“I want to speak to my doctor first.”
“We’ll do what my doctor says.”
“My doctor says PT won’t work.”
“My doctor says I’m done with PT.”
How many of us have experience these frustrating statements when treating? These sentiments are born of an era when physicians solely dictated the orders of therapy to physical therapists. PTs in general are relatively new to the scene as autonomous doctoral-level practitioners in comparison to established medical disciplines. As a result, all too often we find ourselves stuck in scenarios where a patient does not or is delayed in receiving the physical therapy services he or she needs due to taking multiple steps in the healthcare system.
Traditionally, when people sustain a musculoskeletal injury, what do they do? They see a physician, which may not happen right away. They may be referred for imaging, which may not be covered or may not be necessary. Then after all is said and done, if there are no red flags to consider, many are referred to physical therapy.
Direct access is defined by The American Physical Therapy Association as “the removal of the physician referral mandated by state law to access physical therapists' services for evaluation and treatment.” The APTA has long advocated for direct access to physical therapy to make acute injury management more efficient. In a nutshell, patients would be able to see their physical therapist directly, without the need for a physician diagnosis or referral.
When it comes to direct access physical therapy, states are not on the same page just yet.
Currently, the legislation on direct access varies state to state. A comprehensive list of direct access law by state can be found on the APTA website. The states break down into three basic categories:
- Unrestricted Patient Access: no restrictions or limitations whatsoever for treatment absent a referral
- Patient Access With Provisions: access to evaluation and treatment with some provisions such as a time or visit limit, or referral requirement for a specific treatment intervention such as needle EMG or spinal manipulation
- Limited Patient Access: Access to evaluation, fitness and wellness, and limited treatment only to certain patient populations or under certain circumstances (i.e. treatment restricted to patients with a previous medical diagnosis or subject of a previous physician referral).
The evidence in support of direct access is growing in our favor.
Despite legislative barriers to accomplishing direct access in the industry, an area that has seen the most progress is in the military. Physical therapists that are credentialed by the Department of Defense have the ability to not only treat without referral, but also can order diagnostic imaging and prescribe certain medications.
A study published in the journal Military Medicine in 2013 investigated the effectiveness of utilizing a physical therapist as the primary caregiver for musculoskeletal conditions. The following findings were produced for data following patients on a military base in Afghanistan:
- The physical therapist ordered imaging for 11% of patients. The family physician ordered imaging for 82% of patients.
- The physical therapist prescribed medications for 24% of patients. The family physician prescribed medication for 90% of patients.
- The patients treated by the physical therapist first had a 50% greater likelihood of return to duty.
Of course, there are limitations to these findings. We are looking at a small, homogeneous sample size, and the study evaluated only one physical therapist and two family physicians. However, this study demonstrates a model in which a physical therapist as a musculoskeletal gatekeeper yielded both decreased health care cost and improved outcomes.
Physical therapists can diagnose. We are educated at a doctoral level. The APTA’s Physical Therapist Guide to Practice which is widely used in DPT programs outlines examination, evaluation, diagnosis, prognosis, and intervention of patients. We can use these guidelines to identify conditions that are within the scope of practice of a physical therapist.
Additionally, we are trained to identify those who are not a candidate for physical therapy. A physical therapy evaluation is designed to encompass systems review and red flag screening. Anyone who presents red flags or signs and symptoms that warrant further investigation are to be referred appropriately.
A common misconception is that underlying medical conditions can be missed by seeing a physical therapist first. Although there is always going to be an inherent risk of a medical error, the Health Providers Service Organization found that direct access is not a risk factor for increased chance of a claim. The HPSO is at the forefront of liability insurance for physical therapists, and has found no significant increase in the number of claims in states that have direct access.
The process of gaining direct access has been positive, but far from over.
Now, let’s get back to our patient quotes from earlier. What are some strategies and resources to deal with the all too frequent push back on the direct access philosophy? Here are some pointers I find useful:
Go straight to the people: Physician referrals will always make up a piece of our practice, but there is no reason to wait for them to trickle in. Millions of people walk around in pain everyday looking for answers. Start community outreach through workshops, free consults, educational content on social media, or maintaining a presence at community health centers and events. There’s always going to be people to talk to about pain, whether it’s in your clinic or not.
Build a brand as an autonomous practitioner: Once you’ve put yourself out there in the community, utilize the evidence regarding the pros of seeing a PT first. Stand out as the local go-to for musculoskeletal conditions. Patient relationships and word of mouth can go a long way in advancing patients seeking care and referring even more patients once they’ve achieved positive results.
Be an advocate for the implementation and advancement of direct access: The APTA has dedicated a page to resources regarding direct access. There is a comprehensive collection of resources for both education of direct access, how to implement it in practice, and how to get involved in advocacy.
Network with local physicians: MDs are not the villains in this story. Physicians absolutely are the cornerstone of the healthcare system, and referrals are a two way street. Direct access can benefit physicians just as much as it can physical therapists. You have the ability to open up new opportunities for physicians to see patients that otherwise wouldn’t have known where to go. Additionally, the patients we sent to MDs are already screened and are being sent to the specialty that is mostly likely to help them. Creating referral networks and communicating with physicians about your services will help foster collaboration among disciplines.
Think about the implications of patients seeking PT first in the current climate of an opioid epidemic, an obesity crisis, and rising out of pocket insurance costs placed on consumers. There will always be patients who come in with preconceived notions about the role of physical therapy. It’s a daily educational push one patient at a time, but not any less worth doing. We have to offer as physical therapists, and deserve a seat at the health care table just as much as anyone else.