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Re: Chiropractic Demonstration Project
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Re: Chiropractic Demonstration Project - April 1, 2005 9:26:00 AM
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JLS_PT_OCS
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Let's also not confuse Direct Access with Primary Care Provider.
If we follow where SJ's post suggests, no one but board certified internal medicine physicians would see anyone over 65.
Healthy or not, our education is more than adequat to effectively screen people for issues they need to see their physician about.
No increase in either malpractice or liability insurance premiums in Direct Access states, either.
Points to ponder.
J
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Chiropractic Demonstration Project - April 1, 2005 9:52:00 AM
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JLS_PT_OCS
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Looking at my last post, perhaps my spelling is not "adequat", however...
Bt lckily, taht haz notting to due with takin kare of peeple.
An alternate 'grandma' test.... would I want my grandma going to someone who more than likely will just throw a bottle of pills at her(add it to the 50 others they have already put her on) and tell her to come back in 6 weeks; or to someone who may be able to provide some useful treatment for the condition?
In that case, I would argue a consultation with a physical therapist would be far superior to seeing a physician.
Check out this reference:
Journal of Bone and Joint Surgery April 2002
"Educational Deficiencies in Musculoskeletal Medicine"
It notes the rather poor performance achieved by non-orthopedic physicians in the musculoskeletal arena.
Seems to me the choice is clear, and why diagnosis does get harder in the older population, it by no means is impossible. I think most of us WANT to work with people's family physicians anyway, so communication would be likely in any case.
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Chiropractic Demonstration Project - April 1, 2005 10:57:00 AM
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SJBird55
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As I had questioned, do the physical therapists who post here regularly represent the physical therapist population at large? I don't think necessarily an internist is the only qualified professional, but I have very high doubts that the majority of those of us in our profession do take those steps to medically screen appropriately. Some of my rationale for that belief is because I think the majority of therapists work in an outpatient setting... I'd guess mainly for large organizations, such as a hospital or national corporation... and what is generally important in those particular settings is productivity. That type of environment and employer attitude just doesn't seem to ensure "grandma" will receive the appropriate care 95% of the time.
See what generalization does? Sorry, Holly... BCBS MI requires physician referral.
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Re: Chiropractic Demonstration Project - April 1, 2005 11:59:00 AM
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dross
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Its no suprise that the non-ortho physician is weak in musculo-skeletal medicine. When a student gradutes medical school or finishes their first year of residence they are strong in the "core" medical feilds: medicine, peds,psych, obgyn, surgery. Its after residence that they become strong in a specific field. So guys who dig the kidney will be nephrologists but the guys that dig NMS will be othos, pmr, sports med docs. The GP/Family doc knows enough to rule out organic dz/med effects/inflamtory conditions affecting the musculo-skeletal system and refer to PT.
Direct access for PT may put you in a similar positions as the DCs. You will now have to market your clinics. The two guys Jason was talking about were doing the same exact thing but with different approaches. Once you start marketing things get huxterish (is that a word?). You have to do what someone calls "double sales". You need to sell the idea of PT and sell yourself as the PT to go to. Do you really want to this?
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Re: Chiropractic Demonstration Project - April 1, 2005 12:12:00 PM
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Diane
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SJ, please forgive my utter surprised tone at your expression of reluctance. Why should your grandma in question not be able to direct access both you and the MD within the same time frame, you for the aching knee and the MD for the pain in the belly? Why leave her in pain and have a sequential time frame? Makes no sense to me. It's not a question of people seeing either/ or, it's both/ and.
Furthermore, surely something positive has come out of lo, all these many decades of hovering around MDs getting them to trust us, namely communication. Between the two sorts of practitioners why would there not theoretically be a good team emerge for dealing with the general public old or not?
Why be scared of treating old people? They can have multiple dxes, including NMS pain that IS NMS pain! It behooves us to learn to tell the difference. Step up to the plate. Be a batter. Take our turn. Are you are arguing that PTs should keep the ball and chain? Why? Really, why?
Still makes no sense to me whatsoever, that a PT would argue to stay subservient. As you've already pointed out, MDs miss the mark on our area of expertise frequently. I don't think we're as apt to miss theirs!
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Re: Chiropractic Demonstration Project - April 1, 2005 1:21:00 PM
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SJBird55
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There is no data that we as physical therapists are "safe" with the geriatric population. The states that are direct access in the United States technically cannot speak of the "safety" of us treating that population because even if one lived in a direct access state, Medicare hasn't been direct access. So, the statistics and the numbers toss that population out.
I feel that we are just as bad with the geriatric population as some physicians. Why? Well, because frankly, we don't have a significant amount of training specifically directed at the geriatric population. I am going to be the first to admit that I sucked terribly with that population. Honestly, I would have never known until I took a pre-test to see my knowledge of that particular population... and I got 15% correct. 15% of the answers were correct... THAT is terrible. And I am someone who is always reading and attempting to learn. I studied for a year on my own before taking the exam to be a geriatric clinical specialist. I learned so much... The biggest thing I learned was that my critical thinking cap needs to be in high gear with every geriatric patient.
I've never said that I was scared of treating the geriatric population... but they are not an easy population. Anyone who knows me would never use "subservient" as a description of me. For patient safety, I do not think that direct access should just be granted to every licensed physical therapist. I firmly believe that there should be certain criteria that a licensed physical therapist meets before being privileged to have direct access. That isn't a subservient attitude at all - it is a conservative, potentially realistic and reasonable.
Sorry that I'm not so gung-ho with the whole complete direct access issue. My unsupportive attitude or my thoughts that criteria need to be met are from the experiences I have had professionally both with employers and with other physical therapists. I came very close to leaving this profession last year because of how ignorant, how non-evidence based, and how unskilled the care I observed from my peers. And these peers had a wide range in number of years in practice, from 2 years to 15 years. In my opinion, those therapists do not deserve the privilege of direct access. I would never recommend my family to see them for treatment nor would I ever personally choose to employ any of them.
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Re: Chiropractic Demonstration Project - April 1, 2005 2:05:00 PM
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TLB
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SJ,
As someone who practiced in AZ for 10 years and saw my fair share of geriatric pt's and then some I can tell you your way off base here. It's not rocket science to ask medical screening questions, recognize red flags and refer on. I too had experiences similiar to what Holly stated and physician communication, even though they may not like it at times, is key. Also, I would not hesitate sending my 97 y/o grandmother to see you for treatment.
Todd
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Todd
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Re: Chiropractic Demonstration Project - April 1, 2005 4:50:00 PM
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Diane
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All I can say SJ, is that it seems to me that you personally are not ready to take this on as your own issue. Seems to me others definitely are. I would hope that something could be worked out, like dual access, i.e., direct for those who want it and indirect for those who don't (like we had here in BC for decades until 1994, when our college decided they didn't want to have two tiers anymore and declared all PTs direct access.) Then you could stay inside a system of working for insurance under referral. Others could then move outside it, have direct access no-insurance cash practices if they wanted or solo direct access insurance practices if they wanted, or any other sort of mix. There's always a way. The point is, is to get busy and not let any OTHER profession dictate to PT.
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Re: Chiropractic Demonstration Project - April 2, 2005 2:28:00 AM
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SJBird55
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Diane, I am not speaking about myself or my own issue. I have placed myself where I am ready and I have no problems working in direct access. I'm speaking completely from what I have experienced and what I have seen of others in our profession. I can't believe that I'm the only therapist that has seen other therapists provide crappy care.
Todd, thanks. Sure, I have been in multiple situations with physicians. I have no problems communicating and standing firm with whatever issue - even right down to a refusal to continue to treat - which pisses off physicians. I have had the farmer come in with "shoulder pain" to treat who had what I thought were cervical problems. The physician refused to believe that the shoulder pain was referred from the cervical spine. After 3 therapy visits and 3 phone calls and me finally saying that I didn't care what diagnostic tests were done - I refuse to treat him and he needs to be re-evaluated. Hmmm... c-spine fracture. The issue isn't that it is rocket science - the issue is how frequently are medical screenings occurring? Our hospital system refused to have a medical screening form... hmmm, why? Simple - the patient already saw the physician, just treat the patient. Am I way off base? My experiences tell me that I should be concerned about the practice patterns of my peers. Thanks for the compliment.
I strongly feel that in order to ensure public safety and that our profession not become another type of snake oil that there be criteria in place. Since I'm only familiar with Michigan... 1) physical therapist assistants should be licensed (there will be some research published by Resnik that indicates a large difference in outcomes and utilization to such a degree that licensing is beneficial for patients) 2) mandatory continuing education of approved courses 3) 2-3 years of outpatient experience 4) maybe even a re-examination every 5 years at low cost of core materials - such as medical screening, red flags, differential diagnostics
I know it costs money, but to ensure quality and safety of patients, that at the minimum, our licensing board should step up to the plate and have some parameters in place. Full freedom and privilege of direct access without any defined criteria just doesn't seem reasonable to me.
If all the therapists practice as what I have read at this site, I fully agree - there is no problem with patient safety and direct access. I have very large doubts that this particular population of therapists posting represent the profession at large. That's where I have concerns.
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Re: Chiropractic Demonstration Project - April 2, 2005 3:10:00 AM
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Andrew M. Ball PT PhD
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SJ,
I appreciate your example of,
"the farmer come in with "shoulder pain" to treat who had what I thought were cervical problems. The physician refused to believe that the shoulder pain was referred from the cervical spine. After 3 therapy visits and 3 phone calls and me finally saying that I didn't care what diagnostic tests were done - I refuse to treat him and he needs to be re-evaluated. Hmmm... c-spine fracture."
However, you are confusing the topic of system review (in this case the NMS system only), with review of systems. As such, while this is something that any PT should be able to do, it is NOT what we as a profession mean by Differential Diagnostics.
A better example would be the 70+ year old patient who comes in with 7/10 pain of the right shoulder with a diagnosis of "muscle spasm evaluate and treat." Upon eval we find that there is full range, poor posture, general weakness, and a small spasm of the teres minor. We go on to clear the neck and (as expected) find some facet hypomobility, sidebending, and ipsilateral rotation of C4, C5, and C6 (theoretically pressing on the innervating spinal nerves) . . . but we also ask the 7 essential medical screening questions about fatigue, malaise, fever, nausea, etc. and find that the patient reports a growing fatigue/malaise, and nasuea that the physician isn't reported to know about. She also reports, upon our follow-up questioning, that she has a difficulty initiating bowels and that she's generally constipated, but her MD knows about that, and oh yes, she had gall bladder surgery a few years ago. She chuckles as she tells you that, "I know I'm not supposed to, but me and the 'Blue Ladies' go out for a 'Suthun Cookin' meal once a week where I get the best grilled pork chop and collards in the Carolinas!" Upon follow-up questioning, she confirms that the shoulder pain seems to be worst on Sunday afternoons after going to brunch and having her fatty pork chop.
We as DPT's or PT's with Differential Diagnostic trainig should be aware of the fact that the pain could be originating from the teres minor or the spine (although it wouldn't likely be 7/10 intensity and 5/10 intensity at best) -- but it also could be referred pain from the GI system, most likely the gall-bladder. Given the changes in GI symptoms that the patient reports, the OBJECTIVE FINDINGS and our concerns about the outside possiblity of an organ system referal pattern should be reported to the physician.
I have no doubt that most PT's would catch should pain originating from the neck, but would most catch referred pain from the kidneys? the lungs? the GI system/the gall bladder? I submit that the latter constitute REAL organ system diagnostics and that although most DPT's can do this, most experienced PT's can't --- and the ability to do so separates a safe direct-access PT from the dangerous one. Experience only counts for efficiency and effectiveness of care once the nasties are filtered out. DPT's are generally better at the latter than experienced PT's while experienced PT's are generally better at the former.
As I've said all along, this profession needs both skill sets in the same individual! Once again SJ, PLEASE reconsider doing your DPT. As an experienced PT who is nearly complete with a DPT, I say with the wisdom of experience (both clinically and academically), that you simply don't know what you don't know.
I agree that, "it is not rocket science," but disagree that the issue is how frequently it's occuring. Forms are irrelevant, as nothing should prevent you from asking the right questions in your subjective interview --- but your example suggests that you're not thinking diagnostics on an organ system level --- only within the NMS system, and that little bit of knowledge can be quite dangerous without more comprehensive training. Do the DPT. I'd be happy to help you search for an inexpensive one and help guide you toward scholarship programs.
What REALLY scares me isn't the PT's, it's the massage therapists and personal trainers who want to "rub it down" without having the slightest of ideas what could be a more serious problem, because while most PT's don't ask the right questions, I'd be hard pressed to find a single, cash-based, direct-access, portal of entry massage therapist that does . . .
Scary ain't it?
Drew
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Dr. Andrew M. Ball, PT, DPT, Ph.D.
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Re: Chiropractic Demonstration Project - April 2, 2005 7:30:00 AM
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SJBird55
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Drew... the issue isn't about me. I appreciate the offer, but the timing is not now for me to even consider a DPT. And, as I have said, when someone comes up with a valid rationale AND there is some financial gain for me in my "investment" in furthering my education, then I might consider it. If anyone feels really strongly about it and would like to pay for me to get a DPT, sure... sign me up. I won't travel though...
Fine, I gave a bad example. I've had patients that had prostrate issues causing the complaint... bowel problems causing the back pain... neurological conditions that at the time were not diagnosed causing the pain... cancer... urinary tract infections causing the musculoskeletal pain. I do do a review of systems. I actually have a form I prefer to use. I may act like an idiot and do completely stupid things and get laughed at most of the time... but really, I'm not stupid.
Take me out of the picture completely. I am questioning the skills/knowledge/practice patterns of the majority of physical therapists. Jumping on the bandwagon and twisting things to make it appear that I'm the one that needs the help/training/DPT... that isn't the issue. No one arguing on direct access has answered my biggest concern - how the majority of physical therapists practice and if they are doing a review of systems and if they can differential diagnose (and I use that term to mean - know whether the underlying condition present IS treatable via physical therapy intervention). And, the focus of my concern is with the geriatric population.
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Re: Chiropractic Demonstration Project - April 2, 2005 7:30:00 AM
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Diane
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[QUOTE]while most PT's don't ask the right questions, I'd be hard pressed to find a single, cash-based, direct-access, portal of entry massage therapist that does . . .
Scary ain't it?[/QUOTE]Exactly my point.
SJ, I don't think you can have the world perfected before you accomplish direct access in your state. Yes, there are crappy PTs everywhere just as there are crappy anybodies in any profession. See the quote above. Probably crappy PTs could pick up signs/red flags and refer out faster than the best massage therapist.
Therefore I don't consider your argument as a good reason for the whole profession continuing to be kept under thumbs, especially in some states but not in others. Your chagrin at fellow therapists' incompetence apparently hasn't mattered much in the 39 states that already have some version of direct access.
Give members of the public a chance to vote by their attendance. It would all sort itself out in a few months or at most, years. People talk. In every community the patients/clients/PT consumers would have pegged who's 'good' and who should be avoided. Things have a way of sorting themselves out.
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Re: Chiropractic Demonstration Project - April 2, 2005 8:06:00 AM
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TLB
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Drew,
Great post, I was wondering when you would jump in.
[QUOTE] I have no doubt that most PT's would catch should pain originating from the neck, but would most catch referred pain from the kidneys? the lungs? the GI system/the gall bladder? I submit that the latter constitute REAL organ system diagnostics and that although most DPT's can do this, most experienced PT's can't --- and the ability to do so separates a safe direct-access PT from the dangerous one. [/QUOTE]Your right on all accounts, but what SJ is saying or I think she is saying is that, it's safer if this population is not allowed direct access. I disagree and can not think of 2 many MD's in my area who would catch organ system referred pain patterns. Although I know a few good PT's who would. SJ, are your experiences with these PT's in an OP setting? Not to ruffle any feathers but from my experience the IP people seem to not subjectively ask the appropriate questions or they may feel everything is fine since they have the hospital shield to cover them. A lot of it is they don't have time and are pushed much more on a productivity level than any OP PT, I don't care who you work for. When your on your own things are different, much more responsibility and more awareness.
Todd
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Todd
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Re: Chiropractic Demonstration Project - April 2, 2005 11:15:00 AM
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SJBird55
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I'm not saying the geriatric population should not be allowed direct access. I don't think that direct access should just be an all across the board privilege for every single licensed physical therapist. I completely disagree that "people talking" should be what differentiates a good direct access physical therapist from one that is terrible. Our profession should dictate what is required for direct access privileges.
In my opinion, for public safety, bare minimum criteria should be met. I guess the best way to communicate how I would envision it... licensed physical therapists should have the opportunity for direct access. To have the privilege of direct access the therapist should have to apply for that privilege and part of the application process would include resume, CV, number of years of experience, past outpatient experience, any malpractice suits, and successful completion of a computerized exam that entails red flags, differential diagnosis, and appropriate referral to medical professional which would be good for 5 years. At the end of 5 years, reapply and go through the process again - at that point in time a particular number of CEUs should be required to be met also. At least some steps would be in place to attempt to ensure public safety AND our professional licensing board would be the responsible party. I'm sure Tony Delitto would probably comment that the only way to ensure therapists are practicing effectively would be to look at outcomes because just passing a test does not mean translation of what was learned into practice.
Todd, my experiences are in the outpatient setting... both hospital based AND private practice. You'd think there would be "much more responsibility and more awareness" but that isn't what I observed. Honestly, if I hadn't seen what I have over the years, I think my belief would be that we'd be just fine with direct access... but I can't forget some of the crap I've seen. It appears that only I have seen enough crap to question our profession as a whole?
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Re: Chiropractic Demonstration Project - April 2, 2005 2:35:00 PM
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Diane
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SJ, I see you have strong concerns. Probably best to get involved and ensure that you have strong input into the process. I'm sure there are lots of other PTs in your state with ideas that might not include your concerns, who are moving the process along. However it all turns out, I think it's overall good for the profession and the public world wide to be direct access, and really much better, long run, for US PTs in every state.
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Re: Chiropractic Demonstration Project - April 2, 2005 4:24:00 PM
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dross
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From: NJ
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Here's a story from the DC side of the side.
30 year old female presented to the DC with a CC of left sided shoulder pain and left sided pain in the 10-12th ribs, mid clavicular line. The day before presentation she was rear ended while at a stop light by a car doing approx 5 miles per hour. Shoulder pain was 5/10 constant, present during active and passive ROM. No bruising on the ribs but tenderness to palpation.
If I was just a DC I would have rules out rib fx and worked up the shoulder a little more. But since I have the MD training I knew right away she ruptured her spleen and her shoulder pain was from diaphramatic irratation. I called an ambulance, rupture was confirmed on CT, and she had surgery that day.
Many DCs would have missed that and she would have died on the table while being examined for her should pain. I dont know the extent of PT ddx of visceral complaints but is something you want access to without a MD clearance?
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Re: Chiropractic Demonstration Project - April 2, 2005 4:45:00 PM
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steve
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From: Canada
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chirx,
I live in a province with direct access to physio services. Although I would not come out with the differential in this scenario, I would have sent her back to the GP with a presentation like this for further testing. If in doubt, get it checked out. As a physio with direct access, my responsibility is not to come up with a differential but rather to identify when a patient needs further testing.
This said, I'd be curious to see how many GPs would get the differential on this one.
Steve
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Re: Chiropractic Demonstration Project - April 3, 2005 11:51:00 AM
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chiroortho
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Not that it matters that my name has been invoked a few times here...I'm purposely avoiding contributions to this discussion because this is best fleshed out among the PTs.
I don't think my input would be appropriate here. I don't like everything I'm hearing but most points are well taken.
Greg
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Greg Priest, DC, DABCO
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Re: Chiropractic Demonstration Project - April 3, 2005 1:56:00 PM
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Diane
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From: Vancouver, B.C., Canada
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Chirx,
I live in the same province as Steve and enjoy direct access. My practice is cash only. I don't know if Steve's is, but that's actually beside the point: I'm confident in my ability to pick out somatic pain arising from somatic injury and somatic pain arising from visceral tissue just by having done pain pattern and pain behavior education. Surely any intelligent individual can learn to do this. PTs are generally conscientious and intelligent, and love to learn. I see no problem with our profession being taught to recognize ruptured spleens and send them on, fast. (Anything touching the diaphragm can refer pain to the shoulder. Only the spleen will refer to the left shoulder. That's what I learned, in any case..)
In any case, the last hundred years or so have been spent by PT following around closely behind and beside MDs learning all we can. There are and should be maintained, open doors of communication. They should not be permitted to stop our professional evolution. They have stepped aside, at least in this province.
My guess is that you have access to either your point of view as a DC or your point of view as an MD. Neither of these perspectives really gives you much of a glimpse into what PTs know or can elucidate by watching people in pain move, or what we pick up by testing movement, or listening to/ watching them describe their injuries. I assert that what we learn is quite a lot closer to what your MD perspective has given you, a perspective that allows you to judge based on reality/red flag recognition. Not the DC fantasy of DDx.
I guess the question boils down to whether PTs in the US, like in SJ's state, are willing to take on the responsibility of not only learning to tell the difference but to trust themselves to be able to tell the difference when timing is crucial then refer appropriately.
Jason pointed out that direct access isn't the same as primary care provider.
Hucksterism needn't be an issue; I think you still had your DC goggles on when you said that. Lots of PTs enjoy a lowprofile non-huckster fully booked existance in the US in direct access states. I wish more of them would come on to this board and discuss their lives.
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Re: Chiropractic Demonstration Project - April 3, 2005 2:30:00 PM
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dross
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From: NJ
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I wasnt saying that PTs dont have the intellegence or ability to pick on things like ruptured spleens.
Without a few more years of training in general medicine like what medical residents do, you are putting yourselfs in a position to miss something.
Maybe Im coming across wrong. Im all for PTs having direct access, DPT, manipulation and anything else that will advance the profession. I think its absurd that DCs have all this and you dont. But along with direct access and the title of "Doctor' comes inceased responsibility and liability. That was my point. Maybe I'll keep out of this one from now on.
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