[QUOTE]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?[/QUOTE]I think the answer to part one of that (without trying to be facetious) is "yes." I don't think in that case the medical dx would be much different.
Joined: November 15, 2003
Diane I agree!!
As someone who has done PT 'diagnosis' for years, there is a difference. Often it is in our favour anyway - the medical diagnosis is 'arthritis' which is little more than a cop-out, and we might diagnose central sensitisation, (or peripheral) and get on with treating the process, not a structure. Tendonitis is another classic - the med diagnosis is 'torn this that or the other' or some inflammatory condition... and we find it is neural sensitivity or cervical in origin.
Another one is the prolapsed disc...OK, it may be that, but we still treat the process: reduce sensitivity, establish more normal movement patterns, etc etc.
I get scores of referrals for LBP - with all sorts of diagnoses. We can establish roughly, what is radicular, and dermatomal, non-dermatomal (classic chronic pain) and just plain weird. Red flags aside, the diagnosis does not matter much - we treat what we find in assessment.
Back in the 1980s, a senior PT in outpatients told us to ignore the diagnosis- and treat what we find. When it came to a shoulder inservice where we wanted to find a 'true' shoulder condition to workshop - we could not find any; despite about 14 patients currently under treatment for 'shoulder' signs, they were all referred pain from the neck.
So I have never taken much notice of musculoskeletal diagnoses from GPs/physicians; they just aren't familiar enough with interpreting signs. And that goes for some of the specialists as well.
in the end, a diagnosis in this basic field isn't important - the doctor (if they have seen one)has presumably ruled out red flags, and if the patients come straight to us, and flying a red flag - we send them on (or back)quicksmart.
The scariest example of a very wrong medical diagnosis came with a young bloke with quite severe shoulder pain. The medical diagnosis (from a specialist)was: thoracic outlet syndrome. One good look at this poor fellow told me 'uh-oh, something's seriously wrong here' and sent him to his GP. Diagnosis? Collapsed and desiccating C5 from lymphoma.
Yes, the overlap between physiotherapy diagnosis (in my correspondence I simply call it "my conclusion") and medical diagnosis is there, and most noticable in orthopaedic conditions. To add to Diane's and nari's examples of the differences: left shoulder pain was the medical diagnosis - my conclusion left C5 radiculopathy secondary to foraminal encroachment. Medical: groin pull - physio: sartorius strain. Does it matter to the issue of direct access? Not a whit. As professionals, our evaluation conclusions, diagnoses, findings, whatever, are core to our function and to our communication with the patient and doctor(s), not its "title".
It seems it would be a monstrous task to develop a uniform set of standards of practice and uniform system of self-monitoring (College/Board) for the US. However, it would seem important to at least try and move into the same direction to truly be recognised as a "profession", not a "paramedical technician".
Joined: May 11, 2004
Well, if a physical therapist can't medical diagnose (and I am confused as to the definition of those words), then technically, potentially in some states the reality is that the physical therapist really isn't practicing in a "direct access" manner. If calling a sprained ankle a sprained ankle is medical diagnosing... well, there appears to be a huge limitation for physical therapists in a lot of those states that don't allow medical diagnosing. In the states, apparently medical diagnosing is an issue.
[QUOTE]If calling a sprained ankle a sprained ankle is medical diagnosing... well, there appears to be a huge limitation for physical therapists in a lot of those states that don't allow medical diagnosing. In the states, apparently medical diagnosing is an issue. [/QUOTE]And therefore, (if I'm understanding you correctly), a situation where the MDs seem to have rigged it so the chains are hard to break.
Why should anyone expect PTs to be capable of making medical diagnoses, when PTs don't get medical training, or skirting around such diagnoses to make a sensible PT diagnosis and treat that instead, while sending in the medical Dx to get paid, then saying that PTs have to remain in chains because making medical diagnoses isn't allowed? Maybe I just don't get the big slavery picture...
Maybe all PTs in those states have to do is assert their professional right to make/provide a PT diagnosis and get on with having professional direct access.
Anyway, I say, get your organizations to tell the lawmakers that you can make PT diagnoses and that that's how you work according to your training and education, and request that they turn you loose to practice in your state with direct access.
Joined: January 31, 2005
I think that is purely a semantics issue in an attempt to maintain status quo.
I hear this all the time from patients: "She diagnosed me with..." "What's the diagnosis..." Most of these diagnostic labels are inaccurate and unimportant to the management of the condition. MDs are trained to find the part of the body that is broken, torn, cancerous, or infected. In the musculoskeletal world, that has little to do with how to treat people.
Our Orthopedic colleagues would have us treat every "labral tear" or "MCL sprain" the same, as they see the problem to be an anatomic one that of course always needs the same treatment (it's the same problem, right?) This is why they love "protocols" so much and why they like treating surgical pathology that they can debride or repair or fixate. And they are great at it.
But that's not the clinical reality for most patients, things present differently, and we need to, as Nari and others stated, treat what we see. Often these are issues and impairments not picked up by other providers. I don't even address the issue of who can "medically diagnose" since this is an irrelevant issue, in my opinion. Nari's example of back pain is excellent, and serves to reinforce the concept that looking for an anatomic problem to explain pain and movement problems is turning out to be mostly a fool's errand. I like to think I'm not a fool, so my assessment is only for the purposes of treating the patient and when appropriate, it's anatomy-specific for the purpose of communicating with other providers. Sometimes that means "MCL sprain" or "shoulder labral tear" and other times it's "ankle pain". I let the MD do what they gotta do, and I do what I gotta do.
Different missions, different approaches. Both good and necessary in their own way. J
Joined: February 14, 2003
From: Madison WI USA
All, Something to ponder. Are there any direct access states where the insurers actually recognize the direct access? I can tell you that in Wisconsin, to the best of my knowledge there is no recognition by those who pay the bills. To private practice out of pocket payers there is direct access. To the rest of us, there is not, unless we want to provide free care. So, if you dont have direct access yet, even when you do get it, its only a start.
Secondly, regarding the diagnosis issue, my understanding is that the PT diagnosis is what you actually intend to treat.
If you treat the pain, use that ICD9 code. If you treat the contracture, use that one. Ankle sprain? You arent treating the stretched out ligament, you are treating the joint instability this caused, so use the instability dx. LBP? You better stick with the LBP dx, as we really dont know if the HNP is responsible, or the spondy is responsible, or the DJD is responsible, etc. Its OK to be vague in our treatment diagnoses. More than one code is often used, which Im sure you all know.
It's frustrating to have to keep your diagnostic thinking in little code boxes that someone else dreamed up in order to get paid by some outside insurer.
As individual PTs I think our thinking and skills have space to advance when we achieve direct access with cash practice rather than with insurance coverage. As we all improve will our profession not advance?
After all the "structure" I've had to work within for lo, all these many years of practice, I'm most comfortable with cash practice, patient having direct access and paying me for my time, hands, thought and experience, patient is free to go after the insurers themselves for compensation, if they want to, and if they can get anything back.
On the receipts I write my payee/lisence number, the length of the appointment, what it cost, and that it was for "PT." (I don't specify a dx or what I treated or how. That is for my charts in case anyone wants to see it for some reason and they send me a patient-signed permission slip, e.g., patient's lawyer in an MVA situation.)
Joined: April 25, 2004
From: Amherst, WI
Hi Diane and our other Canadian friends,
I've heard about wait lists in Canada for non-emergency medical procedures that are reimbursed by your national health care. How quickly does someone have access to PT?
The reason I'm asking if there is a wait list is that scenairo may make a private practice more attractive and thus more likely to succeed. Here, most PT offices inconvenience their employees on a regular basis in order to claim to take people within 24-48 hours.
[QUOTE]I've heard about wait lists in Canada for non-emergency medical procedures that are reimbursed by your national health care. How quickly does someone have access to PT?[/QUOTE]I'm sure Sebastian has opinions on this and will add, meanwhile here's mine:
First a comment about the medical wait lists: I think the length and impact of these wait lists are exaggerated to gain political leverage by all sides. If you are about to die, you'll get seen medically and treated appropriately virtually all of the time. An exception might be organ transplant; Canada has a strict donor organs only policy. The rare mistakes that are made, e.g., a woman dying in a waiting room while no one noticed she was having a heart attack, are exceedingly rare, get huge publicity, are served up as cautionary tales to the medical profession to improve their already excellent care, and to try to prove that the system is inefficient by those who are constantly trying to erode it. I've always watched news reports about how emergency's are overloaded with a jaundiced eye; when I look behind the reporter at the supposedly overcrowded ER I can see no one, just empty beds, one or two people moving about in a leisurely way. Cognitive dissonance.
If the MD decides something can wait awhile, it waits.. it doesn't really matter except in the patient's mind, most of the time. So the patient's irritation is exploited by the media to make some sort of anti-medical system point. On the other hand, orthopaedic surgeries, hip replacements, that sort of thing, are often delayed quite awhile, and (im)patients go elsewhere to get their new hips. This has become a bit trendy..
Anyway, about PT, direct access for cash has meant personally that I'm not booked solid three weeks ahead. Instead I often have spots open. I insist on 24 hours cancellation notice or the patient has to pay anyway, full fee. Stops me and my time being misused. If someone calls with an emergency, car trouble, sick kid, etc, I use my discretion. Certainly if someone else calls and wants that freed up appointment slot, I will give the late caller a break. I'm usually booked up about three days. My receptionist keeps a wait list for people who call in with some alarming symptom they want seen for (usually pain), and once in awhile I'll overbook (see 7 patients in one day instead of 6) using my own discretion. Nobody ever died from a mere pain. I keep that in the forefront of my mind as I make my way through my life without burning out.
Generally I'd say that PTs are quite accessible here.
I am in full agreement with what Diane has said. Our social ilness care has created some roadblocks - mostly people EXPECTing immediate access to ANY medical service for ANY ailment - and for FREE. As diane says: if you're bleeding or having cardiac or other urgent issues and get in triage, it doesn't matter if you're the prime minister or Joe X, you get the treatment you need ASAP.
With regards to PT, I always have a spot here or there open the next day, tomorrow or the day after - and often I can skip a lunch if urgent. If my time gets fuller - I get a part-time PT whom I've worked with in the past to come a few hours in the other office in my clinic and take the overflow. BTW, our healthcare is NOT national by a long shot: the federal laws stipulating universal health care are national. Each province has its own variation in funding and levels of private enterprise involvement (In Quebec, a patient can get an MRI tomorrow for $600.00 - in Ontario, that is not allowed) - emergency and core health care is pretty closely regulated nationally though.
Joined: March 17, 2005
Alot going here and I haven't read every word. I am glad to see earlier in the thread my opinion is valued, so thank you. I also want to stress that I am 100% for PTs getting direct access and the DPT etc. So if I write anything that can be read as confrontational or taking a stance against direct access, its just in the writing, not in the sentiment.
My whole issue with increased responsibility and liability isnt so much from a medico-legal stand point (malpractice claims etc), but a personal question. Im asking you guys, do you as a person want that responsibilty? It adds a whole new dimension to your jobs. You will no longer be a "therapist." You will be a dignostician, maker of treatment plan, and therapist with no safety net. If you are too secure in your diagnostic abilities you miss something, if you arent secure enough, and you know its on your head, you will refer too many people away. Its not enough to know to refer to a patients GP. "Go see your GP" is a cop out. Even when refering out you have to be fairly certain of the dx or at least something high on your ddx. Otherwise you waste the patients time sending them to a GP and then having him send out again. Time is the difference between full recovery and permanant impairment. This is why medicine is set up with a gatekeeper(gp) who is the first line of defense and he/she directs the referals.
Along with direct access comes marketing your practice. This will move PT advertising out of referals from MD offices and into the Penny Saver, shopping malls, and health fairs along with the other guys. This is where things get a little "cheap." PT s have a nice reputation of good service and respectibility in the health care arena, do you want to risk that?
One more thing. About the medical vs physio dx. I have mentioned this to DCs too. Its not right to use the term MDs when talking about MDs. Its better to specify what type of MD you are talking about ie: ortho, neuro, GP, ER Doc, etc. Its not suprising to hear a dx of "low back pain" from a GP, but it probably doesnt happen when dealing with an ortho. It may make things a little clearer.
Chirx, [QUOTE]Im asking you guys, do you as a person want that responsibilty? It adds a whole new dimension to your jobs. You will no longer be a "therapist." You will be a dignostician, maker of treatment plan, and therapist with no safety net.[/QUOTE]1. This must be SUCH an American issue.. 2. Why wouldn't we take on responsibility? Especially when we look around and see massage therapists (who are still "therapists"..) with that "responsibility"...
[QUOTE]If you are too secure in your diagnostic abilities you miss something, if you arent secure enough, and you know its on your head, you will refer too many people away.[/QUOTE]3. The whole point of most of the page above, is that we and only we are the ones able to make "physiotherapy" or "physical therapy" diagnoses. Why do people try to make us feel insecure by making us think we have to make medical diagnoses without full medical training?
[QUOTE]Its not enough to know to refer to a patients GP. "Go see your GP" is a cop out. [/QUOTE]4. Why??? Why would that not be entirely appropriate?
[QUOTE] Even when refering out you have to be fairly certain of the dx or at least something high on your ddx. [/QUOTE]5. Of course. So what? We have high confidence that we can tell the difference between something that is an us problem and something that is a them problem. Remember, we are raised up beside medical practitioners and rub shoulders with them frequently in hospital.
[QUOTE]Otherwise you waste the patients time sending them to a GP and then having him send out again.[/QUOTE]6. So, we shouldn't have direct access because we might inconvenience some patient some day? I wonder how many times patients have been inconvenienced because they've had to go get a doctor's referral to even see a PT and obtain their opinion. About something that is clearly NMS.
[QUOTE]Time is the difference between full recovery and permanant impairment.[/QUOTE]7. Agreed! See point 6.
[QUOTE]This is why medicine is set up with a gatekeeper(gp) who is the first line of defense and he/she directs the referals. [/QUOTE]8. Not sure I follow why this means PT should be kept in the dungeon, while other health care types roam free.. Are we valuable live stock or something?
[QUOTE]Along with direct access comes marketing your practice. This will move PT advertising out of referals from MD offices and into the Penny Saver, shopping malls, and health fairs along with the other guys. This is where things get a little "cheap." PT s have a nice reputation of good service and respectibility in the health care arena, do you want to risk that?[/QUOTE]9. This makes me laugh. (I can almost see your discomfort of having been a DC poking through.) I never had to do anything remotely like this to make a healthy living. People out there are probably waiting with baited breath for the chance to see a PT without having to go and obtain a referral first.
10. Your last concern about how types of doctors should be recognized, that must also be a phenomenon culturally unique to the US. Here we still have family doctors, although they are getting a bit scarce. I don't concern myself about such propriety where I am.
Glad you are still, after all that, for rather than against PT having direct access.
Joined: November 15, 2003
Ditto to all your responses. I am having difficulty taking on board that fear of responsibility that Chrx has voiced. I guess it is a situation so unfamiliar here, as in Canada.
In the public health system, we have a three open spots a week for emergencies, and these do not occur often. So they are filled up the day before at c.o.b. with names off the waiting list.
It doesn't worry me at all, having a waiting list - it is amazing how often the receptionist, who rings some people who has been waiting four weeks, is told that they are fine - "don't need physiotherapy anymore".
Direct access (ie, the patient decides to see a PT and not bother about the doctor) is what we need as a profession; without that, there is no point in being called a profession - which I define roughly as the ability to set up a solo practice after appropriate university training. Nurses go to university but cannot set up a solo practice as a nurse; so they tend to merge into the 'alternative' field.
Thanks Nari, The whole argument against PTs having direct access anywhere where we still don't always strikes me as paternalistic, and I'm finding the arguments are getting a bit stale. They remind me of:
1. Are you sure you want to be exposed to life without a protective Burgha? (not sure of the spelling.) Think how much more honor you can maintain for the entire culture by continuing to wear one.
2. Yes you are old enough to drive, but I'm worried about handing you the keys. I'm afraid you'll kill yourself. So you'll have to go through life with just your learner's lisence.
3. Now, why would women want to learn to read? Go to school? What for? You'll get married and have children anyway, so any education bestowed on women is a waste of time and money.
4. Now, why would you little ladies want to have a vote? It's a man's world out there, and politics are messy.. would hate to see what would happen if the ladies get involved..
5. What do PTs want direct access for? They have a good enough life working under referral. And they don't have to take on the same responsibility practitioners with direct access have to take.
I thought plumping up the profession with men would put an end to this sort of stuff, guess I was wrong.
Joined: March 17, 2005
[QUOTE]1. This must be SUCH an American issue.. 2. Why wouldn't we take on responsibility? Especially when we look around and see massage therapists (who are still "therapists"..) with that "responsibility"...[/QUOTE]1.Im American, I guess I dont if its an issue. 2.Masage therapy are seen as a luxory item or a novelty. They are not held in the esteem that PTs are, at least not in the States. I would hope you do want the responsibility, I asked if you do. I didnt ask why you do.
[QUOTE]3. The whole point of most of the page above, is that we and only we are the ones able to make "physiotherapy" or "physical therapy" diagnoses. Why do people try to make us feel insecure by making us think we have to make medical diagnoses without full medical training?[/QUOTE]3. What is a medical diagnosis and what is a physiotherapy diagnosis? A dignosis is a diagnosis. My point was a diganosis of a NMS condition can be wrong if the NMS complaints are a symptom of underlying visceral dz or cns path. Nobody is making you feel insecure. But if you see a patient of the street and you dx them xyz but they really have abc then you are responsible. Front line medicine is best left to internists.
[QUOTE]5. Of course. So what? We have high confidence that we can tell the difference between something that is an us problem and something that is a them problem. Remember, we are raised up beside medical practitioners and rub shoulders with them frequently in hospital.[/QUOTE]Us and them problems? There are many kinds of "them." Which one of them are you sending to? I know you well trained. But will you know to refer to a cardiologist, nephrologist, GI, or hem-onc? Thats what Im asking. In the States you dont have to go to the GP first if your insurance will allow it. Its up to the first guy the patient sees to make the appropriate referal.
[QUOTE]So, we shouldn't have direct access because we might inconvenience some patient some day? [/QUOTE]No, you should have direct access.
[QUOTE]10. Your last concern about how types of doctors should be recognized, that must also be a phenomenon culturally unique to the US. Here we still have family doctors, although they are getting a bit scarce. I don't concern myself about such propriety where I am.[/QUOTE]Its has nothing to do with respect or title. There are many subspeacilties of medicine. Some with no NMS experience and others with a concentration in NMS dz. So when saying "MD" it doesnt it relate the type of MD and therefore the experience that MD has with NMS complaints.
You got big chip on your shoulder for some reason. Sorry if I pointed out some issues that you are sensitive about. Again, Im all for you guys doing this. I guess you arent to good with people who are on you your side that may think a little differently.
Joined: May 11, 2004
You know, if we were to actually really and truly come up with a plan that was truly direct access oriented, technically, the only way to come up with an all encompassing solution would be through what Stephen Covey refers to as the Third Alternative in his book the 8th Habit From Effectiveness to Greatness. The best solution to any argument comes from actually listening to what someone is trying to convey... actively communicating what was said to convey some level of understanding of the other view. (And that is a two way street). And then... to come up with a creative solution that meets both party's views. Taking a tactical approach that belittles someone's concerns and questions is not going to end in both parties being proud of the outcome.
Chirx, Jon and I have brought up some valid concerns/points. I don't know, but generally well thought out plans and consideration of "what if" situations put into a policy can help the policy be a better, stronger policy than no behind the scenes thinking. I think this is a great topic to be having a dialog and some interesting points have been made, but the current direction that the dialog is headed isn't going to really accomplish anything beneficial.
Hi Chirx, Most of the points you raised in your last post have been spoken to already, higher in the thread. [QUOTE]You got big chip on your shoulder for some reason. Sorry if I pointed out some issues that you are sensitive about. Again, Im all for you guys doing this. I guess you arent to good with people who are on you your side that may think a little differently. [/QUOTE]Apologies if I came off sounding peevish. I better bow out of this conversation, because: 1. I'm truly baffled about resistance to the idea of PTs having direct access when it's a fact of life in many other countries including my own. So I find myself irritated, for no good reason at that, as it's not even my issue. 2. It's not my country. (I feel like it's me who lives in the land of the free and the home of the brave as far as direct access is concerned...) 3. I don't understand what the fuss is about or why there is "respect" for PT but only as long as PTs remain slaves within a treatment culture that makes them not able to work for themselves. When in 39 states in the same country, they can leave the "system" and have a nice relaxed solo practice if they want.
Chirx: "Im asking you guys, do you as a person want that responsibilty? It adds a whole new dimension to your jobs."
It did. But not much. We have always been responsible for what we did - even before D/A. There was never a "hide behind-the-doctor option" - we were still considered ethically and legally to be responsible for what we did with the patient. So there is only a difference in accessibility.
"You will no longer be a "therapist." You will be a dignostician, maker of treatment plan, and therapist with no safety net."
Always were. D/A did not change that. We have always been held responsible for our assess/treat.
"If you are too secure in your diagnostic abilities you miss something, if you arent secure enough, and you know its on your head, you will refer too many people away."
This is not really an argument that holds water in a general issue such as D/A. This reflects on individual application of knowledge and standards. This statement can be made in slightly different formats about any practitioner. With the general lack of eval skills of musculoskeletal/neuro of the family doc, with the often poor eval skills for spines and necks of orthopods, many patients did not get properly referred. We can be a good filter - and are.
"Its not enough to know to refer to a patients GP. "Go see your GP" is a cop out."
Absolutely true. When we send someone back, we should always indicate why. What doesn't add up, what the worries/yellow flags are - and why.
"Even when refering out you have to be fairly certain of the dx or at least something high on your ddx. Otherwise you waste the patients time sending them to a GP and then having him send out again."
See previous answer. And I am a bit baffled by the basis of this item. WHY would anyone send a patient back UNLESS they have an issue with the condition? There are many times when we had to be the patient's advocate, and GOT the MRI or CT or bone-scan or whatever test confirming what we worried about in the first place.
"Time is the difference between full recovery and permanant impairment. This is why medicine is set up with a gatekeeper(gp) who is the first line of defense and he/she directs the referals."
I am not completely in agreement with the rather strong statement about "Time is the difference...". There are many factors playing a role towards permanent impairment. But anyhow, the timelag between needing and getting an actual doctor's visit and the referral to PT is an issue of often more than three or four days - in some areas in Ontario, weeks. Which is exactly what you indicate as an important factor in rehab. Furthermore, see the previous reply about having to be an advocate at times to actually "open the gate" for a patient.
Having seen the struggle for some of the older PTs in the late 80s and early 90s here with the whole concept of D/A, I can understand the reluctance for accepting this change in the situation in some of the states. It IS a paradigm-shift (there's a 90s word!) for those who have grown up in the 'paramedical" status of PT. That's why you won't see me yell here. It does take time, but there are not as many sharks in this direct access ocean as many may think.
Insurances are not all askin g for a doctors note either. And those that do, will accept a doctor's referral dated after the first PT visit. This allows continuity with treatment while satisfying the patient's insurance requirements. (For me, it doesn't matter - they pay me; how they get their refund/repay is not a huge issue). Not having a referral is never a reason for not seeing a patient here.
I can not think of anything else that I can add to this subject right now, AND I am contributing to huge download times for those with dial-up (sorry!)... Ciao Sebastian