Physical Therapists: Ordering Diagnostic Imaging

[dpthopeful2019]

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Hello all, wanted to reach out to this forum to see if anyone has any new/up-to-date/real-time information regarding imaging in physical therapy. I'm wrapping up my first imaging course, which has implored me to do some research on it--unsurprisingly, the APTA has taken a stance on it but has zero haste or a plan of action to push for prescribing rights. In the program I attend, we are absolutely hammered on imaging. The grading is done by orthopedic surgeons, and it seems as if they are expecting us to be as proficient at reading studies as traditionally trained medical providers. No issue here ofcourse, I absolutely love it and thoroughly enjoy the challenge which is why I have meandered over to this forum to poll you guys. Is the APTA, or rather the PT-PAC, currently lobbying for PTs to get these rights? If they are not, is this more of a state legislature thing and depends on where you practice/hold licensure? (I've seen a few states PTs are able to) I can't fathom a reason why the MSK specialists only second to orthopods are not allowed to order a study to confirm a clinical finding. I'd love for this to be a portion of our scope of practice moving forward. Any information on the outlook or input on the topic is welcome, as I think spurring this dialogue is a good thing. Cheers!

 

[ya1]

I don/t see PTs to be much involved in imaging any time soon. Most of us are not trained for that. We had a basic imaging course (not sure if people with masters degrees even had the basic one?). I do not have enough knowledge to interpret an image. I can understand basic stuff from imaging reports and explain it to patients which may be useful. PTs also can make recommendation for imaging when they communicate with pt's MDs.

 

[dpthopeful2019]

I don/t see PTs to be much involved in imaging any time soon. Most of us are not trained for that. We had a basic imaging course (not sure if people with masters degrees even had the basic one?). I do not have enough knowledge to interpret an image. I can understand basic stuff from imaging reports and explain it to patients which may be useful. PTs also can make recommendation for imaging when they communicate with pt's MDs.

I'm not saying solely interpreting images, but rather gaining rights to order them as well as be able to interpret them for what we're trying to confirm. Most PCPs might glance over the scans they order, but most just read the Radiologist's recommendations and then loop us in. I don't know what program you attend/have attended, but my exposure to rads is rather high. If I can offer an example, what are the differences between how a non-calcific supraspinatus tendinopathy and a calcific supraspinatus tendinopathy present? Absolutely nothing. Non-calcific tendinopathies respond to therapy, calcific ones do not--they need to be aspirated. The only thing that can differentiate the two is imaging. Food for thought.

Thanks for your post!

 

[Smash Atoms]

We get a ton of imaging but at the end of the day is imaging going to change how you treat?

 

[truthseeker]

I think that we are qualified to order imaging, but even the physicians will usually get an over-read by radiologists. PTs in Wisconsin already have the legal right to order imaging (recent) and military PTs have had that right for years (decades?)

 

[fozzy40]

We get a ton of imaging but at the end of the day is imaging going to change how you treat?

100%.

How does it change your treatment plan?

 

[KeikoTanaka]

So from a med student POV, I feel like the answer from a perfect world would be "The Physicians would order all the scans because they all report back to the PCP and he keeps tabs to keep down on exposure / ensure safety when receiving an X-ray". I feel like the contraindications for doing an X-ray may fall outside the scope of practice of a PT, so unless you wanted do a whole History and Physical of other medical conditions to ascertain whether or not an X-ray is even warranted in this case, which kind of throws off the whole flow of a day for a PT who is juggling many clients all at once.

But, in reality, Chiropractors are out here X-raying ppl left and right with no concern in the world so wuddever amirite?

 

[topher031888]

So from a med student POV, I feel like the answer from a perfect world would be "The Physicians would order all the scans because they all report back to the PCP and he keeps tabs to keep down on exposure / ensure safety when receiving an X-ray". I feel like the contraindications for doing an X-ray may fall outside the scope of practice of a PT, so unless you wanted do a whole History and Physical of other medical conditions to ascertain whether or not an X-ray is even warranted in this case, which kind of throws off the whole flow of a day for a PT who is juggling many clients all at once.

But, in reality, Chiropractors are out here X-raying ppl left and right with no concern in the world so wuddever amirite?

Lol, 100% correct about a lot of the chiropractors near where I live.


This is a great comment, it really helps us as PTs see what others know about and or think about our skill set. We really are musculoskeletal experts and are part of mainstream health care and can and will communicate information to the PCP whenever appropriate. There really isn't anything in regards to screening for imaging that would be beyond a competent therapists skill set, heck, a substantial chunk of my DPT education and my residency training has been focused toward better screening and not just orthopedic assessment and interventions. It is very important that we are able to identify potential other causes for pain that may appear to be musculoskeletal in nature but are not. I have yet to see a PCP evaluation as thorough as a PT evaluation simply because we have time. We really have more time to perform history and physical exams than any physician that I know, for example I have at least 40 minutes 1 on 1 for my examinations, sometimes I have a full hour (there is a lot of variation in this between practices and states).

There are a lot of valid concerns from letting another profession order imaging and what you say about chiropractors demonstrates some of those well. There is a large private orthopedic physician practice where I live that orders an MRI for almost all of their spine patients (at least the ones I end up seeing) so in that regard they are behaving any better than the chiropractors. Pt's are certainly not qualified to perform x-rays and our ability to actually read those images will vary greatly (I have had plenty of education about it but very little practice so I rely heavily on the radiologists findings). One of the values that PT's offer in this department is that we are very well trained and can play an important roll in drastically reducing the amount of unnecessary imaging taking place.

We get a lot of direct access in my practice and so a thorough evaluation and medical screening is extremely important. Its a waste of resources and money to have to have a patient go back to their PCP to get the images I recommend when we could just skip that visit, save them a chunk of money, and either refer them on to a specialist or continuing treating if appropriate. One common scenario; I see is someone for whom imaging is indicated (think Canadian C-spine/Ottawa ankle rules) but were referred to PT by their PCP without imaging and I have to send them back to their PCP to get an image before we can continue with PT. One that happened a while back was a child came to my office, had been seen by their PCP and an urgent care for knee pain, had x-rays taken twice of the knee without anything significant being found (this was over two months). Five minutes into his evaluation it was apparent there was a problem with the hip so I call the PCP, told them I was pretty sure he had a hip problem and recommended a hip x-ray and that I suspected a possible slipped capital femoral epiphysis. The PCP ordered the images and two days later the child was in surgery. The PCP and urgent care physician lacked appropriate assessment skills to even recommend the appropriate x-rays so this poor kid ended up with 3 x-rays instead of 1.

I really think we should be able to and we would likely not order that many images because as someone mentioned earlier, it really isn't helpful for treatment of most conditions. Of course, as someone else mentioned, it is helpful sometimes and saving time and money is where we would be valuable.

 

[fozzy40]

Lol, 100% correct about a lot of the chiropractors near where I live.


This is a great comment, it really helps us as PTs see what others know about and or think about our skill set. We really are musculoskeletal experts and are part of mainstream health care and can and will communicate information to the PCP whenever appropriate. There really isn't anything in regards to screening for imaging that would be beyond a competent therapists skill set, heck, a substantial chunk of my DPT education and my residency training has been focused toward better screening and not just orthopedic assessment and interventions. It is very important that we are able to identify potential other causes for pain that may appear to be musculoskeletal in nature but are not. I have yet to see a PCP evaluation as thorough as a PT evaluation simply because we have time. We really have more time to perform history and physical exams than any physician that I know, for example I have at least 40 minutes 1 on 1 for my examinations, sometimes I have a full hour (there is a lot of variation in this between practices and states).

There are a lot of valid concerns from letting another profession order imaging and what you say about chiropractors demonstrates some of those well. There is a large private orthopedic physician practice where I live that orders an MRI for almost all of their spine patients (at least the ones I end up seeing) so in that regard they are behaving any better than the chiropractors. Pt's are certainly not qualified to perform x-rays and our ability to actually read those images will vary greatly (I have had plenty of education about it but very little practice so I rely heavily on the radiologists findings). One of the values that PT's offer in this department is that we are very well trained and can play an important roll in drastically reducing the amount of unnecessary imaging taking place.

We get a lot of direct access in my practice and so a thorough evaluation and medical screening is extremely important. Its a waste of resources and money to have to have a patient go back to their PCP to get the images I recommend when we could just skip that visit, save them a chunk of money, and either refer them on to a specialist or continuing treating if appropriate. One common scenario; I see is someone for whom imaging is indicated (think Canadian C-spine/Ottawa ankle rules) but were referred to PT by their PCP without imaging and I have to send them back to their PCP to get an image before we can continue with PT. One that happened a while back was a child came to my office, had been seen by their PCP and an urgent care for knee pain, had x-rays taken twice of the knee without anything significant being found (this was over two months). Five minutes into his evaluation it was apparent there was a problem with the hip so I call the PCP, told them I was pretty sure he had a hip problem and recommended a hip x-ray and that I suspected a possible slipped capital femoral epiphysis. The PCP ordered the images and two days later the child was in surgery. The PCP and urgent care physician lacked appropriate assessment skills to even recommend the appropriate x-rays so this poor kid ended up with 3 x-rays instead of 1.

I really think we should be able to and we would likely not order that many images because as someone mentioned earlier, it really isn't helpful for treatment of most conditions. Of course, as someone else mentioned, it is helpful sometimes and saving time and money is where we would be valuable.

Good catches. However, I suspect for most that these are more the exception than the rule. 8/10 x-rays do not change the course of treatment. In your peds example, your did the right thing by referring them back because of your concern. If you had ordered xrays you still would've referred them back despite a good catch. However, if the xrays were normal and the pain level is still out of proportion most likely you would've referred them back too for advanced imaging. Conversely, I've worked mainly in the civilian world. I often had to order imaging to convince the therapist that it was "safe" to treat them. Not all but it is something that happens. Now that I work in the military system, PTs do have the ability to order imaging. In my experience their ordering patterns and sometimes misinterpretation ends up being similar to non-orthopedic specialists. Then ultimately they refer them to me (sports and spine PM&R.)

My point is that imaging and xrays in particular are not typically super helpful in the clinical course of things. Ordering MRIs often reveal many things people get excited about and/or do not have the means to do something about it aside from refer them to the next person. If want to keep them, then do it. Imaging should never tell you what you have but should confirm what you suspect. Like I tell residents, you should rarely be surprised at what you find on imaging. If you are surprised, then you shouldn't be ordering it.

To that end, I think we generally need less people ordering things and that includes physicians.

 

[KeikoTanaka]

Lol, 100% correct about a lot of the chiropractors near where I live.

This is a great comment, it really helps us as PTs see what others know about and or think about our skill set. We really are musculoskeletal experts and are part of mainstream health care and can and will communicate information to the PCP whenever appropriate. There really isn't anything in regards to screening for imaging that would be beyond a competent therapists skill set, heck, a substantial chunk of my DPT education and my residency training has been focused toward better screening and not just orthopedic assessment and interventions. It is very important that we are able to identify potential other causes for pain that may appear to be musculoskeletal in nature but are not. I have yet to see a PCP evaluation as thorough as a PT evaluation simply because we have time. We really have more time to perform history and physical exams than any physician that I know, for example I have at least 40 minutes 1 on 1 for my examinations, sometimes I have a full hour (there is a lot of variation in this between practices and states).

There are a lot of valid concerns from letting another profession order imaging and what you say about chiropractors demonstrates some of those well. There is a large private orthopedic physician practice where I live that orders an MRI for almost all of their spine patients (at least the ones I end up seeing) so in that regard they are behaving any better than the chiropractors. Pt's are certainly not qualified to perform x-rays and our ability to actually read those images will vary greatly (I have had plenty of education about it but very little practice so I rely heavily on the radiologists findings). One of the values that PT's offer in this department is that we are very well trained and can play an important roll in drastically reducing the amount of unnecessary imaging taking place.

We get a lot of direct access in my practice and so a thorough evaluation and medical screening is extremely important. Its a waste of resources and money to have to have a patient go back to their PCP to get the images I recommend when we could just skip that visit, save them a chunk of money, and either refer them on to a specialist or continuing treating if appropriate. One common scenario; I see is someone for whom imaging is indicated (think Canadian C-spine/Ottawa ankle rules) but were referred to PT by their PCP without imaging and I have to send them back to their PCP to get an image before we can continue with PT. One that happened a while back was a child came to my office, had been seen by their PCP and an urgent care for knee pain, had x-rays taken twice of the knee without anything significant being found (this was over two months). Five minutes into his evaluation it was apparent there was a problem with the hip so I call the PCP, told them I was pretty sure he had a hip problem and recommended a hip x-ray and that I suspected a possible slipped capital femoral epiphysis. The PCP ordered the images and two days later the child was in surgery. The PCP and urgent care physician lacked appropriate assessment skills to even recommend the appropriate x-rays so this poor kid ended up with 3 x-rays instead of 1.

I really think we should be able to and we would likely not order that many images because as someone mentioned earlier, it really isn't helpful for treatment of most conditions. Of course, as someone else mentioned, it is helpful sometimes and saving time and money is where we would be valuable.

I can't tell if you're offended based on the first line of what you said, if so, I'm sorry, I didn't mean to demean. I know PTs are capable of doing a very thorough P&E, and I 100% believe they should be able to order X-rays. Everything I said was prefaced with "in a perfect world", because, in a perfect world, the PCP wouldn't be rushed to see so many patients per day by unrealistic insurance demons and conglomerate hospital zombies. But alas we're in an imperfect world and perhaps those expectations have bred a culture of rushed physical exams... Also, there's always the possibility they're just bad doctors/are new/having a bad day/who knows?

I think that your story actually helps illustrate what's wrong with a lot of healthcare today. There is too much fragmentation. Urgent care doesn't communicate with PCP...two useless X-rays are performed on the same wrong part of the body, then had to go get a third finally in the right one (Great job btw)...

In what I hope will be a better future with healthcare by the time I'm actually practicing in 5.5 years (im not counting..yes im counting) will be a recentralization back to the PCP hub with streamlined communication between specialists/therapy/emergency/surgical/ancillary services. This way, medical decisions can be me made in real time in a more collaborative effort when warranted: Hey Doc, based on the knee X-ray you had done that I looked at, and based on my own assessment, I don't think this is a knee problem and actually think it could be a hip problem. Given that she has had an X-ray (That both providers in this case can access (when warranted) due to streamlined communication) and based on my own medical assessment, I ordered a Hip X-ray. Then, of course a radiologist would read it, and both PCP and ordering PT/other medical professional will see the assessment and prints, and the proper ortho specialist would be alerted at that time, can see the X-rays, and the patient is sent for surgery. Then after the fact, there would be increased communication in said streamlined communication back to you as the PT who now could take in this patient (as im sure they'll have a lot of somatic dysfunction throughout their life) and should anything ever happen in the future, you don't need to necessarily communicate with the PCP, you've already created a streamlined communication between the orthopedic surgeon who can be updated if any emergent sequela arise. Of course the PCP would be in the loop the whole time by being the "link" between the two specialists. but unless anything really concerns them, they can save the patient time and money by not necessarily always having to physically report back to them.

Sorry for the wall of text.
TLDR: PTs should be able to order/collaborate in ordering X-rays as it pertains to MSK complaints and we need a less fragmented healthcare system in which medical providers (especially PCPs) have a streamlined way to collaborate in medical decision-making to save in costs, time, and unnecessary medical treatment to patients.

 

[fozzy40]

I can't tell if you're offended based on the first line of what you said, if so, I'm sorry, I didn't mean to demean. I know PTs are capable of doing a very thorough P&E, and I 100% believe they should be able to order X-rays. Everything I said was prefaced with "in a perfect world", because, in a perfect world, the PCP wouldn't be rushed to see so many patients per day by unrealistic insurance demons and conglomerate hospital zombies. But alas we're in an imperfect world and perhaps those expectations have bred a culture of rushed physical exams... Also, there's always the possibility they're just bad doctors/are new/having a bad day/who knows?

I think that your story actually helps illustrate what's wrong with a lot of healthcare today. There is too much fragmentation. Urgent care doesn't communicate with PCP...two useless X-rays are performed on the same wrong part of the body, then had to go get a third finally in the right one (Great job btw)...

In what I hope will be a better future with healthcare by the time I'm actually practicing in 5.5 years (im not counting..yes im counting) will be a recentralization back to the PCP hub with streamlined communication between specialists/therapy/emergency/surgical/ancillary services. This way, medical decisions can be me made in real time in a more collaborative effort when warranted: Hey Doc, based on the knee X-ray you had done that I looked at, and based on my own assessment, I don't think this is a knee problem and actually think it could be a hip problem. Given that she has had an X-ray (That both providers in this case can access (when warranted) due to streamlined communication) and based on my own medical assessment, I ordered a Hip X-ray. Then, of course a radiologist would read it, and both PCP and ordering PT/other medical professional will see the assessment and prints, and the proper ortho specialist would be alerted at that time, can see the X-rays, and the patient is sent for surgery. Then after the fact, there would be increased communication in said streamlined communication back to you as the PT who now could take in this patient (as im sure they'll have a lot of somatic dysfunction throughout their life) and should anything ever happen in the future, you don't need to necessarily communicate with the PCP, you've already created a streamlined communication between the orthopedic surgeon who can be updated if any emergent sequela arise. Of course the PCP would be in the loop the whole time by being the "link" between the two specialists. but unless anything really concerns them, they can save the patient time and money by not necessarily always having to physically report back to them.

Sorry for the wall of text.
TLDR: PTs should be able to order/collaborate in ordering X-rays as it pertains to MSK complaints and we need a less fragmented healthcare system in which medical providers (especially PCPs) have a streamlined way to collaborate in medical decision-making to save in costs, time, and unnecessary medical treatment to patients.

I appreciate your optimism! However, this is the exact opposite vision and mission of the APTA. Decentralizing musculoskeletal care away from the medical model where patients need to see physicians first is the overarching theme. PTs want to be first line with respect to musculoskeletal care. I agree in some respects but have have mixed feelings about it overall.

 

[truthseeker]

fozzy40 is right about the vision of APTA to have PTs be more of a front line manager of MSK problems. I really think that our education is sufficient to catch those things that are outside of our scope and our (in general) level of integrity, makes us the perfect profession to manage those folks because we really view ourselves as part of the team, rather than a lone wolf, out to prove how smart we are.

There was a study a few years ago that compared the appropriateness of imaging ordered by PTs vs NPs/PAs, and family practice MD/DOs , vs Orthopedists (of course I can't find it) and PTs recommended the "appropriate" imaging study more often than anyone except the orthos.

that said, I have practiced for 28 years as a PT, have never ordered an image, but have good enough relationships with my docs, that if I want something, they usually will order it for me. PTs have been doing it for years in the military. I think its coming.

 

[topher031888]

I can't tell if you're offended based on the first line of what you said, if so, I'm sorry, I didn't mean to demean. I know PTs are capable of doing a very thorough P&E, and I 100% believe they should be able to order X-rays. Everything I said was prefaced with "in a perfect world", because, in a perfect world, the PCP wouldn't be rushed to see so many patients per day by unrealistic insurance demons and conglomerate hospital zombies. But alas we're in an imperfect world and perhaps those expectations have bred a culture of rushed physical exams... Also, there's always the possibility they're just bad doctors/are new/having a bad day/who knows?

I think that your story actually helps illustrate what's wrong with a lot of healthcare today. There is too much fragmentation. Urgent care doesn't communicate with PCP...two useless X-rays are performed on the same wrong part of the body, then had to go get a third finally in the right one (Great job btw)...

In what I hope will be a better future with healthcare by the time I'm actually practicing in 5.5 years (im not counting..yes im counting) will be a recentralization back to the PCP hub with streamlined communication between specialists/therapy/emergency/surgical/ancillary services. This way, medical decisions can be me made in real time in a more collaborative effort when warranted: Hey Doc, based on the knee X-ray you had done that I looked at, and based on my own assessment, I don't think this is a knee problem and actually think it could be a hip problem. Given that she has had an X-ray (That both providers in this case can access (when warranted) due to streamlined communication) and based on my own medical assessment, I ordered a Hip X-ray. Then, of course a radiologist would read it, and both PCP and ordering PT/other medical professional will see the assessment and prints, and the proper ortho specialist would be alerted at that time, can see the X-rays, and the patient is sent for surgery. Then after the fact, there would be increased communication in said streamlined communication back to you as the PT who now could take in this patient (as im sure they'll have a lot of somatic dysfunction throughout their life) and should anything ever happen in the future, you don't need to necessarily communicate with the PCP, you've already created a streamlined communication between the orthopedic surgeon who can be updated if any emergent sequela arise. Of course the PCP would be in the loop the whole time by being the "link" between the two specialists. but unless anything really concerns them, they can save the patient time and money by not necessarily always having to physically report back to them.

Sorry for the wall of text.
TLDR: PTs should be able to order/collaborate in ordering X-rays as it pertains to MSK complaints and we need a less fragmented healthcare system in which medical providers (especially PCPs) have a streamlined way to collaborate in medical decision-making to save in costs, time, and unnecessary medical treatment to patients.

There was no offense whatsoever, that was not meant to be that way at all. Thanks for excellent response!

 

[topher031888]

fozzy40 is right about the vision of APTA to have PTs be more of a front line manager of MSK problems. I really think that our education is sufficient to catch those things that are outside of our scope and our (in general) level of integrity, makes us the perfect profession to manage those folks because we really view ourselves as part of the team, rather than a lone wolf, out to prove how smart we are.

There was a study a few years ago that compared the appropriateness of imaging ordered by PTs vs NPs/PAs, and family practice MD/DOs , vs Orthopedists (of course I can't find it) and PTs recommended the "appropriate" imaging study more often than anyone except the orthos.

that said, I have practiced for 28 years as a PT, have never ordered an image, but have good enough relationships with my docs, that if I want something, they usually will order it for me. PTs have been doing it for years in the military. I think its coming.

I was trying to track that study down as well but can't find it anymore. Thankfully I do have a similar situation with most of the other providers I work with and getting the appropriate imaging has never been an issue, the only real issue is it has often required an

Good catches. However, I suspect for most that these are more the exception than the rule. 8/10 x-rays do not change the course of treatment. In your peds example, your did the right thing by referring them back because of your concern. If you had ordered xrays you still would've referred them back despite a good catch. However, if the xrays were normal and the pain level is still out of proportion most likely you would've referred them back too for advanced imaging. Conversely, I've worked mainly in the civilian world. I often had to order imaging to convince the therapist that it was "safe" to treat them. Not all but it is something that happens. Now that I work in the military system, PTs do have the ability to order imaging. In my experience their ordering patterns and sometimes misinterpretation ends up being similar to non-orthopedic specialists. Then ultimately they refer them to me (sports and spine PM&R.)

My point is that imaging and xrays in particular are not typically super helpful in the clinical course of things. Ordering MRIs often reveal many things people get excited about and/or do not have the means to do something about it aside from refer them to the next person. If want to keep them, then do it. Imaging should never tell you what you have but should confirm what you suspect. Like I tell residents, you should rarely be surprised at what you find on imaging. If you are surprised, then you shouldn't be ordering it.

To that end, I think we generally need less people ordering things and that includes physicians.

I 100% agree, I think in the last year I have only recommended imaging 5-10 times, it really isn't helpful the vast majority of cases. What you are explaining is something we as PTs are constantly preaching to our patients. Especially when it comes to MRI, there is such thing as too much information. I remember reading a study (wish I could remember where) that said something like 5-15% of imaging is actually helpful for treatment.

Most of the imaging I recommend is either because there was clear indication of it, usually following trauma or certain red flags that became apparent during the examination, or they have failed to improve through conservative care. Even then it is still only occasionally helpful but is often done to rule out potential more sinister causes. For example we had a patient in our clinic that presented with no concerning symptoms, just hip pain that behaved like your typical arthritic joint. Had been referred by her PCP. Did not improve after a few weeks so she went and had some imaging done and revealed what turned out to be breast cancer. The other 99% of the time it comes back and its just typical degenerative changes that may or may not even be related to their current problem.

 

[nd_dpt]

I can't tell if you're offended based on the first line of what you said, if so, I'm sorry, I didn't mean to demean. I know PTs are capable of doing a very thorough P&E, and I 100% believe they should be able to order X-rays. Everything I said was prefaced with "in a perfect world", because, in a perfect world, the PCP wouldn't be rushed to see so many patients per day by unrealistic insurance demons and conglomerate hospital zombies. But alas we're in an imperfect world and perhaps those expectations have bred a culture of rushed physical exams... Also, there's always the possibility they're just bad doctors/are new/having a bad day/who knows?

I think that your story actually helps illustrate what's wrong with a lot of healthcare today. There is too much fragmentation. Urgent care doesn't communicate with PCP...two useless X-rays are performed on the same wrong part of the body, then had to go get a third finally in the right one (Great job btw)...

In what I hope will be a better future with healthcare by the time I'm actually practicing in 5.5 years (im not counting..yes im counting) will be a recentralization back to the PCP hub with streamlined communication between specialists/therapy/emergency/surgical/ancillary services. This way, medical decisions can be me made in real time in a more collaborative effort when warranted: Hey Doc, based on the knee X-ray you had done that I looked at, and based on my own assessment, I don't think this is a knee problem and actually think it could be a hip problem. Given that she has had an X-ray (That both providers in this case can access (when warranted) due to streamlined communication) and based on my own medical assessment, I ordered a Hip X-ray. Then, of course a radiologist would read it, and both PCP and ordering PT/other medical professional will see the assessment and prints, and the proper ortho specialist would be alerted at that time, can see the X-rays, and the patient is sent for surgery. Then after the fact, there would be increased communication in said streamlined communication back to you as the PT who now could take in this patient (as im sure they'll have a lot of somatic dysfunction throughout their life) and should anything ever happen in the future, you don't need to necessarily communicate with the PCP, you've already created a streamlined communication between the orthopedic surgeon who can be updated if any emergent sequela arise. Of course the PCP would be in the loop the whole time by being the "link" between the two specialists. but unless anything really concerns them, they can save the patient time and money by not necessarily always having to physically report back to them.

Sorry for the wall of text.
TLDR: PTs should be able to order/collaborate in ordering X-rays as it pertains to MSK complaints and we need a less fragmented healthcare system in which medical providers (especially PCPs) have a streamlined way to collaborate in medical decision-making to save in costs, time, and unnecessary medical treatment to patients.

I can barely get a medical assistant on the phone when calling a doctors office, let alone have "streamlined communication" with all healthcare providers involved in a patient's care.

 

[KeikoTanaka]

I can barely get a medical assistant on the phone when calling a doctors office, let alone have "streamlined communication" with all healthcare providers involved in a patient's care.

In this system that I envisioned, there would be a very integrated EHR that all specialties/healthcare professionals would use. Therefore, when I say "streamlined" I mean in the sense that you can quickly text/message/email providers with as much simplicity as using Facebook Messenger. If you are talking about a particular patient, you can seamlessly click and bring up their whole chart all the while your conversation is tagged and saved to that patient's chart. Therefore if insurance ever looked back, they'd see such conversation associated with particular charts. Information can be easily shared between providers when relevant, and can be seamlessly become part of your new note for said patient.

For example, it's the end of the day, I have nothing more to do than just finish up notes / check emails.

Important emails about emergent labs/imaging/hospitalizations of your patients would be "red flagged" and the provider would be notified right away if any of those red flags come in on their phone or their main computer. Therefore during the next little break they have, they know they need to get these biopsy results/chest xrays/emergency provider calls/reports answered right away. This would bypass the medical assistant and front desk all together.

All non-emergent patient emails about refills/rescheduling/scheduling could be directed to Medical Assistants/Front desk's email and would have a low acuity color flag associated.

Obviously it would be impossible for you to message said provider and expect a response right away, but if your patient suddenly has a seizure during your appointment and is rushed to the ER, that would be a red flag message and the provider would see right away (Assuming they have access to their phone/computer)

Obviously there's a lot of kinks to iron out about how it'll all work... but as EHRs get better, I inevitably see this happening.

 

[fozzy40]

@KeikoTanaka I encourage you to keep this idealism because ultimately I think everyone (especially patients) would benefit from collaboration. I think what you are describing is about transparency and ease of data acquisition. Google (of course) is working on something like this already. Very awesome.

 

[dpthopeful2019]

Hey guys, sorry a bit late to getting back this forum--life's got a hell of a set of legs and will run away with the time if you aren't careful I'll tell ya.

I can't tell if you're offended based on the first line of what you said, if so, I'm sorry, I didn't mean to demean. I know PTs are capable of doing a very thorough P&E, and I 100% believe they should be able to order X-rays. Everything I said was prefaced with "in a perfect world", because, in a perfect world, the PCP wouldn't be rushed to see so many patients per day by unrealistic insurance demons and conglomerate hospital zombies. But alas we're in an imperfect world and perhaps those expectations have bred a culture of rushed physical exams... Also, there's always the possibility they're just bad doctors/are new/having a bad day/who knows?

I think that your story actually helps illustrate what's wrong with a lot of healthcare today. There is too much fragmentation. Urgent care doesn't communicate with PCP...two useless X-rays are performed on the same wrong part of the body, then had to go get a third finally in the right one (Great job btw)...

In what I hope will be a better future with healthcare by the time I'm actually practicing in 5.5 years (im not counting..yes im counting) will be a recentralization back to the PCP hub with streamlined communication between specialists/therapy/emergency/surgical/ancillary services. This way, medical decisions can be me made in real time in a more collaborative effort when warranted: Hey Doc, based on the knee X-ray you had done that I looked at, and based on my own assessment, I don't think this is a knee problem and actually think it could be a hip problem. Given that she has had an X-ray (That both providers in this case can access (when warranted) due to streamlined communication) and based on my own medical assessment, I ordered a Hip X-ray. Then, of course a radiologist would read it, and both PCP and ordering PT/other medical professional will see the assessment and prints, and the proper ortho specialist would be alerted at that time, can see the X-rays, and the patient is sent for surgery. Then after the fact, there would be increased communication in said streamlined communication back to you as the PT who now could take in this patient (as im sure they'll have a lot of somatic dysfunction throughout their life) and should anything ever happen in the future, you don't need to necessarily communicate with the PCP, you've already created a streamlined communication between the orthopedic surgeon who can be updated if any emergent sequela arise. Of course the PCP would be in the loop the whole time by being the "link" between the two specialists. but unless anything really concerns them, they can save the patient time and money by not necessarily always having to physically report back to them.

Sorry for the wall of text.
TLDR: PTs should be able to order/collaborate in ordering X-rays as it pertains to MSK complaints and we need a less fragmented healthcare system in which medical providers (especially PCPs) have a streamlined way to collaborate in medical decision-making to save in costs, time, and unnecessary medical treatment to patients.

In this system that I envisioned, there would be a very integrated EHR that all specialties/healthcare professionals would use. Therefore, when I say "streamlined" I mean in the sense that you can quickly text/message/email providers with as much simplicity as using Facebook Messenger. If you are talking about a particular patient, you can seamlessly click and bring up their whole chart all the while your conversation is tagged and saved to that patient's chart. Therefore if insurance ever looked back, they'd see such conversation associated with particular charts. Information can be easily shared between providers when relevant, and can be seamlessly become part of your new note for said patient.

For example, it's the end of the day, I have nothing more to do than just finish up notes / check emails.

Important emails about emergent labs/imaging/hospitalizations of your patients would be "red flagged" and the provider would be notified right away if any of those red flags come in on their phone or their main computer. Therefore during the next little break they have, they know they need to get these biopsy results/chest xrays/emergency provider calls/reports answered right away. This would bypass the medical assistant and front desk all together.

All non-emergent patient emails about refills/rescheduling/scheduling could be directed to Medical Assistants/Front desk's email and would have a low acuity color flag associated.

Obviously it would be impossible for you to message said provider and expect a response right away, but if your patient suddenly has a seizure during your appointment and is rushed to the ER, that would be a red flag message and the provider would see right away (Assuming they have access to their phone/computer)

Obviously there's a lot of kinks to iron out about how it'll all work... but as EHRs get better, I inevitably see this happening.

@KeikoTanaka Really appreciate you for your responses! I know you've got to be short on time with all the studying your crammed up in, so the fact that you've taken the time to contribute to this forum post with useful/positive info is surely admirable. I'd also like to thank you for your confidence in us as professionals, means a ton. How far along are you in medical school? What branch of medicine are you most interested in? I assume something orthopedics or maybe even radiology due to the content of this topic lol

@KeikoTanaka I encourage you to keep this idealism because ultimately I think everyone (especially patients) would benefit from collaboration. I think what you are describing is about transparency and ease of data acquisition. Google (of course) is working on something like this already. Very awesome.

@fozzy40 I'd like to extend a thank you for your contribution to this topic as well. I've surfed these forums for a little over a year now, and every post I've seen you interact with you've been insightful and pleasant. I agree with your assessment that the patient would benefit more from furthered collaboration, unfortunately I feel as though sometimes we as healthcare professionals get so wrapped up in our own hoo-plah, that we forget we are ultimately in service to our patients.

I don/t see PTs to be much involved in imaging any time soon. Most of us are not trained for that. We had a basic imaging course (not sure if people with masters degrees even had the basic one?). I do not have enough knowledge to interpret an image. I can understand basic stuff from imaging reports and explain it to patients which may be useful. PTs also can make recommendation for imaging when they communicate with pt's MDs.

@ya1 BTW Are you currently practicing? Is what you posted a personal conviction, or something you think is representative of the entirety of PTs? Figured I'd pose these questions just for my personal inquiry.

@topher031888 and @truthseeker (tagging you guys just cause) Do any of you think PT's should have access to other Rx rights? Funny enough, one of the Orthopods I mentioned in my original post brought forth a conversation about how they believed it'd help out tremendously with patient care if PTs had the ability to Rx things like NSAIDs, muscle relaxers like flexeril, steroids for iontophoresis like hydrocortisone/dexamethasone, assistive devices/DME, wound care supplies, etc. so that they weren't being bugged all the time for a signature. For reference about my relationship with the MD, I participate in some research with him and a few other classmates outside of our didactic stuff, so my rapport with him is pretty good. Not sure if he was just polishing our egos, but it sounded sincere. He is a professor at a PT school so I am definitely considering the source btw lol. Anybody have a take on this?

Cheers y'all

 

[KeikoTanaka]

@KeikoTanaka Really appreciate you for your responses! I know you've got to be short on time with all the studying your crammed up in, so the fact that you've taken the time to contribute to this forum post with useful/positive info is surely admirable. I'd also like to thank you for your confidence in us as professionals, means a ton. How far along are you in medical school? What branch of medicine are you most interested in? I assume something orthopedics or maybe even radiology due to the content of this topic lol

At this moment in time, I am in my second year, second semester of school. Last year of pure didactics. Next 2 years will be clinical rotations, electives-purely in the 4th with only 2 mandated electives in osteopathic manipulative medicine. I am actually most interested in general internal medicine. I love all aspects of medicine, not necessarily surgery because I enjoy the more cerebral aspects of medicine, and I feel like it has the most flexibility to practice towards my interests and be whatever you make of it. Emergency medicine is still an option for me as it is also very broad, but unfortunately I don't think my body will ultimately enjoy the undulating shiftwork of emergency medicine. I also really always want to know how everything turned out, and having relationships with people. Plus I want a really cozy outpatient office space also lol. if I did IM I'd consider doing an Osteopathic manipulation/sports medicine as a fellowship as well.

 

[truthseeker]

Hey guys, sorry a bit late to getting back this forum--life's got a hell of a set of legs and will run away with the time if you aren't careful I'll tell ya.





@KeikoTanaka Really appreciate you for your responses! I know you've got to be short on time with all the studying your crammed up in, so the fact that you've taken the time to contribute to this forum post with useful/positive info is surely admirable. I'd also like to thank you for your confidence in us as professionals, means a ton. How far along are you in medical school? What branch of medicine are you most interested in? I assume something orthopedics or maybe even radiology due to the content of this topic lol




@fozzy40 I'd like to extend a thank you for your contribution to this topic as well. I've surfed these forums for a little over a year now, and every post I've seen you interact with you've been insightful and pleasant. I agree with your assessment that the patient would benefit more from furthered collaboration, unfortunately I feel as though sometimes we as healthcare professionals get so wrapped up in our own hoo-plah, that we forget we are ultimately in service to our patients.



@ya1 BTW Are you currently practicing? Is what you posted a personal conviction, or something you think is representative of the entirety of PTs? Figured I'd pose these questions just for my personal inquiry.

@topher031888 and @truthseeker (tagging you guys just cause) Do any of you think PT's should have access to other Rx rights? Funny enough, one of the Orthopods I mentioned in my original post brought forth a conversation about how they believed it'd help out tremendously with patient care if PTs had the ability to Rx things like NSAIDs, muscle relaxers like flexeril, steroids for iontophoresis like hydrocortisone/dexamethasone, assistive devices/DME, wound care supplies, etc. so that they weren't being bugged all the time for a signature. For reference about my relationship with the MD, I participate in some research with him and a few other classmates outside of our didactic stuff, so my rapport with him is pretty good. Not sure if he was just polishing our egos, but it sounded sincere. He is a professor at a PT school so I am definitely considering the source btw lol. Anybody have a take on this?

Cheers y'all

My take is that dex for iontophoresis, DME, and wound care supplies would be great. Patients self prescribe OTC NSAIDS anyway, I really am not interested personally in prescribing muscle relaxers, but the rest of the stuff is a risk to nobody, and if we can expedite care it would benefit everyone. The patient gets what they need sooner(most docs sign off on DME anyway, that would be one less thing on their desk or queue to sign), the PTs would be less frustrated etc . . .

 

[Fiveoboy11]

100%.

How does it change your treatment plan?

Idk that it does often change the treatment plan. I personally feel imaging is far overrated. But in the context of physical therapists having the authority to order select imaging procedures it is meant as a screening tool to rule out conditions that make treatment contraindicated and not so much to guide treatment.

 

[LostLlama]

It is enough to be a physical therapist and strive to master all that this entails without compounding an already over-inflated education system with MORE classes when a profession already exists solely for that specialty. Besides, I really like tuning forks.

 

[KeikoTanaka]

Besides, I really like tuning forks.

lmao I love this comment. I'm in my Neuromusculoskeletal module right now in 2nd year med school and the physician giving us our lecture made a comment something along the lines of: "The majority of neurologists practicing right now are above the age of 50 which means they trained at a time when MRIs weren't available. You know what that means? THERE WERE DOCTORS WALKING AROUND THE HOSPITALS WITH TUNING FORKS TO LOCALIZE THE LESIONS!! Can you imagine that!?" Because now everyone just orders imaging. I'm sure they still use tuning forks though 😉

 

[deleted797640]

It is an insurance provider issue not necessarily a scope of practice issue. The US military allows PTs to order imagine as well as prescribe certain medications.

 

[Deecee2DO]

No one is qualified to truly interpret MSK imaging safely other than a radiologist. Orthos chiros and physiatrists are ok at it but still no comparison. Just leave that stuff to the MSK trained rads. If youre looking to broaden scope to order imaging then youre going to have to have the knowledge to interpret and I think that would be a safety issue

 

[dpthopeful2019]

No one is qualified to truly interpret MSK imaging safely other than a radiologist. Orthos chiros and physiatrists are ok at it but still no comparison. Just leave that stuff to the MSK trained rads. If youre looking to broaden scope to order imaging then youre going to have to have the knowledge to interpret and I think that would be a safety issue

My original post was more geared towards PTs having the authority to order imaging, but I'll take the bait.

PTs, especially those with the OCS/SCS Board certifications, outscored every other discipline in medicine besides orthopedic surgeons in diagnosing MSK related pathologies. While I agree there could and/or should always be more education, I think physical therapists could do a fine job at determining appropriateness of getting imaging & interpreting them. Even the average therapist's MSK examination skills are exceptional, and that is what a diagnosis should be based on.

Imaging should only be used to confirm a clinical finding.

 

[Deecee2DO]

My original post was more geared towards PTs have the authority to order imaging, but I'll take the bait.

PTs, especially those with the OCS/SCS Board certifications, outscored every other discipline in medicine besides orthopedic surgeons in diagnosing MSK related pathologies. While I agree there could and/or should always be more education, I think physical therapists could do a fine job at determining appropriateness of getting imaging & interpreting them. Even the average therapist's MSK examination skills are exceptional, and that is what a diagnosis should be based on.

Imaging should only be used to confirm a clinical finding.

PTs outscored physiatry? Can i see the study? Also, it may seem like knowledge is there for interpreting imaging but in actuality you dont know what you dont know. Having gone through both chiropractic school and medical school I didnt realize this until i got to medical school. Even as a chiro i wasnt qualified despite thinking I was since we receive over a year (several hundred hrs) of msk radiology which is still more than PT and medical school alone. Still think we should leave it to the rads. I do believe PTs knowledge of MSK dx would outscore any specislty in medicine except ortho/PMR but imaging is a different skill

 

[truthseeker]

here is a summary, I'll find the specific article. I looked before but had no luck. it does exist however, I have read it.

https://www.orthopt.org/uploads/content_files/files/DxProcImagPhysTherPractice_FINAL.pdf

 

[truthseeker]

Here is the article. it does not specifically mention physiatry.

https://www.jospt.org/doi/abs/10.2519/jospt.2005.35.2.67

 

[truthseeker]

sorry, here is the full article.

https://www.jospt.org/doi/pdf/10.2519/jospt.2005.35.2.67