists can be held liable if they miss a brain tumor causing intraocular pressure.
A psychologist can be held responsible if someone commits suicide who wasn't placed on anti-depressive medication.
Those conditions are within a scope of practice of their disiplines, just as a HNP is within the scope for a DC.
I am not really trying to cook up an argument to limit you. I am just figuring out how you will cope, that's all.
As one poster noted, you are spending a lot of time with a patient, up to 20 or 30 minutes. That is great insulation against malpractice suits, something DC's unfortunately don't have the luxury to do. So even if you do miss, the patient will be less likely to name you because as you said, they don't necessarily feel it is your responsiblity to catch incidental pathology.
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Re: Direct Access to PT's - What's it like? - October 22, 2003 5:05:00 AM
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mato_tom
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I fail to see what the issue is anyway. When patients go to see a dentist (DDS), optomotrist (OD), psychologist, (PsyD), or audiologist (AuD), (all of whom have direct-access in most states) no one is expecting them to diagnose medical conditions outside of their scope. Doctors of physical therapy are no different. ...........................
you mean licensed PTs are no different...having a doctoral degree in PT gives you no extended rights or responsibilities...
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Re: Direct Access to PT's - What's it like? - October 25, 2003 5:20:00 PM
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Andrew M. Ball PT PhD
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No Tom. I don't mean any licensed PT.
DPT's have imaging coursework, as well as coursework in differential medical diagnostics that BSPT's and MPT's don't generally have --- of if they do it's a mere course or two. BSPT's and MPT's aren't expected to determine NMS condition from say, a gall bladder problem or GI problem --- DPT's are. Legally, a DPT who misses a tumor on an x-ray or treats a T12 pain missing a GI tumor will be heald to higher account as the BSPT's or MSPT's training isn't sufficient for the PT to make those kinds of assessments to the level of the DPT.
As a non DPT, that includes me, by the way.
Drew
Drew
[This message has been edited by Andrew M. Ball PT PhD (edited October 26, 2003).]
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Re: Direct Access to PT's - What's it like? - October 26, 2003 6:31:00 AM
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arufa
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I don't know how long ago you went to school but in my MPT program we learned a lot about diff dx. I am not saying that DPTs don't get more, but I feel confident in my diff dx skills.
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Re: Direct Access to PT's - What's it like? - October 26, 2003 6:52:00 AM
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Andrew M. Ball PT PhD
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I felt conifident too . . . until I was asked to teach the course in a DScPT program. I didn't realize how much I didn't know and I suspect that's the norm for most MPTs.
DPT's get more intensive training in that regard . . . it's just that simple. I'm not talking about the red-flag diagnostics that MPTs tend to think of either . . . I'm talking about off the street, PT as the portal of entry kind of diagnostics.
Drew
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Re: Direct Access to PT's - What's it like? - October 26, 2003 10:16:00 AM
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mcap56
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I used to work for a university that had a DPT program. Pathology, differential dx and related courses were taught by MDs on what they claim is MD level. The students had to know what tests to order and what the normal values should be.
This is much more than I received. However, I still would question the value. Medical students learn how to differential dx, what tests to order, etc. But the education is reinforced during their clinical rotations and then their residencies. They are thoroughly tested on the information during their USMLE exams.
The DPTs I know probably forget most of the information after they graduate. Like anything else, it's use it or loose it.
My classes all seem to want to do more case studies. And in those case studies, we cover a lot of "red-flag" cases. But to students, it's an exercise of limited value. It is not as hard to determine when to order tests. The real skill is determining when NOT to order tests. Students think almost every abnormal sign requires further work up. It's easy to sit and class and reel off a list of things you would do. In the clinic however, you know that isn't the case. You can't refer back every patient who you are concerned about.
Students, DPT or not, have not been in clinic enough to guage the wide variety of normal that is out there. Only after seeing patients with suspicious signs, who turn out after workup to be negative do you start to appreciate the range of clinical normal. For example, over the course of my experience, I have suspected VBAI insufficiency in a number of patients. About 6 have gone on for MRAs....all turned out normal. I would still be cautious in the future and referral was warrented in those cases, but I think students have to learn, with practice and experience, when to consider referral. IF not, any patient with headache could be a candidate.
I am in favor of the DPT. The patho, pharm and radiology they get is much more than I got 8 years ago. However, if I want to catch suspicious cases, give me a good clinician with experience any day. Someone who truly knows when something isn't behaving as it should. Perhaps as the DPTs move along in their careers, they will have the best of both. I would just be careful however, in implying that the training they get in school makes them that much more qualified. For our scope of practice, it may not.
mcap
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Re: Direct Access to PT's - What's it like? - October 26, 2003 10:43:00 AM
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Dr.Wagner
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To aid in clarification the pathology taught in medical school is not just a single course (ie "pathology"...to view the notes I learned in medical school go to [URL=http://www.pathguy.com),]www.pathguy.com),[/URL] sure it is taught for 1 year 2-4 days a week with lab, in addition we learned pathology in the 2nd year courses entitled Internal Medicine, cardiology, surgery, oncology, histology, and then further in physical diagnosis. In essence the entire second year of medical school is spent on pathology, treatment and differential diagnosis.
This is of course reinforced clinically in years 3 and 4 with exams at the end of each month until one takes USMLE/COMLEX steps 1&2.
Hope that helps...going to the [URL=http://www.pathguy.com]www.pathguy.com[/URL] website to view our notes (with histology slides) gives an idea of our notes.
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Re: Direct Access to PT's - What's it like? - October 26, 2003 1:30:00 PM
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Andrew M. Ball PT PhD
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I've often talked about "DPT phase I" and "DPT phase II." It's going to be a few years before the DPT II's hit the ground running in the clinic with DPT clinical instructors and employers willing to use their abilities to the fullest. Right now, many PT's are intimidated by the DPT and cough up the "no substitute for experience" defense.
It's a moot point. The DPT and experience won't be mutually exclusive forever. There are many people going back for a DPT, and there will, in time, be DPT's and DScPT's with experience.
The argument, is therefore little more than one of a temporary transition situation that won't exist in a few years. I agree that much of what is taught in DPT programs in terms of diff dx, pathology, and imaging is currently lost by DPT's . . . but that won't be forever. The weakest links of the profession will be elevated, or eliminated. Practice acts and reimbursement will develop to meet educational standards. I envision an eventual tiered system in each state. DPT's and DScPT's WILL have a larger scope of practice that includes the imaging and diagnostics that those without will not be permitted to engage.
Drew
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