physiotherapist & physical medicine/rehab physicians

[aaaphysio]

i have a chronic problem of conflict between physiotherapist / occupational therapist practice and physical medicine & rehab (PMR )physicians practice at the hospital. The PMR are dominating , directing & managing the rehab services, all outpatients have to be seen by them prior to therapy even if referred from specialists physicians ( Neuro, ortho...etc). The PMR prescripe the plan of care to PT/OT including e.g. list of goals , treatments , frequency of sessions & decision to discharge. They are claiming that this is the system of John Hopkins , Cleavland & many other settings especially in USA. I would like to get your support in providing me with evidence from best practice settings that this is not the case. Physios practice all over autonomus , have direct access at many palces of the world , are managing the rehab services and don't need the PMR to supervise them.

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[pudding_bowl]

Yup we are lucky here in New Zealand - we have first practitioner rights. A patient can choose to come to the physio without any referral and we will treat them appropriately. That is key, appropriate treatment. Our physio board and training scemes are heavily focussed on providing a 'no harm' service. And if you can do some good then all the better. What it boils down to is that we have a training which has a heavy component covering typical non-physio presentations and clinical reasoning such that we can identify when a patient has come to physio inappropriately and requires a referral on to an appropriate provider.
We certainly have supervision from without our profession if it is required (e.g. for new graduates), but there is no PMR team telling us what to do.
Any more questions about the NZ system are encouraged - I'm quite proud of it really when I think of other places in the world that don't have the same rights.

[quorthon]

i recalled an interview from Grant Watson on a greek physio magazine, where he was talking about the fact in NZ insurance companies have direct negotations with physios about therapy costs and compensations....This is also great, and i am unhappy that in Greece the situation is not so favourable for our profession too.....The so called supervision from PMR doctors is not so heavy as aaaphysio says in Kuwait but if u working on a rehabilitation center u ultimately become a puppet on the hands of PMRs!not to mention that in order for a patient to get his money back from a physiotherapy treatment he must have a medical referral from the beginning.....of course many patients come DIRECTLY to us with no referral and they follow treatment according to our evaluation and principles with better outcomes.....The reason is simple why this happening....A classic referral from a doctor in greece is like that : "10 sessions of TENS,ULTRASOUND and DIATHERMY" They only prescribe 3 or 4 passive modalities and of course the patient cannot be cured by that,only...

[gcoe]

This is a really tricky problem for all of us. In NZ we are lucky however things could always change if the rehab drs decided to get organised here.

As for evidence for our treatments I think you have to be prepared to provide evidence as each situation arises, and as there is so much evidence now out there for PT rather than us giving you a list I suggest you get better at accessing and appraising it as the need arises.

If you effectively can do this again and again you can demonstrate your ability to practice autonomously. For evidence of interventions: Do you use PEDro? - The great thing about PEDro is that it is so quick to access and will give you evidence for guidelines, systematic reviews and clinical trials on any subject in physiotherapy that has been researched.

to demonstrate our effectiveness as primary practitioners we also have to provide evidence for our diagnoses as well as interventions and prognosis.

Have you got good evidence-based textbook such as:

Practical Evidence-Based Physiotherapy: Amazon.co.uk: Robert Herbert, Judy Mead, Gro Jamtvedt, Birger Kare Hagen: Books

There are other books but I would highly recommend this for honing your skills at locating, appraising and applying evidence as you need to.

As primary care practitioners we also need to show we can triage for non musculoskeletal disorders that require further investigation. The US has made great strides with this. William Boisonault is a PT who has published exellent textbooks on the topic:

Goodman C, W Boissonnault, K Fuller. Pathology: Implication for the Physical Therapist, 2nd edition., WB Saunders Co., 2nd edition. 2002.

Boissonnault W. Medical Screening for the Physical Therapist. On CD-ROM; 20 hours of material including written examination, December, 2003.

Boissonnault W. Primary Care for the Physical Therapist: Examination and Triage. WB Saunders Co., Publication date September, 2004.

have a look at his website:http://www.orthorehab.wisc.edu/physi...sonnault.shtml


We also need to be politically astute, supporting and encouraging our PT associations to lobby for direct access. Such issues as patient assurance of safety and cost effectiveness direct access make for strong arguments to government bodies

[quorthon]

in the last post i was taliking about the majority of therapists in greece and how they act,namely as those who execute simple orders by MDs....Personally i avoid this philosophy in my own clinical practice...I always come on a deal with the patient to embark on a INDIVUALISED treatment that is based through my own evaluation and reasoning, forgetting completely what the doctor said.....Some times when a patient is very reluctant on that i merely say to him, "Has your doctor examined u at all in the first place???If not, how HE can decide what the treatment regime should be??" By that, many patient been convinced....But to make an treatment indivualised and adapted to patient needs u need some form of an "algorithm"...That means it is not enough always to take a simple medical history, u need something to guide u to treatment! This is what McKenzie method has helped me a lot, because even though i am not always depend on its treats, i use widely and in every patient the ASSESSMENT FORM, as been proposed by Mckenzie, and from that point i contribute my own style and techniques, besides the McKenzie's therapist techniques....
Nevertheless i should agree with u about the fact that physios MUST be aware of serious pathologies and how they can appear in a clinical setting....Boissonaul has made fantastic job on that, and i remebered when i first studied a fantastic article-series that was published on JOSPT in 1990....He included all the organ systems (cardiovascular,gastrointestinal, etc) and how their syptoms can misjudge and confuse the therapist...I think also that Grieve had made relevant reviews in the past

[aaaphysio]

thank you guyes for your replies. I am quite clear about how to practice with autonomy and have independent clinical decisions. what i need at present is to submitt to my administration evidence or information about renowned hospitals in the world where PTs practice indpendent of PMR

[quorthon]

but in the end if u want to be a better,more skilled and truly INDEPENDENT physio u need to be in a free-lancer field,means in your own private clinic....Its simple if u think about it, u have the financial motivation and based on that u study, u review a lots of time many issues in order to give better services to your clients (and u earn more money)...Unfortunately a colleague who works in a public hospital or rehab, where he is permanent (he cannot be fired by no means) got few motivations to become better clinician....He just follows a routine,nothing more

[gcoe]

With all due respect, quorthon, physiotherapists working in hospital settings offer different services to those in private practice. In private practice you are generally limited to the ambulant patient. In the hospital settings you see a much wider variety of patients and have opportunities to contribute to such areas as inpatient and community rehabilitation, high levels disablement, tertiary level care, and patients who may be very ill, that you don’t get to do in private practice. What motivates physios working in these settings has little to do with financial motivation and a lot to do with doing the best for people who really need our care. In my experience here in NZ and Australia physios working in the hospital system come with a variety of motivations, and abilities but most are very dedicated to being the best clinician they can be and often have knowledge and skills that private practitioners don’t have. I think it is a case of working in a different and often more challenging environment.

In our system physios in the public hospital system are team members who work with ( and not for) Drs, occupational therapists, nurses, speech language therapists, rehab assistants, radiographers and so on in close teams. Physios enjoy quite a high level of autonomy but remain accountable to the team, patients and their team leaders. I am not saying that the system is ideal or that there aren’t negative influences on physios but to suggest that the only way forward is private practice is absurd.


aaaphysio

I re-read your question and realise I didn’t get it right, rather went off on an autonomy lecture! Your question is quite clear. Give me a few days to think about it and I’ll see if I can come with something that might be more useful

[pudding_bowl]

Working in a hospital here in NZ - and being the only physio in it. I still undertake professional development and constantly press myself to become a better physio. So It's not quite true that being a permanent staff makes you 'lazy' per say. Though I can probably think of some people who are guilty of it.
Sorry aaaphysio - the hospital I work for certainly isn't big enough or famous enough to be considered reputable. So I can't help you much further. Hopefully Gcoe has some good stuff for you.
Good luck

[quorthon]

sorry if anyone misunderstood my words but i was speaking mostly about how things in greece are....Colleagues who work in greek public hospitals have a mistaken philosophy about the profession....I ve been there as an applicant and i saw how things are....They dont give a damn about anything new as far as scientific evolution, and few of them interesting on what new happening in our occupation.....And i think its very encouraging to hear from you fellows that colleagues in hospitals around the globe have different behaviour as professionals....
the only thing i disagree with you gcoe is about the variety of patients u face in a private practice or in a hospital....Perhaps in a rehab (mostly and NOT in a public hospital) u will see different clinical situations, but in a private practice u have much more time to deal with a patient and u are stimulated to learn more and more about it....I think because as a private practician u got the entire RESPONSBILITY of the treatment....In a rehab center or hospital u act as a part of a team,this of course doesnt mean that u get "lazy" as has pudding bowl correctly noted...Its a matter of character some times, if u want to develop your profession skills

[physiobob]

It would be my opinion from working in the public health system in the past that therapists become disenchanted with their professional remit. What they could do and what they have time to do are sometimes very different. What they know to be effective and what they can provide based on resources and length of treatment time/sessions can also be far from ideal. Unfortunately you also get your share of chronic treatment seekers in that environment as they don't have to pay directly for it. This further leads to diminished moral within the hospital staff.

It is nice to see these days that cleaver and forward thinking departments are looking at new ways to improve moral. Group exercise and rehab programs are are good way to keep numbers up and provide more time to achieve results.

It is up to departments to present these ideas to any people who refer to them and get them involved in order to keep/foster a team approach to patient care.

[Michael7]

I'm still confused.....
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the physiotherapist's role is to diagnose, develop the plan of management & use physical means as massage , manipulative therapies, acupuncture, exercise & electro physical agents in treatment.
now I want to know what is the role of PMR physician ? & Does he use phsical means & tools also like physiotherapist?

& what's the system in USA ?

[quorthon]

as far as i know in some countries like New Zeland and Sweden as well physiotherapists have a major role in DIAGNOSIS and they can formally REFER the patient to make special exams like X-rays,MRI or whatever....It depends of local health sytem in each country.....Here in Greece physios have no legal right in diagnosis (MDs do that) musculoskeletal disorders...But many times if a patient comes DIRECTLY to us, we can offer better services as far as diagnosis and management of his condition, because physicians dont screen thoroughly the patient in many occasions,resulting in many diagnostic misjudgements.....I have often noticed that during my daily experience

[gcoe]

Yes that is right re: physios in NZ. We don't have an exact medical equivalent in the medical profession like physiatrists in the US or physical medicine drs. We do have musculoskeletal physicians and sports physicians - but they are a relatively small body. Such physicians may practice some physiotherapy modalities and may also use injections and drugs and could refer on for physiohterapy.

We also have rehab physicians mainly in the hospital system. The rehab physicians are generally valued members of rehab teams and tend to confine themselves to overall medical diagnosis management referring on for physiotherapy where appropriate. Likewise physios refer to the rehab physician for medical management issues. These physicians may take a leadership role in a more traditional multidisciplinary team although in other teams the physician is really just another team member. Generally there is a good relationship between rehab physicians and physios although there is always some potential for conflict and disagreement. Rehab services remain under-financed and under resourced so all staff tend to be maximise what resources are available rather than squabbling over care.

[Michael7]

I understood that there's a great difference between countries in the organization of rehab team & I think it is also different in education.
but I have a question about education if you please , in the US if the physiotherapist have a DPT certificate, has the right to manage cases without a referral from a physician? or the physician also is a leader of the team?
and is there a board or something like that for non American physiotherapist to work there?
Finally, New Zeland is really a developed , civilized country .

[aaaphysio]

so , that means that PMR physicians are part of the medical staff and have nothing to do with managing the rehab services administratively nor supervise/prescribe plan of care. I wish i get people from USA working with them at public hospitals to confirm that

[gcoe]

Yes that is right. Most of the admin work is done by health managers who could be from just about any background. For example, in one of our major rehab centres in a large DHB the manager is from a nursing background but her role is the overall mangement of both rehab wards. The job is purely administrative. Clinicians are employed to provide clinical services not administrate. Sometimes a clinician might hold a managerial job but be expected to carry a caseload but this is all defined in their job description - eg a 50%/50% split between responsibilities.


Certainly Drs don't prescribe physiotherapy - they refer for assessment and management. And as Drs have the fattest salary packages the DHB is unlikely to give them a managerial job - costs to much. That is not to say that at the higher management level Drs are not present

NZ isn't unique in this. Australia would operate somewhat similarly.

[Fyzzio]

Hi,
just wanted to make a more generalised comment in regards to autonomy of Physiotherapists.
The way Physios and Physicians are educated and work depends on the health system and legislation of the country of practice. I have heard that in several European countries you receive a live-long registration. As people might know, in NZ we have to apply for re-certification every year. This is a work intensive system, requiring lots of professional development and good documentation, but ensures quality of work and safety for the general population.
So, if you would like to change Physios and Physicians attitudes, responsibilities and training, you have to start changing the system. Good luck.

@ quorthon: Where you think that you do independent practice, you (apparently) have not been formally educated to do so - so please be careful as to what you say. There is a huge difference between a three year Physio diploma in countries like Greece, Germany, Spain, etc. and the 4 year Auzzie, Scottish, Irish and NZ degree (.. and the three year British one -as far as I'm concerned; ... I do not know much about others). There is also a reason behind the length and depth of training, so you cannot just switch from one to the other.

I have met many European Physios with "just a diploma" and all of them do individualised treatment plans, evaluate their treatment and alter approaches if indicated. Their treatment effects are just as good as anyone elses and they have all started using an evidence-based approach. This is certainly an analytical way of working and is based on their training, but does not neccessarily mean they can practice autonomously, as it is common here in NZ.

I also find your comment about the finincial motivation to become a better clinician rather interesting, as in my experience, this causes exactly the opposite result.

Regards,
Fyzzio

[gcoe]

Thanks Fyzzio

Some good points you are making.

Professional autonomy does come at a cost - rights come with responsibilities. In gaining autonomy we need to be very prepared so that we do no harm to patients who are vulnerable or need care beyond our scope of practice. It only takes one sensational case of malpractice to taint the profession in the eyes of society and can send the profession back decades. I recall in Australia we were lucky not to have a serious adverse effect from a neck manipulation while other professions got tainted with unsafe practice over a couple of adverse events.

Entry level courses, regardless of whether they are Bachelors, Masters or Doctorate must have the appropriate content. such as pathology of a wide variety of medical conditions (beyond the types of conditions we treat) so we can understand what we are seeing, pharmacology so we know when we are seeing side effects or adverse effects and know we are safe to treat the patient a certain way, and skill in triage for non physiotherapy - problems so we quickly refer on when there is a problem - these are all basic skills for primary care practice.

Standards do vary all around the world and what is considered a physio's scope also may vary somewhat. However hopefully the WHOLE world wide profession is moving in the same direction towards autonomy. This is important for the international standing of the profession. It doesn't matter if it takes some countries a little longer to reach autonomy as long as we are all moving that way.

It wasn't that long ago that NZ didn't offer baccalaureate education. even in the early 90's We just had a 3 year diploma from a technical institute and we were then definitely under the wing the medical profession then. So it is possible for things to change quite quickly.

Entry into the universities and having a research capability seem particularly important steps for raising the professions standing

[quorthon]

reply to phyzzio:
U right about the training programmes in europe...To be more specific in Greece is 7 semesters (3 and a half duration) and 1 semester of clinical practice as applicant in a public hospital.Also it is true that as far as Greece concerned, the educational programme in physio school in Greece is of a low-level because we dont study the most recent scientific evidence in our profession..For example is almost ridicilous that when i was in physio scholl we get stuck on passive modalities so much, when in the meantime its clinical value and validity has discarded in a huge percent!! U got the point??? We never get through of the most recent evolutions and as far as i know from people who study THIS TIME physio in Greece, they are been taught the same stuff!!!!
But from my personal view this situation does not have to limit us in a passive role in practicing...When i graduated and start working as employee in other clinics and rehab centers i was just applying treatment without evaluate and assess what i was doing to patient...By taking McKenzie courses and finally the certificate on the Method (Cert.MDT) a new horizon had opened in front of me....I first learned the word "DIAGNOSIS" in my clinical context...And if u can diagnosed (of course i dont mean diagnosis as a physician can do, but diagnosis in MECHANICAL problems which are the majority in what we see in clinical practice) of course u can be more effective in TREATMENT....U can know what the prognosis will be, u can even know when u will come to a "plateau" in your treatment...And the most important is to recognize early which patients are CONTRAINDICATED for physical therapy....The so called "red-flags"....I ve seen that many times, when a patient comes to my clinic, he is "misdiagnosed" by his physician, and through the evaluation procedures we can see that a serious pathology is beyond his "mechanical" pain....Its not my duty to SPECIFY the patholgy but it is my duty to refer the patient to a specialist physician for further evaluation...
We are not here to play doctors but i think that each physio can take the RESPONIBILITY of a patient from the start (provided that he has a proper scientific base)...If we insist on just executing physician referrals whithout knowledge of what we especially doing with the treatment that they have described, then we take our profession many decades ago as gcoe said....We OURSELVES,through proper practice can firstly get the profession many levels higher and then comes the rest!!

[gcoe]

I am not aware of such a programme but that doesn’t mean it doesn’t exist. Have you considered rather than pursuing a medical career building on your basic physiotherapy qualification. For example in the UK and also now in Australia Extended scope physiotherapists? Depending on the situation and extended scope practitioner might carry out injections, ultrasound scans and limited prescribing along with more traditions physiotherapy modalities? Another option may be to become a specialised orthopaedic manual physiotherapist or other such speciality. It certainly may be worth considering rather than having to start with a basic medical qualification.

[quorthon]

ajs123 u should consider some options in what physiotherapy field u want to expertise......For example musculoskeletal,neurological,pediatrics or cardiopulmonary.....I was wondering also that when i graduated myself....Dont try to be good in all of that, find one that suits your personal ambitions and get DEEP to it....I would recommend u if want to expertise on musculoskeletal take McKenzie courses..When u get familiar to this method u will see that you dont need so much other techniques like Manual therapy (Maitland or Kalterborn concepts) or Trp release etc.
Of course this is my personal opinion and i am not trying to make promotion in this forum of a particular method..But when something is really effective, we must share it with other colleagues!
And when u get better and better on some specialty you will see my point...U expand your career and get a status in the health community, without nessecarily become an MD...

[pudding_bowl]

is there a program that allows a physiotherapist to become a doctor in physical medicine ... is it possible ?

Do you mean you'd like a doctorate of physiotherapy?
You can of course undertake a Phd and become a dr. of physiotherapy that way. There is not yet a PD qualification (like MD ) however the way things are going it's possible that this may become the future of our profession.
If you want to become a doctor that specialises in physical therapy such as a physiatrist then you'd have to go to medical school and specialise.

[quorthon]

i think too that sometime in future this will happen,because its better for all of us if we are qualified and expertised in a particular field....we will practice a lot better then...

[Michael7]

from the web site of association of academic physiatrist:

There are approximately 8,300 board certified physiatrists in the United States who are trained to diagnose, treat, and direct a rehabilitation plan that provides the best possible patient outcomes. The physiatrist directs a comprehensive rehabilitation team of professionals that may include physical therapists, occupational therapists, recreational therapists, rehabilitation nurses, psychologists, social workers, speech-language pathologists, and others.

what does it mean,the word direct?
is this the situation in US ?!