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Toni Talks about PT Today

Are We Ready for Direct Access?

Published December 10, 2008 9:09 AM by Toni Patt
This semester I'm taking a class addressing differential diagnoses. Its purpose is to prepare me to screen patients for medical problems prior to initiating therapy. Each chapter covers a different system and reviews the signs and symptoms of medical conditions that might mimic physical therapy diagnoses. The purpose of the class is to prepare me to practice in a direct access environment. Though the class has barely begun, it's been an eye-opening experience.  

Before starting this class I would have told you I know this stuff. I would have said since I work so much in acute care, I'll recognize the difference. I would have been wrong.  We've barely covered the patient interview, and I've found myself inadequate. Who knew to ask such questions? Working in acute care has spoiled me. I always have a current H&P to work with. The medical conditions, PMHx, home meds, etc. are written down for me. Until recently I didn't realize what was involved in getting that information. Any PT will agree that getting useful information from patients is difficult at times. It would be next to impossible to get this kind of information if you didn't know the questions to ask and what to ask in follow-up.

Even though there is a lot of information I don't think it will be difficult to learn. As I get into the readings I'm seeing some logic in the process.  By the time I finish I should have no problem knowing how to obtain the information and what to do with it. I have an excuse for my lack of knowledge. This wasn't taught when I went to school back in the day.  I've yet to see a CE course covering the material. Until this class I hadn't had an opportunity to learn. DPTs are exposed to this during the education process.  The patient interview process won't be a problem for them. What about everyone else?

My understanding is that as we move closer to everyone being a DPT, those of us who aren't will be grandfathered along enabling us to keep practicing. I don't think additional education of that nature will be required. If I'm correct, therapists who aren't DPTs will be able to practice as one.  In a profession that is pushing for direct access across the board that scares me. It's all fine and good to say existing PTs can continue to practice.  The problem I see is allowing those same therapists to work in a direct access setting without requiring them to have the same education.  I'm not talking about therapeutic skill. I'm talking about knowledge and liability.

My understanding is that no restrictions will be placed on the grandfathered therapists. I speak from experience when I say in this area there will be a knowledge gap. My textbook is filled with case studies illustrating instances when a PT did and didn't pick up on an alternative diagnosis. I have no reference point to say how rare such instances are. All it would take is one major mistake and someone's career would be over.  I wonder if the APTA has thought of this.

I don't want to get into the "everyone needs to be a DPT" debate. I now think someone practicing in a direct access setting should be a DPT.  Maybe the PT world is debating the wrong subject. I know many PTs with strong opinions about the DPT, but no one who has any opinion about direct access. I can make a strong argument either way using exactly the same information. Among my friends the general consensus is it won't happen anytime soon because insurances and physicians will resist. That may be true. But if it were to happen in 10 years the majority of us would still be practicing and no more prepared than we are now. There are a lot of therapists in my age group this will affect. Are we going to be prohibited from practicing in those settings because we lack the knowledge deemed necessary to do so? If there is a sudden rush for transitional DPTs, the schools will be overwhelmed. The process takes between 1 to 3 years. It might be a solution for some but it won't be timely.

I have no idea what the answer to this might be. Maybe I'm creating a problem where none exists. I might be reading more into this than is actually there. I'm basing my comments on myself and I went to school a long time ago. The curriculum has changed so much it might not be a problem for more recent graduates.  We live in a sue-happy society. I can easily imagine a PT being sued over less. As soon as I started reading the first chapter I started thinking about this.

7 comments

I'll also add that non DPT PTs SHOULD NOT be grandfathered in.  That's an absurd notion that should be put to rest immediately.  It undermines the time, effort, and resources all others have put in to obtain such a degree.  All DPTs and non-DPT PTs should respect this notion.  This would only result in discrediting the degree.  If the APTA wants the DPT to be taken seriously, grandfathering all PTs in will not be the way to do it.  As a future DPT that will be spending lots of time, effort, and currently unearned money (i.e. student loans) to obtain the DPT degree; I will be politically active and get other DPTs involved in order to protect their degree.  All non-DPT PTs should respect this by pursuing the tDPT if desired and support the notion to not bastardize the degree.  If grandfathering the degree does occur, I will be assured my effort was a waste of time.  Respect your profession and future colleagues. DO NOT support the grandfathering of the degree.  You may want to compare this to the PharmD.  This is a different ballgame completely as PTs are attempting to build credibility and bypass the long-standing notion of Physicians being the gatekeeper.  PharmDs aren't taking such bold steps.

Mike Lee December 5, 2010 4:31 PM

I think the APTA should lobby for Direct Access ONLY for DPTs.  This would legitimize the degree.  To allow BsPTs or MSPTs to get directly reimbursed for direct access negates the degree in my opinion.  

To do this would be beneficial as the DPT would have a clear market value over BsPTs and MSPTs.  To increase earning potential of the DPT over other PTs would create the incentive for existing PTs to pursue the tDPT, which to my understanding, should be re-modified to mirror the eDPT standards.  Currently the tDPT doesn't doesn't hold it's graduates to the same standard as the eDPT does.  The result waters down the degree and pays due respect to those spending thousands of dollars and three years in school refining their skills as a DPT.

One glaring reality is that the DPT only really benefits those working in settings that could utilize direct access.  So those working in a hospital setting, in a nursing home, or home health don't benefit financially at all.  Since the APTA has initiated a movement for ALL future PTs to graduate as DPTs, I wonder what the long-term results will be.  Most DPTs are going to desire to work in the outpatient facility, which already is the case in most instances.  I wonder if the movement for other professions to step into the hospital, nursing home, and home health settings would occur.  

I wonder if the APTA didn't shoot themselves in the foot in some ways.  One thing I find interesting is the increase autonomy PTAs have had over the years.  Some states don't require PTs to be on site at all.  There's been talk of PTAs being dropped from the APTA where they could start their own governing body.  There has also been talk of the educational standard of PTAs moving to the BS degree.  Is it possible for PTAs to eventually replace PTs in the hospital, nursing home, and home health settings by legislative efforts claiming they can also perform "Physical Therapy" at a lower cost than their DPT counterparts?  After all the PTs have allowed PTs to do a majority of the treatments.  Could they increase their educational standards and end up competing with PTs in these settings?  Will DPTs be primarily in the outpatient settings where the DPT can be utilized?  After all most would want to utilize their skills in these settings anyways.  Thoughts?

Mike Lee December 5, 2010 1:01 PM

What is with all you PT's who agree that we cannot and do not have enough knowledge to treat our patients and do our jobs?  If you really feel that way, I think you all should go back to PT school.  I personally feel that as a PT, I am better at making a diagnosis than most doctors can without an x-ray.  Often, I am right and the doctor is wrong  So lets not place the doctor in such high esteem.  If the doctor does not have the x-ray or MRI report, they often CANNOT even READ the film!  How long have you all been working in this field?  Perhaps you are not paying close attention to details.  

Donna, MPT April 27, 2009 1:29 AM

I would like to say that many of us have been pushing for direct access to PT for a long time, especially in states that were behind the times, such as NY.  Even back when it was just a dream, I knew that PT's are their own worse enemy.  If you dont have the confidence in your area of expertise to perform independently and make proper judgements, then you should refer your patient to his or her doctor.  Lets not make a debate over competence that will interfere with autonomy for the rest of us.  There are so many "professions" that practice PT techniques without a license and do so with almost no training, and NEVER needed a script!  Here we are, trained to advance degrees and for years we needed a script from a doctor to do procedures like simple exercises!  A patient can go to an athletic trainer to learn strengthening exercises following a sports injury, but needed a script to go to a PT who knew more about rehabing the injury than the ATC.  A patient can see a massage therapist for back pain and get a massage, but needs a script to see a PT.  Likewise for chiropractors.  People can go to a GYM and have a personal trainer show them how to do back stabilization exercises, but needs a script to see  PT who knows much more about the postural stabilization and how it works.  This is outrageous practices.  And to think that PT's such as Toni are stating that they dont feel they have the skills necessary to carry out a patient interview and treatment without additional classes??  WOW, you really should re evaluate your background.  I felt confident in my ability to carry out PT services at my first job when I graduated.  What school did you go to?  Somewhere overseas??  After moving to a state that did not have direct access, from a state that did, my biggest frustration was that doctors did not refer patients to PT soon enough, or at all.  Often I had patients coming in with scripts when they should have been referred months previous.  They would say that their doctor "did not think they needed to go to therapy". And by the time they were referred, their condition was so much harder to treat.  I always thought that PT's should be the ones doing the referals to the docs, NOT the other way around.  If a person comes in to therapy and the PT suspects a medical condition beyond the scope of practice, the PT needs to refer the patient to their doctor.  People get so much worse waiting around for the doctor to finally give a PT referal script, and often patients dont even get one, or the doctor has no idea that he/she should be making referrals.  So lets work together PT's and stop being our own enemies.  Bad enough we gave half our practice away to OT's, massage therapists, athletic trainers, cardiac rehab nurses, physiotrists.....etc.  What will we have left?  Gait training littleold ladies following hip fractures?  Oh, no, now that is the nurses job!  Oh, maybe we can teach post surgical knee arthroscopy patients how to measure crutches.

Donna, Physical Therapy - MPT April 27, 2009 1:18 AM

I would like to say that many of us have been pushing for direct access to PT for a long time, especially in states that were behind the times, such as NY.  Even back when it was just a dream, I knew that PT's are their own worse enemy.  If you dont have the confidence in your area of expertise to perform independently and make proper judgements, then you should refer your patient to his or her doctor.  Lets not make a debate over competence that will interfere with autonomy for the rest of us.  There are so many "professions" that practice PT techniques without a license and do so with almost no training, and NEVER needed a script!  Here we are, trained to advance degrees and for years we needed a script from a doctor to do procedures like simple exercises!  A patient can go to an athletic trainer to learn strengthening exercises following a sports injury, but needed a script to go to a PT who knew more about rehabing the injury than the ATC.  A patient can see a massage therapist for back pain and get a massage, but needs a script to see a PT.  Likewise for chiropractors.  People can go to a GYM and have a personal trainer show them how to do back stabilization exercises, but needs a script to see  PT who knows much more about the postural stabilization and how it works.  This is outrageous practices.  And to think that PT's such as Toni are stating that they dont feel they have the skills necessary to carry out a patient interview and treatment without additional classes??  WOW, you really should re evaluate your background.  I felt confident in my ability to carry out PT services at my first job when I graduated.  What school did you go to?  Somewhere overseas??  After moving to a state that did not have direct access, from a state that did, my biggest frustration was that doctors did not refer patients to PT soon enough, or at all.  Often I had patients coming in with scripts when they should have been referred months previous.  They would say that their doctor "did not think they needed to go to therapy". And by the time they were referred, their condition was so much harder to treat.  I always thought that PT's should be the ones doing the referals to the docs, NOT the other way around.  If a person comes in to therapy and the PT suspects a medical condition beyond the scope of practice, the PT needs to refer the patient to their doctor.  People get so much worse waiting around for the doctor to finally give a PT referal script, and often patients dont even get one, or the doctor has no idea that he/she should be making referrals.  So lets work together PT's and stop being our own enemies.  Bad enough we gave half our practice away to OT's, massage therapists, athletic trainers, cardiac rehab nurses, physiotrists.....etc.  What will we have left?  Gait training littleold ladies following hip fractures?  Oh, no, now that is the nurses job!  Oh, maybe we can teach post surgical knee arthroscopy patients how to measure crutches.

Donna, Physical Therapy - MPT April 27, 2009 1:18 AM

Toni,

Hopefully those who do not have a DPT will recognize it and not want to practice as one and try to do the things a DPT knows how to do.  

We should all know our shortcomings but we shouldn't have to be reminded of them.  Those with a DPT certainly should have the knowledge yet they might not have the experience a BSPT possess.  

I have found those with a BSPT are sometimes reluctant to share their knowlege openly, I have to coax it out of them and ask a lot of questions.  BSPT's are smart and were trained well and have the experience but I wonder if they might not be used to the idea of being the primary provider.

Also it is nice to have a an MD we can refer back to if the patient is not improving.  Or do you think the MD will gladly accept us refering to them?  Then the MD will say, "See this could have been prevented if you came to me first instead of the PT"

Karen December 15, 2008 9:36 AM

Toni--

Again, another good post.  This topic has been debated on many forums.  I agree that I think PTs who have not recieved the DPT may not have adequate knowledge to handle direct access. Having been someone who graduated with a BS, then quicly went into a tDPT program, I recognize the shortcomings of an entry level BS.  When my program went to the MPT, the cirriculum did not change.  I think the stance by the APTA also ademently recognizes that DPTs should be prepared for direct access.  However, I think there will be more variation in the direct access practices than you elude to.  State practice acts will surely be revised.  I do think that you may see many states will allow direct access...but only by DPTs. Since I live in a state that houses the AMA, I think we'll be hard pressed in the state before we have "real" direct access (we have partical at this time).  However, I don't think the demand for direct access by patients will be utilzed well in the beginning. It will take a lot of educating of the consumer and I think it will be several years after implementing direct access before consumers are using it on a regular basis. I think this will allow PTs who desire this privlidge to return for the education they need.  I would welcome the comments from anyone praciting in a full direct access state.  I would like to ask what percentage of your case load actually utilizes direct access?  I imagine that physicians will continue to be our number one source of referrals.  

Direct access is in place in many places in the world...Canada being one of them and to the best of my knowledge, without any dire consequences.  

We must also remember that the DPT is not designed to "diagnosis" a medical illness, just that it's designed to help one pick up when it does not fit a normal neuromusculoskeletal pattern.  There is an excellent article called "Smart Handles in Neurological Diagnosis" by Hawkes which describes many essential physical exam techniques and observations which I think PTs are certainly capable of understanding.  

Finally, let's remember that direct access may also help patients avoid seeing a medical practicioner who really doesn't understand musculoskeletal medicine.  A study by Freedman found that 85% of medical school graduates fail to demonstrate competency on a musculoskeletal exam.  Further studies have also revealed that only about 1/3 of medical schools require physicians to take a course in musculoskeletal medicine.  I think there is a clear need for direct access in PT.  

Christie, Physical therapist December 11, 2008 9:21 AM
Streamwood IL

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