Midlevel encroachment on PAIN

[docsleeper]

This affects you guys going into pain drastically also. Please get involved.
Please use the link to write to CMS. It is provided by the American Society of Anesthesiologists. It takes 5min. Just cut and paste.


http://www.asahq.org/For-Members/Adv...-Medicine.aspx


Add some of your own words to it too and let them know how dangerous and ridiculous it is.

---

Members don't see this ad.

 

[MedBronc23]

I also got an email about this from Pain Council for AAPMR today. Hot topic, and we pain physiatrists and those interested in interventional pain in our practices need to fight this tooth and nail. For patient safety and the for all the hard work many of us have put in not only learning procedures but obtaining the medical knowledge to be pain physicians.

Dont get DoctorJay started on this

 

[physasst]

I don't understand the issue here. If you are arguing that CRNA's should not see pain patients, I agree, as this is not in their scope of training.

However, are you saying that PA's or NP's should not? If so, why? Care to elaborate? I've been in musculoskeletal and emergency medicine for almost 15 years. I've done more injections and procedures and have been credentialed to do them for years.

I'm curious as to what your objections might be, and if you might have any data to support that assertion.

 

[Louisville04]

I don't understand the issue here. If you are arguing that CRNA's should not see pain patients, I agree, as this is not in their scope of training.

However, are you saying that PA's or NP's should not? If so, why? Care to elaborate? I've been in musculoskeletal and emergency medicine for almost 15 years. I've done more injections and procedures and have been credentialed to do them for years.

I'm curious as to what your objections might be, and if you might have any data to support that assertion.

By more procedures, I think you mean peripheral joint injections? The objection is CRNA's doing spinal procedures without proper training (i.e. not in the scope of CRNA training program)

 

[physasst]

That, and when practicing in the ED, more lumbar punctures than I can honestly remember. Actually, I was teaching the junior residents and interns often on how to do them.

New PAs often get enamored of doing procedures, but I always try to tell them that anyone can do a procedure with the right training. I care a lot more that they know WHY they are doing the procedure, what the proper indications are for the procedure, and what do to when they have a complication.

I agree that CRNA's are not really trained for that, but others might do very well with the right training and collaboration.

For example, PAs are working pretty successfully in many areas in interventional radiology and doing many of these procedures.

Just remember, there's enough work for all of us, and some of us aren't any threat to you.

 

[DOctorJay]

Equating an interlaminar or transforaminal epidural steroid injection to a lumbar puncture isn't quite fair and I assume YOU understand the difference. The problem is when people who don't know what they don't know and do these procedures.

For instance a laterally placed interlaminar can easily become a posterior approach transforaminal (anatomically) and if you're using particulate steroid then you're putting the patient at risk.

 

[physasst]

Agreed, and thanks for understanding that I do know the difference. I never meant to imply that there was no skill involved. Of course there is, but those skills can be taught and learned by different providers.

There shouldn't be ANY provider, physician or otherwise doing these without proper training and credentialing. There is no argument from me there. My point was, that you CAN train non physician providers to give them safely as well.

For example, I have just transferred into PM&R Spine here, and while I did a number of US guided Central Lines in the past, have experience with US in EM, and have done numerous peripheral joint injections in Ortho, I have not done them with US. This is a new skill, and I have to learn it properly. It would be hubris on my part to assume that I can "just do them".

 

[PMR 4 MSK]

Procedural management can be done by monkeys. Doctors prove this over and over when everyone gets a "series of three" followed by bilateral facets, RFA, etc, and no attempt is made to really diagnose and treat using less invasive methods. The diagnosis and treatment of chronic pain is the sole preview of medicine, particularly MDs and DOs.

Anyone can write a prescription for Vicodin or gabapentin. Anyone can write a script for PT. anyone with training can get a needle into the epidural space.

Knowing when to do these, how often and how much to use at any given time, in the right patient after the right diagnosis in all dimensions of the biopsychosocial systems is what makes chronic pain management inappropriate to be treated by mid levels.

 

[physasst]

Procedural management can be done by monkeys. Doctors prove this over and over when everyone gets a "series of three" followed by bilateral facets, RFA, etc, and no attempt is made to really diagnose and treat using less invasive methods. The diagnosis and treatment of chronic pain is the sole preview of medicine, particularly MDs and DOs.

Anyone can write a prescription for Vicodin or gabapentin. Anyone can write a script for PT. anyone with training can get a needle into the epidural space.

Knowing when to do these, how often and how much to use at any given time, in the right patient after the right diagnosis in all dimensions of the biopsychosocial systems is what makes chronic pain management inappropriate to be treated by mid levels.

Agreed.....except for the inappropriate part. I think PAs can treat chronic pain successfully, but agree that there has to be additional training. For example, in my new position, I am currently going through all of the rotations that the senior residents go through, and have to take several tests along with a long list of objectives that have to be completed and signed off by the attendings.

It would be very easy for me to say, nah, I've been a PA for well over a decade, I just took my recertification boards for the third time, I have 7 years of Orthopedic experience, a MS in Sports Medicine in addition to my PA, 2 years of Neurosurgical Spine experience and I can just hit the ground right away, build my own panel, and start practicing right away...but that's not appropriate. At this point, the other providers in the group have to be comfortable with my knowledge base, and know that I can comfortably run my own panel...while knowing that I will ALWAYS consult with one of them when I am unsure of something.

Besides, I am refreshing a lot which is never a bad thing, and I am learning new things well. I am always open to that....

We aren't your enemy..... I hop you don't see it that way....

 

[Fiveoboy11]

Procedural management can be done by monkeys. Doctors prove this over and over when everyone gets a "series of three" followed by bilateral facets, RFA, etc, and no attempt is made to really diagnose and treat using less invasive methods. The diagnosis and treatment of chronic pain is the sole preview of medicine, particularly MDs and DOs.

Anyone can write a prescription for Vicodin or gabapentin. Anyone can write a script for PT. anyone with training can get a needle into the epidural space.

Knowing when to do these, how often and how much to use at any given time, in the right patient after the right diagnosis in all dimensions of the biopsychosocial systems is what makes chronic pain management inappropriate to be treated by mid levels.

Interesting thread...

Maybe someone can explain to me why it's ok for physician's to encroach on many other professions, i.e. physical therapy, but it's not ok for other professions to encroach on PROCEDURES that they do. Nice double standard. I've seen numerous patient's after injections from great and all knowing doctors have extremely poor results, flare ups, set backs, etc. But that's ok somehow.

For the record, physician's on average most certainly do NOT know when to refer someone to physical therapy (check the research, and your ego), and physical therapists are not midlevels. The definition of midlevel is not up to physician's or the AMA to decide. I think we all can attest to the lameness that results from so much physician power, especially with regard to MSK chronic pain conditions. I wonder how many chronic pain conditions were preventable or will never be cured despite the great and super godlike skilled treatments of physicians.

 

[physasst]

BTW, the term midlevel...is really kind of insulting...if I am the "midlevel", what does that make the nurse or other members of the healthcare team. The term "non physician" provider is more accurate, and doesn't carry the negative connotations of that other word.

 

[bedrock]

Agreed.....except for the inappropriate part. I think PAs can treat chronic pain successfully, but agree that there has to be additional training.

We aren't your enemy..... I hop you don't see it that way....

Wrong. You aren't prepared to completely manage chronic pain fellowships without a 12-month full-time pain fellowship, which is only open to MDs, and assumes significant medical knowledge before you even start the fellowship. No weekend course, or time with some spine surgeons, etc can even begin to make up for that.

Can PAs/NPs be a useful part of a pain team, certainly. Can they run the pain team and manage pain patients completely on their own? Hell no.

If you don't accept that last part, then yes you are the enemy we are fighting.

 

[bedrock]

BTW, the term midlevel...is really kind of insulting...if I am the "midlevel", what does that make the nurse or other members of the healthcare team. The term "non physician" provider is more accurate, and doesn't carry the negative connotations of that other word.

Dude, get over yourself. You are a mid-level.

It's the easiest way to distinguish PAs/NPs from the nurses on the front lines and from the physicians who are ultimately responsible for patient decisions.

If you wanted to be a physician you should have gone to medical school. End of story.

 

[physasst]

Wrong. You aren't prepared to completely manage chronic pain fellowships without a 12-month full-time pain fellowship, which is only open to MDs, and assumes significant medical knowledge before you even start the fellowship. No weekend course, or time with some spine surgeons, etc can even begin to make up for that.

Can PAs/NPs be a useful part of a pain team, certainly. Can they run the pain team and manage pain patients completely on their own? Hell no.

If you don't accept that last part, then yes you are the enemy we are fighting.

Well, I'm sorry that you feel that way. It must be hard to have such a constant chip on one's shoulder. Turf battles never help, and with new payment mechanisms, IE; Prometheus, other providers will be managing more and more.......would you like to help guide that and make sure that proper training is established, and that triage models ensuring the right pain patient is seen by the right provider? Or would you prefer to yell and diminish your future colleagues bemoaning the loss of a bygone era when physicians managed everything? The choice is yours.....

Look, can PAs manage every pain patient on their own? Of course not. But there are also quite a few that don't require the services of a physician. PAs already have 12-18 month residencies in multiple specialties.....eventually there will be one in PM&R and/or Pain Management.

This is an interesting thread though....I'm actually doing a behavioral paper with a friend who is a medical sociologist on the concept of physician "status" in medicine and how this affects inter professional dynamics.... This will help with that paper. For full disclosure, in addition to being a PA, I have a research doctorate in organizational science and behavior, and primarily study physician/provider behavior.....mainly Audit and Feedback research at this time....

 

[physasst]

There is someone that has to get over themselves...but I am thinking that it is not likely me....LOL.

FWIW, I never wanted to go to medical school....I could have ....scored a 34 cumulative on the MCAT, and had a 3.8 GPA in undergrad.......took the MCAT when I was trying to decide....joined the Navy instead....

Not everyone wants that path.....

 

[bedrock]

Well, I'm sorry that you feel that way. It must be hard to have such a constant chip on one's shoulder..

No one has a bigger chip on their shoulders than midlevels who think they are physicians. Clearly your chip is enormous. If your reported MCAT was accurate and your science GPA (3.8 could be in social studies) was strong then maybe you could have made it. You didn't find out, which clearly still eats at you. However, all your prestigious online doctorates don't add up to physician, sorry.

If you don't have a chip on your shoulder, then why are you posting in a physician forum?

It's the militant 10% of PAs/NPs like yourself who think they are doctors that keep many physicians from hiring any midlevel. We had a discussion about that a year or two ago in the pain physician forum and I initially supported PAs working as part of a pain team. Midlevels like you make me rethink that position.

 

[Nymphicus]

Not everyone wants that path.....

But everyone wants the rewards...

 

[physasst]

I'm posting here to learn more. Why else? Also, please point to where I ever said I was a physician. I'm not and have never had a desire to be so. Lastly, I would point out that I clearly said that PAs cannot manage every pain patient. We aren't physicians. I was nothing but polite until your dismissive attitude.

If you cannot see that as a problem, than I don't really know what else to say. Am I militant? Perhaps, but not as much as you think. I am more supportive of team care, but was trying to point out that sometimes the team needs to divide the load...you responded with an attitude of superiority and dismissiveness, and then accuse me of being the aggressor...that's an interesting conversational style.

 

[PMR2008]

No one has a bigger chip on their shoulders than midlevels who think they are physicians. Clearly your chip is enormous. If your reported MCAT was accurate and your science GPA (3.8 could be in social studies) was strong then maybe you could have made it. You didn't find out, which clearly still eats at you. However, all your prestigious online doctorates don't add up to physician, sorry.

If you don't have a chip on your shoulder, then why are you posting in a physician forum?

It's the militant 10% of PAs/NPs like yourself who think they are doctors that keep many physicians from hiring any midlevel. We had a discussion about that a year or two ago in the pain physician forum and I initially supported PAs working as part of a pain team. Midlevels like you make me rethink that position.

Bedrock, don't worry about responding to this guy/gal. Totally not worth it and obviously you will not change his/her thinking. We have all discussed this many times and the overwhelming majority of the pain physicians on this board have agreed with your opinion.
:troll:

 

[DOctorJay]

this post is not directed towards physasst personally, simply posting to shed more light on the subject.

one thing that really bothers me is when terms used specifically for physician training are ripped off by other fields to make their training sound as if it is in some way comparable to ours. for a PA or PT to say they completed a residency is a slap in the face to all of us physicians who actually RESIDED in hospitals, were woken up at all hours of the night to attend to the needs of patients, and spent years and thousands of patient encounters honing our skills.

if you want respect from physicians then stop ripping us off and pretending to be us, everyone calling themselves "doctor" these days and PAs trying to change the their title to "physician associate".

 

[physasst]

this post is not directed towards physasst personally, simply posting to shed more light on the subject.

one thing that really bothers me is when terms used specifically for physician training are ripped off by other fields to make their training sound as if it is in some way comparable to ours. for a PA or PT to say they completed a residency is a slap in the face to all of us physicians who actually RESIDED in hospitals, were woken up at all hours of the night to attend to the needs of patients, and spent years and thousands of patient encounters honing our skills.

if you want respect from physicians then stop ripping us off and pretending to be us, everyone calling themselves "doctor" these days and PAs trying to change the their title to "physician associate".

Not taken personally at all. As far as the residencies, they are pretty intensive, at least some. The Baylor EM residency for PAs is crazy....90-100+ hours per week, heavy curriculum...etc. I don't know enough about the others to speak about them....I know that when I was fresh out of school in NS, the place I was at wanted to "get me up to speed" therefore I had to do every other night call for 8 months.....it sucked.....but I learned a TON....felt nauseous and like a zombie from lack of sleep...but I think of it fondly now.

While I have a doctorate, I never call myself that...even in academia. I don't actually like the title at all. I completed the degree to have access to funding and to further my research knowledge.....I don't think non physicians should call themselves doctor in clinical settings...too much potential for confusion...

As far as physician associate, there I will politely disagree. That was our original name...in fact the Yale PA program still calls them physician associates, and that was the intent of Dr Eugene Stead who founded the profession. We only wish to return to what we were originally intended to be called....

 

[Fiveoboy11]

this post is not directed towards physasst personally, simply posting to shed more light on the subject.

one thing that really bothers me is when terms used specifically for physician training are ripped off by other fields to make their training sound as if it is in some way comparable to ours. for a PA or PT to say they completed a residency is a slap in the face to all of us physicians who actually RESIDED in hospitals, were woken up at all hours of the night to attend to the needs of patients, and spent years and thousands of patient encounters honing our skills.

if you want respect from physicians then stop ripping us off and pretending to be us, everyone calling themselves "doctor" these days and PAs trying to change the their title to "physician associate".

Wrong. The DO/MD profession does not own the term residency, or fellowship. The physical therapy profession is a separate and distinct profession from medicine (MD/DO/PA). The only midlevel as far as a physician is concerned, is a PA. In my opinion, the "supervision" of PA's is laughable and only a statement on a lame message board topic like this. In reality, the vast majority of PA's and in the vast majority of situations practice autonomously. The only reason for the supervision garbage is to make MD/DO's feel warm and fuzzy inside and boost their ego.

Any profession has the right to attain a doctorate level, or a residency/fellowship, especially ones that do not attempt to practice the same way another profession does. If you disagree, why don't you call up a seasoned PT, FAAOMPT, since the training is a slap in the face and see how well you can argue about the management of MSK conditions.

The slap in the face is how the physician professions have floated on the hard work and knowledge of physical therapists for years and years. How much do PM&R physicians pad their salary in relation to physical therapy? 50k/yr? The slap in the face is the quack PM&R associations calling physical therapists incompetent and dangerous when interestingly enough 200,000 people die per year due to medical malpractice. The slap in the face is the American Money Association corrupting the bill about to pass in CA allowing for pt direct access to PT's and making it illegal for money mongering POPTS to exist. Too bad the corrupt and pathetic CMA forked over some dinero and had the bill amended without anyone knowing.

The efficacy of physicians vs physical therapists in treating MSK issues that are amenable to conservative care is not even close. Yet, it is a joke for PT's to have doctorates, and do residencies?

Stop wasting time with this arrogant and hipocritical garbage. Physicians and their associations deserve everything that comes their way if you ask me.

 

[DOctorJay]

Wrong. The DO/MD profession does not own the term residency, or fellowship. The physical therapy profession is a separate and distinct profession from medicine (MD/DO/PA). The only midlevel as far as a physician is concerned, is a PA. In my opinion, the "supervision" of PA's is laughable and only a statement on a lame message board topic like this. In reality, the vast majority of PA's and in the vast majority of situations practice autonomously. The only reason for the supervision garbage is to make MD/DO's feel warm and fuzzy inside and boost their ego.

Any profession has the right to attain a doctorate level, or a residency/fellowship, especially ones that do not attempt to practice the same way another profession does. If you disagree, why don't you call up a seasoned PT, FAAOMPT, since the training is a slap in the face and see how well you can argue about the management of MSK conditions.

The slap in the face is how the physician professions have floated on the hard work and knowledge of physical therapists for years and years. How much do PM&R physicians pad their salary in relation to physical therapy? 50k/yr? The slap in the face is the quack PM&R associations calling physical therapists incompetent and dangerous when interestingly enough 200,000 people die per year due to medical malpractice. The slap in the face is the American Money Association corrupting the bill about to pass in CA allowing for pt direct access to PT's and making it illegal for money mongering POPTS to exist. Too bad the corrupt and pathetic CMA forked over some dinero and had the bill amended without anyone knowing.

The efficacy of physicians vs physical therapists in treating MSK issues that are amenable to conservative care is not even close. Yet, it is a joke for PT's to have doctorates, and do residencies?

Stop wasting time with this arrogant and hipocritical garbage. Physicians and their associations deserve everything that comes their way if you ask me.

thanks for schooling me on physical therapy. I hold a Masters of Science in Physical Therapy.

you call me arrogant and hypocritical yet I'm the only one in the conversation with experience in both fields.

 

[Fiveoboy11]

thanks for schooling me on physical therapy. I hold a Masters of Science in Physical Therapy.

you call me arrogant and hypocritical yet I'm the only one in the conversation with experience in both fields.

You have offered no evidence, reasoning, or patient centered ideas to back up your arguments that other professions (besides MD/DO) are not worthy of doctorate level education and/or residency/fellowship training. The only thing you have spewed out is me minded, physician centered, look at me arrogance. Other professions that have residencies and/or fellowships do not have to reach the amount of hours or years of training as MD/DO residencies/fellowships do, and the reason is because many other professions do not perform intervents that save/kill peoples lives, are dangerous, not to mention completely different professions as mentioned above. If you disagree with that, stop saying you have done a residency as it is a slap in the face to Neurosurgeons. Don't think dentists, and pharmacists could not easily have been an MD/DO specialty and pathology/psychiatry could be separate and distinct professions as dentistry and pharmacy really are. A lot of the arguments you make are based on history and brainwashed thoughts, not critical thought.

I'm well aware that you have a Master's in physical therapy as I've seen you post that about 10 times. Thanks for schooling me on the greatness of physician training, but what I don't get is how lame the majority of physician's conduct a MSK exam and develop a treatment plan despite the real doctoral training and residency/fellowships in family medicine and internal medicine (my goodness they sure know MSK).

 

[PMR 4 MSK]

I agree. Remove all barriers. Anyone who wants to do anything in medicine can do it. Joe factory workers wants to remove grandma's appendix? Go for it. Susie Homemaker wants to do your LESI? Go ahead.

You want opioids for your chronic pain? Make them legal for everyone OTC. Save me the headaches.

Stop regulating things. Get rid of degrees. Get rid of licenses. Make my life 100% easier. Let reputations alone dictate who sees who.

 

[Fiveoboy11]

I agree. Remove all barriers. Anyone who wants to do anything in medicine can do it. Joe factory workers wants to remove grandma's appendix? Go for it. Susie Homemaker wants to do your LESI? Go ahead.

You want opioids for your chronic pain? Make them legal for everyone OTC. Save me the headaches.

Stop regulating things. Get rid of degrees. Get rid of licenses. Make my life 100% easier. Let reputations alone dictate who sees who.

Nice extrapolation. I never remotely implied any of this.

It would be nice for a profession such as my own to be able to practice as patients need and as we're trained. Arguments against PT's for treating within their scope unrestricted is based on propaganda and money, nothing else.

Perhaps you ought to look at things from a realistic standpoint. Are PM&R physicians trained in physical therapy during their standard training? No? Do they bill for and imply they practice/know physical therapy? Yes. But that's ok.

I advocate for professions to be as well educated and trained to provide the best care for patients. This includes physical therapy residency/fellowship and continuous alteration in baseline education for best patient care and outcomes. Physical therapists do not want to practice medicine, physicians do try to control physical therapy and many try to practice it. Face the facts.

 

[RUOkie]

Wrong. The DO/MD profession does not own the term residency, or fellowship. The physical therapy profession is a separate and distinct profession from medicine (MD/DO/PA). The only midlevel as far as a physician is concerned, is a PA. In my opinion, the "supervision" of PA's is laughable and only a statement on a lame message board topic like this. In reality, the vast majority of PA's and in the vast majority of situations practice autonomously. The only reason for the supervision garbage is to make MD/DO's feel warm and fuzzy inside and boost their ego.

Any profession has the right to attain a doctorate level, or a residency/fellowship, especially ones that do not attempt to practice the same way another profession does. If you disagree, why don't you call up a seasoned PT, FAAOMPT, since the training is a slap in the face and see how well you can argue about the management of MSK conditions.

The slap in the face is how the physician professions have floated on the hard work and knowledge of physical therapists for years and years. How much do PM&R physicians pad their salary in relation to physical therapy? 50k/yr? The slap in the face is the quack PM&R associations calling physical therapists incompetent and dangerous when interestingly enough 200,000 people die per year due to medical malpractice. The slap in the face is the American Money Association corrupting the bill about to pass in CA allowing for pt direct access to PT's and making it illegal for money mongering POPTS to exist. Too bad the corrupt and pathetic CMA forked over some dinero and had the bill amended without anyone knowing.

The efficacy of physicians vs physical therapists in treating MSK issues that are amenable to conservative care is not even close. Yet, it is a joke for PT's to have doctorates, and do residencies?

Stop wasting time with this arrogant and hipocritical garbage. Physicians and their associations deserve everything that comes their way if you ask me.

So it is legal for a PT to own a clinic that employs a physician but not the converse? Chiropractors own physician clinics all over the country (I would not work for one, but that is another argument), but I can't own a PT clinic because Rep Stark's mom died in a [partially] physician owned hospital.

When you have to pay the same malpractice insurance as I do, you can have your direct access.

Interestingly, I don't personally know a single PT (even the DPTs) that wants direct access, since they value the interaction with their physician referrers.

 

[RUOkie]

. Are PM&R physicians trained in physical therapy during their standard training? No? Do they bill for and imply they practice/know physical therapy? Yes. But that's ok.
.

I don't know of ANY physician who uses any of the physical therapy codes. I prescribe lots of PT, but don't 'practice' PT. I have never even heard of a physician "practicing" PT (it is not worth our time), EXCEPT when he/she EMPLOYS a PT in his/her office (for non-medicare)

 

[SSdoc33]

You have offered no evidence, reasoning, or patient centered ideas to back up your arguments that other professions (besides MD/DO) are not worthy of doctorate level education and/or residency/fellowship training. The only thing you have spewed out is me minded, physician centered, look at me arrogance. Other professions that have residencies and/or fellowships do not have to reach the amount of hours or years of training as MD/DO residencies/fellowships do, and the reason is because many other professions do not perform intervents that save/kill peoples lives, are dangerous, not to mention completely different professions as mentioned above. If you disagree with that, stop saying you have done a residency as it is a slap in the face to Neurosurgeons. Don't think dentists, and pharmacists could not easily have been an MD/DO specialty and pathology/psychiatry could be separate and distinct professions as dentistry and pharmacy really are. A lot of the arguments you make are based on history and brainwashed thoughts, not critical thought.

I'm well aware that you have a Master's in physical therapy as I've seen you post that about 10 times. Thanks for schooling me on the greatness of physician training, but what I don't get is how lame the majority of physician's conduct a MSK exam and develop a treatment plan despite the real doctoral training and residency/fellowships in family medicine and internal medicine (my goodness they sure know MSK).

you want to get paid more and act like a doctor? then become one. your jealously is as clear as day.

i agree that for the majority of MSK conditions, direct access for PTs are reasonable. until a AAA pops. or cancer goes untreated for a year. or a whole host of things that therapists don't have the training or medical knowledge to accurately diagnose or refer out. as a rule, therapists are trained to provide THERAPY. they/you are not trained to DIAGNOSE a problem. now, as physicians we may not always do the best job either, but i can assure you that we will be better able to rule out the dangerous stuff than therapists.

 

[PMR 4 MSK]

I've probably billed PT codes a dozen times in my life, if that. Some docs get more into it and have pts get modalities (mostly worthless, but thats another arguement) and therapeutic exercise, including training for HEP. I also don't know any docs who want to do the PT, and most any docs not trained in pain would have no clue how to do anything in PT. We don't want to.

We pain docs want to diagnose, prescribe meds, prescribe therapy and stick needles in people. We leave the therapy to the therapists - physical, occupation, speech, psych, counseling, etc.

What is amusing to us is how many people without an MD or DO want to play doctor. PTs are getting DPTs. Some introduce themselves as "Dr." NPs are getting DNPs. At some point, PAs with get DPA I assume (Which will make for an akward title).

If you have the education, training and experience to do what we do, go ahead and do it. "Level the playing field" as people like to put it. If you feel you can do it better, time and patient referrals will prove that. If you are wrong in your self-assessment, the lawyers will prove it for you.

The most dangerous person in the world is not a terrorist, but a health care "provider" (doctor, PT, PA, NP, etc) who doesn't know what their own limitations are.

 

[physasst]

Actually PAs will not be getting a doctorate. We don't want one. We had a big meeting with various stakeholders in March of 2009, and it was decided that we will not ever pursue a doctorate. That is NOT on the PA agenda.

 

[AndyDufrane]

come on, I can't believe how long this thread has become, bottom line, if you want to become a medical doctor, do it the traditional way, go to medical school, if you can't/didn't make into med school, stop pretending and wasting everyone's time, DPT/CRNA/NP/PA are not equivalent to medical doctors, end of discussion, that is a fact, arguing otherwise would be like being mad about gravity, or being upset that every day the sun comes up/down

 

[physasst]

come on, I can't believe how long this thread has become, bottom line, if you want to become a medical doctor, do it the traditional way, go to medical school, if you can't/didn't make into med school, stop pretending and wasting everyone's time, DPT/CRNA/NP/PA are not equivalent to medical doctors, end of discussion, that is a fact, arguing otherwise would be like being mad about gravity, or being upset that every day the sun comes up/down

Actually, speaking only for myself, not jealous. I think, after over 20 years in healthcare, that physicians are for the most part over trained for most medical problems and conditions.

In the ED, I saw probably 90-95% of what came through the door on my own. I would consult when needed, but that was rare. Hell, one local Health System ED that I used to moonlight at doesn't even have ANY physicians on site. It is staffed and run exclusively with PAs.

Are you familiar with Clayton Christensen? If not, you should be. Disruptive Innovation occurs in all industries and with all products, including healthcare delivery. I would posit, and have written about this, that PAs, NPs, CRNAs, Nurse Midwives, and others ARE the disruptive innovation in health care delivery. We are taking over duties that were once the exlcusive domain of physicians. Does that mean we are physicians? No.....we are not....but the logical fallacy that only a physician can perform a physicians duties is simply not true. There have been no studies looking at outcomes measurements that show inferior care with alternative providers. Obviously, these studies are difficult to conduct as there is some physician involvement, but in the absence of any other data to the contrary, it's what we have.

There will ALWAYS be a need for physicians, because patients occupy a spectrum of illness and severity of disease. There will ALWAYS be some patients that shouldn't be seen by PAs or NPs alone, and will require physician involvement. But there will also be a huge number of patients that don't need physician involvement.

Societal attitudes also are changing. Many younger people don't have the same reverence for physicians that older generations used to hold. One of my friends, anecdotally, is a software engineer, and he basically states that he thinks of physicians/providers as being equivalent to an auto mechanic...."I'm broke, fix me"....and that there is nothing inherently special about being a provider.

I'll state it again, we aren't going anywhere. PAs and NPs will be involved in all specialties...would you rather be part of the problem? OR, would you rather ensure that there is proper training, education, and credentialing for PAs and NPs? The choice is yours, but simply complaining about it isn't going to make the problem go away.

 

[SSdoc33]

Actually, speaking only for myself, not jealous. I think, after over 20 years in healthcare, that physicians are for the most part over trained for most medical problems and conditions.

In the ED, I saw probably 90-95% of what came through the door on my own. I would consult when needed, but that was rare. Hell, one local Health System ED that I used to moonlight at doesn't even have ANY physicians on site. It is staffed and run exclusively with PAs.

Are you familiar with Clayton Christensen? If not, you should be. Disruptive Innovation occurs in all industries and with all products, including healthcare delivery. I would posit, and have written about this, that PAs, NPs, CRNAs, Nurse Midwives, and others ARE the disruptive innovation in health care delivery. We are taking over duties that were once the exlcusive domain of physicians. Does that mean we are physicians? No.....we are not....but the logical fallacy that only a physician can perform a physicians duties is simply not true. There have been no studies looking at outcomes measurements that show inferior care with alternative providers. Obviously, these studies are difficult to conduct as there is some physician involvement, but in the absence of any other data to the contrary, it's what we have.

There will ALWAYS be a need for physicians, because patients occupy a spectrum of illness and severity of disease. There will ALWAYS be some patients that shouldn't be seen by PAs or NPs alone, and will require physician involvement. But there will also be a huge number of patients that don't need physician involvement.

Societal attitudes also are changing. Many younger people don't have the same reverence for physicians that older generations used to hold. One of my friends, anecdotally, is a software engineer, and he basically states that he thinks of physicians/providers as being equivalent to an auto mechanic...."I'm broke, fix me"....and that there is nothing inherently special about being a provider.

I'll state it again, we aren't going anywhere. PAs and NPs will be involved in all specialties...would you rather be part of the problem? OR, would you rather ensure that there is proper training, education, and credentialing for PAs and NPs? The choice is yours, but simply complaining about it isn't going to make the problem go away.

You want to handle runny noses and splinters, be my guest. But when it comes to sticking a needle in a spine, I don't want it to be by the bimbo who barely passed an online community college basic chemisty course. Elitist? You bet.

 

[Fiveoboy11]

So it is legal for a PT to own a clinic that employs a physician but not the converse? Chiropractors own physician clinics all over the country (I would not work for one, but that is another argument), but I can't own a PT clinic because Rep Stark's mom died in a [partially] physician owned hospital.

It has to do with conflict of interest, waste of money, and power over a totally different profession that has no basis besides politics, history and money. Personally, I would be against PT's owning practices that employ physicians.

When you have to pay the same malpractice insurance as I do, you can have your direct access.

This makes no sense. A PT's malpractice insurance will never be as high as a physician's. The reason is because the interventions physician's provide and the reasons patients seek the care of physicians are far more dangerous.

Interestingly, I don't personally know a single PT (even the DPTs) that wants direct access, since they value the interaction with their physician referrers.

I know many, there's about 80k that are members of the APTA. The basis for anti-direct access among PT's is highly associated with BSPT education, ownership of private practice clinics, and brainwashed train of thought. The evidence strongly shows that direct access to PT's is safe, cost effective, and provides good outcomes. There is no reason not to have direct access, not a legitimate one anyway.

 

[Fiveoboy11]

I don't know of ANY physician who uses any of the physical therapy codes. I prescribe lots of PT, but don't 'practice' PT. I have never even heard of a physician "practicing" PT (it is not worth our time), EXCEPT when he/she EMPLOYS a PT in his/her office (for non-medicare)

I don't know of a single physician personally who does either. There's been numerous examples of physician's billing for physical therapy across the nation. Physician's are not trained or qualified to provide physical therapy, it should never be billed, even by PM&R physicians, chiropractors, etc.

If anyone else wants to argue about this I'll find the resources about fraudulent billing and abuse among physicians billing "physical therapy." Or the millions of medicare dollars wasted by physician's who think physical therapy is within their scope of practice.

 

[Eilat87]

I don't know of ANY physician who uses any of the physical therapy codes. I prescribe lots of PT, but don't 'practice' PT. I have never even heard of a physician "practicing" PT (it is not worth our time), EXCEPT when he/she EMPLOYS a PT in his/her office (for non-medicare)

Yeah man, come on guys.

It's like a psychiatrist doing therapy.

 

[physasst]

You want to handle runny noses and splinters, be my guest. But when it comes to sticking a needle in a spine, I don't want it to be by the bimbo who barely passed an online community college basic chemisty course. Elitist? You bet.

Ha, well, I'm not aware of any "bimbo who barely passed an online community college basic chemistry course" practicing as PAs.....is there some variation in knowledge, skills, and ability...yep, you betcha there is, just as with physicians. I know physicians I would trust with my daughters life without question....and I know more than a few that I wouldn't trust to treat my dogs.....

I was a corpsman in the Navy stationed with the Marines Second Recon Battalion in Desert Storm. There is something that I learned there that the siloed educational system in health care right now doesn't teach...and it creates this useless friction.....esprit de corps. We are in the trenches together. I can go ahead and just try to fumble my way through thing OR, I can work with partners that truly value my education and skills and want to see me properly trained to do those procedures.

I think that is likely the next obstacle to tackle and have heard this discussed at multiple policy meetings in the US. Health Education system reform. PAs and MDs should be taking most courses together. Not all, of course not, but when possible....

This already happens of course. A fair number of PA schools are located at Medical Schools, and they will often take classes with their MD colleagues. I wonder if there is a different attitude among MD's graduating from those schools, versus siloed educational models. That would be an interesting study actually.

 

[Fiveoboy11]

you want to get paid more and act like a doctor? then become one. your jealously is as clear as day.

I'm quite fine with my pay and I never said anything about that. What I did mention was how physician's mooch off the hard work of other professions, including in rehab and especially on PT's. How often do you PM&R physician's refer to PT's, or wait "order PT" or "prescripe PT"? I wonder what amount of money is put in your pockets in relationship to physical therapy.

i agree that for the majority of MSK conditions, direct access for PTs are reasonable. until a AAA pops. or cancer goes untreated for a year. or a whole host of things that therapists don't have the training or medical knowledge to accurately diagnose or refer out. as a rule, therapists are trained to provide THERAPY. they/you are not trained to DIAGNOSE a problem. now, as physicians we may not always do the best job either, but i can assure you that we will be better able to rule out the dangerous stuff than therapists.

PT's graduating today are qualified to screen for non MSK issues, we do it all day long. You can babble on about anectdotal BS all you want, provide me with some evidence. FYI, personal trainers and massage therapists have unrestricted direct access to patients in the US. How many of those patient's are seen by physicians prior to undergoing those treatments? How about the fact that many countries already have unrestricted direct access to physical therapy that patient's commonly go to and seek (i.e. the UK, new zealand, australia, and many more). Can you provide me with any evidence that PT's are dangerous if given direct access, especially considering the fact that personal trainers and massage therapists often see the exact same patient groups and have far less training, etc.

 

[Fiveoboy11]

I've probably billed PT codes a dozen times in my life, if that. Some docs get more into it and have pts get modalities (mostly worthless, but thats another arguement) and therapeutic exercise, including training for HEP. I also don't know any docs who want to do the PT, and most any docs not trained in pain would have no clue how to do anything in PT. We don't want to.

That's a dozen times too many. Bill your own codes and stop thinking you know physical therapy.

We pain docs want to diagnose, prescribe meds, prescribe therapy and stick needles in people. We leave the therapy to the therapists - physical, occupation, speech, psych, counseling, etc.

For the love of god, stop grouping "therapists"

What is amusing to us is how many people without an MD or DO want to play doctor. PTs are getting DPTs. Some introduce themselves as "Dr." NPs are getting DNPs. At some point, PAs with get DPA I assume (Which will make for an akward title).

I find it amusing how physician's pretend to know physical therapy and think they should scribble some know nothing gardbage on scripts relentlessly. Thank you so much doctor for writing "strengthening, ROM, US, HP." Get over yourselves.

If you have the education, training and experience to do what we do, go ahead and do it. "Level the playing field" as people like to put it. If you feel you can do it better, time and patient referrals will prove that. If you are wrong in your self-assessment, the lawyers will prove it for you.

I don't have any desire to do what you do (pill pushers, over imaging, promotion of dependence and walmartized train of thought quick and easy solutions). I like my job and I'd like to do it without interference.

The most dangerous person in the world is not a terrorist, but a health care "provider" (doctor, PT, PA, NP, etc) who doesn't know what their own limitations are.

The most dangerous healthcare professional is the physician groups. Check the stats, 200k die per year in the US due to medical malpractice. Maybe if physicians were focusing on their own job, and where their expertese and skill are desperately needed, they would have the time/focus to provide better care to the patient's who need THEIR care.

 

[Fiveoboy11]

come on, I can't believe how long this thread has become, bottom line, if you want to become a medical doctor, do it the traditional way, go to medical school, if you can't/didn't make into med school, stop pretending and wasting everyone's time, DPT/CRNA/NP/PA are not equivalent to medical doctors, end of discussion, that is a fact, arguing otherwise would be like being mad about gravity, or being upset that every day the sun comes up/down

Nobody said anything about wanting to become a medical doctor. Personally I find a lot of the behavior and action of physician's repulsive and disgusting. DPT's do not think they are "equivalent" to physician's. However, seems to me that physician's do not grasp that they are not trained in every aspect of healthcare to where they need to be involved and supervise everything. Not the case. It's more about different professions wanting you to do your own jobs and stop doing ours than it is about us wanting to do yours.

 

[Taus]

trying to stay out of the inflammatory bs here..... I have a legit question

As a PM&R resident who has trained in a variety of academic and private practices, I have never seen PT "billed" for. What would a physician bill for? We prescribe specific home exercise programs... but didn't think that was billed for. We clearly don't "do" PT, so this doesn't really make sense to me, unless a physician group employs therapists and does the billing. As for an individual physician billing PT based upon what they did in a clinic visit.... I just don't see it... what am I missing here?

 

[Fiveoboy11]

trying to stay out of the inflammatory bs here..... I have a legit question

As a PM&R resident who has trained in a variety of academic and private practices, I have never seen PT "billed" for. What would a physician bill for? We prescribe specific home exercise programs... but didn't think that was billed for. We clearly don't "do" PT, so this doesn't really make sense to me, unless a physician group employs therapists and does the billing. As for an individual physician billing PT based upon what they did in a clinic visit.... I just don't see it... what am I missing here?

It doesn't really matter what you see. The reality is millions of dollars are wasted because of physician billing for phyiscal therapy that they are untrained and unqualified to provide. It is not hard to find the statistics on this.

Perhaps ignoring all the anti non-physician propaganda and looking at the facts would be helpful.

 

[Taus]

I don't have any desire to do what you do (pill pushers, over imaging, promotion of dependence and walmartized train of thought quick and easy solutions

Your attitude and hostility prevent any legit conversation here. I have been fortunate to work with excellent therapists in a very collegial and collaborative atmosphere that benefits our mutual patients.

 

[fozzy40]

You can blame physicians all day long but we are not the main problem. PTs have plenty of direct access. Don't hate the player, hate the game...as I've said before.

 

[PMR 4 MSK]

The most dangerous healthcare professional is the physician groups. Check the stats, 200k die per year in the US due to medical malpractice. Maybe if physicians were focusing on their own job, and where their expertese and skill are desperately needed, they would have the time/focus to provide better care to the patient's who need THEIR care.

Well then, when your family members have cancer, get hit by a car, or whatever, I hope you get the high quality care you deserve from your PA, NP, CRNA, etc. obviously you would not see a doctor because we kill way too many people. Your disdain for the profession is obvious and your arrogance for your own is amazing.

By your line of reasoning, we should eliminate doctors. Then no one will die any longer.

Doctors - no longer saving lives, just ending them prematurely!

 

[PMR 4 MSK]

I always love wanna-be docs who constantly attack doctors for being imperfect. This is the group just waiting for something to go wrong, often due to chance alone, and then enter the lawsuit lottery.

Feel free to try doing what we do. You will fail, miserably. If you say " I could do that but I don't want to!" you are completely full of ****.

 

[Fiveoboy11]

Well then, when your family members have cancer, get hit by a car, or whatever, I hope you get the high quality care you deserve from your PA, NP, CRNA, etc. obviously you would not see a doctor because we kill way too many people. Your disdain for the profession is obvious and your arrogance for your own is amazing.

By your line of reasoning, we should eliminate doctors. Then no one will die any longer.

Doctors - no longer saving lives, just ending them prematurely!

I swear it is impossible to make an argument with you guys as you twist things around left and right. If anyone in my family had cancer or got hit by a car I would certainly want them to see a physician. I never implied otherwise. I've seen doctors, and I see one right now and I've never stated or implied anything negative about physicians to my family. To my fellow PT's and friends, yes I have as it's easier to talk to them about things like that.

My line of reasoning in no way implied that I think we should get rid of doctors. I'm aware that people will die regardless in cases. However, the point I was making, and by my line of reasoning I was saying this: physicians try to control everything in healthcare and many times they do not have any business doing so (i.e. physical therapy). Due to this they are overburdened, probably stressed out, overworked etc. THIS is likely one of the main causes for medical malpractice deaths.

 

[Fiveoboy11]

You can blame physicians all day long but we are not the main problem. PTs have plenty of direct access. Don't hate the player, hate the game...as I've said before.

There's 17 states in the US with unrestricted direct access to physical therapists. Probably less than 5% of patient visits are direct access, bummer for all the patient's with MSK issues. You don't know what you're talking about.The AMA/ACA are the reason why PT's do not have unrestricted direct access in all 50 states. In the 17 states where unrestricted direct access is in place, most insurances will not cover PT without a physician referral, thus few patients directly access a PT. Many states where direct access legislation was put in place were done in the 70's and 80's. Now here we are in 2012 and states where new legislation is passing have all kinds of restrictions placed with them. Why? Because the AMA/ACA lobbies for them without basis.

 

[Fiveoboy11]

I always love wanna-be docs who constantly attack doctors for being imperfect. This is the group just waiting for something to go wrong, often due to chance alone, and then enter the lawsuit lottery.

Feel free to try doing what we do. You will fail, miserably. If you say " I could do that but I don't want to!" you are completely full of ****.

Stop saying I'm a wanna be, I have no desire to be an MD or DO. I don't think I could do an injection, etc and I know I would fail miserably if I tried. News flash for you, your physician colleagues fail miserably when it comes to physical therapy and general management of MSK conditions, but somehow they control it.