We all like to think of ourselves as important. “No one can do my job as good as I can.” We all think like this, or at least I hope we do.
- “One successful strategy for reducing the backlog of patients, developed in the United Kingdom, is for physiotherapists to screen patients referred by GPs before a first consultation with an orthopaedic surgeon.”
I wouldn’t have thought that this was possible in the US when I first entered the profession of PT, but now I at least think that it is plausible. There are many hurdles to overcome, and the first is money. If a surgeon is not seeing a patient, then the surgeon is not making money. The ideal of this scenario is to have surgical candidates see the surgeon and for non-surgical candidates to see non-surgeons.
On the flip side, therapists will have to become owners of the profession. I have worked with many PT’s that really enjoy the “paint by number” system, otherwise known as protocols, but protocols don’t necessarily fit in an environment like the one described. We have to be able to think independently and assess patients either using pattern recognition or using something like the Hypothesis Oriented Algorithm for Clinicians.
- “gatekeeper role for physiotherapists is supported by the growing body of evidence that it is effective, and that physiotherapy is an appropriate treatment for many musculoskeletal conditions”
As much as I agree with the statement that PT is effective, I don’t know if this statement supports the use for PT’s as a gatekeeper. I envision the role of gatekeeper as more of an assessor instead of a “treater”.
In the case of back pain, there are assessments that can be used prior to treating the patient in order to determine how much “help” the patient will need. When assessing the patient, there are odds ratios to determine a patient’s need for surgical intervention compared to conservative interventions.
These are the themes that a therapist must know in this type of setting.
- “In the UK, the initiative has resulted in reduced and more appropriate referral to orthopaedic surgeons, more timely interventions for those unlikely to benefit from surgery, and a shorter waiting time for appropriate care for all patients.”
This is very important. Just imagine that you need a back surgery for something very serious, such as an infection or cauda equina (just know that it is serious), but you have to wait in line to see the doctor because someone has a “pulled muscle” (not very serious). If those that are definite surgical candidates can get to see the surgeon faster, this would reduce the need for the surgeon to screen the patient in order to determine the next step.
In other words, if you have back pain, it is classifiable in about 80% of cases. Roughly 70-80% of those cases could be treated appropriately with PT initially. This would prevent about 56-64% of patients needing to see the orthopaedic in order to initiate treatment.
- “receives an average of 150 new referral each month to the orthopaedic outpatient department. Three orthopaedic surgeons and a registrar are available to screen 10 new and 18 review patients each week in one 3-hour clinic session…the waiting list for non-urgent care patients…waiting time of 164 weeks until their first appointment”
AND WE THOUGHT WE HAD TO WAIT A LONG TIME TO SEE THE DOCTOR! Think about this. If you had to wait over 3 years to see the doctor, would you rather wait that long or see a PT in a much shorter time? We are not at that point yet in our country, but it is coming. You will notice that you are seeing less of your MD and more of your PA’s and APN’s. There are not enough physicians to take care of all of the patients that want to see the doctor. The net question is would your rather see an expert or non-expert for your problem. There was a study, that I will go back and find to write about at a later date, that shows in terms of minimal competency, only orthopedic surgeons and PT’s pass a basic test for musculoskeletal conditions. Again, why would you want to see any one other than these two professionals for a musculoskeletal problem?
- “Conditions considered for inclusion were musculoskeletal-related knee, shoulder or back pain (with or without leg pain)…excluded if their subjective history suggested any sinister disorder requiring urgent medical attention, or if they had psychosocial issues that contribute to symptom chronicity”
This study essentially compared a PT’s ability to assess patients to that of an orthopedic surgeon. I don’t know how much I agree with this because we are calling the orthopedic surgeon’s assessment the gold standard, but for lack of a better tool…it will have to do. To be fair, it was the only profession that scored higher than PT’s in terms of musculoskeletal competency.
- “The physiotherapy screening appointment involved a comprehensive assessment, a provisional diagnosis and the development of a management plan in consultation with the patient…reported to the patient’s GP by letter in the same week, and a copy of the letter was filed in the patient’s medical record.”
This is where the rubber meets the road. The PT’s had to assess the patient nd diagnose the patient. Good luck with that in the states. Until we have a greater influx of DPT’s the idea of diagnosing is more like a dream. We have been pre-programmed that the physicians (MD’s, DO’s) diagnose and we give a “physical therapy diagnosis”. WTF! We have the knowledge, but not the cajones! Instead, we tell you what the problem is, but won’t tell you for fear of stepping on toes.
Because our profession is not a direct access profession, such as chiropractic care, we depend on physicians’ referrals to physical therapy. If we upset the physicians, we may see those referrals decrease in overall number.
- “ Principal outcome measures of the preliminary study were:
-proportion of new referrals not needing to see a surgeon;
-the level of agreement between the physiotherapists and the orthpaedic surgeon on diagnoses and management decisions, and
-the patients’, GP’s and surgeon’s level of satisfaction with the physiotherapist-led screening initiative”
In my opinion, this is also listed in terms of order of importance. If we can cut down on the number of referrals not needing to see the surgeon, then we will effectively make the health care experience more efficient. This is the new buzzword in healthcare.
If we can agree with the surgeon’s diagnosis, that is good, but we are making the assumption that the surgeon is correct.
Finally, is the satisfaction of all involved in the study. This may be biased, as a doctor may not be satisfied with another professional taking point on a medical case.
- “The orthopaedic surgeon agreed with 74% of the management decisions made by the physiotherapists…differences only in differentiating back pain of mechanical or nerve root origin, and knee pain of cartilage or articular origin.”
This is good, but not great. This only states that we both agree with each other. The good thing is that there is not much of a difference between seeing the therapist or the surgeon in regards to the diagnosis.
- “experienced, well qualified physiotherapists can competently and safely undertake screening of patients referred to public hospital orthopaedic outpatient clinics with non-urgent musculoskeletal pain”
This bodes well for our profession and health care in general, especially the financial aspect of health care costs. Unfortunately, giving PT’s full, unrestricted access to patients is not on the horizon in the US.
- “In the current climate of health care workforce shortages, there is a growing interest in allied health professionals undertaking additional tasks in extended roles. Two-thirds of the patients screened in this trial did not need to see a surgeon at the time of referral, but required non-surgical care, predominantly physiotherapy and exercise.”
With the shortages of MD’s, there is an increased need for other professionals to fill that gap. Physical therapy is one profession that can manage the orthopedic aspects of the MD shortage.
I consider recommending the type and schedule for PT before a surgical procedure to be an underrated art that provides a ton of value to patients–and something I wish we could explore more in practice in the US.