Gatekeeper Or Physical Therapist: Who Knows Best?

In our current health care system, physicians (and now, to some degree, chiropractors) serve as the gatekeepers. They refer patients for medications, for imaging, and for the services of other health care providers. Patients then enter the system via the bottom end of the funnel. Access to care is, by and large, controlled by the gatekeeper.

But the current system is severely handicapped by this funnel. Patients are demanding access to care, access to a clinician’s skills, and access to information.

There was a time and place when this gatekeeper model made sense. A physician has training in differential diagnosis and in the prescription of medication and imaging studies. They receive fairly extensive training in these areas, thus it makes good sense for them to know when either is appropriate given the patient scenario.

We now have far more health care options available to the patient – but the same gatekeeper is still controlling all of them. A prime example is physical therapy. The funnel effect still exists for the patient.

The question then becomes quite compelling. Who knows which patients are appropriate for physical therapy – and should that decision be made by the physician, or the physical therapists themselves?

Consider this: how much training does a physician get in school specifically related to rehabilitation and exercise prescription?

Frankly, not very much – if any. That is the simple reality.

How much training does a physical therapist get in being able to recognize medical conditions that are outside our scope of practice?

Frankly, plenty. They have sufficient education to recognize the presence of red flags, and are then bound by their scope of practice to refer to an appropriate provider for further assessment.

Advanced nurse practitioners face a similar problem. Seriously now - how much training is really required to assess the common cold and get the patient to the appropriate care?

Yet the physician has almost a God-given “right” as the ordained gatekeeper to “prescribe” physical therapy, even though they generally know little or nothing about it. This makes even less sense when you consider that physical therapists in Texas require a physician script for treatment, but not assessment. If physicians are fine with a physical therapist performing an assessment, and if a PT is capable of establishing that a patient is appropriate for PT, and has the training to do so (which the physician doesn’t have), and the PT is bound by their scope of practice to NOT treat patients that are inappropriate for physical therapy intervention - then why is there a need to have a physician script for PT treatment – something that physicians know even less about?

Imagine, for a moment, the tables are turned. Imagine a physical therapist being in control of, say, an orthopedist. Imagine, if you will, an orthopedist requiring a script from a physical therapist in order to perform surgery.

I know what you’re thinking: that sounds utterly ridiculous and insane. And you would be correct. But when the coin is reversed, suddenly it is supposed to make better sense?

The AMA continues to tell patients and legislators alike that patient safety is the concern behind direct access to physical therapy. If safety is such an issue, how did they ever decide to let massage therapists be the first line of assessment and treatment, yet not physical therapists? Hell, some massage therapists will go so far as to wave crystals over chakras with no consideration for “differential diagnosis”. And that’s ok? Seriously?

The excuses are just that – silly excuses. There has yet to be any data presented in any country to confirm that direct access to physical therapy increases the utilization of PT services, increases the cost of care, or increases medical malpractice claims. In some countries, they are actually expanding the role of the PT as a first line health care provider instead of having a 19th century view of “PT as technician” such as the AMA does in the United States.

But when you have a legalized monopoly, logic obviously doesn’t matter.

Much like the old Nike commercials with Bo Jackson that said “Bo knows”, how about “PTs know PT”? Aren’t physical therapists the ones that are supposed to know physical therapy? It’s our domain! How about this thought – let a physical therapist use their training within their scope of practice, for assessment and treatment, based on their judgment because, hey, it’s their profession? There is no other acceptable answer – for physicians, or for physical therapists.

A novel thought, indeed.

";" alt="">

Photo credits: Wikipedia