Learning about what therapists do

[9732doc]

I'd like to better understand the specifics of what the PTs, OTs and Speech Therapists are actually doing with my patients both on the inpatient and outpatient side. I feel like this is a critical element of being a physiatrist, but I'm not really seeing where I will learn this in residency. When I make a prescription for therapy, I should be able to say more than 'eval and treat'. It is often suggested to go watch therapy session to learn about what the therapists are doing, and while useful, this is a pretty inefficient way to learn. Are there are any resources geared toward physicians to learn about the specifics of therapy? If not, that would be a very useful book for a physiatrist and PT/OT/SLP to get together and write.

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[DMBandFan86]

You should pick things up as you go. Learn more about modalities. As you know therapists don’t always do what you write on a Rx anyways

 

[j4pac]

If your contemplating something like an oral spasticity med or a med for autonomic dysreflexia/orthostasis, tell your therapists and try to see them together in therapy. It’s always nice to have a particular goal in mind.

 

[sloh]

I'd like to better understand the specifics of what the PTs, OTs and Speech Therapists are actually doing with my patients both on the inpatient and outpatient side. I feel like this is a critical element of being a physiatrist, but I'm not really seeing where I will learn this in residency. When I make a prescription for therapy, I should be able to say more than 'eval and treat'. It is often suggested to go watch therapy session to learn about what the therapists are doing, and while useful, this is a pretty inefficient way to learn. Are there are any resources geared toward physicians to learn about the specifics of therapy? If not, that would be a very useful book for a physiatrist and PT/OT/SLP to get together and write.

For outpatient MSK rehab I would recommend:

JOSPT

BJSM

Blog — Greg Lehman

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PT Inquest

PT Inquest -

PT Inquest was started as a way to discuss the use of science and evidence in the practice of physical therapy. The podcast explores current research discussing strengths, weaknesses, and clinical application in an honest, open,...

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Scot Morrison

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Derek Griffin

https://twitter.com/DerekGriffin86?s=21

David Poulter

https://twitter.com/Retlouping?s=21

 

[Beeftenderloin]

I'd like to better understand the specifics of what the PTs, OTs and Speech Therapists are actually doing with my patients both on the inpatient and outpatient side. I feel like this is a critical element of being a physiatrist, but I'm not really seeing where I will learn this in residency. When I make a prescription for therapy, I should be able to say more than 'eval and treat'. It is often suggested to go watch therapy session to learn about what the therapists are doing, and while useful, this is a pretty inefficient way to learn. Are there are any resources geared toward physicians to learn about the specifics of therapy? If not, that would be a very useful book for a physiatrist and PT/OT/SLP to get together and write.

My wife is an experienced PT who has done both outpatient and high acuity in patient care and I can tell you it actually drives her nuts when the script says anything other than “eval and treat”, for the exact reason that you are on here asking about. Most PM&R, neurologists, PCPs or Ortho docs don’t have a great understanding of what is actually going on in therapy sessions, what goes into a detailed PT(OT/ST) eval and plan of care in a patient with complex therapy needs. Often they don’t understand or respect the extent of training and level of expertise that a doctorate level trained therapist has. Or that once you write that script for therapy they are within their license to treat whatever they think is most pressing based on their evaluation and the patient goals.

If you want to better understand what’s going on in therapy sessions to be a better physiatrist, have a better understanding of the full scope of your patients care, and to communicate better with your therapy colleagues thats great! Just don’t do it with the expectation that you’ll be able to pick up and understand whats going on in therapy with anywhere near the level of expertise your therapist has. Stick to “eval and treat.”

I say all that recognizing there are good therapists and bad therapists. Just like there are good physicians and bad physicians.

 

[PMR2008]

From my prospective if a therapist is not going to do what I ask them to do I send my patients to a different one. I do specify what type of therapy I want the patent to do but at the same time I know my expertise is with diagnosing and injecting patients. The therapists I work with respect that and there is an open line of communication.

 

[9732doc]

If you want to better understand what’s going on in therapy sessions to be a better physiatrist, have a better understanding of the full scope of your patients care, and to communicate better with your therapy colleagues thats great!

Thanks for your thoughts. My goal is the above. I really do want to know what they are doing for my own knowledge and to communicate better with the therapists.

 

[PMR2008]

Spend time with them. I spent a couple hours a week while I was setting up my practice with local therapists. Worked well for marketing. The same can be done during residency if you have a patient cancellation or a light day.
Also read through the book Therapeutic Exercise : Foundations and techniques and if you have time The introduction to Physical therapy by Michael Pagliarulo. You can buy order editions for less than $20 each

 

[jesspt]

Thanks for your thoughts. My goal is the above. I really do want to know what they are doing for my own knowledge and to communicate better with the therapists.

Re; Outpatient ortho PT - there are published Clinical Practice Guidelines that you could review in order to better understand the PT interventions that are best supported by evidence for particular conditions. They can be found here.

 

[Fiveoboy11]

Refer with the understanding that you're not trained in therapy evaluation or treatment in any significant way that justifies "ordering" or "prescribing" particular evaluation or treatment. If you have a specific precaution or desire for particular treatment that's fine but trying to dictate a PT POC for example is unprofessional and should be considered bullying, abuse and malpractice in my view. The PT POC is up to the PT and the patient.

 

[Beeftenderloin]

From my prospective if a therapist is not going to do what I ask them to do I send my patients to a different one. I do specify what type of therapy I want the patent to do but at the same time I know my expertise is with diagnosing and injecting patients. The therapists I work with respect that and there is an open line of communication.

Right, and usually thats what happens. Prescribing doc writes a script for X. She does an eval and determines the patient needs Y. She contacts the prescribing doc and explains why she thinks they need Y and everyone is on the same page and it’s all good.

 

[Fiveoboy11]

Right, and usually thats what happens. Prescribing doc writes a script for X. She does an eval and determines the patient needs Y. She contacts the prescribing doc and explains why she thinks they need Y and everyone is on the same page and it’s all good.

Contacting the "prescribing doc" because the evaluation leads the PT in a particular direction as opposed to some "script" lead is hilarious to me. Bad fundamentals and impressively wasteful of expertise if you ask me.

 

[PMR2008]

Refer with the understanding that you're not trained in therapy evaluation or treatment in any significant way that justifies "ordering" or "prescribing" particular evaluation or treatment. If you have a specific precaution or desire for particular treatment that's fine but trying to dictate a PT POC for example is unprofessional and should be considered bullying, abuse and malpractice in my view. The PT POC is up to the PT and the patient.

Definitely not dictating therapy. But you are speaking with physiatrists here. We know a lot more about therapy than the average physician. We learn how to use modalities. I am trained as an osteopath and frequently will do things that a therapist can do. Muscle energy, strain-counter strain, HVLA, trigger point injections, soft tissue mobilization, exercise demonstration and prescription, modalities etc. Not saying most docs know this but in general Physiatrists have a lot more knowledge about this. In no way would I ever assume I can do therapy as good as a therapist. It is a team approach and they help me tremendously.

 

[PMR2008]

Just because I ask in my script to use a modality they might not have thought of or focus on specific muscles I noticed are causing issues is not 'malpractice' it is 'ideal practice'. The patients and therapist I have worked with for years appreciate this approach and again I am happy to help them if needed. They know a targeted injection will help therapy progress versus continuing to try more modalities and therapy.

 

[Fiveoboy11]

Just because I ask in my script to use a modality they might not have thought of or focus on specific muscles I noticed are causing issues is not 'malpractice' it is 'ideal practice'. The patients and therapist I have worked with for years appreciate this approach and again I am happy to help them if needed. They know a targeted injection will help therapy progress versus continuing to try more modalities and therapy.

It's not "ideal practice" if you're wrong and/or if your "script" primed the PT to just "follow the script" now did it? I suspect the quality of PT evaluations diminishes with more specificity on the "script" as opposed to allowing them to do their job they are fully trained and licensed to do.

 

[Fiveoboy11]

Definitely not dictating therapy. But you are speaking with physiatrists here. We know a lot more about therapy than the average physician. We learn how to use modalities. I am trained as an osteopath and frequently will do things that a therapist can do. Muscle energy, strain-counter strain, HVLA, trigger point injections, soft tissue mobilization, exercise demonstration and prescription, modalities etc. Not saying most docs know this but in general Physiatrists have a lot more knowledge about this. In no way would I ever assume I can do therapy as good as a therapist. It is a team approach and they help me tremendously.

No profession comes close to knowing what the physical therapy profession knows about physical therapy. First place among physicians does not make you a physical therapist.

 

[PMR2008]

I am not in a mood to discuss this online since you are not getting my point. If you read what I said " In no way would I ever assume I can do therapy as good as a therapist."
I have had a great relationship with the therapists I work with since the last 8 years and there is a reason for that. Best of luck with your practice.

 

[Fiveoboy11]

I am not in a mood to discuss this online since you are not getting my point. If you read what I said " In no way would I ever assume I can do therapy as good as a therapist."
I have had a great relationship with the therapists I work with since the last 8 years and there is a reason for that. Best of luck with your practice.

Well it's a touchy subject for me and I suspect for many other PT's as well. Have a good night.

 

[j4pac]

Well it's a touchy subject for me and I suspect for many other PT's as well. Have a good night.

I’m an interested in hearing the opinions on care from PTs and OTs. Completely disregarding a fellow MSK expert’s opinion screams insecurity. If others want to completely disregard my opinion...that’s fine. I’m not losing sleep over it.

 

[CallYap]

A touchy topic.
I would write a diagnosis I have discussed with the patient on what to do. If the PT has some other diagnosis they want to work on, I am OK with that when I am notified.
Frequency and durations are negotiable, depending on the progress. Medicare usually requires an evaluation every 30 days, and other insurance need some F/U.
I have some specific program or modality that I prefer and usually puts that down, but also write others in a general way to give leeway.
Goals and precautions are part of the script. Usually, the care plan comes back and adjustments are made. Most people are reasonable, and they accommodate my preferences as much as I do theirs. PM&R

 

[Fiveoboy11]

A touchy topic.
I would write a diagnosis I have discussed with the patient on what to do. If the PT has some other diagnosis they want to work on, I am OK with that when I am notified.
Frequency and durations are negotiable, depending on the progress. Medicare usually requires an evaluation every 30 days, and other insurance need some F/U.
I have some specific program or modality that I prefer and usually puts that down, but also write others in a general way to give leeway.
Goals and precautions are part of the script. Usually, the care plan comes back and adjustments are made. Most people are reasonable, and they accommodate my preferences as much as I do theirs. PM&R

You doctors are so hyper focused on some belief that "PT" is treatment that you prescribe, that you're incapable of having any legitimate clue. In my view, patients get inferior physical therapy care because of this physician gatekeeper snake oil paradigm. We evaluate the patient regardless of what your nearly useless diagnosis or script says and that's a requirement. It's not something you approve of. We don't get your ok to do our job. You don't give leeway because it's not yours to give. All aspects of physical therapy is under the full control of the Physical Therapist with no exceptions and that includes the goals and frequency and duration. Physicians with delusions of training, understanding and expertise may misuse and abuse power to circumvent that fact and/or some PT's may enable it, but that's another issue. I'd like to see a lot more formal complaints made by physicians against PT's when they don't get what they want because at least that'd put them under scrutiny as well and allow the PT to not be silenced.

 

[RangerBob]

You doctors are so hyper focused on some belief that "PT" is treatment that you prescribe, that you're incapable of having any legitimate clue. In my view, patients get inferior physical therapy care because of this physician gatekeeper snake oil paradigm. We evaluate the patient regardless of what your nearly useless diagnosis or script says and that's a requirement. It's not something you approve of. We don't get your ok to do our job. You don't give leeway because it's not yours to give. All aspects of physical therapy is under the full control of the Physical Therapist with no exceptions and that includes the goals and frequency and duration. Physicians with delusions of training, understanding and expertise may misuse and abuse power to circumvent that fact and/or some PT's may enable it, but that's another issue. I'd like to see a lot more formal complaints made by physicians against PT's when they don't get what they want because at least that'd put them under scrutiny as well and allow the PT to not be silenced.

I am thankful I have no go-it-alone therapists with that attitude on my unit.

The best therapists (and doctors) realize this is a team effort and that collaboration will result in the best treatment for patients.

When I assign precautions for a patient, my therapists listen. If I want to try something in therapy they listen (and correct me if it’s a bad idea). When my patient has no significant spasticity on exam but demonstrates problematic functional spasticity with movement, my therapists point it out and ask if we can start an oral med. The same for neurostimulants after BI. I don’t say “I’m the MD, you’re the PT, so I’ll ignore whatever you say and go with my own plan.” Instead I say “that’s a great idea!” And if it isn’t, I tell them why. This back and forth is what helps us get our patients rehabilitated and back home.

 

[avalon10]

You doctors are so hyper focused on some belief that "PT" is treatment that you prescribe, that you're incapable of having any legitimate clue. In my view, patients get inferior physical therapy care because of this physician gatekeeper snake oil paradigm. We evaluate the patient regardless of what your nearly useless diagnosis or script says and that's a requirement. It's not something you approve of. We don't get your ok to do our job. You don't give leeway because it's not yours to give. All aspects of physical therapy is under the full control of the Physical Therapist with no exceptions and that includes the goals and frequency and duration. Physicians with delusions of training, understanding and expertise may misuse and abuse power to circumvent that fact and/or some PT's may enable it, but that's another issue. I'd like to see a lot more formal complaints made by physicians against PT's when they don't get what they want because at least that'd put them under scrutiny as well and allow the PT to not be silenced.

Physical therapists with delusions of grandeur make me laugh.

 

[Fiveoboy11]

I am thankful I have no go-it-alone therapists with that attitude on my unit.

The best therapists (and doctors) realize this is a team effort and that collaboration will result in the best treatment for patients.

When I assign precautions for a patient, my therapists listen. If I want to try something in therapy they listen (and correct me if it’s a bad idea). When my patient has no significant spasticity on exam but demonstrates problematic functional spasticity with movement, my therapists point it out and ask if we can start an oral med. The same for neurostimulants after BI. I don’t say “I’m the MD, you’re the PT, so I’ll ignore whatever you say and go with my own plan.” Instead I say “that’s a great idea!” And if it isn’t, I tell them why. This back and forth is what helps us get our patients rehabilitated and back home.

I'm not go it all alone. I actually read physician reports and take anything they or any other healthcare professional has to say into account. That is not the case with regard to the majority of physicians in relation to physical therapy with their flippant attitude. There is zero chance the average physician comes close to being as thorough as the average physical therapist in reviewing the others work. The level of half ass it is incredible and obvious, but my point is that the physical therapist is in charge of physical therapy and not an orderly or a technician that does what you want.

 

[Fiveoboy11]

Physical therapists with delusions of grandeur make me laugh.

Nearly all physicians have delusions of grandeur with regard to physical therapy, so it's really not so funny

 

[avalon10]

I'm not go it all alone. I actually read physician reports and take anything they or any other healthcare professional has to say into account. That is not the case with regard to the majority of physicians in relation to physical therapy with their flippant attitude. There is zero chance the average physician comes close to being as thorough as the average physical therapist in reviewing the others work. The level of half ass it is incredible and obvious, but my point is that the physical therapist is in charge of physical therapy and not an orderly or a technician that does what you want.

I never read 99.99% of physical therapist reports because they're generally nonsense and useless documenation. Physical therapists can be useful, but most of them seem to not know what they're talking about at all. I can't believe how often a physical therapist tells a patient that their problem is that "their hips are out of alignment" or "one leg is longer than the other" or they have "piriformis syndrome." Or a million other ridiculous things.

Physical therapists are good at teaching people exercises but that's about it. Despite the "Doctorate of Physical Therapy" degree lol. Maybe 30 years ago PTs had associates degrees. And most of them have knowledge that still reflects that degree.

 

[avalon10]

Nearly all physicians have delusions of grandeur with regard to physical therapy, so it's really not so funny

I don't think a single physician in the world has "delusions of grandeur with regard to physical therapy" LOL. What a joke.
The average PT knows basically nothing about medicine. They have gotten a joke of a degree in their "Doctorate of Physical Therapy" and basically their job is to teach a patient strengthening exercises.
I had a roommate who was in PT school, and many of the people I met thru him have left the field and feel like they wasted their lives. I would feel the same way, I'm sure.

 

[RangerBob]

I'm not go it all alone. I actually read physician reports and take anything they or any other healthcare professional has to say into account. That is not the case with regard to the majority of physicians in relation to physical therapy with their flippant attitude. There is zero chance the average physician comes close to being as thorough as the average physical therapist in reviewing the others work. The level of half ass it is incredible and obvious, but my point is that the physical therapist is in charge of physical therapy and not an orderly or a technician that does what you want.

I appreciate you read physicians reports. I read my therapists reports as well (or talk to them in the halls). PM&R physicians do want do know what you're doing. Most others don't care as long as the patient feels better.

I disagree to some degree though about PT not being there to do what we want. Yes, you are a professional and the expert when it comes to PT, but when it comes to the diagnosis and pathophysiology behind the patient's injury, that's our domain. And it's yours as well if it's MSK-related, but we're still ultimately the ones responsible for the patient's care. We need to rule out more concerning issues. We need to decide what's absolutely or relatively contraindicated. And we need to convey that to you. If I send a post-fusion patient to you but forget to say what their precautions are, and then you have them doing cartwheels and somersaults and the patient gets injured, the patient may sue you. And then your lawyer is likely to point their finger at us physicians, and that's where the finger-pointing ends.

We prescribe PT just as we prescribe medications, and if we don't write down thorough instructions then it's the same as telling a pharmacist "patient has high blood pressure--eval and treat." Of course, if we trust the therapists, then we don't need to include so much detail. I write "eval and treat" for all my inpatient therapy orders. I trust them all, and if there are any contraindications I write them down. For outpt scripts I put more details in as the quality of therapy varies.

 

[avalon10]

I appreciate you read physicians reports. I read my therapists reports as well (or talk to them in the halls). PM&R physicians do want do know what you're doing. Most others don't care as long as the patient feels better.

I disagree to some degree though about PT not being there to do what we want. Yes, you are a professional and the expert when it comes to PT, but when it comes to the diagnosis and pathophysiology behind the patient's injury, that's our domain. And it's yours as well if it's MSK-related, but we're still ultimately the ones responsible for the patient's care. We need to rule out more concerning issues. We need to decide what's absolutely or relatively contraindicated. And we need to convey that to you. If I send a post-fusion patient to you but forget to say what their precautions are, and then you have them doing cartwheels and somersaults and the patient gets injured, the patient may sue you. And then your lawyer is likely to point their finger at us physicians, and that's where the finger-pointing ends.

We prescribe PT just as we prescribe medications, and if we don't write down thorough instructions then it's the same as telling a pharmacist "patient has high blood pressure--eval and treat." Of course, if we trust the therapists, then we don't need to include so much detail. I write "eval and treat" for all my inpatient therapy orders. I trust them all, and if there are any contraindications I write them down. For outpt scripts I put more details in as the quality of therapy varies.

A physical therapist reading a physicians report is the equivalent of an airport baggage handler reading the airline pilot’s flight plan.

He’s helpful at what he does, but has no way of understanding the big picture.

Not that there is anything wrong with being a baggage handler, but it’s just going outside one’s level of knowledge.

Most doctors and airline pilots are just cogs in the machine, too.

 

[RangerBob]

A physical therapist reading a physicians report is the equivalent of an airport baggage handler reading the airline pilot’s flight plan.

He’s helpful at what he does, but has no way of understanding the big picture.

Not that there is anything wrong with being a baggage handler, but it’s just going outside one’s level of knowledge.

Most doctors and airline pilots are just cogs in the machine, too.

I think there's quite a difference, given that there's much more overlap between a physiatrist and therapist than pilot (a professional) and baggage handler (could be a high school drop-out).

My therapists read my notes and find them very helpful in guiding their therapy. And if I missed something they point it out.

My therapists know pretty well the common meds we can use to help with agitation, arousal, mood, bowel/bladder, etc. They may not know the mechanisms of action and side effect profiles to be aware of, but it's still not all Greek to them.

 

[j4pac]

I'm not go it all alone. I actually read physician reports and take anything they or any other healthcare professional has to say into account. That is not the case with regard to the majority of physicians in relation to physical therapy with their flippant attitude. There is zero chance the average physician comes close to being as thorough as the average physical therapist in reviewing the others work. The level of half ass it is incredible and obvious, but my point is that the physical therapist is in charge of physical therapy and not an orderly or a technician that does what you want.

I read all of my therapy notes...but I have to admit...it's tough, because literally 99% of the notes that I read are not meant to be read by anyone other than billers. They are templated, copy paste, and tell me nothing. But I sift through them regardless hoping to find the 1% of notes that actually say something. It's actually incredibly rare that I see changes pre-and-post treatment at treatment completion in their documentation. There is no effort to conceal that they are just copying forward.

Not all therapists are like that...but not all physicians are the types of doctors that you present. It is commendable that you read physicians notes. If your patients are as challenging as mine, then you'd need every possible advantage to have any real chance of having a positive outcome. And that includes reading your other providers notes.