Direct Access: Where's the Beef? The Challenge From Chiropractors

By William Boissonnault, Academy Practice Committee Chair

The American Physical Therapy Association (APTA) and its Components continue to work towards achieving unrestricted patient direct access to our services. This objective is also a practice affairs priority of the AAOMPT. Medical Societies /Associations/Academies and Chiropractic organizations have been the primary groups opposing our legislative efforts. The following will focus on the Chiropractors' opposition, while the Medical groups' will be addressed in a later issue. The following is presented with the caveat that all professional organizations have the right and responsibility to advocate for patient/public safety and well-being, so the fact these organizations are challenging our initiatives is not inappropriate. What's questionable is the credibility behind the arguments and their motives.

Chiropractic organizations consistently point out the risk to patients coming to physical therapy without a referral, the inadequate physical therapy education related to diagnosis and pathology and the inability of physical therapists (PTs) to make a medical diagnosis.  During the Wisconsin Chapter's previous quest for direct access the chiropractors frequently raised this question; "A patient coming to physical therapy with back pain and an underlying occult colon cancer; without being able to make a medical diagnosis-how would they know a patient referral is warranted?"

Patient Safety: Patient/public safety is no less of a concern to the APTA than it is compared to ANY medical or chiropractic professional society.  This priority is clearly noted in numerous statements found in the APTA's Standards of Practice, Code of Ethics and Guide to Professional Conduct. In addition, many Chapters have added language to their respective practice acts holding PTs accountable for appropriately referring patients/clients. For example, the Wisconsin State Statutes and Administrative Code contains the following language: "DUTY TO REFER. (a) A physical therapist shall refer a patient to an appropriate health care practitioner if the physical therapist has reasonable cause to believe that symptoms or conditions are present that require services beyond the scope of the practice of physical therapy."

Physical Therapist Professional Education: Medical Screening for Patient Referral: Physical therapists have long received training in recognition of patient examination findings that are unusual for conditions appropriate for physical therapy management. This curricular content area has been "beefed up" even more so with the transition to DPT level entry-level education. Documents such as APTA's Normative Model of Physical Therapist Professional Education, CAPTE Evaluative Criteria for Accreditation…, and the Minimum Required Skills of Physical Therapist Graduates at Entry-Level contain curricular guidelines that all physical therapy programs must adhere. The required course content related to the ability of knowing when to refer a patient to a physician and other health care practitioners is clearly articulated. This curricular content is found in all examination/evaluation/diagnosis courses and throughout programs' clinical science tracks. Textbooks edited and authored by PTs on the topic of pathology, medical screening and differential diagnosis have been in existence for over 15 years and in some of the texts a number of physicians have contributed chapters.

Physical Therapists Can't Diagnose-Patients At Risk! It is not necessary for PTs to make a medical diagnosis of conditions such as cancer or infection in order to recognize when a patient should be referred to a physician. Making such a medical diagnosis would place PTs outside the scope of their educational training and practice guidelines. Physical therapists have routinely collected patient health history information (illnesses, surgical history, medication use etc.), detailed descriptions of presenting complaints, review of systems and conducted a comprehensive physical examination. This information provides PTs with the necessary guidance as to when to refer the patient to the appropriate practitioner.

Are Patients At Risk When They Have Direct Access to Physical Therapy Services?? Nationally, many states have long had direct access to physical therapy services legislation in place. There is no evidence of PTs being convicted, or having had their licenses revoked or suspended related this practice privilege, nor reports of adverse patient events. Lastly, a recent article published in the Journal of Orthopaedic and Sports Physical Therapy (October 2005 issue, pages 674-78) described over 50,000 patients being seen by PTs via direct access. Not one incidence of patient injury or adverse event or of PTs having their license revoked or suspended related to care these patients received had been reported!

Physical Therapists' Ability to Medically Screen Patients for Referral: Approximately 30 case reports describing patients being referred by PTs to physicians secondary to health status concerns have been published since 1990 in the Journal, Physical Therapy and the Journal of Orthopaedic and Sports Physical Therapy. The patients came to physical therapy with a variety of complaints (e.g. back, neck shoulder pain); the PTs examined the patient, recognized unusual examination findings and referred the patient.  This patient referral led to a more timely diagnosis by the physician of a multitude of conditions including fractures, cancer and infections. Some of these patients had been referred to physical therapy by a physician, while others had come to physical therapy via direct access. These published reports represent a small sampling of what happens in physical therapy practices on a daily basis. If you'd like a copy of this case report reference list please contact me boiss@surgery.wisc.edu.

Where's The Beef? The credibility of the chiropractic organizations' expressed concerns regarding patient direct access to our services is in question. I am reminded of the Wendy's fast food restaurant commercial from years past that featured a spunky elderly woman who compared the size of the Wendy's hamburger to those featured at other fast food facilities.  Peeking inside the other restaurants' burger buns and having trouble seeing the tiny burger she declared, "Where's the beef?" For decades, the chiropractors have brought up all kinds of issues when attacking our initiatives, but where's the beef? Where's the evidence supporting their concerns? After all of these years opposing our legislative efforts you would think they would present some shred of evidence related to public harm or irresponsible practice. My response to their question; "a patient with low back pain with an underlying, occult colon cancer without being able to make a medical diagnosis-how would the physical therapist know a patient referral is warranted" is; PTs diagnose colon cancer like chiropractors do, WE DON"T! But we routinely collect patient examination information that would typically raise the concern regarding the patient's health status leading to a patient referral. This timely referral would lead to a physician (MD or DO) making the correct diagnosis.

Lastly, is the chiropractic organizations' motive really patient safety? As noted in the Practice Corner from Articulations, Vol. 12, No. 1, 2006 what is found in the document The Future of Chiropractic Revisited: 2005-2015 is that PTs are considered THE primary economic threat to the future of chiropractic practice. What better way to help "hamstring" a competitor than limit access to their services? In this regard it's not so much a question of "Where's the beef", but the beef presented is rotten!

Summary: To insure our credibility, when negotiating with other organizations and legislative bodies, we must be certain that our initiatives are truly in the public's best interest. We must rely on available facts and credible evidence to support our case, and when talking to legislators not fall back on the argument "we're not being treated fairly by others (DCs) "as a strategy to win their support. Providing legislators with examples of evidence (e.g. examples of patient data health history collection forms utilized by PTs, abstracts of articles mentioned above, letters from insurance companies describing incidences –or lack of- malpractice suits filed against PTs, etc.) along with succinct testimony should help win support for our initiatives. In some states the opposition to our direct access efforts has been formidable, but as the evidence mounts (an assumption), such as decreased health care costs associated with patients seeking physical therapy services directly along with the positive rehabilitation outcomes, we will be successful.

From the AAOMPT official newsletter: Articulations (2006) 

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