Our Talent Our Gift

Our vision and where we want to be… have we thought about this evolution? I accept professionals evolve; I do. I think we all need to have a heart to heart chat with the various changes some seem to be desiring.

Acquiring the ability to order diagnostic tests and prescribe medications seems to be important to many globally. Why is that?

I tend to think we need to sit back and think about gains and losses. (Yes, losses.)

Will acquiring the ability to order diagnostic tests or prescribe medications truly improve our ability to practice? I don’t think so.

For our scope of practice, how often do the results from a diagnostic test alter our treatment plans? When we are interested in having a diagnostic test, how often is it needed so an appropriate referral happens? If the reason for the diagnostic test is to help the patient have the right person intervening, wouldn’t it be better if the right person were involved with the ordering of the diagnostic tests so the right test was ordered and the right intervention can happen as soon as possible? Aren’t our examination and evaluative skills adequate enough to critically think and immediately know when the patient does need to be referred for care that is outside our scope of practice?

Another odd question: Most of the musculoskeletal diagnostic tests have a huge focus on the biomedical model.  How has the biomedical model helped society and cost of care? Is the biomedical model proving to have value? Does the biomedical model negatively impact outcomes in certain situations? Do we really want to so readily align ourselves with a broken model?

What happens to our listening ability, our examination skills, our time with the patient when we acquire the ability to order diagnostic tests? I think this is my biggest fear. Will we become a bit lazy? Will we become dependent on the almighty diagnostic test to tell the story versus hearing the story from the patient and verifying the story with our manual and observational skills?

Do we truly want to prescribe medications? Society as a whole is already over-medicated. What is actually gained via prescriptions? Won’t most over the counter medications and education be reasonable enough for most musculoskeletal issues? We have enough patients desiring the quick fix. Our interventions offer a long term solution versus a quick fix.

We are unique professionals. We have the luxury of time with our patients. We have mastered the ability to listen, to show empathy and to problem-solve with the patient. We merge the story we hear with what our hands feel and our eyes see.  I don’t think having the ability to order diagnostic tests or to prescribe medications enhances our value. I think by having such ability we unnecessarily increase cost of care. I view the desire to order diagnostic tests and prescribe medications as a venue to stroke our own egos and fall prey to the outdated biomedical model.

I’m sure many of you have thought about this same issue. Does ordering diagnostic tests and prescribing medications enhance our talent and our gift or will it hurt us long term?

Looking forward to your thoughts!

Until next time,

~Selena

 

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Comments

Dr. Ben Fung

As always, great thoughts, Selena! I must definitely agree: diagnostics & pharmaceutical really don’t add true value to social economic welfare – nor – does it to our profession at large. I would value imaging > drugs between the two; and in certain cases, such as diagnostic ultrasound – could prove situationally useful. Nevertheless, I think what would add the most value in this vein of thought is to elevate the PT profession to the point where direct access and the right to diagnose N-MSK (what we know better than ANY other health profession) conditions is given us to best serve society at large.

Rachael Lowe

It’s a very valid point. Will extending our scope of practice dampen our clinical reasoning expertise?

Selena Horner
Selena Horner
June 17, 2013 at 11:53 am

Ben, I think we do need to be careful as some of us begin to use imaging. Is it helpful? Sure. I tend to believe our current abilities are very good at knowing whether we can or cannot help the person in front of us. I also tend to think we are pretty good at knowing when the physician or a specialist should be brought into the scenario.

Rachael, I think yes. I think we’ll begin to take the “easy street” and overutilize diagnostic tests. Why? It’s easier than thinking. It improves our confidence. And then, over time, we lose what makes us unique and valuable.

Rob
Rob
June 17, 2013 at 12:09 pm

I think this industry already have an overzealousness towards prescribing NSAIDs to patients, even in spite of quite a lot of emerging studies that indicate that NSAIDs do nothing at all to help the condition, and may inf act be hindering a full recovery.
I think physiotherapy has moved away from where it should be, and it has allowed other professions to move in, I’m talking about myotherapists as a prime example. These Diploma qualified professionals are assessing and treating patients more effectively than a number of physios that I know. I can think of a few examples where a myo has succeeded in helping a patient to a near-full recovery in 1 or 2 treatments, when a physio has failed in 5 or 6 treatments. Myo’s clinical reasoning, diagnostic and pathological knowledge and skill is generally spot on. This industry needs to pull it’s head in and realise the prestige it once had is slipping away. Just my 2c.

Selena Horner

Rob, you bring up an excellent point. The pros and cons that should be included in making the decision to order either medications or imaging. In some cases, ordering brings on some negatives that need to be overcome to reach a successful outcome.

Rachael Lowe

Imaging is sometimes guilty of leading us down the wrong path, what use is that….?

Selena Horner

Does anyone know how often imaging is truly needed in a primary care setting for musculoskeletal complaints? I’m thinking of situations where a patient enters the system and initiates care with a physical therapist first.

Dan Rhon

Ok Selena, I promised you a response and here’s to keeping my word, albeit very late 🙂

As always, another great post and thanks for sharing your thoughts and opening this topic up for discussion.

I think we need to be careful in saying that something which can be misused is not useful. Few things are inherently “bad”, and this is where moderation, balance, appropriateness, etc are all things we might need to focus more on, rather than simply saying no across the board. . I can certainly understand the hesitation in taking on an additional responsibility, especially when there is a potential downside. Sure, we are not immune as a profession to also going down a path where it is misused. But having the ability to use this medical technology in no way means that our listening ability, examination skills, or time with patient has to be compromised. I just think that is a faulty assumption. Here are the main reasons why I think having these privileges is important for your practice as an MSK clinicians:

1. If we want to be direct access clinicians for MSK care, we need to have ALL the tools at our disposal to take care of our patients. It doesn’t mean we USE all the tools all or even most of the time. Patients will learn to trust you more if they know you have the ability to order these tests, but instead provide appropriate rationale for why it’s not necessary. We limit our potential as direct access providers, if our patients still feel in some cases that they need to see their PCM for a MSK complaint.

2. The research we do have already shows that we are one of the most responsible professions when it comes to utilizing imaging. Studies show that PT’s that have this privilege use it much less, and when they do, they are more diagnostically accurate than any other medical profession, except for orthopaedic surgeons, for which it is equivalent to (Moore, JOSPT, 2005).

3. I think it enhances you ability to communicate and reassure your patient. They are often not satisfied with rationale they get to not get imaging, and that is why they continue to put pressure on PCMs or simply go to someone else until they get it. We know that patients with LBP that see a PT within 14 days, rather than after 14 days of their visit to the PCM, regardless of the care they get, have significantly less advanced imaging during the following 18-month period (Fritz, Spine, 2012). I think this is due in part to the education and assurance they receive, that this is not a condition that requires it (we don’t really know from that study, but just my thoughts). Again, having the ability to order it, but successfully explaining to your patient why it is not necessary is a powerful way to not only improve patient satisfaction, but on a larger scale, cut down (or put a dent) on unnecessary imaging.

Regarding medications, there is a time and place where this is appropriate. Some patients will want this, even if advised to the limited benefits. The truth is that there are some short-term benefits that they may experience for which NSAIDs may be warranted. Again, misuse should not imply that they are not useful. If your patient has to go and see their PCM after seeing you, just so they can get some NSAIDs, then some might question the overall value of the direct access role. This is also an opportunity to provide quality education to patients on the role of NSAIDS, evidence to support efficacy, etc, and along with that comes the probability that these meds will be used even less.

It almost seems to me that we are afraid that we can’t handle the responsibility appropriately, so instead we need to play it safe and keep our distance. I think our profession has much more to offer and can rise above that. The focus can’t be on imaging or medications however, but rather on providing safe, quality, evidence-based care. They only help you do that in the select times when it’s appropriate.

Selena Horner

Thanks for sharing your perspective, Dan.

For me, it’s actually more than just a fear of handling the responsibility appropriately. There is also an identity aspect. Right now, physical therapists have a huge opportunity to be a cost-effective solution for the majority of musculoskeletal problems. As soon as we add the capability to order imaging and prescribe medications, our cost-effective value changes. If our profession begins to test those waters and has this additional responsibility, will we be as cost-effective?

I view imaging as so much more than just improving patient satisfaction or a tool at our disposal. This article on comparative cost-effectiveness kind of lays out my thoughts on the impact of imaging better than I can verbalize. Level 4, Level 5 and Level 6 in the table: Six Levels of Efficacy and Challenges for Comparative Effectiveness Research are more in line with my thoughts. I still wonder how often imaging is actually required. How often will our outcomes change because we have the ability to order diagnostic imaging?

Although your point #2 sounds reasonable, I’m not convinced. The population sample was military physical therapists versus civilian physical therapists. I’m not sure if the clinical decision-making of the military population is representative of all physical therapists.

In point #3, the therapists in the system analyzed did not have the capability to directly order images. I think #3 strengthens my argument that diagnostic imaging isn’t truly a necessary tool.

Maybe I’m completely wrong… In my opinion, having the ability to order imaging doesn’t necessarily improve patient care. IF the imaging is done appropriately, I will guess the imaging will provide a different working diagnosis. IF a different working diagnosis occurs, the patient has the exact same problem as if physical therapists couldn’t order imaging: waiting for appropriate care and waiting for access to care. The patient is either waiting on the front end for diagnostic testing OR waiting on the back end for access to care. If it were me, I think I’d rather wait for the testing… once someone knows something is wrong & different care is required, it certainly messes with one mentally, increases frustration, increases dissatisfaction of the health care system, increases fear.

Great discussion… thank you for making me think more deeply, Dan.

~Selena

Dan Rhon

Great thoughts Selena, and thanks for sharing that article as well. The value in this discussion is that we have 2 PT’s that come from opposite practice environments when it comes to this issue. For me personally, I have never known “not being able to order imaging”, and so I can appreciate that my perspective comes with that bias. That has been a tool in my toolbox since day one, and therefore I guess already a part of my identity. I’m cautious in saying that because in no way does this mean that “imaging” is part of my identity. I have no barriers to using it, but it is actually a tool that I very rarely pull out.

I won’t say that it’s “absolutely necessary” for me to have that privilege, because in truth I could probably call up someone else and ask them to do this, but I will say that there are times when imaging is absolutely appropriate and helpful, and preventing additional hassles for my patients goes a long way in improving satisfaction.

Your point on how often imaging is actually required I believe is an entirely different question. To me there are 2 questions: 1) Is diagnostic imaging absolutely necessary to provide effective patient care?… and 2) Do you need to use diagnostic imaging always or often to provide effective care? I certainly agree that it is required much less than it is actually used, for a variety of reasons, and absolutely not necessary most of the time. But to say that there is never a time when it is necessary is wrong. The series of cases in PTJ this month (Sept 2013 – Link: http://bit.ly/14YD3AR), which I believe had initiated this chat on twitter, specifically highlights how care was improved for these patient by having these privileges. It’s hard for me to say that there is absolutely no value in diagnostic imaging at all.

If the results from imaging change the plan of care, I certainly don’t think that poses the “exact same problem” for the patient. I would rather wait for imaging testing as well, as you’ve stated above, but waiting means you are choosing to defer the testing until the point where it might be more appropriate, not that it would never even be considered appropriate, which aligns perfectly with my overall point.

“A tool is only as good as the the skill of the craftsman using it”

Luis F Prato
Luis F Prato
September 9, 2013 at 12:09 pm

While I think that expanding our skill set is not the problem, and the vision of being the practitioners of choice for MSK care indeed requires we have more tools at our disposal, it is the current educational model that would limit the proper learning and their application for most PT’s. I feel that only with a residency or following the military model/direct access all across the country is how we can have ALL PT’s properly trained in prescription and diagnostic imaging interpretation. I agree that at this point our identity is not well defined to the public, and I feel that we may add to the confusion when some PT’s can do something and some others can’t. I feel we should give priority to promoting our existing skills and ability to manage movement impairments and continue to show how we are different not just complimentary to physicians

Selena Horner

So…. I’m swaying my opinion just a little bit. Maybe, just maybe the practice setting is key. I’m liking this model where physical therapists are in an orthopaedic office and the first in line for assessing patients to determine if conservative care will be adequate: http://www.biomedcentral.com/1471-2474/14/162

Selena Horner

Luis, thanks for sharing your thoughts. I hadn’t thought of the concept of increased confusion in the situation where some physical therapists are “advanced” and others are not. I agree with your thought on that aspect.

Jorge_ze
Jorge_ze
September 9, 2013 at 12:45 pm

Hi Selena, and everybody!
Good questions. Here in Spain we can not prescribe Imaging test, but recently passed prescripcción of certain medications and what is most important, technical aid prescripcción otherwise enter an administrative mess.
Personally, I consider myself a professional of movement, so I do not need those tests, if it is true, if you consider that test, important, we would resort to referral to another health professional.

Raúl Ferrer

Hi Selena,

It is certainly a thought we should do in depth, not the first time we see such different economic interests appear driveing the development of our profession, in Spain it it is more usual than we would like, and I think this may be a case more.

Is it really necessary? there are no others professional paths of development? no other professionals who already know how to do this we have to learn we to do?

Bill Egan
Bill Egan
September 9, 2013 at 3:47 pm

Interesting comments and discussion so far everyone. One question that arises with advanced standing in PT and the ability to order imaging and medications is what degree of education should be required? Is entry level DPT in US enough? Should post graduate residency or other certification be required to obtain this privilege? In the UK I think post-grad training is required? I practiced in the military and we were required to follow several steps to obtain and maintain credentialing as a neuromusculoskeletal evaluator (NMSE) which granted imaging and selected medication privileges. This included mentoring from radiologists and orthopedic surgeons, physician peer review, and a 2 week post graduate course. I am not sure what the requirements are now and they may vary by facility. Dan may be able to provide more up to date info here.

Another issue to consider is which other non-physician US healthcare providers can order imaging? It may depend on the state, but in my state (NJ) PA, NP, and DC can all order imaging as part of their scope of practice. Are these providers better equipped to order imaging compared to PT’s?

This commentary led by Bob Boyles is an excellent overview of this issue. http://bit.ly/1ajVnFy

Bill

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