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Re: Paris to offer t-DPT to DC's?
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Re: Paris to offer t-DPT to DC's? - January 30, 2006 12:01:00 PM
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Jeep
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From: USA
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Buddy-
I don't take my own films anymore. I just fax the order to the imaging center I send the patient to. Works really great. And each film I order gets read twice--- the rad and me. I feel confident the rad cleared it for any pathology, and I use it for clinical correlation. Our state wisely mandates that a minumum of 3 hrs of our yearly CEs be in imaging(plain,MRI,CT etc). The imaging centers around here offer alot of imaging CEs, and many have a DC rad on staff.
PS-
The imaging center gives the films to the patient to carry back to my office.
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Re: Paris to offer t-DPT to DC's? - January 30, 2006 2:44:00 PM
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drbuddy
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From: Pennsylvania
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Aww, you still get those archaic things? I get a nice little CD and I can zoom, change contrast brightness and contrast, etc.
Reports are faxed within 24 hrs.
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Re: Paris to offer t-DPT to DC's? - January 31, 2006 1:06:00 AM
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TMondale
Posts: 131
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From: Newton-Wellelsley Hospital
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Buddy,
I would like that reference if you have it. Interesting that you don't take any yourself these days. That tells you how usefull they are to the practicing clinician. Unless your searching for the dreaded subluxation, where's the efficacy? Emergent and traumatic cases still need to be seen in the ER; otherwise they are of little value.
Glasgow as far as the skills of interpreting plain film radiographs being central to the DPT,
I think not at all. It's an interesting side bar but doesn't make us one bit better at doing our job. We don't need to primarily order them; I can get one on a patient any time I want ( and have). We need to know when and why (see Ottawa knee,ankle, and foot rules, and Canadian C-spine rules). There are professionals who interpret these for a living, no need for us to dable beyond our own ego boost, and intelectual exercise.
Tim
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Re: Paris to offer t-DPT to DC's? - January 31, 2006 1:22:00 AM
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TMondale
Posts: 131
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From: Newton-Wellelsley Hospital
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Jeep,
Sorry I didn't see your message before I posted, but this is classic. What clinical correlation are you referring too? I can see ruling out fracture, disease, or traumatic injury dislocations ( again all preferably emergent medical services) but clinical correlation? Do insurance companies actually reimburse for this?
Tim
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Re: Paris to offer t-DPT to DC's? - January 31, 2006 1:54:00 AM
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Sebastian Asselbergs
Posts: 1206
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From: Barrie, Canada
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OK, I'll pipe up:
Since when is there an "ownership" of studying? If a person with a vested interest in an educational institution is wooing a specific group of practitioners -what's the big deal? It doesn't change what the students will have to demonstrate at their board exams - no matter what their background. I do not see DCs "flocking" to this programme - Paris might catch a few more, but DCs have ALWAYS had the option to take a DPT - this one may just give more credit to their DC coursework. Does not change the national exam standards. It may change some subluxationists' minds about what they're doing...LOL
_____________________________
Mundi vult decipi
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Re: Paris to offer t-DPT to DC's? - January 31, 2006 3:04:00 AM
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Jeep
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From: USA
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These are two studies I am aware of. Perhaps Buddy can add to the list.
de Zoete A, Assendelft WJ, Algra PR, Oberman WR, Vanderschueren GM, Bezemer PD.
Reliability and validity of lumbosacral spine radiograph reading by chiropractors, chiropractic radiologists, and medical radiologists.
Spine. 2002 Sep 1;27(17):1926-33; discussion 1933.
PMID: 12221360 [PubMed - indexed for MEDLINE]
Taylor JA, Clopton P, Bosch E, Miller KA, Marcelis S.
Interpretation of abnormal lumbosacral spine radiographs. A test comparing students, clinicians, radiology residents, and radiologists in medicine and chiropractic.
Spine. 1995 May 15;20(10):1147-53; discussion 1154.
PMID: 7638657 [PubMed - indexed for MEDLINE]
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Re: Paris to offer t-DPT to DC's? - January 31, 2006 4:22:00 AM
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Jeep
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From: USA
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[QUOTE] Interesting that you don't take any yourself these days. That tells you how usefull they are to the practicing clinician. [/QUOTE]I fail to understand your line of reasoning here.
[QUOTE] where's the efficacy? Emergent and traumatic cases still need to be seen in the ER; otherwise they are of little value. [/QUOTE]Are these the only indications you feel neccessitate/efficacious for imaging?
[QUOTE] There are professionals who interpret these for a living, no need for us to dable beyond our own ego boost, and intelectual exercise. [/QUOTE]Perhaps you are unaware---- but before the Wilk vs AMA ruling in the late 80s, MDs were prohibited and risked losing their license if they accepted a referral from a DC, took films for a DC, or read films for a DC. We were forced to do all aspects of our own radiology and subsequently got very good at it. Things are very different now. Why take our own films now, when imaging centers are competing for the DC market? and if such a center is convienient for service?
It had, and has, nothing to do with ego---- it's responsible patient standard of care and management.
[QUOTE] What clinical correlation are you referring too? [/QUOTE]History, consultation, special tests, P.A.R.T.S.
(P - pain/tenderness
A - asymmetry/alignment
R - range-of-motion abnormality
T - tone/texture/temperature of soft tissues
S - special tests (e.g. imaging and laboratory tests)
which is used to ascertain and arrive at E/M(evaluation/clinical impression/diagnosis/management) decisions.
[QUOTE] I can see ruling out fracture, disease, or traumatic injury dislocations ( again all preferably emergent medical services) but clinical correlation? [/QUOTE]Well, degenerative changes, congenital anomalies, any contraindications to treatment, prompting one form of treatment instead of another(a congenital or acquired unilateral segmental fusion eg. would definately factor into my treatment approach), incidental findings, unrelated to CC have been found, prompting a referral, which in turn saved the life of a patient.......to name a few.......
which need to be clinically correlated to the decision making which I addressed above.
[QUOTE] Do insurance companies actually reimburse for this? [/QUOTE]Yes, .......as they well should..... part of a "best practice" paradigm.
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Re: Paris to offer t-DPT to DC's? - January 31, 2006 5:30:00 AM
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drbuddy
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I order advanced imaging when I feel I need more information to make a diagnosis. There are plenty of guidelines out there that suggest when imaging should be done. I usually order imaging for trauma with moderate to severe pain or severely limited ROM, cases that do not respond well to an initial trial of care, any 'odd' pain (such as I found in a patient with a dissecting abdominal aorta), or radiation of pain into the flanks, groin, or extremities. For radiating pain, I started out waiting to see response to care, but then realized it is better to be safe than sorry. Sure, most of the time it is just a disc, but you never know when it is something like a tumor, collapsed vertebra from mets, aneurysm, cysts, etc.
I dont take radiographs myself because I do not have a xray machine in my office. It is not cost effective. I order xrays when I feel they are warranted. My patients usually just go to the local hospital to have that done. I also can order MRIs, CT scans, bone scans, and blood work if I think it is necessary. Other than radiographs and MRIs, I usually refer to their family MD and let them deal with it.
Jeep posted the study I was describing. Specifically, I think the one I read was the 1995 article.
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Re: Paris to offer t-DPT to DC's? - January 31, 2006 7:57:00 AM
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TMondale
Posts: 131
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From: Newton-Wellelsley Hospital
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Jeep,
Thanks for the referrences. As for your justification for plain films, I guess I would have to know how often you order them.
In terms of your clinical correlation if you are suggesting that plain films should play a regular role in your clinical decissions you gotta be kidding. You show anybody where there is support for this notion in any well done literature.
We do the same thing with the same patients and rarely ever require a plain film radiograph to correlate any findings or impressions outside of traumatic injuries, that yes should be referred to the appropriate allopathic or osteopathic medical services.
Tim
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Re: Paris to offer t-DPT to DC's? - January 31, 2006 8:28:00 AM
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UTDC
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Tim,
Maybe I could clarify part of this issue. If a...
1. 55 year old male walks into our office with a CC of insidious onset LBP and previous hx of colon CA.
2. 14 year old ballet dancer with new atraumatic onset of LBP.
3. 50 year old female with an apparent C6 radiculopathy.
4. Trauma as you mentioned.
5. Acute ankle pain meeting the Ottowa rules
etc, etc.
These are just a few things off the top of my head
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Re: Paris to offer t-DPT to DC's? - January 31, 2006 8:52:00 AM
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TMondale
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UT,
You wouldn't refer all of these to the appropriate medical services? Part of any best practice paradigm should involve this as refer on, just like it is for us.
No offense meant to any of the Chiro's in this regard.
By the way back to the original meaning of this post Dr. Paris, think of him what you might, and (I certainly have no inside knowledge of this particular venture) has the health and vitality of the PT profession foremost in his teachings and actions at all times. He has done a great deal for this profession and had a tremendous influence on countles therapists. He deserves the respect of all those who are fighting for a better professional accountability, and environment.
Tim
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Re: Paris to offer t-DPT to DC's? - January 31, 2006 8:58:00 AM
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KIDPT23
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PaulPT---nope!!
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Re: Paris to offer t-DPT to DC's? - January 31, 2006 9:21:00 AM
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UTDC
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Tim,
In most cases of this presentation, I would not refer. Let's review:
1. 55 year old male walks into our office with a CC of insidious onset LBP and previous hx of colon CA.
Are you of the opinion that every back pain patient with a hx of ca should be referred out? The PCP's in my area would string me up by my thumbs- or maybe they should go back to oncology??
2. 14 year old ballet dancer with new atraumatic onset of LBP.
Teenagers with back pain should be referred?
3. 50 year old female with an apparent C6 radiculopathy.
This is one of the most common presentations to a chiropractic office. I termed it a "apparent" radiculopathy. Who should this one go to? Neurosx? PM&R? In your opinion, this should happen without any imaging or EDX testing?
4. Trauma as you mentioned.
All trauma should be referred out immediately? The whiplash patients, the ankle sprains etc? etc?
5. Acute ankle pain meeting the Ottowa rules
We should refer out without an xray? Again, see #1 above.
I'm all for appropriate medical referral, the key word being appropriate. PCP's and specialists do not want to be flooded with cases such as this with no workup.
It apprears that I have failed in my attempt to clarify the issue- sorry.
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Re: Paris to offer t-DPT to DC's? - January 31, 2006 10:31:00 AM
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TMondale
Posts: 131
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From: Newton-Wellelsley Hospital
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UT,
Thanks for the tutorial; it's all clear now.
Just loooked at the referrences; your profession represented itself well in the lumbar spine.
My problem is not with your competence, but rather with your justification for plain films in more than just a fairly small number of cases that provide evidence that they are appropriate. Utilization, (no small issue these days) is more my problem with routine use of this diagnostic. Cost and exposure to radiation might be other pertinent issues.
We might have to agree to disagree on this one.
Tim
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Re: Paris to offer t-DPT to DC's? - January 31, 2006 10:51:00 AM
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Jeep
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From: USA
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Tim-
What part of PT do you work in at the Newton/Wellesly Hospital? How long? Always in the same dept? Have you always worked in a hospital? Is it in the USA?
Not being nosey, but it may provide some enlightenment/understanding as to your opinions on this issue for us.
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Re: Paris to offer t-DPT to DC's? - January 31, 2006 11:36:00 AM
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drbuddy
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Tim,
I agree, we need to watch the overutilization of expensive diag tests. In the past year, I've only referred about 10% of my patients for further imaging. I tend to see more chronic cases, so they've usually been through the gamut. Guess what though? Most MDs could care less about expense and utilization of imaging. Almost everyone I've seen with musculoskeletal pain has had some sort of imaging. Not sure if it's because it makes diagnosis easier, or if it is due to the high number of malpractice cases lately and rising malpractice premiums. Maybe they are just covering their asses.
For me if there is any doubt or something is fishy on the exam or in the history, I'll opt for having the test done.
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Re: Paris to offer t-DPT to DC's? - January 31, 2006 2:14:00 PM
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TMondale
Posts: 131
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From: Newton-Wellelsley Hospital
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Buddy,
Fully agree with your last post.
Jeep,
I see you live in the USA, bold of you to divulge so much about yourself. I'm in an acute care hospital, out patient department, but I've been lots of places. My perspective comes from wanting to provide the best posible services to my patients in the most efficient manner. I try to avoid and promote avoiding unnecessary interventions in all ways, to the extent I can control my part of that. I'm all for what's appropriate and necessary. Buddy sounds like he's got a good handle on things; Jeep you should read his posts.
Tim
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Re: Paris to offer t-DPT to DC's? - January 31, 2006 2:18:00 PM
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Jeep
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From: USA
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Funny Tim!!!!!
Buddy and I are on the same page, in case you haven't been paying attention.
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Re: Paris to offer t-DPT to DC's? - January 31, 2006 5:36:00 PM
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UTDC
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Hi Tim,
You state: [QUOTE] My problem is not with your competence, but rather with your justification for plain films in more than just a fairly small number of cases that provide evidence that they are appropriate. [/QUOTE]When you say "your competence" I assume that you are referring to the chiropractic profession, not me as an individual. If you have an issue with the examples I posed to you, I would be curious to hear your viewpoint.
With that being said...If your issue is the routine use of diagnostic imaging without a clinical rationale, I believe that we are in agreement.
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Re: Paris to offer t-DPT to DC's? - February 1, 2006 3:22:00 PM
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TMondale
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From: Newton-Wellelsley Hospital
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Buddy, Jeep and UT,
Keep up the good fight. Your profession needs you.
Tim
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