Are DPTs subordinate to medical doctors?

[mdbold]

Must DPTs follow a doctor's orders, like a nurse might, or do they get to do their own thing? I know I'm asking this in rehab science so the answers might be biased, but maybe I can get some insight.

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[hefe]

What do you define as "subordinate" and what practice settings are you referring?

A nurse is not a physical therapist, so they will not practice the same way.

Yes, a physician can write prescriptions for a physical therapist to follow, but this does not mean they are always best prescribing specific physical therapy exercises unless their residency setting (PMR) trained them for such.

There is a lot of variability and play depending on where you practice. The doctor does not know all, neither does the physical therapist, so ideally they should collaborate for the patient's benefit...

So, the physical therapist generally works a team-based approach where discussion of treatment ideas are discussed freely between the practitioners in the health care team. Doctors will prescribe the treatment modality of physical therapy among others, and usually the physical therapist is allowed to examine and treat within the physical therapy capacity.

However, with the current state I would not introduce myself a as Dr. Such and Such, especially in a hospital setting. You would simply say you are the patients physical therapist. You've earned a doctorate degree, however you are not a medical doctor. For the time being it is not worth battles of who's stepping on who's toes and can be called doctor. Ego issue abound in either trying to gain it (nursing) or conserve it (medical doctors). So at this point a silly title isn't worth it in the hospital. Your name tags speak for themselves, and you'll be best to let them deal with titles.

Best thing you can do is educate the patient in what you do while you are treating and help them understand the importance of such.

If you're getting worried of a medical doctor breathing down your back the whole time while you are practicing, this is rather false. There's a good degree of autonomy within your scope of practice. Each person needs to understand their respective roles and appreciation for such knowledge will follow.

 

[Fiveoboy11]

It depends upon the perspective. In my state (Arizona) physical therapists have direct access rights, and this is the case in the majority of the US. In those instances the physical therapist is in charge of physical therapy based upon law. It is inappropriate to disregard medical contraindications or precautions at the same time though. However, in the real world, this is nearly irrelevant. Physician's either do not respect that, don't care, or don't know. Perhaps they have been trained to believe they are in charge of everything relating to pt health care. Also, virtually all insurance companies require a physician prescription in order for PT services to be reimbursed. And in that case, in order to be reimbursed, the PT can only treat the body part(s) mentioned on the script.

By the way, an above post mentioned that physician's trained in PM&R are qualified to prescribe physical therapy treatment. A residency program for a physician does not decide when a person is qualified to provide physical therapy. Physical Therapy school followed by passing the state board does. Only a physical therapist is qualified. Other professionals may get a way with it, but it is, and always will be flagrantly inappropriate to do so.

Physical therapists are definitely thought of as a physician's subordinate. If you work in a private practice clinic, you are expected to follow a physician's "orders" to the letter so you don't piss them off. Often times when looking for a job in Physical Therapy the job summary will mention "Provide physical therapy under the supervision of a physician...." In general, based on my own experience, physician's do not respect physical therapist's as clinicians or specialists and therefore they apparently feel it is appropriate to tell a PT what to do for treatment.

Hopefully this will change with time, and I think it will.

 

[summerX]

I have been out of school a little bit and it seems that in school we were never told to follow what the physician tells you to do. I went into physical therapy thinking I would have autonomy. I have never seen anything in APTA or from my state licensing board that says we have to do what a physician tells us to do. In school we would come up with a plan of care, exercises and treatments that were appropriate, and we learned when it was appropriate to not pick up a patient for services and when to discharge patients. We were told that we were to follow indications, precautions, and if there was surgery a protocal that a physician gave us. Then, when I got out of school, I realized that in many settings you are told what to do by the physician and various members of the healthcare team and you basically are very restricted or aren't allowed to not pick up or discharge a patient. I am shocked. Secondly I have noticed that in certain settings we are seen by other healthcare members as a lifting/ sitting in chair/ out of bed service. There are some patients where I work that are appropriate and thank me, and I look foward to seeing them. Sometimes I walk into a patients room and the family member says o good you are the physical therapist- you are going to be getting them in the chair. Then I look at the patient and they are completely immobile. As for physicians orders, I usually follow them at least partially ( I believe that this is multidisciplinary ) or progress to what they want me to do. However this has gotten me in some trouble. I am currently looking for a different type of setting with more autonomy.

 

[mac_kin]

hey

 

[goyo1010]

Secondly I have noticed that in certain settings we are seen by other healthcare members as a lifting/ sitting in chair/ out of bed service. There are some patients where I work that are appropriate and thank me, and I look foward to seeing them. Sometimes I walk into a patients room and the family member says o good you are the physical therapist- you are going to be getting them in the chair. Then I look at the patient and they are completely immobile. As for physicians orders, I usually follow them at least partially ( I believe that this is multidisciplinary ) or progress to what they want me to do. However this has gotten me in some trouble. I am currently looking for a different type of setting with more autonomy.

I saw this at the acute care hospital where I observed. The nurses and doctors, especially the newer ones, would call/page the Physical Therapy department just to move the patients out of seats or the bed... The PT I was shadowing always got mad because that it wasn't her job to constantly move patients and she had to see this many patients in a certain time period and getting called to move patients detracted from her actual job. She said the nurses and doctors saw the PTs as simply movers. She couldn't complain though or the nurses/doctors would become angry and the whole hospital would go to h*ll.

 

[Fiveoboy11]

It's nice to see I'm not the only one who is bothered by this type of thing PT's encounter all day long.

 

[jesspt]

I can't speak with any kind of knowledge about settings other than outpatient orthopaedics, as I have spent most of my carreer in ortho. However, in this setting, I have encountered little of the referring providers lording over the physical therapy treatment process, or demanding that certain things be included in the treatment of their patients. Generally, most of the physicians in the area are pretty "hands-off" about this type of thing.

A few exceptions:

1. Post-surgical patients - I generally follow a variation of the Pottery Store Rule (http://schott.blogs.nytimes.com/2009/04/21/pottery-store-rule/) - Once a joint has been operated on by a surgeon, that surgeon "owns" it. They have seen the quality of the tissue, and know intimately how that tissue has been affected by the surgical intervention. So, I tend to follow any specific post-op intructions pretty closely.

2. The " I need to write down any possible treatment intervention down on the prescription pad so the PT is "authorized" to provide the service" precription that I sometimes recieve. Example: PT for Low Back Pain to include ROM, strengthening, lumbar stabilization/core strengthening, US, e-stim, myofascial release, manual therapy, home exercise program. For some reason, these tend to come from PM&R physicians more than other disciplines in my experience.

I tend to view these type of precriptions as "suggestions", and use my clinical judgement accordingly. My rationale is then put in a plan of care that is returned to the physician.

So, I guess I don't really feel "subordinate." I am making independent decision about patient care all of the time on a typical day.

 

[summerX]

She said the nurses and doctors saw the PTs as simply movers. She couldn't complain though or the nurses/doctors would become angry and the whole hospital would go to h*ll.

Yah in the hospital where I just quit/resigned it is acceptable for a CNA to page the PT to get the patient out of bed. Actually, the CCO told the therapy department that we are responsible for all of the transfers in the hospital during the day. We have to do it or we are not helping the patient. I mean are you joking...lol. Eventually the nursing supervisor wrote me up for arguing with the nurses/CNAs, but it is impossible for me to do physical therapy if I am constantly responding to pages. The hospital literally does go to h*ll if we don't move these people around, but you really shouldn't need to be a PT to be able to transfer/hoyerlift someone out of bed.

So now I am just looking for a better setting/environment. I am debating between outpatient ortho and home health... or maybe a bit of both if possible🙂

 

[fozzy40]

Example: PT for Low Back Pain to include ROM, strengthening, lumbar stabilization/core strengthening, US, e-stim, myofascial release, manual therapy, home exercise program. For some reason, these tend to come from PM&R physicians more than other disciplines in my experience.

Out of curiosity, do you find PM&R prescriptions more helpful? I'm sure there is a lot of variability between providers but generally speaking.

 

[TheOx777]

Yah in the hospital where I just quit/resigned it is acceptable for a CNA to page the PT to get the patient out of bed. Actually, the CCO told the therapy department that we are responsible for all of the transfers in the hospital during the day. We have to do it or we are not helping the patient. I mean are you joking...lol. Eventually the nursing supervisor wrote me up for arguing with the nurses/CNAs, but it is impossible for me to do physical therapy if I am constantly responding to pages. The hospital literally does go to h*ll if we don't move these people around, but you really shouldn't need to be a PT to be able to transfer/hoyerlift someone out of bed.

So now I am just looking for a better setting/environment. I am debating between outpatient ortho and home health... or maybe a bit of both if possible🙂

I am a pre-PT so I have plenty of years to learn the ins/outs of various hospital settings. How is it that a nurse supervisor has the authority to write you up? Does the rehab supervisor have the same authority to write a nurse up if they are viewed as "out of line"?

 

[mac_kin]

hey

 

[jesspt]

Out of curiosity, do you find PM&R prescriptions more helpful? I'm sure there is a lot of variability between providers but generally speaking.

Frankly, no. But they make up a very small percentage of my referral base, so I don't have a very large sample from which to draw conclusions.

I typically prefer to be made aware of any underlying pathology that might have beern found with imaging studies, as well as any potential "yellow flags" if they revealed themselves during the phsyician's examination. Other than that, "eval and treat" works just fine.

I certainly respect the physiatrist's vantage point and expertise in managing a patient's condition from the medical aspect. But I pride myself in keeping abreast of the latest research regarding how physical therapy can best impact the function of a patient with a musculoskeletal condition, and it has been my experience that it is sometimes difficult for physicans to puruse the physical therapy relevant literature to that same degree. And, it seems (at least around here) that many physiatrists seem to be very knowledgeable about physiatric interventions (injections, ESI, pharmocological management of pain, etc) and much less so about PT specific interventions such as mechanical diagnosis and treatment, treatment based classification schema for patients with low back pain, instrument-assisted soft-tissue mobilization, etc.

 

[fozzy40]

Frankly, no. But they make up a very small percentage of my referral base, so I don't have a very large sample from which to draw conclusions.

I typically prefer to be made aware of any underlying pathology that might have beern found with imaging studies, as well as any potential "yellow flags" if they revealed themselves during the phsyician's examination. Other than that, "eval and treat" works just fine.

I certainly respect the physiatrist's vantage point and expertise in managing a patient's condition from the medical aspect. But I pride myself in keeping abreast of the latest research regarding how physical therapy can best impact the function of a patient with a musculoskeletal condition, and it has been my experience that it is sometimes difficult for physicans to puruse the physical therapy relevant literature to that same degree. And, it seems (at least around here) that many physiatrists seem to be very knowledgeable about physiatric interventions (injections, ESI, pharmocological management of pain, etc) and much less so about PT specific interventions such as mechanical diagnosis and treatment, treatment based classification schema for patients with low back pain, instrument-assisted soft-tissue mobilization, etc.

I appreciate your honesty but that's what I figured. You do bring up a good point though about what should be included in the prescription but I'll bring this up in another thread. Thank you!

 

[S6MD]

You've earned a doctorate degree, however you are not a medical doctor. For the time being it is not worth battles of who's stepping on who's toes and can be called doctor. Ego issue abound in either trying to gain it (nursing) or conserve it (medical doctors).

I don't think it has as much to do with ego as it does patient safety. Why should a physical therapist ever introduce themselves as Dr. in an inpatient setting? Why should a nurse? Or any allied-health professional? The lay population can't distinguish between Ph.D, DPT, DNP and MD. In a hospital setting, doctor is a medical doctor and that shouldn't really change.

 

[goyo1010]

Lol, this topic has been argued to death on SDN. You can find posts upon posts upon posts upon posts of perspectives from both sides, including much vitriol and degrading remarks concerning physical therapy. This thread is not about this, but about whether or not physical therapists are subordinate to physicians. I know where this is going to lead, so let's just circumvent this whole thing, shall we?

I don't think it has as much to do with ego as it does patient safety. Why should a physical therapist ever introduce themselves as Dr. in an inpatient setting? Why should a nurse? Or any allied-health professional? The lay population can't distinguish between Ph.D, DPT, DNP and MD. In a hospital setting, doctor is a medical doctor and that shouldn't really change.

 

[Yohan]

Lol, this topic has been argued to death on SDN. You can find posts upon posts upon posts upon posts of perspectives from both sides, including much vitriol and degrading remarks concerning physical therapy. This thread is not about this, but about whether or not physical therapists are subordinate to physicians. I know where this is going to lead, so let's just circumvent this whole thing, shall we?

Well stated! 👍

 

[Fiveoboy11]

I don't think it has as much to do with ego as it does patient safety. Why should a physical therapist ever introduce themselves as Dr. in an inpatient setting? Why should a nurse? Or any allied-health professional? The lay population can't distinguish between Ph.D, DPT, DNP and MD. In a hospital setting, doctor is a medical doctor and that shouldn't really change.

A physical therapist does not introduce themselves as a doctor in an inpatient setting, never witnessed that once in my career. You know what I have witnessed though, a physician in a POP walk into the PT clinic introduce themselves as Dr. so and so to a patient and perform a patient visit as he/she would in the office. So, apparently it is ok for a physician to call themselves Dr. in a PT domain, but not ok for a DPT to call themselves Dr. in a physician domain. Seems hypocritical to me.

Currently, in a hospital setting, a "doctor" could be a psychologist (PhD), podiatrist (DPM), MD or DO. It is not only MD's. I'm sure I'm missing some too.

Any profession has the right to educate within their scope to a doctor level. That doesn't mean all those people walk around calling themselves Dr. every two seconds. The patient safety argument, and patient confusion arguments are not even valid relative to this from my perspective. Perhaps the physician way of doing things (nearly complete passivity on the part of the patient) is a large part of the issue. From my point of view, healthcare should foster consumer's/patient's who are aware and knowledgeable about their health, this includes them recognizing that "doctors" (MD's/DO's) are not the only "doctors."

 

[truthseeker]

A physical therapist does not introduce themselves as a doctor in an inpatient setting, never witnessed that once in my career. You know what I have witnessed though, a physician in a POP walk into the PT clinic introduce themselves as Dr. so and so to a patient and perform a patient visit as he/she would in the office. So, apparently it is ok for a physician to call themselves Dr. in a PT domain, but not ok for a DPT to call themselves Dr. in a physician domain. Seems hypocritical to me.

Currently, in a hospital setting, a "doctor" could be a psychologist (PhD), podiatrist (DPM), MD or DO. It is not only MD's. I'm sure I'm missing some too.

Any profession has the right to educate within their scope to a doctor level. That doesn't mean all those people walk around calling themselves Dr. every two seconds. The patient safety argument, and patient confusion arguments are not even valid relative to this from my perspective. Perhaps the physician way of doing things (nearly complete passivity on the part of the patient) is a large part of the issue. From my point of view, healthcare should foster consumer's/patient's who are aware and knowledgeable about their health, this includes them recognizing that "doctors" (MD's/DO's) are not the only "doctors."

Holy crap fiveoboy, you really sound like you have an axe to grind. You are behaving like someone who is bitter about not having the same respect a physician has. They have earned it and you have to as well. In any health care setting if you are introduced as "Dr. X" 99.9% of the time the person is a physician. Yes, occasionally they are a psychologist or something but the point of the DPT was/is not to give you a title.

 

[goyo1010]

AVOOIIID THIS TOPPIIICCC!!!!

blagharaghletowui!

 

[jesspt]

A physical therapist does not introduce themselves as a doctor in an inpatient setting, never witnessed that once in my career. You know what I have witnessed though, a physician in a POP walk into the PT clinic introduce themselves as Dr. so and so to a patient and perform a patient visit as he/she would in the office. So, apparently it is ok for a physician to call themselves Dr. in a PT domain, but not ok for a DPT to call themselves Dr. in a physician domain. Seems hypocritical to me.

Currently, in a hospital setting, a "doctor" could be a psychologist (PhD), podiatrist (DPM), MD or DO. It is not only MD's. I'm sure I'm missing some too.

Any profession has the right to educate within their scope to a doctor level. That doesn't mean all those people walk around calling themselves Dr. every two seconds. The patient safety argument, and patient confusion arguments are not even valid relative to this from my perspective. Perhaps the physician way of doing things (nearly complete passivity on the part of the patient) is a large part of the issue. From my point of view, healthcare should foster consumer's/patient's who are aware and knowledgeable about their health, this includes them recognizing that "doctors" (MD's/DO's) are not the only "doctors."

Sheesh. I don't know which MD/DO/DPM pissed in your kool-aide, but it has apparently left a sour taste in your mouth.

As a profession, we will make absolutely no inroads with physicians with an antagonistic approach. If we alienate them right off the bat with our attitude, we're probably worse off.

 

[Fiveoboy11]

Holy crap fiveoboy, you really sound like you have an axe to grind. You are behaving like someone who is bitter about not having the same respect a physician has. They have earned it and you have to as well. In any health care setting if you are introduced as "Dr. X" 99.9% of the time the person is a physician. Yes, occasionally they are a psychologist or something but the point of the DPT was/is not to give you a title.

I'm not even following how this reflects anything I said, or anything I actually believe.

I don't think I deserve the level of respect a physician gets. I never said the point of the DPT was to give me a title. When did I even imply that? I have no desire to be called Dr. and I have never introduced myself as one.

 

[Fiveoboy11]

Sheesh. I don't know which MD/DO/DPM pissed in your kool-aide, but it has apparently left a sour taste in your mouth.

As a profession, we will make absolutely no inroads with physicians with an antagonistic approach. If we alienate them right off the bat with our attitude, we're probably worse off.

Naa, I don't even drink Koolaide. At least the way I post stirs things up on here, more people view, more are exposed to the issues. That is a good thing if you ask me. I'll happily take the fall so more people are informed, whether they agree or not.

 

[Danae00]

Can't speak for how it works in the US, but in Canada PT is direct access across the country so autonomy is expected. We work with doctors, not under them.

I haven't done many placements yet as as student, but in talking to my CIs and colleagues I have heard that the most most doctors who choose to refer to PT will include their suspected or known diagnosis, giving perhaps weight bearing or post-surgical precautions/indications, and an "assess and treat" type of order.

Pretty much the rest is left up to the PT. Even in inpatient settings the PT is responsible for looking up lab values, diagnostic imaging results, reviewing the medications (not to change them, but looking for meds that might impact rehab), reading the chart notes, assessing the patient, and coming up with the treatment plan. The doctors defer to the PTs in any mobility related issues. The PTs on the other hand defer to the MDs in terms of medical issues.

 

[Danae00]

I saw this at the acute care hospital where I observed. The nurses and doctors, especially the newer ones, would call/page the Physical Therapy department just to move the patients out of seats or the bed... The PT I was shadowing always got mad because that it wasn't her job to constantly move patients and she had to see this many patients in a certain time period and getting called to move patients detracted from her actual job. She said the nurses and doctors saw the PTs as simply movers. She couldn't complain though or the nurses/doctors would become angry and the whole hospital would go to h*ll.

Yuck! The nursing staff and MDs that I'm working with right now are really great. Only if someone is a complex case (either medically or if the ability of the patient to mobilize is really unclear) will the nursing staff wait for a PT to assess the pt. The PT then can leave orders for the nursing staff on how to safely mobilize (i.e. 2 person mod assist sit->stand with 2WW, 1 person mod assist with transfer belt ambulate with 2WW and please have someone follow with wheelchair as pt may get SOB). We also can leave orders for the nurses such as to walk a patient 2-3x a day or get a patient up in a chair for at least an hour. We really work as a team to do whatever is in the patient's best interests.

The only time we tend to get paged is if our patients are cancelling their appointments due to a medical issue that arose. 🙁

 

[dg1984]

Most of the prescriptions that I see simply read "evaluate and treat". That is all you need as a physical therapist. In the outpatient orthopedic setting the referrals are vague and that doesn’t bother us as PTs. In the modern DPT programs we are instructed to treat anything that walks through the door and refer to the physician if the problem appears to lie outside of our scope of practice.

There is a huge problem comparing PT to nursing, PAs, NPs, or any other allied health field. These other professions aid physicians in medical practice. None of them, including doctors, are experts or qualified by law to practice physical therapy. Out autonomy is guaranteed and increasing as health care moves forward because there is no other provider that is competent or qualified to practice physical therapy.

To fozzy40 (who I have a lot of respect for based on our previous interactions)... The PM&R prescriptions for PT that include specifics are usually outdated treatments that have not withstood the test of time and research. "Evaluate and treat" is about all we need. Maybe it's a product of good schooling or good clinics, but in my experience physical therapists practice with a tremendous amount of autonomy.

In regards to post-surgery. The best rehab protocols are developed by PTs, possibly in conjunction with other MDs and researchers. Simply following a doc’s rehab protocol based his own mediocre anecdotal experience is setting the profession back 60 years. We aren’t glorified techs. If you find yourself doing this, please review the literature and step it up a notch. Don't belittle the profession by regressing to the mean after school and taking the easy way out. Do your homework, know the research and help your patients. Blindly following doctor's orders IS NOT what physical therapy is about. Maybe in 1960, but not now.

 

[dg1984]

As a side note, I agree with everything JessPT has said. I don't want to discount the surgeon's input. You HAVE to be able to read and understand the op report. But again, this doesn't tell you what to do, it tells you what you can not do. Something you should have a good handle on based on the surgical procedure.

I often find that the truly good orthopedic surgeons realize their great outcomes are a result of their great surgery + great rehab. Great surgery + mediocre rehab will give you mediocre outcomes.

 

[fozzy40]

To fozzy40 (who I have a lot of respect for based on our previous interactions)... The PM&R prescriptions for PT that include specifics are usually outdated treatments that have not withstood the test of time and research. "Evaluate and treat" is about all we need. Maybe it's a product of good schooling or good clinics, but in my experience physical therapists practice with a tremendous amount of autonomy.

Is that all physiatrists? Personally, I stay pretty up to date with current treatments.

 

[dg1984]

I am a novice clinician, so I am only speaking on limited experience with only a few PM&R docs. I am sure there are some awesome physiatrists out there (some of whom we have had lecture us throughout school). Bottom line, it doesn't speak well on the doctor's behalf to recommend 10-15 minutes of ultrasound. If you stay up to date with physical therapy literature and you can honestly support one treatment option over another, by all means write it and maybe even call us.

Like JessPT said, if you have any yellow/red flags based on patient interactions or imaging we would love to know. Also, giving us some general diagnostic information is useful. At some point physicians must realize that PTs provide a physical therapy evaluation and diagnosis that guides our treatment. For the sake of this post and its original message, a physician usually indirectly informs us what is unacceptable to do. If a patient has tethered cord, I would love the script to have “TETHERED CORD NO TRACTION” in bold letters. I feel that is more how physicians guide PT treatment, by making us aware of what must be avoided.

Also, Fozzy40, I am welcome to any and all questions regarding current research and treatment modalities. If you have any questions about the latest treatment methods or how I would handle a patient I would love to chat. It would be great if something that could actually help a patient came from these nauseating threads.