Joined: March 17, 2005
All right then. The outpatient PT practice is a lot more dx and mngt then I thought. Is it this way in the states? So now we have PMR docs, PTs, Internist w/ sports med fellowship, and DCs all fighting for the Musculo-skeletal practice. It should be interesting to see what happens. Lucky for Im covered Im 2 out of 4 of those:)
Joined: January 31, 2005
OK, let's redirect this thing. This reminds me of the manipulation discussion earlier...people who generally agree only focusing on the details where they don't.
Chirx, I think you have very valid concerns, and I appreciate you bringing them up. They are important questions. I won't speak for Diane, but it may be that the nerves are a little exposed overall, especially after being held in the role we have been in for so long. You are a friendly and supportive messenger carrying concerns that are usually veiled in threats and aggressively restrictive legislation by others, not clothed in the friendly dialogue you present. Perhaps that may be at the root of why the debate is getting heated.
I fully understand your concerns, chirx. I see people direct access, and like most PTs, my radar is probably unnecessarily sharp for non-NMS problems in others, and I probably communicate to patient's family doctors and send patients to see their family doctor concurrently more than I need to. I think that is as much about courtesy as about confidence.
When you say the only person that should be doing front line medicine is internists, surely you include family practice or emergency people (with 3+ years residency and board certification) in that group as well? We should keep in mind here, that there are a lot of people giving medical advice and recommendations who are not physicians.
And not just other health care people. LMTs, personal trainers, sports coaches, and even Uncle Morty are doing that for people they know. And it comes out just fine. I'm not saying that's the optimal situation, but it is what it is. I think physicians get their feathers ruffled when they find out that they aren't the only medical game in town and that sensible health and medical advice can be provided by others. Just as PTs get their feathers ruffled when they find out that personal trainers, ATCs, and strength coaches are doing rehabilitation, and we PTs find out that sensible fitness, health and rehab advice can be given by others. "But that's my job!" is always the protest. "They're not trained as well!" goes the saying. Now, this is aimed at all of us medical people.
Do I need to be an electrical engineer to put in a ceiling fan? Do I need to be an electrical engineer to know what basic household wiring I can advise on, and what wiring needs to be addressed by an electrician? Of course not. The argument goes, "nobody ever died from putting in a ceiling fan." That's true. But who's got the issues with malpractice here? PTs? LMTs? Personal Trainers? Podiatrists? Dentists? No. Physicians do. That's because everyone in our country(even Uncle Morty) is exceedingly good at getting people with life and death stuff to the right person, the appropriate MD specialist for treatment or the appropriate primary care MD for triage.
I make this point just to get across that all of us may be taking ourselves too seriously when it comes to how key our services are.
When you are sick, you go to your family doctor. When a patient has a medical issue i'm unsure is NMS, that's who I recommend. I can recognize Orthopedic emergencies when I see them, and get those to the surgeon. I can recognize medical emergencies and call an ambulance. But I neither want nor ask to be a gatekeeper for medical care, therefore the ultimate destination for that patient, after his visit with the family physician, is not up to me. If I'm a dermatologist, I can see people off the street, and while I would have training as a physician (years ago), you wouldn't want me doing anything but referring to the family physician for non-skin problems, right? He/she neither wants nor needs to be an ER or Family practice doc. Of course, dermatologists can recognize a medical emergency and refer appropriately (but can't EMTs also?). Other than that, they go to their GP. So I really don't see the recommendation to visit the GP as a cop-out. Certainly everyone else in the world does it.
Years ago before joining the military, I was a trainer for my little brother's soccer team. While traveling in Europe, one of the other kid's dads, a GYN guy, ran onto the field when a kid got hurt. You should have seen his attempt at exam, he immediately tried to rule out the medical emergency, and then recommended the kid visit a family or emergency doctor. Was he copping out, too? What about his responsibility? It's the same with PTs.
Think about all the DCs out there from straight schools, who don't even have any medical training at all. While their malpractice rates are higher than PTs, they certainly enjoy full access to patients and payers... Does that make any sense given your concerns?
So this is the kind of the environment I see out there, and I see PTs being very competent to jump out there (as they are already doing in many, many other places) and start helping people. What do you think? J
Joined: January 31, 2005
chirx, you're right, there is a lot of competition. But I think we are cheaper than many(if not all) of those providers, and have a wider array of skills and things to offer for the majority of patients. That's why we will survive and thrive, if the market is fair.
In the military, the Ortho guys don't want to see something unless they can inject or cut on it. That makes sense, that's what's they're trained for. They are happy to get our referrals. They neither are trained to nor want to do rehab. They like that the rehab trial has already failed and they can get right on with the further diagnosis and management of it.
The PMR or pain people want to try the invasive/pharma stuff they know, like ESIs and opiates, nerve blocks, etc. They neither are trained nor want to do rehab, as they get paid A LOT more than us in large part because of the higher risk of their procedures. They like that the patient has had a rather comprehensive rehab and manipulation trail and is ready for the next level of care, the stuff they like to do.
The sports med people like our referrals, because they get a chance to do what they like: determination of further referral, management at their level, and one more PT referral they don't have to write. They have enough on their hands managing medical issues with their athletes, and are neither trained nor want to do rehab.
The DCs are outside the medical model (for good reason, and by preference of many of the practitioners) and are conservative spinal specialists. They don't do anything a good PT can't (as far as actual treatment interventions of value) and they are neither trained nor most of them want to do rehab. Very few of them are trained to and like doing that, and they should be free to do so. But the vast majority of DCs I've met or talked to rather enjoy their role, from what I can see. Just as PTs enjoy ours.
So you see I think we provide a service that no one else does anywhere near as well as we do. In terms of standards of practice, education, and research. And I think we fit well into the medical model with our MD colleagues also. I'm not worried about my job. Just as i'm sure you're not either. :) J
Good morning, I'm in a better mood now. (Sorry for the previously cranky tone SJ and Chirx. Thank you Jason and Sebastian for taking up slack and letting me go away to recuperate. Drew, I hope you update your 12-step program for PT direct access sometime soon.)
Maybe someone can tell me exactly what this "medical diagnosis" obstruction to direct access for PT is all about? I never heard of such a thing. I hope that doesn't infer that all PTs have to go get a DPT to be able to have direct access. That is so arbitrary and unnecessary.
Joined: March 17, 2005
You guys are all correct in everything you say. Everyday I get even more distanced from Chiropractic so please dont think I have an allegence to the DCs. I think by leaving chiropractic and going for 4 more years of school plus 3+ years of residence should tell you Im dedicated to the health care arena and my future patients. I really want nothing more then good collabrative relationships with people who can do better for my patients then I can and vice versa. I think its what we all want. I hope its what we all want. The concerns I posted have nothing to do with me or my career. I dont gain or lose anything regarding PTs advancements. The concerns were put up for you guys to think about. And you all thought them through. That was what I was hoping to do. No one did this for me when I was going to chiro school and I wish someone had. If I helped shed some new light on an old topic for someone then Im glad I was able to help. At the very least I learned a world of info about the ins and outs PT politics, so thank you!!
Joined: November 16, 2001
Interesting topic and quite timely. I attended a rehab seminar over the past weekend presented by 2 PTs. Very well done and informative. One PT was from Southern California the other was from Chicago. Both are respected members of your profession and have published in peer-reviewed journals. Neither are DPTs.
I asked each PT seperately about direct access and about DPT status. First, both thought the DPT was a bad idea and for the same reason; neither wanted the increased liability/responsibility that they felt the DPT brought or will bring. Second, though both felt direct access was a good thing, neither personally would treat a patient without referral from a physician. Again this was due to liability issues that neither were willing to accept.
I don't have a point (except maybe this is more of an American issue), just sharing the observations of two well known PTs.
jbeneciuk: in Florida, yes it is legal. See my previous post, I think on page one, it all comes down to the details of the PT vs. Chiro practice acts and legality is dependent on the wording of these acts in each state, sad but true, NOW..
Wisecracker: The only PT's I know who are against the professions move to the DPT are those that don't have one and don't want to spend the time and money to get one. Any talk of concerns about increased liability and responsibility is just a cop out in my opinion. As for direct access-many of us have these privleges already (39 states) and many of us see direct access patients either with reimbursement by insurance, self pay or in the military, where is the evidence that there is increased risk and liability? There is none! Anyone who thinks the physician referral for "back pain" which can often be procured with a phone call releases you from liability if you screw up and say burn somebody who has sensory deficits with a hot pack (which last I checked was the most likely PT procedure to result in a lawsuit) is sadly mistaken! Truth is if we are acting as professionals, we are ALREADY responsible! Rick
There seems to be some worry that PT's won't be able to spot red flags and deal with problems outside the scope of their practice. However, you already do this, in every clinic I have been in it is very common to find issues that are not NMS and refer them to physicians. I think there is a misconception that the patient population will change and EVERYONE will come to PT first to be diagnosed. The experiences of those practicing with Direct Access contradict this. It is unlikely that they see more red flagged patients than other PT's. This fear seems to exist more in the minds of people than in actuality. It is like swimming, swimming in shallow water isn't as scary as swimming in deep water but if it's over your head it doesn't really make any difference.
Some believe that their peers aren't capable of making good judgements regarding referring out patients. If they aren't competent in this with Direct Access then they aren't competent without it. It is a separate issue that may need to be addressed.
As to the "respect" of doctors and the medical community. I have to agree with Diane. The Taliban was full of respect for women and argued that Westerners had no respect for women. Doctor's respect for PT's is similar, they respect them if they "know their place." Personally, I think you could do with less of this type of respect and have a little more competition and disagreement.
I think the DPT issue is making the DA issue more confusing. Most of the DPT proponents see themselves as acting similar to doctors, with a strong background in differential diagnosis, imaging and pharmacology. I think this should be the future of PT, but NONE of it is necessary for DA. There is no requirement to be able to diagnose problems outside of your scope of practice, simply to be able to identify them and refer them out. I think your argument as a profession would be much stronger if you speak with one voice regarding this and say DA doesn't require the knowledge and skills of a DPT, only DPT expands the scope of practice.
My wife works in an OP rehab. facility with a wellness center attached. She employs a massage therapist and personal trainers. A "client" can come in with a problem, get soft tissue mobilization from a MT and exercise prescription from a trainer but the most qualified person there, the PT, can't even see them unless they are a "patient" with a prescription, she also can ONLY treat what is on the prescription. It is ludicrous things such as this that makes me wonder why any PT opposes DA.
I agree that PT's need to speak with one voice, and I agree with Rick in that the only PT's against the DPT's are those who don't have or want one --- and more importantly, don't want to ever take responsibility for that choice should it turn out to be a bad one should it ever prove to be an obstacle to their own professional opportunities. As such, a well known guru working the continuing education circut will be at a competative disadvantage if they DON'T get one. The wise ones, Kevin Wilk, PT, DPT; Andy Guccione, PT, DPT, PhD; and (I think) Gary Grey, PT among them, are leading by example --- just in case.
Again, I agree that PT's need to speak with one voice, as I fear that we're on the verge of a mixer/straight type of split within OUR profession over the DPT and Direct Access/Direct Reimbursement issue --- despite the fact that the discussion over the merits and risks of each, in my opinion anyway, are long over. Where I would disagree, however, is with the idea that the DPT enjoys, or should enjoy, a greater scope of practice. I think what Randy means, is that NO PT works their scope of practice fully, and that the DPT may allow a fuller utilization of practice scope via the potential for greater scope of expertise, in specific areas (e.g. diff dx, imaging, etc.) than most BSPT's and MPT's. Is that about right?
Andrew M. Ball, PT, DPT, Ph.D. Orthopedic Physical Therapy Resident Carolinas Rehabilitation
Randy, [QUOTE]My wife works in an OP rehab. facility with a wellness center attached. She employs a massage therapist and personal trainers. A "client" can come in with a problem, get soft tissue mobilization from a MT and exercise prescription from a trainer but the most qualified person there, the PT, can't even see them unless they are a "patient" with a prescription, she also can ONLY treat what is on the prescription. It is ludicrous things such as this that makes me wonder why any PT opposes DA. [/QUOTE]You're right, that is ludicrous.
Joined: March 21, 2005
Would it be correct to assume that if a PT is also a massage therapist and a personal trainer they could open up a clinic and provide "rehab services" without any worry about DA laws? And all reimbursement would be fee for service? I think I have found a new niche for myself. I'm halfway there with my CSCS. The only benefit to having a PT degree is to be able to "iron" patients with US and provide e-stim, of course, with the almighty MD or DC's permission. Honestly, the last paragraph in Randy's post really has me PO'ed.
Zack, I think you'd have to give up the right to practice e-stim and ironing (oops I mean ultrasound..), unless you got DC certification of course, then you could say you were offering PT modalities. :rolleyes:
Joined: January 31, 2005
Zack, you are right to be justifiably upset. And Randy is right on with how he describes the situation. This is an issue that will take probably several generations to "iron out", and we are now only in the very first stages of the evolution of our health care system. So be of good cheer, knowing that you can provider better quality services for the money than anyone else, and that our continuing standards of practice, education, and research will only help us continue to outstrip our competition in the health care marketplace. We will continue to develop healthly collaborative relationships with physicians and establish the efficacy and cost-effectiveness of our care. You can laugh and tell your kids what it was like back in the stone ages, when you needed a slip of paper and documented long term goals to even touch a patient. :)
Joined: June 8, 2005
From: Atlanta, GA
I attended masters level courses alongside PT, SA, and those in other highly competitive programs...I was just taking elective classes for my Biology degree and wanted to learn more about Human Physiology and Biomechanics and so I took Advanced Anatomy, Neuroanatomy, Neurophys., and Pathophysiology. The PT classmates were the most dedicated and scored the highest on the exams because the program was so stringent on accepting and retaining students that only the best got in and even fewer stayed. The numbers were like 75 a semester out of a few thousand applicants?? I could be off but the number of openings compared to applicants was extremely small.
So, if the basic PT degree was so hard to begin with, and believe me I saw the tears and broken marriages of my PT classmates. Why would anyone deny them PCP status? I don't get it. They even encouraged me not to formally apply after I finished my BS degree because it was so grueling. So I know they can see the red flags and provide comprehensive care just as well as any other practitioner out there. I decided to do an MD/PHD and focus on Reproductive Endo. It seemed easier than the PT route!!
When the long lonely lab research got to me finally, I abandoned my stipend, my silly lab students, and my charming professors who traveled the Ukraine while I crunched the numbers of their reproductive defect surveys from the Chernobyl first and second generations. And what did I do?? I went to chiro. school, on a whim, to see if the biomechanical, PCP diagnostic enviroment with a responsibility to meet the needs of those who sought a last resort would be any fun.
School was horrifyingly rudimentary, but I saw many professors who managed to pull the good things about the profession up above the mire and conduct and follow the research and use sound reasoning and patient care protocols to effect excellent outcomes in their practices.
Now I have a practice where I speak to a primary care MD almost weekly to discuss any cross referrals and update our notes. He asks me to order blood work and sometimes I ask him to shoot a film if I think I need it.(I am scared of x-rays in my office) We deal with a lot of uninsured people who are loath to seek proper care. So I work the chiro, nutritional, supplement, lifestyle end of things for these patients and he takes care of the things I cannot; and we use each other's guidance to choose a proper course of referral in difficult cases.
Many patients come in to my office, which is a holistic health center also, and haven't seen a doctor in 10 years and want to order a complete blood panel. We offer the blood chemistry to help pinpoint patients needs or minor imbalances in regards to nutrition and supplementation, but the test also serves as a basic medical screening tool.
They find us to be sweet and accessible I guess, and would rather ask me or the other girls when they happen upon us, as they are visiting our retail store if we can help them improve their health, etc. I have a hard time because I often want patients to have a neuro opinion and MRI, or abdominal or pelvic CT to rule out certain things during a course of treatment, but they are very reluctant in some ways and it is frustrating when they expect that I can be responsible for all their health needs.
Also, I wish I could refer to PT's, I have no way of knowing if I truly can and all the PT/OT visits a patient may have with BCBS are wasted because the ins. won't re-imburse if they just walk in to you, or someone like me refers them. Many patients seem to have a strange and irrational fear of getting dismissed/prescribed by a specialist or MD of whatever sort, and I can't quite understand their stubborness.
I work with great doctors and practitioners of all types and usually cooperation is the rule not the exception. I talk to my mom's DC, Acupuncturist, Internist, and Orthopod long distance all the time lately over her bad knee and finally decided to send her to try prolotherapy. All of her docs were gunning for arthroscopic surgery followed by ultimate knee replacement later. None had heard of the prolo.,and after explaining it only the internist thought it was a good idea. But all had excellent arguments for their prescribed course of action and operated at the utmost level for their specialty, she just opted for a totally different road.
The combined opinions and expertise of these doctors all who dealt with NMS issues in varied ways was priceless and totally important for determining the best course of action. At alll times they were respectful, engaging and helpful and somewhat delighted/amused to learn that I would get my mom so involved in her own care plan.
So PT, DC, MD Specialty, and all other sorts of healthcare profesionals are absolutely needed to fulfill their specific role and as a collaborative force in a healthcare arsenal available to patients. I don't see myself and a PT as mutually exclusive and neither do half of the insurance companies I bill with. If I use my activator to release a stubborn trigger point so an adjustment/manipulation of the shoulder is easier on me and the patient...I hardly equate that to what you do. And my billing codes reflect as much. Rehab, exercise prescriptions, and detailed focused functional exams and treatment should probably be arranged by in part by a PT and in part by chiro with each functioning in different capacity, but collaborating where needed. In my experience, that is how it often happens anyway.
I hope you do become direct acess or portal of entry providers,it would ease the burden and provide patients with more opportunities to choose their own care.
Plus, I sure don't want to do a bunch of un-reimbursed "same segments" myofascial work with my ailing chiropractic wrists just to help my ligamentous manipulations hold better when you can do it better, faster, safer, and most likely get paid by the ins. company without affecting the chiro. benefits.
Sorry this was long but I had a lot to get off my chest!
Just my opinion...hope it was helpful or at least mildly enlightening.
Joined: April 6, 2004
From: San Antonio, Tx., USA
Randy, first sentence, third paragraph. I agree, I feel that tone coming through here. Everyone's entitled to their opinion, and I'm allowed to disagree, which I do. Initially with the DA and DPT I argued for a clinical doctorate as a prerequisite for DA, with grandfathering for current licensed PT because I thought it would be oriented to improved PT diagnostic and treatment knowledge and skills. Now that I know more about the DPT curriculum, I no longer hold that opinion. My addendum to your sentence about the competence of referrals with and without direct access, would be that I don't think the DPT would make referrals any less or MORE likely to happen, but perhaps more likely to be fewer false positives, in other words, perhaps more referrals that result in positive medical findings. Personally, if I have erred, on the side of caution, then so be it, just because I haven't a DPT diff. dx. screening course. I suspect, but can't prove, that I would still refer or communicate to physicians the same as I do now.
Joined: January 31, 2005
Thanks for inquiring within. I think many of us can get along just fine, but there are true issues between our professions that will always be there. I will still judge each pracitioner individually and not by the letters after their name, but I truly think the most important thing is a level playing field in terms of access and reimbursement and just decide to let each other do our own things. Namaste... Jason.