Are We Ready for Direct Access?

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.  

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.

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.

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"

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.