Direct Access: Is It Safe?
Yes! Okay, I will expand.
One of the central arguments brought forth by groups opposing direct access to physical therapists is that of safety. This argument implies that the only safe way for those with musculoskeletal dysfunction to receive care is to have all complaints first checked by a physician. This is in line with the traditional role of physicians as gatekeepers. But, does this argument hold water, and is there any evidence that can guide us as to the safety of physical therapists in a direct access role? Before you read on, you may want to check out yesterday’s NYT article about the public’s eroding confidence in physicians.
Examining the Logic
Before we get to any review of evidence, let’s first bring up a point of logic and examine the reality of physicians and musculoskeletal dysfunction. In medical school, students spend very little time learning orthopaedic examination, and rightly so. The skill of physicians lies in managing the integrated, complex patients, with medical problems responsive to pharmaceutical management. This takes time to learn. So much time, that by the time medical students become residents, they are good at a lot of things, but only have basic knowledge of musculoskeletal complaints. This lack of orthopaedic knowledge is routinely supported by research (such as 7% of Harvard medical students passing a competency exam). By the time students are in residency, the specialized nature of their learning effectively precludes further development of these skills for all but orthopaedic residents.
Alternatively, physical therapists almost singularly specialize in musculoskeletal dysfunction and movement. As a biased “consumer,” I would want to see the professional with the most training in the area of my problem. The anti-direct access safety argument does not dispute this variation in training. It lies more central to the ability of physical therapists to detect serious medical problems, such as when that low back pain is cancer, or when that shoulder pain is a cardiac problem. No doubt, physicians are good at this. But, are physical therapists? If evidence can show that physical therapists are competent diagnosticians, then the logic behind the safety argument falls apart, right?
Examining the Evidence
Conveniently, physical therapists in military settings have been seeing patients via direct access for years, and can provide a case to study safety in this setting. This 2005 study by Moore et al. examined over 50,000 patients seen through direct access over 4 years and concluded that patients are at minimal risk for negligent care, with no adverse events resulting from PT management. Granted, some evidence exists that those in uniformed services may be above average in musculoskeletal management, but this could be offset by the complex and varied conditions seen in military clinics, as I can attest to first-hand. When physical therapists in a general private practice population were studied, correct decisions differentiating between patients with musculoskeletal vs. medical conditions were high, and even higher when the physical therapist was a board-certified clinical specialist. When directly comparing physical therapist competency in musculoskeletal management with physicians, the results speak for themselves:
“Experienced physical therapists had higher levels of knowledge in managing musculoskeletal conditions than medical students, physician interns and residents, and all physician specialists except for orthopaedists. Physical therapist students enrolled in doctoral degree educational programs achieved significantly higher scores than their peers enrolled in master’s degree programs. Furthermore, experienced physical therapists who were board-certified in orthopaedic or sports physical therapy achieved significantly higher scores and passing rates than their non board-certified colleagues.”
I hope that I have at least provided enough evidence to support my enthusiastic “Yes!” that I began this post with. Perhaps, I have also provided enough evidence to suggest that some risk exists when seeking general physician care for musculoskeletal complaints, given their lower levels of training and competency compared to orthopaedists and physical therapists.
Now that we have concluded that direct access can be done safely, perhaps more safely by physical therapists who are board-certified specialists and have clinical doctorates, we can move on and examine some other issues central to direct access. Next up: reimbursement.
- Direct Access: An Overview
- Direct Access: Is it safe?
- Direct Access: Reimbursement, also see Part II
- Direct Access: The Netherlands
- Direct Access: Making it Work
- Direct Access: The Future
Photo by harryalverson.
Physio-Info and the $100G Club
For all of you who were fans of the PABC Physio-Info Blog, it is back on line with renewed vigor! New outreach librarian, Suzanne Geba takes over where Eugene Barsky left off. I’ve always found this blog to be a resource, and I wish Suzanne good luck.
Secondly, as the eye of my consciousness stays pointed toward the west coast, what do you think of this ad for a Home Health Physical Therapist? It encourages applicants to join the "100 Grand Club!"
Salary:
Just announced: Rehab Therapists can earn over $100,000/year. Become a member of the $100 Grand Club!
Umm…
No "clubs" of earning should exist among healthcare professionals! What are we, real estate agents?
ERIC
Direct Access: An Overview
Direct Access Review:
Direct access refers to the ability of a patient to access physical therapy services without a physician’s referral. Currently, over 40 states have some form of direct access. Each state’s interpretation of this is a bit different, ranging from states with almost no restrictions on direct access, to states where direct access exists by name only, not truly allowing physical therapist treatment for health problems. Insurance reimbursement for direct access physical therapy is variable with Medicare most notably not reimbursing for physical therapy unless a physician’s referral is in place.
The rationale for direct access is one of consumer choice, reduction of the physician gate-keeper role, reduced costs, and improved outcomes through improved access. Obviously, several parties are opponents to direct access, citing potential harm to patients and possible over-utilization of healthcare resources by physical therapists gone wild.
Is Direct Access Working?
When I was in school in the mid-late 90′s, quite a bit of direct access legislation was being pushed through state legislatures. As a student, I was very excited. What could be better than patient’s having easier access to my profession? And, why is a physician’s referral needed anyway if I’m learning all these examination and differential diagnosis skills? I looked forward to the day when the state I lived and practiced in approved direct access and I could really rock!
Well, that day has come and gone, and I must say, direct access to physical therapists has not made much difference. The vast majority of patients still come to physical therapists via physician referral. One study investigating direct access in Massachusetts found that only 8% of patients were being seen without a physician’s referral. The study cited practice limitations and lack of reimbursement as the primary reasons for this low number. I would also add lack of consumer awareness of direct access to this mix as well.
Though that study was from 1998, I would estimate that the numbers are still about the same. With such small numbers of patients using direct access, I doubt that any of the proposed benefits to cost, access, or outcomes are being realized.
APTA Vision Sentence for Physical Therapy 2020
"By 2020, physical 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."
That is the vision statement guiding the physical therapy profession into the future. Direct access is still a priority despite the lack of effect thus far. The reasons physical therapists support direct access are noble ones (cost, patient access, consumer choice, reduced burden on physicians). But why, if direct access provides a benefit to the healthcare system, has it not been more widely accepted and utilized? Why are the barriers still there?
Upcoming Posts:
Over the next two weeks we will look at several aspects of direct access, asking some pertinent questions and examining some interesting evidence. We will look at the case of a physical therapist from Philadelphia who is trying hard to expand direct access, and we will set forth some ideas about how, if it is justified, can direct access to physical therapists become more pervasive in today’s healthcare environment.
- Direct Access: An Overview
- Direct Access: Is it safe?
- Direct Access: Reimbursement, also see Part II
- Direct Access: The Netherlands
- Direct Access: Making it Work
- Direct Access: The Future
Let’s begin a public conversation about direct access.
ERIC
ReWalk: Back on Your Feet?
This device that enables mobility for those with spinal cord injuries is pretty cool!
[Link and Video via Medgadget]
Paying for a Bad Job?
"Trying to Save by Increasing Doctors’Fees"
Here’s a new strategy to increase reimbursement: do a bad job, for a long time, harm patients, act with disregard…get paid more!
The key to getting paid more is that everyone in the profession needs to do it, and patients must only be seen for brief moments and superficial interactions.
I’m making fun of paying doctors more to do a good job because it is easy to do, but some solid ideas exist underneath the apparent nonsense. Paying for phone and e-mail consultations is a good idea. Keeping better track of patients is a good idea, and does require more money (and probably a better healthcare "system" as well).
I wonder, if this experiment succeeds, and that group of 5 doctors get’s to continue receiving an extra $300,000 a year to do a good job, how then can other professions likewise increase their reimbursement for doing a good job?
Looking ahead at NPA Think Tank
Over the next couple of weeks, NPA Think Tank will take on a couple of interesting topics: Direct Access and Continuing Education. Specifically, are physical therapists doing a good job of getting patients into their clinics directly, and is our current model of continuing education a dinosaur? Stay tuned!
ERIC
No Pens? Well at Least My CE is Free!
Just as the AMA was celebrating the vote in their favor against a reduction in the Medicare fee schedule, the doctors across the nation now have to cope with this.
What’s a doc got to do to get a pen around here?!
Small advantages like free pens and pads seem trivial, but they are part of the overall advantage physicians are awarded in the marketplace. Among less trivial freebies is the fact that pharmaceutical companies fund most continuing education for physicians. (That link leads to a good read in BMJ.)
It may seem like no big deal to require a certain amount of continuing education to maintain license when the courses are free…but for other healthcare providers, like physical therapists, (who are busy buying pens and paper on their own) the cost of continuing education courses can be overwhelming at $400 a piece. Pfizer’s recent decision to stop funding courses for docs is a pretty big deal.
And then one begins to ponder whether or not continuing education courses are all that effective…
Can the Wii Replace Regular Exercise?
With Wii becoming all the rage lately, not to mention finding its way into physical therapy clinics everywhere, it’s important to realize that not much is know about the effects of using the Wii. Some argue that it can be a replacement for traditional exercise, while others (me) argue it is not. Well, the researchers are off and running, and some early data is already starting to come back.
A group of researchers in the UK measured energy expenditure while playing the Wii and compared it to similar sedentary video games, in this case, the XBOX 360. Energy expenditure was measured using a system that estimates energy costs using sensors called the IDEEA (intelligent device for energy expenditure and activity). The group studied was boys and girls aged 13-15 years. They played Project Gotham racing on the XBOX, and Wii Tennis, Bowling, and Boxing.
Not surprisingly, the Wii resulted in greater energy expenditure than traditional sedentary video games. The average increase in energy used during Wii-play was about 51% greater than when playing the "old-fashioned" video games.
But, when researched compared the increased energy expenditure when using the Wii to actually performing the activity the Wii came up short.
The researchers conclude:
"Active gaming used less energy than authentic bowling, tennis, and boxing, and the exercise was not intense enough to contribute towards the recommended amount of daily physical activity for children"
A couple of caveats are that the IDEEA is not the best way to measure arm activity, which is what the Wii entails, and that the children were standing up and playing, which is always a good thing for breathing, bones, joints, posture, etc. Also, in terms of Wiihab, perhaps the use of the Wii as a graded activity is warranted. Finally, the Wii Fit seems the most likely aspect of the Wii to serve as an alternative to traditional exercise, but that was not evaluated in this study.
So, exercise, Wii is not. Fun, active video game…Wii is. One more interesting fact from the study…boys used more energy than girls while playing the Wii.
Graves, L., Stratton, G., Ridgers, N.D., Cable, N.T. (2007). Comparison of energy expenditure in adolescents when playing new generation and sedentary computer games: cross sectional study. BMJ, 335(7633), 1282-1284. DOI: 10.1136/bmj.39415.632951.80
A New Scientific Method?
I found this post about science without theories to be fascinating.
"It may turn out that tremendously large volumes of data are sufficient
to skip the theory part in order to make a predicted observation."
This correlative science is discussed as part of medical care further down in the article. Perhaps this should be the biggest motivation to comprehensive, vast electronic medical records capable of providing such large data sets that useful information can come from patient encounters.
"…computers can extract patterns in this ocean of data that no human could ever possibly detect."
Dr. Miss America? Dr. Mr. President?
I must first point you to my post at EIM, where I have links galore about Ashley Glenn, the Quinnipiac University Doctor of Physical Therapy student who has been crowned Miss Connecticut.
Next, go check out Respectful Insolence, and find out more about the chiropractor running for president. Seriously.
This listing of presidents by educational level is interesting; Woodrow Wilson served as president with a PhD from Johns Hopkins University. A precedent also exists for Miss America contestants and higher education, in 1974 a law student crowned a doctoral student!
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The online encyclopedia of Physical Therapy.
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