The Physiatrist(PM&R) and the DPT

[DPTErudition]

I have been doing some research lately into the field of physiatry and the direction the apta is taking pt with vision 2020 and I find myself quite intrigued.

For those who are unaware, a physiatrist is an Md that goes to med school for 4 years plus 4 years of residency +/- fellowship. They are involved in the rehabilitation of patients from a medical standpoint

It would seem to me that the push for direct access steps on the toes of the field of physiatry. According to the apta ...

"Therapy will be provided by physical therapists who are doctors of physical therapy, recognized by consumers and other health care professionals as the practitioners of choice to whom consumers have direct access for the diagnosis of, interventions for, and prevention of impairments, functional limitations, and disabilities related to movement, function, and health."

Now, one thing that immediately comes to mind is what happens when a pt with direct access fails to catch an underlying condition that would contraindicate rehabilitation? How would insurance be affected by such a catastrophe? I'm speaking of a situation in which the doctor of physical therapy carried out all that they were trained to do, but had limited backgrounds in pathology and pharmacology. I am aware that pts are only to work within their scope of practice and refer the patient to a physician when they see it necessary, but there is always the chance for a surprise medical problem.

It is my understanding that there are many differences between the two fields, both having their ups and downs. PTs definitely win on patient interaction and there is surely no substitute for having the opportunity to provide hands-on therapy to patients, teach them exercises, and watch them improve.

Physiatrists teach some rudimentary exercises, can diagnose medications and or injections and diseases, extensivley go over the patient's medical history, and prescribe treatment. But having the patient's best interests in mind, would it not make sense for them to initially see a physician that does have an extensive background in medical pathology? If there are medications that will benefit the patient's rehabilitation, would you not want these prescribed or would that indeed indicate a referral to a physician? Further, concerning the student debt to income ratio incoming classes at schools like USC are paying ridiculously large sums of money compared to what the average salary is. While it is true that most of us are definitely not in pt for the money, it is indeed a factor that should be considered. The average starting salary for a physiatrist in L.A. is about $181,000 compared to a new pt in the same area being about $69,000.

I guess I am kind of playing Devil's advocate, one thing that I have always been taught is that having passion for something involves raising questions about the subject. I would like everyone's input on the subject. It would also be interesting to know why some of you chose physical therapy over becoming physiatrists. Personally, I find that you often establish a greater rapport with patients as a pt. Physically employing all of the modalities, excercises, and techniques is appealing to me as well. It has also been discussed that being a pt can be physically exhausting. I would speculate that physiatrists might have greater career longevity than pts due to their own physical limitations. Later on down the road I may seriously look into becoming one, but for now I think I'll focus on enjoying myself before a summer of gross anatomy.

In all truth I knew very little about Physical Medicine & Rehabilitation until quite recently. I'm currently very happy to continue pursuing PT and look forward to school. I think anyone interested in PT should definitely check it out though.

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[lee9786]

I have been doing some research lately into the field of physiatry and the direction the apta is taking pt with vision 2020 and I find myself quite intrigued.

For those who are unaware, a physiatrist is an Md that goes to med school for 4 years plus 4 years of residency +/- fellowship. They are involved in the rehabilitation of patients from a medical standpoint

It would seem to me that the push for direct access steps on the toes of the field of physiatry. According to the apta ...

"Therapy will be provided by physical therapists who are doctors of physical therapy, recognized by consumers and other health care professionals as the practitioners of choice to whom consumers have direct access for the diagnosis of, interventions for, and prevention of impairments, functional limitations, and disabilities related to movement, function, and health."

Now, one thing that immediately comes to mind is what happens when a pt with direct access fails to catch an underlying condition that would contraindicate rehabilitation? How would insurance be affected by such a catastrophe? I'm speaking of a situation in which the doctor of physical therapy carried out all that they were trained to do, but had limited backgrounds in pathology and pharmacology. I am aware that pts are only to work within their scope of practice and refer the patient to a physician when they see it necessary, but there is always the chance for a surprise medical problem.

It is my understanding that there are many differences between the two fields, both having their ups and downs. PTs definitely win on patient interaction and there is surely no substitute for having the opportunity to provide hands-on therapy to patients, teach them exercises, and watch them improve.

Physiatrists teach some rudimentary exercises, can diagnose medications and or injections and diseases, extensivley go over the patient's medical history, and prescribe treatment. But having the patient's best interests in mind, would it not make sense for them to initially see a physician that does have an extensive background in medical pathology? If there are medications that will benefit the patient's rehabilitation, would you not want these prescribed or would that indeed indicate a referral to a physician? Further, concerning the student debt to income ratio incoming classes at schools like USC are paying ridiculously large sums of money compared to what the average salary is. While it is true that most of us are definitely not in pt for the money, it is indeed a factor that should be considered. The average starting salary for a physiatrist in L.A. is about $181,000 compared to a new pt in the same area being about $69,000.

I guess I am kind of playing Devil's advocate, one thing that I have always been taught is that having passion for something involves raising questions about the subject. I would like everyone's input on the subject. It would also be interesting to know why some of you chose physical therapy over becoming physiatrists. Personally, I find that you often establish a greater rapport with patients as a pt. Physically employing all of the modalities, excercises, and techniques is appealing to me as well. It has also been discussed that being a pt can be physically exhausting. I would speculate that physiatrists might have greater career longevity than pts due to their own physical limitations. Later on down the road I may seriously look into becoming one, but for now I think I'll focus on enjoying myself before a summer of gross anatomy.

In all truth I knew very little about Physical Medicine & Rehabilitation until quite recently. I'm currently very happy to continue pursuing PT and look forward to school. I think anyone interested in PT should definitely check it out though.

I hear exactly what you're saying. I've been having a hard time distinguishing between the PM&R and the DPT so thanks for shedding some light. It seems to me that the DPT is stepping on toes and is trying to go somewhere where they really aren't adequately trained. From what I've been reading the the DPT isn't all that much different than the MPT.

Is the direct access to DPTs going to hurt the PM&R docs? Seems like it would to me. Like you stated if a mistake is made how does this affect insurance as well as possible lawsuits for misdiagnosis? What is the future of the PT profession? This is what I've been researching. I haven't quite made a full commitment to the PT profession yet. I do think it fits me personally because I'm generally a analytical, compassionate, and social type of guy that values health and quality of life. We'll see... great post.

 

[truthseeker]

Yes there is overlap but I think that toes are safe. The OP mentioned the incidents where a direct access PT misses something serious. In my practice, we are the first line of real evaluation anyway. Patient has LBP, they don't do MRI, Myelography, EMG etc . . . unless they have neurological signs. We do the real physical exam and if we cannot reproduce or alleviate the symptoms we refer them back and tell the FP that the symptoms don't seem musculoskeletal. Remember, Their training (correct me if I am wrong here PM&R lurkers) tends to be that of a generalist (if one can be a generalist in the rehab field) learning the basics of ortho, neuro, and speech/communication issues related to TBI, SCI, CVA, etc . . . Only in their residency or even in their pre medical school careers do they develop a sense of specialization. There is one physiatrist in my area who was an ATC before med school and his physical exam skills are outstanding. A good friend of mine is a pediatrician but was an ATC for 7 years before so his ortho eval skills are exemplary.

 

[jesspt]

Many that post on this board seem to believe that direct access is something new. It has, in fact, been around in many states, for over twenty years. So, patients in many states will not be getting

direct access to DPTs

. Rather, they have had direct access to PTs. So, the potential for the scenarios previously mentioned to occur has been around for a long time., and I can't say that I think to many toes have been stepped on.

Also, as Thruthseeker has mentioned, for many patients, their physical therapy examination is the first truly comprehensive examination they have received. As those of you who will be attending physical therapy school will soon find out, as a PT, you have been prepared to determine which patients have pathology which will be a contraindication to standard physical therapy interventions, and additionally (and equally as important) you are also trained to determine who is and is not likely to benefit from therapy.

I am aware that pts are only to work within their scope of practice and refer the patient to a physician when they see it necessary, but there is always the chance for a surprise medical problem.

Yup, but this is the same risk that is present in almost any health care field.

 

[DOctorJay]

I'm not sure why you think patients aren't receiving comprehensive examinations from their physicians. Please expand.

They're not receiving comprehensive physical exams from PTs either, unless you guys have started doing fundoscopic exams, rectals, etc, etc.

(FWIW I'm a former PT)

 

[DOctorJay]

Many that post on this board seem to believe that direct access is something new. It has, in fact, been around in many states, for over twenty years. So, patients in many states will not be getting . Rather, they have had direct access to PTs. So, the potential for the scenarios previously mentioned to occur has been around for a long time., and I can't say that I think to many toes have been stepped on.

Also, as Thruthseeker has mentioned, for many patients, their physical therapy examination is the first truly comprehensive examination they have received. As those of you who will be attending physical therapy school will soon find out, as a PT, you have been prepared to determine which patients have pathology which will be a contraindication to standard physical therapy interventions, and additionally (and equally as important) you are also trained to determine who is and is not likely to benefit from therapy.

Yup, but this is the same risk that is present in almost any health care field.

In what other field of health care do patients go to an Allied Health Professional before a physician? The risk is not the same.

 

[DPTErudition]

Doctor Jay, what made you decide to pursue osteopathic medicine and leave pt? Did you consider PM&R? You do make some valid points.

I understand that direct access is not something entirely new, but I do know that even in some states where it is allowed, it is not utilized. If an insurance company refuses to reimburse for services rendered without a physician's referral, not much can be done. Therapy is something that the general public cannot afford without insurance and I don't really think pro bono work is common in the field.

edit: nevermind Jay, I see that you are doing your PM&R residency next year.

 

[soccer31]

In what other field of health care do patients go to an Allied Health Professional before a physician? The risk is not the same.

physician assistant, nurse practitioner, etc....

 

[PTapp]

I'm not sure why you think patients aren't receiving comprehensive examinations from their physicians. Please expand.

They're not receiving comprehensive physical exams from PTs either, unless you guys have started doing fundoscopic exams, rectals, etc, etc.

(FWIW I'm a former PT)

You know what he/she means. Don't try to flip it around. I don't want to start a controversy here but I don't remember receiving a comprehensive physical from a FP that is comparable to PT's. I got a lot of scripts though.

 

[truthseeker]

I'm not sure why you think patients aren't receiving comprehensive examinations from their physicians. Please expand.

They're not receiving comprehensive physical exams from PTs either, unless you guys have started doing fundoscopic exams, rectals, etc, etc.

(FWIW I'm a former PT)

Jay,

You know as well as I do that the orthopedic exam you did as a PT was/is more comprehensive than the vast majority of Family Practice orthopedic exams when you practiced as a PT. I have no doubt that your PE will be more thorough and comprehensive than most PM&R docs when you are done, but that is exactly what I was referring to in my first post. Yours will be more orthopedically advanced than a classmate of yours who, for example, was a chemistry major before med school.

Don't be absurd. Of course we don't do fundoscopic exams but my point is, we don't try. We do however, do Lachman's tests and mortise tests and know that a high ankle sprain is clinically determined by whether someone can stand on a plantar flexed foot, and what an apprehension sign is, and can identify adhesive capsulitis vs impingement syndrome and . . .

When I say more comprehensive PE, I mean strictly within our scope of practice. I am not going to tell some woman that she needs a pap smear but I do ask medical questions about vaginal bleeding and if she says yes and it is unusual I will encourage her to go to her PCP or GYN.

I think you are trying to stir something up. No one here is claiming to do what PM&R does. But we do do a portion of what you do better than most PM&R docs simply because that is ALL we do.

 

[lee9786]

I was unaware that "direct access" has been around for a long time. Thank you jesspt for clearing this up for me. This post has been very informative. Thanks for everyone's contribution. It's been very helpful.

 

[DOctorJay]

physician assistant, nurse practitioner, etc....

if practicing correctly these providers are physician extenders. this means their attending is ultimately responsible for the care of the patient. PAs and NPs typically don't see patients who are new to the practice either. not a good comparison.

 

[DOctorJay]

truthseeker...

ok ok, i'll back off a bit. i knew what you guys were getting at but it's important (to me anyway) to clearly elicit a point of view, especially for people reading this forum who may not have enough experience to read between the lines of what is being said here.

is your MSK eval better than most FPs? I would say yes because as you pointed out it's a huge portion of what you do and is the reason you receive "eval & treat" referrals from the FP (expertise in your area). but remember, although the FP may not have performed the same level of MSK eval, THEY HAVE RULED OUT OTHER PATHOLOGIES, which makes it safe for you to perform your specialized, valued, and important function!

Now I have rotated with some fantastic PM&R docs and can say that their physical exam skills are incredible especially in the evaluation of back pain. All the PM&R docs I've worked with have had exemplary msk physical diagnosis skills.

I'm clearly a stickler for semantics. Back to the discussion.

 

[Elbrus]

truthseeker...

ok ok, i'll back off a bit. i knew what you guys were getting at but it's important (to me anyway) to clearly elicit a point of view, especially for people reading this forum who may not have enough experience to read between the lines of what is being said here.

is your MSK eval better than most FPs? I would say yes because as you pointed out it's a huge portion of what you do and is the reason you receive "eval & treat" referrals from the FP (expertise in your area). but remember, although the FP may not have performed the same level of MSK eval, THEY HAVE RULED OUT OTHER PATHOLOGIES, which makes it safe for you to perform your specialized, valued, and important function!

Now I have rotated with some fantastic PM&R docs and can say that their physical exam skills are incredible especially in the evaluation of back pain. All the PM&R docs I've worked with have had exemplary msk physical diagnosis skills.

I'm clearly a stickler for semantics. Back to the discussion.

In my own clinical practice I regularly refer patients back for missed conditions, despite having them ruled out.. within the last two weeks, two individuals with cancer ("LBP", "hip pn."), in January a C1-2 dislocation due to osteomyelitis of dens ("torticollis"), in the last year new MS ("BPPV"), discitis ("LBP"), a psoas abcess, and the list continues. All of this was caught upon the initial PT exam, no monkeying around. As a healthcare provider this is part of our responsibility as well, pre-filtered by another provider or not. Journals like JOSPT regularly feature such cases encountered in clinical practice which may mimic non-MSk patholgy. Safety doesn't end in the primary care or other specialists office. We are responsible for this as well, don't you agree?

 

[jesspt]

They're not receiving comprehensive physical exams from PTs either, unless you guys have started doing fundoscopic exams, rectals, etc, etc.

Now, this is just plain silly, and is obviously your attempt at being sensational as you try to make a point. I was originally discussing PTs working within their scope of practice as direct access providers. Fundoscopic exams obviously fall outside the scope of a physical therapist.

but remember, although the FP may not have performed the same level of MSK eval, THEY HAVE RULED OUT OTHER PATHOLOGIES, which makes it safe for you to perform your specialized, valued, and important function!

This is certainly possible, but based on my experience doesn't occur all of the time. Much like Elbrus, I have referred patients back to their referring providers due to picking up on missed pathology that will not benefit from PT intervention.

But we do do a portion of what you do better than most PM&R docs simply because that is ALL we do.

As a PT, I'm obviously biased here, but I agree with this whole-heartedly. It has been my experience that PM&R physicians are excellent at the medical management of patients with musculoskeletal conditions (as well as neurological conditions). But many tend to miss the boat regarding the physical rehabilitative aspects of these same patients. They tend to be the group that sends referrals my way asking for all kinds of non-evidenced based garbage like Muscle Energy Techniques, Myofascial Release, Strain-Counter Strain, etc.

As an aside:
Jay, many of these techniques are rooted in Osteopathy. What has been the stance of your Osteopathic education regarding these techniques, many of which have been refuted by current literature. (BTW, not trying to start an argument here, but I rarely get a chance to discuss this type of thing with my referral sources).

 

[lee9786]

They tend to be the group that sends referrals my way asking for all kinds of non-evidenced based garbage like Muscle Energy Techniques, Myofascial Release, Strain-Counter Strain, etc.

As an aside:
Jay, many of these techniques are rooted in Osteopathy. What has been the stance of your Osteopathic education regarding these techniques, many of which have been refuted by current literature. (BTW, not trying to start an argument here, but I rarely get a chance to discuss this type of thing with my referral sources).

I'd be interested to hear on this one as well.

 

[DOctorJay]

I plan on responding. Really busy right now.

 

[jesspt]

I totally understand. No hurry.