The issue is that money corrupts a lot of people. I think if all PTs were motivated like you and educated and willing to work for better outcome for the patient, then obviously, that helps patient care. But if PTs go into business and start selling gadgets and hiring tons of PTAs to administer a lot of modalities and billing payors for DMEs and everything else under the sun, and they hang on to patients for months and months while not making progress, and they don't know their own limitations, that is where the plan derails.
I absolutely agree, but doesn't this also apply to physicians? For example, an argument of the APTA against Physician-owned PT clinics is the opportunity for fraud when a physician refers to his own clinic. Yet not many physicians would yield to that argument. Your assumption is that PTs would take advantage of the system if given the opportunity, my response is that they are no more likely to do so than any other professional. Not to mention that I would rather go about my days giving individuals (and an entire profession!) the benefit of the doubt. With that said, your fear is justifiable, and it is a concern that I also share.
Just like you have seen physicians miss pathologies, I have seen as many if not more PTs miss even basic MSK issues. I had a patient who was seen by a PT for 8 weeks for "greater trochanteric bursitis" with no improvement. The PT then sent the patient to an orthopod for a bursitis injection. The orthopod referred the patient to me to evaluate her spine, and I diagnosed her with L5 radic. When I tried to get her into a good McKenzie therapist for her lumbar spine, Medicare denied any more PT because she had already met her cap. Now I have to do an injection to buy time until December when the cap re-sets. Same thing goes for cervical radic misdiagnosed as shoulder issues - trying to get work comp to allow for another course of PT when the patient already "failed" 8 weeks of PT - is very difficult.
Two things:
1) Often times physicians miss pathology because it appears during the course of rehabilitation, and thus may have not been evident during evaluation. In these scenarios (that happen often), wouldn't you prefer a PT that is trained to recognize non-mechanical pathologic processes that require immediate referral back to the physician? If so (and I hope so), is there really a difference between this and a physical therapist initially screening a patient off the street?
2) I would be lying if I didn't wholeheartedly agree with you that some of what passes as physical therapy out there is disgusting. With that said, even as a current student, I know with 100% certainty that not a single individual in my class would do such a horrid job if placed in the scenarios you mentioned. For the very examples you have provided, I will reiterate what I have been saying from the start: current trends in PT training are significantly raising the standard level of care provided across the profession.
I think direct access is fine but there should be a time limit after which there is automatic referral to a physician (hopefully a MSK specialist) and there are limitations like that in many states with direct access.
I can not agree more with this. The very foundation of our society is built on a principle of checks and balances. If PT isn't effective during the first few weeks of treatment, then the PT is incompetent or the patient isn't a candidate. I don't know about straight referral...that just brings us back to where we started. I think an update note is sufficient (and some states adopt this model).
PCPs treat a lot of patients all day and they have to triage - MSK issues are rarely life threatening and therefore is not a priority for them. Honestly, the whole field of pain is "elective" - which is one of the issues with our field. The first things that are going to get cut or rationed in a system trying to cut cost are the elective stuff - and that includes PT, MSK care, and other "elective" services.
I agree to a point. Many of the advances in orthopedic surgery are only possible with excellent post-op rehabilitation. Many a time pre/post-op PT care is just as important as the surgery itself, thus cuts in PT (specifically in areas of post-op care) would be devastating to orthopedics. In fact, for this very reason, orthopedic surgeons intimately involved in my department have coined the phrase "rehab-modified surgery" to describe various surgeries that they have refined to yield a better rehabilitation course.
The government is already looking at systems to regulate cost including "medical home models", accountable care organizations, etc. PTs are going to have to prove that their model of care is more cost effective than the medical model. Taking the elbow example - if a PCP had seen the patient, diagnosed him/her with lateral epicondylitis, dispensed a brace and prescribed some topical NSAID or maybe even a steroid injection, gave a handout on exercises to do at home - and the patient got better, that obliterates the need for ortho or PT. That PCP just saved the system money by not ordering an MRI, not ordering PT, not ordering an ortho consult, etc.
105% agree, but it's situation-dependent. If my patient would have better short and long term functional outcomes via NSAIDs and a brace than PT, then I am all for the NSAIDs and brace. However, aside from trauma, a large majority of what a PT sees are overuse injuries secondary to postural and biomechanical faults...these must be corrected otherwise NSAIDs and brace = minimal long term benefits, and would just lead to increased costs as the condition potentially worsens secondary to "new and improved" compensations.
You also have to remember that often, patients go to physicians for the reassurance that what they have is not "cancer". They also want medications - if it weren't for medications, many patients would not participate in PT.
I am 50/50 on this one. In my experience, many patients come to PT because they want to avoid medications at all costs. Of course we have patients as you describe...who couldn't do it without meds.
A lot of my patients don't want to pay the copay to see a PT twice a week. They'd rather take the $4 generic Rx of pain medication and call it a day.
This is a problem across healthcare: patients are looking for the easy way out, and society in turn suffers via an obese population that is dying of preventable diseases. It is up to every healthcare professional to share in the responsibility of patient education.
As you said earlier: "I tell the patients that medications and injections are temporary but the benefits of PT will last long term."
A physician may just write "eval and treat" on a script, but he/she is performing a medical physical exam, taking a history and ruling out red flags, looking at the list of meds the patient is on and reviewing labwork to prescribe the appropriate medication, deciding on what imaging to order, writing a note for work, taking into account the family and social situation of the patient, ruling out the need for a surgical consult (and sometimes they will refer to PT to justify a surgical referral - i.e. failed conservative management - so it may not be that a physician "missed" something), and then talking the patient into going to PT. And that MSK issue may have been only one of ten issues the patient brought up during a visit.
The intricacies of an initial evaluation do not escape me. It is not because we often see "eval and treat" on a script that PTs think they can handle direct access to patients: PTs believe that the level of training that the DPT provides prepare us well enough to function in that role. Although very different from a physician's evaluation, the goal of our training is to recognize when a physician referral is appropriate. It flips the current model, and since the majority of patients that present with MSK issues actually have a MSK issue (think horses when you hear hoofs), it eliminates the cost of a middle man. Your question really is (sorry if I am putting words in your mouth): Can PTs successfully recognize those patients that do have underlying pathology? My answer is: the current available evidence suggests yes; more studies required.
Going on observations is a nice way to get exposed to physician practices - but what you don't observe are the unsaid words in the physician's head, the differential diagnosis he/she may have quickly gone through and ruled out, the thinking behind prescribing meds or PT, the relationship the patient may have with the physician after many years of care, and all the red flags the physician just ruled out in a visit. Just like me going to a PT gym and observing therapists would not give me a good insight into how a PT thinks and what kind of evaluation process a PT goes through in his/her head, a PT going to a physicians office to shadow cannot fathom all the thoughts we have in our heads.
I agree with your points, especially regarding the physician-patient relationship...for those where this still exists, I don't think any medical model could compare.
I may have not represented myself accurately. The observations I mentioned earlier were before starting PT school. My current thoughts and comments regarding the medical community stem from courses in PT school, taught by physicians (PMR, Orthopedics, Neurology, Sports Med), whose entire purpose was to explain "how a physician thinks." Albeit an outside look into an inner thought process, these courses have greatly impacted my ability to communicate with physicians of all specialties when it comes to patient care. These physicians, who are leaders of the medical community in this region, volunteer their valuable time to further our (PT) education, and I know my colleagues and I are ever grateful for their efforts. As such, I feel I have a decent perspective when it comes to the medical management of my patients.
I could say that a personal trainer knows how to build muscle and use good form - why not just send to a personal trainer? yoga and pilates is good for the core, why not just tell a patient to take a yoga class? how about just sending to a chiropractor who also gives exercises to do at home? Why not just look up some PT on youtube to teach some basic strengthening exercises?
Because I am interpreting this last bullet as you trying to emphasize a point which I addressed above, I will not get into it. It's a shame, cause coming from a 'decorated' personal training and fitness instructor background, I've got some pretty darn good come backs to those examples
.
