Can a PT diagnose and treat a patient without an MD?

[maxplanck]

Can a PT diagnose and treat a patient without the patient first being examined and diagnosed by an MD?

Say, for example, that a patient has back pain. Can a PT diagnose and treat the patient's back pain (assuming that the PT's diagnosis indicates that physical therapy is an appropriate treatment) without the patient first being examined/diagnosed by an MD?

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[DancerFutureDPT]

Yes and no.

I wouldn't say they ever diagnose. My PTs have diagnosed me correctly, but it still required an MD for confirmation. They can't diagnose, but they can highly suggest that this is probably what the diagnosis is, and then send to an MD/DO for confirmation. PTs cannot (as far as I know) order MRIs, Xrays, or CTs, which a lot of the time is required to properly diagnose a patient. My PT could tell I had tendonitis in my FHL, but the MRI showed not only that, but also tenosynovitis of the FHL, plus 3 other tendons that hadn't yet showed symptoms. I wish I could see a PT without a prescription though, because my tendonitis acts up a lot and I hate having to call MDs to get a prescription. Fortunately now I've worked at a clinic long enough that I can in essence treat myself (do the exercises I did in PT, ultrasound myself on my lunch break, talk a PT into helping release tight muscles/tendons), and I know MDs well enough who will fax me a prescription if I need one since I've seen them millions of times. It's still annoying though. lol

In the case you described, the PT would probably send the patient to an MD anyway, just to make sure it's not something else disguising the problem. How much would it suck to treat a patient for back pain only to find out they really had 3 herniated discs that needed surgery, or a problem with their kidneys that the patient thought was muscular. These are extreme circumstances, but not totally impossible. (Although PT wouldn't do much good in this case, so it would get figured out sooner or later).

In some states PTs can see patients without having an MD referral/prescription ("direct access" states). It is my understanding that in these states people can go to PT like they would any other doctor. I'm not totally clear how that works with insurance - I'm guessing they still cover it, and that the PTs give a more generic diagnosis code (like back pain, tendonitis etc.), as opposed to the super specific ones a patient might get if they see an MD for a diagnosis. However I believe insurance companies can deny the claim if they don't think it's medically necessary, in which case an MD diagnosis can help support the necessity of the PT.

 

[truthseeker]

The route a patient takes to get to PT depends first upon the state practice act where the PT practices. If they allow direct access, the patient can come directly to PT. Their insurance company may or may not pay for PT without a referral.

The irony of the referral language in most state practice acts that don't allow direct access is that they accept referrals from dentists, chiropractors, nurse practitioners, and PAs as well as MD/DOs. Few of them have anything near the orthopedic training we have and are ill qualified to tell us, in most cases, if PT is appropriate or what our plan of care should be.

The referrals I get are almost always accompanied by a very vague or even absent actual diagnosis. e.g. "shoulder", or "back pain", or "knee pain" so I would say that my assessment determines the ICD-9 code that is used for billing purposes and therefore, yes, PTs do in some cases diagnose.

FYI

dancer, MRIs (and CTs and Xrays) are lousy predictors of the pain generator. Take 1000 people with no complaints of back pain and do MRIs on their backs and you will find 35% of them have diagnosable "problems". If you took an MRI of an anonymous person, you would not be able to predict first, if they have a problem or not. Look up some of the work by Nachemson.

 

[MinnDasota]

dancer,

truth is right. Depends on the state. We are taught to diagnose musculoskeletal and certain other issues based on history and physical exam and to look for red flags when PT is not warranted. MRIs, Xrays, and other tests are not always specific or sensitive for correct pathology. For the most part, MDs should only order these if they think positive or negative findings will change their course of treatment. There are exceptions to this of course.

We have direct access in both states that I practice in and those patients that choose to come see me first usually come in with classical musculoskeletal issues. There are limits to how long we can treat without a referral though. In Connecticut, we can treat for 6 visits or one month and in NY we can treat for 10 visits or one month (whichever comes first). Medicare/workers comp do not allow direct access at this time.

 

[MotionDoc]

http://www.eclipsconsult.com/eclips/article/Orthopedics/S0276-1092(08)70318-3

Physical Therapists make physical therapy diagnoses that revolve around physical impairments that cause movement dysfunction. MDs make medical diagnoses and treat on the cellular level.

For a PT to make a medical diagnosis (cancer, for example) is ludicrous because he/she does not have the necessary medical training, but that does not mean that a PT cannot notice "red flags" that indicate cancer. On the flip side, for an MD to try and make a PT diagnosis is also ludicrous (but mind-bogglingly accepted in some areas) even though many GPs have 2 or 3 lectures on MSK injury and treatment, and the literature shows (like TruthSeeker pointed out) that they are unable to accurately diagnosis MSK issues.

The role of MDs in Physical Therapy is to screen for underlying medical conditions that can present as MSK injury. For example, early stages of herpes zoster can present as radicular symptoms...in a situation like this, a PT must know and be able to recognize the warning signs, and then refer the patient out to his MD.

 

[maxplanck]

Thanks very much!!