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Re: Chiropractic Demonstration Project
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Re: Chiropractic Demonstration Project - April 3, 2005 3:09:00 PM
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Diane
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Joined: March 9, 2001
From: Vancouver, B.C., Canada
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Thanks Chirx, glad you are for PTs having direct access. Also, I think a lot of PTs share my opinion that we don't need to have the title of "doctor" to have direct access. Liability issues are a separate issue, I imagine from state to state.
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Re: Chiropractic Demonstration Project - April 3, 2005 7:14:00 PM
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steve
Posts: 470
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From: Canada
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Chirx,
Your input in this forum has been respectful, well thought and always welcome. Please dont take my post as anything but an example of how a PT would function in a direct access role. I would also think that most therapists in non direct states would also be able to differentiate patients who need further medical screening as they would function in a safety check manner with the GP.
Steve
Steve
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Re: Chiropractic Demonstration Project - April 4, 2005 2:33:00 AM
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Sebastian Asselbergs
Posts: 1205
Joined: September 29, 1999
From: Barrie, Canada
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Just a repetition of something that obviously needs repeating: in our province with direct access since 1993, our liability is less than $400.00 per year.
In our education, so much emphasis is placed on what red and yellow flags are, that some of my colleagues here have become known by the family physicians as "paranoid" - in jest. We have not heard or seen ANY case published in our quarterly college publication - nothing regarding missing something major. Please note that that ONLY means that no complaint was made!
Chirx and Greg and others - hang around, ok?
_____________________________
Mundi vult decipi
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Re: Chiropractic Demonstration Project - April 4, 2005 7:41:00 AM
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JLS_PT_OCS
Posts: 1684
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From: USA
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Yes, non-PTs, please stick around, your input is valuable.
I can appreciate where SJ is coming from.
I think anyone who takes the time to become an expert in their field (as she surely has) and works to constantly improve themselves (as she surely does), will at some point become disappointed and disillusioned with their peers.
It happens in every profession. I post and read on DC forums where the chiros say that about each other. I read and talk to MDs/DOs who say that about some of the people they work with. Personal trainers and strength coaches say that about each other all the time. Hell, my father said that about some people in his profession, and he was in corporate finance!!
The point is that there will always be "crappy" people in any field who you wouldn't trust to watch your cat, much less treat a family member.
Should we let those people hold back the progress of the entire profession?
I think not.
I fully understand your concerns, SJ, I really do.
But think about this: massage therapists need no referral to treat people, neither do personal trainers, aerobics instructors, chinese medicine people, or acupressure people.
Think of all these groups. Does anyone really think that they are better or more educated than PTs? Does anyone really think that scores of people are dying every year because these practitioners don't appropriately refer someone to their physician?
Their liability insurance rates are quite low, as are ours. What does that tell you? The people who really are in a position to know, the insurance adjusters, are protecting their rear ends always, and they aren't missing things when it comes to deciding who should pay higher rates and why.
And that should speak volumes to us, that our education is currently more than adequate to be safe, and the DPT will only help us be more effective in these ways. PTs in other countries (commonwealth countries specifically) have been doing this safely for decades with bachelor's degrees!
SJ, you ask for evidence that it is safe, I think there are volumes of it!
I disagree with Drew's contention that the DPT is required for you to really be safe and know differential diagnosis and "you don't know what you're missing." Drew, you seem to be coming across a little high on your horse here, at least to me. It doesn't seem like you mean to, and I agree we should all be pushing the DPT as you do an excellent job of on this forum.
But there is just no evidence that further education is required to be a safe practitioner in the direct access situation.
Instituting some kind of tier system as SJ suggests only serves to reinforce the current servitude PTs are in, and we can all agree that won't help us move forward.
The chiros are hungry. They know they have to prove themselves, they know they're facing a lot of resistance, they have to get out there and market hard, lobby hard, and work to get more privileges and access to patients and status in the community. They do a very good job of that.
What's with us? Much broader skill set and much more to offer beyond the spine, no subluxation garbage, no mall spinal screenings, no applied kinesiology, no unnecessary Xrays, and yet still some people would have us cling to the apron strings of traditional medicine.
Medical mistakes, both medication errors and surgical complications are one of the top 10 leading causes of death in the US. Physicians have a very good residency training/ quality control system in place. There will always be some bad apples.
We shouldn't let the few bad apples spoil the barrel of direct access and professional autonomy for all of us.
Sorry about the rambling post again...
Jason.
_____________________________
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 4, 2005 11:10:00 AM
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SJBird55
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From: Michigan
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I have never seen myself as "servitude" an any way, shape or form. Anyone who is responsible and is accountable for decisions and actions is definitely not in a "servant" role. Anyone who chooses to make decisions within his/her scope of practice is also not in a "servant" role. Technically, we don't need direct access to practic that way. I'm really not against direct access... I believe the opportunity should be there, but at the same time, the privilege to practice in a direct access manner should have criteria to be met. That would help ensure safety (we'd regulate the standards) and I think it would help with both our credibility and help us continue to be in the mainstream of traditional medicine and not fall prey to becoming a snake oil scam. And, I also think that maybe physicians would respect us having that direct access privilege especially if we were examined to prove that we definitely can refer appropriately.
I just see things differently and that's from my own experiences. Some things I have seen and experienced would make a billy goat barf. Maybe I am wrong and maybe I am ultra conservative in my opinion... but we are talking about the lives of others and their dependency on us to know what the heck we're doing.
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Re: Chiropractic Demonstration Project - April 4, 2005 11:37:00 AM
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JLS_PT_OCS
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I don't argue any of that, SJ.
Except the part where you seem to think we should have something "extra" to do direct access.
I know you've seen some crazy stuff, we all have. From all sorts of providers. They will always be out there.
The overwhelming stack of evidence supports that PTs can and should be doing this direct access stuff, and are exceedingly safe at it. Our education in fact encourages communication with other providers, especially the primary care physician.
Your 'criteria to be met' is called the licensure exam.
And making decisions is nice, but if we are dependent on someone else to initiate or "OK" that process, then that is servitude, and subordination. Nobody wants to be a primary health care provider, nobody wants the family doctor's job. We do want free and unrestricted access to patients and reimbursement for same. Taking half steps becuase there are some bad apples out there won't help us evolve. Heck, think of Joanne Gallagher, that "straight" DC from pennsylvania, who told her patient's mother to go off of the seizure meds, that the subluxations were causing the problem. Of course, the patient died. And "Dr" Gallagher's in some hot water. Should we immediately strip all chiros everywhere of their licenses because of her actions? Of course not.
The mark of a good profession is how few of those "bad apples" get through. I think given what we know of the data about things like liability insurance and malpractice rates, that we can be proud of PTs everywhere.
Why is it that a personal trainer can see a patient with back pain off the street and design an exercise program for them respecting their limits, but in some states we still need a slip of paper from a physician?
Would you consider trainers "snake oil"? Their liability insurance rates aren't bad at all. I should know, my wife's a trainer.
How does this argument to restrict PTs from direct access make any sense given all this information?
We have been kept in this subordinate position for far too long, watching other, less well educated, providers be allowed full independence and the ability to openly market their services (think LMTs and personal trainers). And now some other providers attempt to restrict our practice (think DCs and MDs). So if we can't have enough confidence to fill the vision the APTA has set out (and commonwealth countries already have fulfilled) well, then, we deserve to lose.
So pass the Ultrasound gel. Yes, doctor. No, doctor.
PLEASE.
If that happens, I'll just burn my PT license and open up a strength and conditioning clinic. That way I can be truly independent. What a sad statement that is, huh?
When are we going to wake up?
Jason.
_____________________________
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 4, 2005 1:14:00 PM
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Jon Newman
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From: Amherst, WI
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I think comparing massage therapists to PTs is a bit of apples to oranges. Massage therapists as well as DC's have always been considered outside of mainstream medicine and PT's have always been in. The AMA's stance is that PT direct access is tantamount to the practice of medicine. Logically, according to this stance, what we are currently doing is practicing medicine under the supervision of an MD. Medicine is to be regulated. Much to the chagrin of the powers that be, alternative "medicine" has largely escaped much of this regulation.
PT's help people minimize movement impairments and increase participation in life.
DC's fix subluxations and their sequelae. Insurance pays but what a long complicated history of how they came to be viewed as a legitimate insurance reimbursed practice. I don't claim to be any sort of expert but some lucky circumstances combined with poor judgment on the AMA's(?) part certainly helped out. Although I could be mistaken about this. Rest assured, I'll be corrected if I am wrong.
Massage therapists massage. Private pay is how business is done.
Personal trainers tell you you're too weak and inflexible and show you how to correct this fault. Again, private pay is how business is done.
I'm not sure that we need to be regulated any more than the others if we stick to our guiding philosophy. Now if we insist on medicalization of what's wrong with the person in pain, perhaps the regulation is warranted to protect the public. Why not pass a board certified direct access test if we wish to develop differential diagnoses to treat? What would be the bad thing that develops from this scenario?
_____________________________
[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: Chiropractic Demonstration Project - April 4, 2005 1:15:00 PM
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nari
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From: Australia
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Jason
Well said.
Sebastian wrote about family physicians thinking PTs tend to be paranoid, it may apply here as well; but I have not noticed it to be a problem.
GPs (as we call them here) are probably only too pleased to have some of their appointments shaved off their daily grind.
Are there courses in the USA which could offer education on 'red flags' or that sort of thing?
Here the red flags AND yellow flags ( not our yellow flags, only medical ones) are part of undergrad. As SJ pointed out, it is not rocket science to pick a potential red flag...
Nari
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Re: Chiropractic Demonstration Project - April 4, 2005 1:20:00 PM
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chiroortho
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[QUOTE]In our education, so much emphasis is placed on what red and yellow flags are, that some of my colleagues here have become known by the family physicians as "paranoid" - in jest.[/QUOTE]Sebastian, I am certain that this is why I NEVER hear of a PT causing harm due to a missed diagnosis. I'm sure it's happened, just like some folks tell me that there are little green men out there...I just haven't seen one. I don't doubt for one second that if anyone really crunched the numbers that matter, the LIABILITY numbers, that the case for direct PT access would be made easily. Just not in my state. :) (Just kidding guys) [QUOTE]But think about this: massage therapists need no referral to treat people, neither do personal trainers, aerobics instructors, chinese medicine people, or acupressure people.[/QUOTE]This is the best possible argument that PTs have IMO. Good grief, I employ two LMTs because of the nonsense that my patients used to tell me that they dealt with when I used to refer patients out for massage therapy. And you aren't qualified for direct access?! Give me a break.
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Greg Priest, DC, DABCO
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Re: Chiropractic Demonstration Project - April 5, 2005 1:47:00 AM
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JLS_PT_OCS
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From: USA
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Well said Greg.
Jon, while I think comparing LMTs and PTs educationally is apples and oranges, comparing their access to patients is not. That's what's so unbelieveably ridiculous about this direct access situation.
Subdividing the profession with one group getting direct access and one group not just perpetuates that thought that PTs cannot all handle this.
In the UK they are injecting joints! Come on, people!
Now, I'm not suggesting we do THAT, but that's an example of the kind of access PTs have. Oh, yeah, in the UK most PTs have bachelor's degrees.
Nari- our education, even before the DPT, is rich with red flag type education (recognizing when someone may have a non-musculoskeletal problem).
We also have a lot of CEU courses here that are designed to sharpen those skills for us. This is also a major emphasis of many of the DPT programs, as I understand it.
At any rate, the fact that we are even having this conversation is a good example of why the DCs will always win at legislative and marketing efforts. They are just more motivated, better organized, better funded, and brought up to be independent providers and not (need to) collaborate. Not that many of them don't want to, but that many of them may not be viewed positively by the family doctor, so they better learn to be their own boss and do their own thing. That is an advantage here in this situation.
So if you are a PT and don't support immediate and unrestricted direct access and reimbursement for all PTs everywhere, then let me look up the address of the Arkansas Board of Chiropractic Examiners so you can send a donation, because that's really what you're doing.
(that felt good.)
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 5, 2005 2:14:00 AM
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Sebastian Asselbergs
Posts: 1205
Joined: September 29, 1999
From: Barrie, Canada
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Here it's pink elephants on the weekend, Greg.
One part of this issue is the existence of a strong regulatory College of Physiotherapists. The "protection of the public" is a core tenet of the College. The strict standards of practice and guidelines with regular publications of complaints and visible deterrence decisions are making a difference. Advertising restrictions, restrictions on words we can use ("expert" being one of them), continuing education reviews (allowing even the online community as a valid part), any clinical or business aspect of our practice etc etc. Our national exam has a strong focus on safety of the patient in all aspects, and is designed to establish eligibility for the College's certificate for "Independent practice" (I like the word "independent").
I think many non-direct access states should use the example of other, direct access states (Canada and Oz included). The arguments against it, have been used before and they are really not new or profoundly different. The proof of it working is out there (and here).
I really want ALL physios to stand behind this concept - not doing so, is in my opinion, a statement of lack of confidence in your own education.
I think this horse has stopped moving - so...
ciao
_____________________________
Mundi vult decipi
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Re: Chiropractic Demonstration Project - April 5, 2005 2:29:00 AM
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TMondale
Posts: 131
Joined: January 3, 2005
From: Newton-Wellelsley Hospital
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SJ,
I've missed some time here, but the fears you express about PT's and direct access are simply unfounded. I don't know where you've been but to claim you've seen things that frighten you about our ability to handle this is unusual at best. I, like the many that post here have also had many years in practice with a wide range of experiences. I say that we in general are hypervigilant to potentially co-morbid medical condtions that require further medical workup. Our ability at this is second only to medical doctors, and superior to many already treating autonomously.
This blaming others for your insecurities and all that would do this has no place in the field.
When we acquire the privilage of direct access feel free not to participate.
Tim
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Re: Chiropractic Demonstration Project - April 5, 2005 3:05:00 AM
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SJBird55
Posts: 2438
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From: Michigan
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Tim, I like the idea that both Jon and Sebastian present...
I just firmly feel that there should be some steps in place to ensure patient safety (for the exact reason that we are considered part of traditional medicine). If direct access is an all across the board thing, then those things should be in place - maybe the board exam should be more difficult to reflect what is important in what we do and maybe it should highly stress various scenarios, critical thinking, red flags, yellow flags and appropriate referral. Maybe it should also stress evidence based decision making. All I know is that the exam wasn't very difficult.
And, I have never said I had insecurities. I'm not insecure - I'm concerned about the mass majority of physical therapists on the whole. Where do the majority of physical therapists function? What percentage are members of the APTA? What percentage are required to have continuing education?
I just don't have the rose colored glasses that everyone else seems to be wearing and firmly believe that a direct access system should be thought out with patient safety first and foremost. I would be very agreeable to what Sebastian suggests - that system he described isn't in place here though. I'm just not getting from the majority of all of you posting here that any safety measures need to be in place with direct access. Maybe it's all semantics?
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Re: Chiropractic Demonstration Project - April 5, 2005 5:09:00 AM
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Jon Newman
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I have no idea what's up with the states that don't have direct access by now. Get your fund raising in gear and "donate" to the right people so you can have a stepping stone toward your piece of pie. But not the pie itself.
The pie most PT's envision is direct access with third part reimbursement. In other words, we want what chiropractors have (not massage therapists or personal trainers). And when DC's already have a bigger slice of pie and are offered another piece in addition (and we're not, while sitting at the same table with them), it's insulting.
I don't think DC's got this initial status through good politics as much as through the blunders of others. Group think; they definately had that but are beginning to lose it...good for them.
Now that one group escaped the purview of the MD's you can be assured that it is unlikely going to be allowed to happen again. And the more we try to look and act like doctors the more MD's are going to resist our efforts--they already think we practice medicine.
SJ, while I'm all for being a member of the APTA, it is has little to do with clinical competence. For example, a vast majority of MD's do not belong to the AMA.
Why do others think DC's get to play in the greener pasture?
jon
_____________________________
[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: Chiropractic Demonstration Project - April 5, 2005 3:51:00 PM
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Andrew M. Ball PT PhD
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Joined: July 28, 2002
From: Charlotte, NC
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SJ,
I think I get your point, and I don't disagree that there should be some kind of safety mechanism before a PT should be allowed to practice in a direct-access way. If you look at the house bill sponsored by Arlen Spector, there are a few guidelines in terms of education and/or experience.
Here's the thing, though, one of the hallmarks of a profession is the ability to self-police. I believe that WE as a profession should set the guidelines as to what constitutes a (D)PT prepared for direct-access, not the legislature.
A few years ago, I wrote an article that was published in Acute Care Perspectives with Erin E. Midkiff, PT, DPT; and Bob Kizlik, PhD. Here are a few snippets that may be important to the the discussion at this time:
ABSTRACT:
Physical therapist discussions of whether or not physical therapy is a profession are usually filled with opinion and devoid of any standardized method of assessment. This article discusses the twelve points of the “Kizlik Kriteria,” used to evaluate both whether or not, and to what degree, an occupational group has achieved recognition as a profession. Here, the authors argue that physical therapy remains an emerging profession. More importantly, it seems there are more appropriate questions to ask regarding the present and future status of physical therapy, as well as the challenges and rewards associated with each.
Ask a physical therapist if physical therapy is a profession and you’re likely to hear a passionate, “Yes!” After all, physical therapists don’t think of themselves as paraprofessionals; they think of themselves as something more. They treat patients with dignity and respect --- that is to say that patients are treated “professionally,” and most physical therapists see their job as something that requires more skill and training than the services provided by clothing salesman at the local mall. All of this is to be commended, but does this really mean that physical therapy has arrived as a bona-fide profession?
As a doctoral student at the University of Virginia, Bob Kizlik, PhD posed the same question of his own profession, teaching. What he proposed is that all professions are defined by twelve specific characteristics, which we refer to as the “Kizlik Kriteria.” Fail to meet all twelve characteristics, and the occupation in question isn’t a profession at all. It is, at best, emerging. The purpose of this article is to review these characteristics and assess how physical therapy fares. In an inspirational speech, one of his first as APTA president, Ben Massey, Jr. proclaimed that, “We Have Arrived!” The question we ask, in relation to Dr. Kizlik’s criteria, is “have we?” This suggests the answer is more complicated than “yes” or “no”.
Preparation for and induction into the profession is provided through a protracted preparation program, usually in a professional school on a college or university campus.
Physical therapy certainly is a profession in this regard. Upon graduation from high school, it generally takes four years to complete an undergraduate degree, and an additional three to complete a DPT, the emerging standard in physical therapist education.
The profession has agreed-upon performance standards for admission to the profession and for continuance within it.
Again, physical therapy qualifies as a profession, at least upon cursory examination. There is a national board exam for admittance into physical therapy, and state boards of physical therapy examiners that regulate continuation within it. However, the standards required to both acquire and sustain licensure varies from sate to state. The resulting potential for great variability between neighboring clinicians begs the following: has physical therapy arrived as a profession in some states and not in others?
The profession is organized into one or more professional associations, which, within broad limits of social accountability, are granted autonomy in control of the actual work of the profession and the conditions which surround it (admissions, educational standards, examination and licensing, career line, ethical and performance standards, professional discipline).
Between the American Physical Therapy Association, the Commission on Accreditation of Physical Therapy Education, the State Physical Therapy Associations, and the Boards of Physical Therapy Examiners, physical therapy has arrived in this regard as well.
The profession is based on one or more undergirding disciplines from which it builds its own applied knowledge and skills.
Clearly physical therapy has arrived in this regard. Physical therapy has its foundations as much in biology, chemistry, and physics as it does in psychology and healing art.
Each profession is concerned with an identified area of need or function (for example, maintenance of physical and emotional health, preservation of rights and freedom, enhancing the opportunity to learn).
Although physical therapy has a defined area of practice, that is to say neuromusculoskeletal diagnostics and treatment, far less than the majority of the profession engages in true portal-of-entry care. Some of this stems from insurance regulations, some from fear of the unknowns of cash-based-practice, and some from fear of financial backlash resulting from putting one’s clinic in direct competition for patients with one’s primary referral source. Whatever the case, it’s clear that the area of need within which physical therapists operate isn’t clearly defined and universally agreed upon within the group, much less effectively communicated to other professions and the public at large. Are we diagnosticians or do we focus upon treatment borne from physician orders? The answer to this question often depends upon the practice setting of the individual therapist. Have we arrived in this regard? That’s for you the reader to decide.
Professions are occupationally related social institutions established and maintained as a means of providing essential services to the individual and the society.
The question here is, “Are physical therapy services essential?” Based upon the fact that so few cash practices exist, we suggest that the answer to this question may be something of a professional ego-bruise. If our services are truly essential, or at least perceived by the public to be such, why (in contrast to other non-medical clinical doctors such as dentists, optometrists, and chiropractors) aren’t patients willing to pay the physical therapist up-front for service provision of what the patient perceives to be immediate need? The fact that the question is pause for thought begins to contradict the notion of physical therapy as anything more than an “emerging profession.” It may also be necessary to address differences between specializations in this regard: are some branches of physical therapy more essential to the present health care system than others? In addition, upon which definition of “essential” do we base this judgment -- the specialty services that the public perceives as urgent and necessary or the services that are actually supported by current best evidence?
The profession collectively, and the professional individually, possesses a body of knowledge and a repertoire of behaviors and skills (professional culture) needed in the practice of the profession; such knowledge, behavior, and skills normally are not possessed by the nonprofessional.
Is our body of knowledge truly unique? If so, why is it that increasingly, other providers of care (such as athletic trainers and massage therapists) are providing services at what the public believes to be equal value at lower cost and greater ease of access? In short, are the skills of neuromusculoskeletal diagnosis and treatment that we proclaim accepted and internalized by the public?
Members of the profession are involved in decision making in the service of the client. These decisions are made in accordance with the most valid knowledge available, against a background of principles and theories, and within the context of possible impact on other related conditions or decisions.
This is certainly the APTA’s vision for physical therapy, and there are certainly some physical therapists that function as portal-of-access primary-care providers of care, but this is certainly not the universal norm. Physical therapists working in hospitals have the opportunity to influence the clinical decision making process, but usually this is limited to the treatment course, and many physical therapists are bound by non-evidenced-based outdated rehab protocols of tradition upon which the referring physician insists. Do we influence the clinical decision making process? Depends upon the setting, but the standard isn’t portal-of-access primary care, nor do physical therapists generally exert much more than low-level subordinate influence in the diagnostic process of a physician-lead interdisciplinary team. Have we arrived as a profession in this regard? You decide.
There is a high level of public trust and confidence in the profession and in individual practitioners, based upon the profession's demonstrated capacity to provide service markedly beyond that which would otherwise be available.
There is certainly a high level of public trust in physical therapists, but if physical therapy were to dissolve and disappear, would our services be missed or would athletic trainers, massage therapists, and chiropractors assume the roles that we think of as our own? Would patients notice?
Individual practitioners are characterized by a strong service motivation and lifetime commitment to competence.
Physical therapists are certainly committed to service and a “lifetime commitment to competence,” but that very phrase is evolving. What does it mean to be “competent” as a physical therapist? Does it mean the ability to take a patient off the street, differentially diagnose, and treat, independent of physician referral as doctors of physical therapy, or does it mean being technically skilled in a particular therapeutic technique? Until there is better cohesiveness within the profession regarding what it means to be “competent” (and from the experience of the authors there are clearly two separate and distinct camps with respect to the issue) we the authors suggest that true, universally accepted competence standards cannot be achieved.
Authority to practice in any individual case derives from the client or the employing organization; accountability for the competence of professional practice within the particular case is to the profession itself.
In physical therapy, the idea that authority to practice derives from the patient/client is debatable. Very often, the authority to practice flows from physician referral --- without which the physical therapist could not financially survive. Only in strictly cash-based practices does the authority to treat truly derive solely and directly from the patient/client, and given how few cash-based physical therapist clinics exist, suggestions of physical therapist autonomy and professional authority in practice may be overstated. Not in legal terms perhaps, but because cash practices tend to compete not with other physical therapist clinics so much as their physician and chiropractic referral streams, perhaps in practical business terms.
There is relative freedom from direct on-the-job supervision and from direct public evaluation of the individual practitioner. The professional accepts responsibility in the name of his or her profession and is accountable through his or her profession to the society.
The truth is that supervision and accountability of physical therapy to other professions or institutions varies from setting to setting. Is the primary allegiance of the physical therapist working in early intervention to the special education system or to physical therapy? Is the primary allegiance of the physical therapist working in acute care to the attending physician or to professional autonomy? Finally, it must be considered that as a group of either burgeoning or established professionals, we’ve not yet had open and candid discussion about the idea that freedom from supervision and public review is really what physical therapists want as a group. Especially with respect to acute care, where the potential for patient injury is high, do we really want the buck to stop with us?
Conclusion
Based upon our evaluation of physical therapy on the basis of the Kizlik Kriteria, we suggest that physical therapy has not yet arrived, but remains an emerging profession. More than that, we suggest that asking the question “Is physical therapy a profession,” is not specific enough to warrant a clear response. As physical therapy marches into the new millennium, we suggest that a more appropriate question be raised in every hospital, clinic, and physical therapist education program:
“In what area of specialization, and in what areas of the country, is physical therapy more of a profession than others?”
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Dr. Andrew M. Ball, PT, DPT, Ph.D.
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Re: Chiropractic Demonstration Project - April 5, 2005 4:14:00 PM
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SJBird55
Posts: 2438
Joined: May 10, 2004
From: Michigan
Status: online
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In reading all some of the "direct access" states... heck, I'd say some of them really aren't "direct access." I'd say some of them do have some safety measures in place.... and then... what is "medical diagnosis?" Many of them state that physical therapists cannot medical diagnose... that means? I mean, does that mean that I'm not qualified to know an obviously torn rotator cuff tear or a blown ACL? I would argue that quite a few states that are listed as "direct access" really aren't what I would consider direct access.
I firmly feel that the PT board should be group to "police" the profession. (Each state seems to have it's own laws on how a PT can practice... and each state has a licensing board.) Yes, our educational systems and the board exam should definitely reflect what is the important knowledge base that a physical therapist needs to possess AND should defnitely capture the important issues for true dirct access. Physical therapists should be the ones to spearhead the legislative changes... but saying that, the physical therapists generally aren't going to get what they want unless they put safety features into the legislative changes. Well planned out and rounded consideration for patient safety, physician's views and physical therapists' views is really the only win-win situation. I say that, but there are a few states that are direct access with zero restrictions.
Jon, being a member does not equate to any competence - but it does mean that there is a potential for members to be exposed to various topics and to peer-reviewed articles. Granted, if one never opens up the journal or read the information what's the point... but at least the opportunity was there.
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Re: Chiropractic Demonstration Project - April 5, 2005 4:36:00 PM
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Diane
Posts: 1507
Joined: March 9, 2001
From: Vancouver, B.C., Canada
Status: offline
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[QUOTE]I'd say some of them really aren't "direct access." I'd say some of them do have some safety measures in place.... and then... what is "medical diagnosis?" Many of them state that physical therapists cannot medical diagnose... that means?[/QUOTE]Here, with direct access, PTs are required to provide a "physiotherapy" diagnosis. MDs are required to provide a medical diagnosis.
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Re: Chiropractic Demonstration Project - April 5, 2005 4:43:00 PM
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Jon Newman
Posts: 1707
Joined: April 24, 2004
From: Amherst, WI
Status: offline
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I have to ask. What's the difference?
jon
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[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: Chiropractic Demonstration Project - April 5, 2005 5:48:00 PM
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Diane
Posts: 1507
Joined: March 9, 2001
From: Vancouver, B.C., Canada
Status: offline
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The difference is who is making a diagnosis based on whose body of knowlege, I should think. A diagnosis made by a PT doesn't have to be identical to a diagnosis made by an MD, in that it is deemed here that PTs are not trying to be medical doctors, are not trained to be medical doctors, don't want to be or need to be medical doctors or doctors of any sort in order to "diagnose" someone in order to treat them in a logical science-based way, i.e., in a physiotherapy way.
Any medical "problems" that might walk in to a PT office are streamed to an MD, based on nothing more than a suspected red flag.. they don't need to be physiotherapeutically or medically diagnosed to be referred on to the appropriate provider.
E.g.: A woman in the last stages of pregnancy came to see me about pain in her left leg. When I took a look, the painful leg was swollen compared to the other leg. I invited her to have a lie down while I called her doctor. The doctor called me back within a few minutes, I told her about the patient's leg, she said, "Tell Mrs. X to get in a cab and come straight to the X hospital. Tell her I'll meet her there in emerge." I called the patient a cab, told her the MD's instructions, she went straight to emerge, was admitted, spent the rest of her pregnancy on bedrest and bloodthinners, survived, has a nice 8 or 9 year old child now, I see her on the street sometimes and she always says hello.. I think she appreciates that I didn't try to give her a physiotherapy dx for something that was clearly a medical problem.
E.g.: A medical doctor came to see me for pain in her shoulder. She'd exhaustively tested herself with MRI, CT scan, xray etc and found nothing bad. She had dxed herself "arthritis." She also had neck tension, pain behind her head on the same side, slept always on the same side as the neck/shoulder pain, and always carried her huge bag on the other shoulder. She suspected carotid bruits on the same side too. She got a funny noise in that ear, frequently. She had limited elevation/abd/external rotation in the affected shoulder. We sorted out her behaviors and she could see her own contribution, agreed to change things. I worked on her soft tissues, axilla etc., to no avail as it turned out, which surprised me because that usually does the trick first visit.. so the physiotherapy Dx was, "AC problem." Next visit I treated her with a pencil eraser shoved gently but firmly, for several long moments, into the v-space just medial to her AC joint, and voila, about 50% of her missing range returned. The refined diagnosis was "tight conoid ligament." Next visit, more pencil work, she got back another 30%. I worked on her neck, did some clever skin stretching around her ear, waited patiently for her brain to lengthen out some important and delicate structural stuff around the jaw line/hyoid, and the noise in her ear went away. She asked me to show her the pencil procedure, and I complied, using a skeleton. She asked me if I thought that bruits, which are considered to be secondary to buildup inside the artery causing turbulance, could exist secondary to mechanical compression, since hers seemed to be gone for the time being, and I said I didn't know, but didn't think such a thing was entirely outside the realm of possibility. (I liked that she was thinking outside her normal parameters.) Her comfort level of her neck rose as the sessions progressed. The PT dx here was "unilaterally tight contractile structures in the neck secondary to useage adaptation." By visit #4, her range was all back to her satisfaction and her neck felt better and her noise in her ear was still gone.
Anyway, take-away point: Sometimes a physiotherapy diagnosis must be arrived at during or after the fact. It's more a process arrived at through treatment than a fixed decision in a moment in time. I don't worry about what order to do things in. I'm not going to know the "PT diagnosis" often until I wade into that person's nervous system a little and find out. Often just wading in will fix the "problem" and then I can give a retroactive physiotherapy dx of "persistant pain resolved with soft tissue manual treatment."
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Re: Chiropractic Demonstration Project - April 5, 2005 6:09:00 PM
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Jon Newman
Posts: 1707
Joined: April 24, 2004
From: Amherst, WI
Status: offline
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So here we have a case in which you recognized a painful condition not ammenable to PT--no diagnosis made at all.
How about someone who comes with ankle pain. They suffered and ankle inversion incident about 3 weeks ago and it is not getting any better but not really getting worse either. They are tender of the ATF. There is some minor bruising that is resolving. They are able to walk with a mild limp. It feels good at rest. It's quite sore when first stepping on it but limbers up with use. It's quite sore at the end of the day. No bony tenderness present.
Do we try to state it is an ATF sprain or we do we say they have a sore ankle that's ammenable to PT. If we say the first, how is that different than a "medical" diagnosis?
Note that I'm just trying to bring out some of these issues for clarification purposes.
jon
_____________________________
[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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