Mid-level Upcreep in PM&R?

[Osminog]

I’m starting my first year of medical school in a few months, and I recently shadowed a PM&R doc who’s been in practice for a decade or so. Her job seemed really cool—nice balance of medication management and procedures, and she has a pretty laid-back, flexible lifestyle.

One thing the doc complained about to me is that the physical therapists at the rehab center she frequently refers patients to sometimes contradict her when talking to patients and/or alter the therapy regimen that she orders. She said that DPTs are now emboldened by the fact that their degrees are doctorate-level, and that they are eager to step outside the scope of their practice. To give me an example, she told me that it was not uncommon for DPTs to inspect her patients’ EMGs and draw faulty conclusions from them.

Was this physiatrist exaggerating, or is this a serious area of concern in the field? Are physical therapists to PM&R what CRNAs are to anesthesiology, or what NPs are to family medicine?

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[Taus]

No. They are valuable members of the rehab team, but regardless of what they may say to a patient the only treatment they are providing is physical therapy. Also, I do make some recs re what I’d like them to include in the therapy and precautions, but they do know more about physical therapy than I do.

 

[PMR2008]

There are always other professionals who will try to do what you do or think they can do it better. It could be PA's,CRNA's, NP's, Chiropractors, therapists, family med docs who perform EMGs etc. Unfortunately patients end up suffering at times.
Unless you are a surgical specialty turf war with other non physician's is part of any practice. I have a good relationship with the DPT's I work with. At least in my state DPT's have direct access but can not make a diagnosis. They can not inject or prescribe medications. Also they can not order diagnostic imaging. So they are pretty limited.
They are a part of the team at my practice and certainly at times they point me to the right direction and vice versa.

 

[RangerBob]

I've never heard of a PT reading an EKG...

I do not worry about mid-level creep. Totally different field. And very helpful--my PT's come to me all the time and point out things like "so-and-so is getting some shoulder impingement signs" or "can I do a Dix-Hallpike on so-and-so? I think they have BPPV." You'd be amazed how often patient's will also not think to tell their MD something but they mention it to their therapist (who is working with them for an hour at a time).

I expect any therapist working with me (or that I refer a patient to) to abide by the precautions/contraindications I tell them. And I'll tell them the diagnosis (and if they think I'm wrong, then let them convince me--more power to them. But I work inpatient so the patient usually comes with a clear diagnosis...). But otherwise eval and treat and do what they do best.

Many PT's I've spoken with aren't happy about the DPT. They feel like they're just spending another year in school/borrowing more but not actually gaining anything tangible unless they go into academia/research.

 

[Bostonspine]

There are only a few of those DPT types and you just change your referral pattern... this is also why you ask you patient what they did in pt and there understanding of any referral you make so you can judge the quality. After practicing a few years you’ll know who’s good for what

 

[Musculo]

I’m a PT transitioning to med school in the fall. Yeah, there’s no mid-level creep for a PT. As said above, there’s a lot that is outside a PTs scope of practice that would prohibit them from realistically being an independent provider (such as not being able to order imaging). Did you mean read an EMG? Actually PTs can perform EMGs, so long as they receive additional training and become a certified in that practice (need to show evidence of performing a certain number of tests and pass a board exam). But I’m thinking that didn’t happen in this case since the physiatrist says the PT is interpreting them incorrectly. If not trained, that’s wildly out of his/her area of expertise.

 

[j4pac]

I’m a PT transitioning to med school in the fall. Yeah, there’s no mid-level creep for a PT. As said above, there’s a lot that is outside a PTs scope of practice that would not prohibit them from realistically being an independent provider (such as not being able to order imaging). Did you mean read an EMG? Actually PTs can perform EMGs, so long as they receive additional training and become a certified in that practice (need to show evidence of performing a certain number of tests and pass a board exam). But I’m thinking that didn’t happen in this case since the physiatrist says the PT is interpreting them incorrectly. If not trained, that’s widely out of his/her area of expertise.

Brings up the question of how you define expertise. How many cases? What level of complexity of cases? Which board exam? As a guy who has done a ton of EMGs...consider me a skeptic that there is a good avenue for a PT to become competent and not dangerous at performing EMG. I’d love to be enlighten though.

 

[Osminog]

I’m a PT transitioning to med school in the fall. Yeah, there’s no mid-level creep for a PT. As said above, there’s a lot that is outside a PTs scope of practice that would not prohibit them from realistically being an independent provider (such as not being able to order imaging). Did you mean read an EMG? Actually PTs can perform EMGs, so long as they receive additional training and become a certified in that practice (need to show evidence of performing a certain number of tests and pass a board exam). But I’m thinking that didn’t happen in this case since the physiatrist says the PT is interpreting them incorrectly. If not trained, that’s widely out of his/her area of expertise.

Ha, good catch. I meant EMGs. I'm not sure why I wrote EKGs. I edited the OP accordingly.

 

[Musculo]

Brings up the question of how you define expertise. How many cases? What level of complexity of cases? Which board exam? As a guy who has done a ton of EMGs...consider me a skeptic that there is a good avenue for a PT to become competent and not dangerous at performing EMG. I’d love to be enlighten though.

500 abnormal exams with the reports/findings reported to the licensing board. PTs have a specialty licensing board, the ABPTS. They have to submit proof that they worked under either a board certified PT or an MD/DO.

I’m not here to debate expertise or not. I think what’s outline above is pretty accurate picture of the role of PTs. I just brought up that particular piece about EMGs because it’s a very little known thing that PTs can do. There are less than 200 board certified PTs in the country that can perform EMGs. I taught a PT course and even the student PTs has not heard of this specialization.

 

[j4pac]

500 abnormal exams with the reports/findings reported to the licensing board. PTs have a specialty licensing board, the ABPTS. They have to submit proof that they worked under either a board certified PT or an MD/DO.

I’m not here to debate expertise or not. I think what’s outline above is pretty accurate picture of the role of PTs. I just brought up that particular piece about EMGs because it’s a very little known thing that PTs can do. There are less than 200 board certified PTs in the country that can perform EMGs. I taught a PT course and even the student PTs has not heard of this specialization.

My concern is what happens when it’s not CTS. That’s one of the most important roles of EMG...to rule out mimickers of conditions such as CTS. No chance I’d let a PT perform an EMG on my family member, just like I wouldn’t let a FP doc do a cervical TFESI on my loved ones. I don’t think that PTs understand the liability that they are buying.

 

[Musculo]

My concern is what happens when it’s not CTS. That’s one of the most important roles of EMG...to rule out mimickers of conditions such as CTS. No chance I’d let a PT perform an EMG on my family member, just like I wouldn’t let a FP doc do a cervical TFESI on my loved ones. I don’t think that PTs understand the liability that they are buying.

They are specifically asked to provide a report of polyneuropathy, peripheral neuropathy and a proximal lesion, so they would be able to differentiate between proximal and distal lesions and rule in/out mimickers. Where the utility of having a PT be able to do an EMG becomes close to nil is at the next step, which typically involves neurology or ortho for intervention/management beyond PT. So if they would end up there anyway, why not start there? There’s not much liability to be had by performing the tests since PTs basically work under physician orders. And it’s not like a surgeon would operate based off someone else’s EMG findings.

 

[j4pac]

They are specifically asked to provide a report of polyneuropathy, peripheral neuropathy and a proximal lesion, so they would be able to differentiate between proximal and distal lesions and rule in/out mimickers. Where the utility of having a PT be able to do an EMG becomes close to nil is at the next step, which typically involves neurology or ortho for intervention/management beyond PT. So if they would end up there anyway, why not start there? There’s not much liability to be had by performing the tests since PTs basically work under physician orders. And it’s not like a surgeon would operate based off someone else’s EMG findings.

Physicians that have PTs performing EMGs under their own license are much braver than I am. Thank you for increasing awareness on this topic.

 

[Splenda88]

If you are not cutting these days as a doc (aka surgery), midlevels will encroach into your territory. That does not mean they are doing a good job, but that is the landscape we (physicians) are in right now.

Almost everyone after getting another professional degree suddenly discovers it's cooler to be a doctor (aka physician).

 

[GoSpursGo]

Several posts were deleted for being inflammatory. Let's please try to keep this discussion civil.

 

[lobelsteve]

Lots of folks do EMGs. PMR/Neuro, PT, Neurophys techs, Chiro.

I have never come across anyone other than a handful of PMR docs who did fellowships in EMG (not necessary) that were able to establish concordance between EMG/imaging, history, and exam. 99% of EMGs done are useless and report on things that just are not there.

 

[fozzy40]

I would definitely be concerned about scope of practice creep from multiple fields. The PA and NP agendas are pretty well positioned.

 

[Piebaldi]

Lots of folks do EMGs. PMR/Neuro, PT, Neurophys techs, Chiro.

I have never come across anyone other than a handful of PMR docs who did fellowships in EMG (not necessary) that were able to establish concordance between EMG/imaging, history, and exam. 99% of EMGs done are useless and report on things that just are not there.

I would agree with the whole EMG thing. EMG is going the way of the dodo, and given the obscurity and lack of exactitude of location of pathology, they are essentially useless for any real surgical planning. So many possibilities for things to go wrong, that it's not worth it. Imaging is the way to go. Not to mention that reimbursement has essentially made it useless as well. If I was a surgeon, I would not order EMGs.

 

[fozzy40]

In the military, it is common for PTs to perform EMG/NCV with interpretation.

EDx I think is a great tool to answer specific questions. The problem is that most questions are the wrong ones...haha.

EMG I think also is probably more helpful to hand surgeons compared to spine surgeons.

In the creep discussion, I think that EMG is not the major threat.

 

[sloh]

I would agree with the whole EMG thing. EMG is going the way of the dodo, and given the obscurity and lack of exactitude of location of pathology, they are essentially useless for any real surgical planning. So many possibilities for things to go wrong, that it's not worth it. Imaging is the way to go. Not to mention that reimbursement has essentially made it useless as well. If I was a surgeon, I would not order EMGs.

Pretty useful for teasing out upper extremity pathology especially if it's equivocal whether symptoms are due to cervical radiculopathy or carpal tunnel. Some carpal tunnel symptoms can be quite severe and radiate proximal to the wrist. In comparison to many spine surgeries, carpal tunnel release confers good results. Agree that poor reimbursement makes EMG/NCS hard to justify from a financial standpoint.

 

[Piebaldi]

Pretty useful for teasing out upper extremity pathology especially if it's equivocal whether symptoms are due to cervical radiculopathy or carpal tunnel. Some carpal tunnel symptoms can be quite severe and radiate proximal to the wrist. In comparison to many spine surgeries, carpal tunnel release confers good results. Agree that poor reimbursement makes EMG/NCS hard to justify from a financial standpoint.

There are so many external factors, patient factors, provider factors that can affect the results that I would not be comfortable doing them. Yes I would agree prob the highest potential is for hand surgeons and carpal tunnel surgeries, but for radics in general, etc. useless.

 

[fozzy40]

The results are useless because of why they are ordered: pain. Personally, I rarely order EMG studies and when I do it's to explain weakness and not pain. If anything, I perform a limited exam to answer certain questions.

I digress. Creep is real.

 

[bear2020]

I don't know anyone who would request or accept an EMG result from anyone other than a physiatrist or neurologist. We have seen a few from chiros in the community and we simply tell patients "we can't use this". Just because people say they can do something. doesn't mean they know what they're doing.