I can remember being in PT school during the late 90's and talking about an article written in the mid 90's by an under cover reporter who went to 10 PT clinics and got 10 different diagnosis for their back pain. It was not a flattering article for the PT profession! My classmates and myself sat around and said "wow, glad we are going to be part of changing all that inconsistency." We figured with our classes in differential diagnosis and up to date orthopedics, this would certainly change. Not to mention, we were going to have the brand new "Guide to Physical Therapy Practice" to lean on, we were all set.
- Well, I've had two encounters in the past week that makes me think we still have a very long way to go. The first case was a lady that came to my clinic from a familiar referral source requesting this patient see a McKenzie Trained therapist. Although I am not McKenzie certified (and I explained this to both the MD office and the patient before seeing her) I am very familiar with the concepts and know how to treat a patient with discogenic pain with radicular symptoms. I find out after evaluating the patient she spent 4 weeks at another PT clinic that didn't give her one extension exercise or trial traction with her during that time. Her presentation was textbook disc, unilateral pain down lateral calf and foot. Increased pain with flexion, relief with extension. Numbness and tingling, worse with sitting, better in standing. And so on, and so on. I mean, you could have used her for a licensure board question. So how is it that there are clinics out there that have no idea about standards of care for a disc injury? This was not some tricky, fringe diagnosis, or even something that required a series of special tests. This was a disc injury, arguably the most diagnosed back problem in the United States. You can easily argue that the clinic should be categorized as incompetent. When I encounter these stories I don't jump up and down thanking the PT gods that I gained a new patient, I get frustrated that I have to associate myself with this level of therapist that holds the same license I do.
- The second case I happened across was on the sidelines of my daughter's soccer game. One of my fellow parents had an ankle splint on. I asked him what he did, and he mentioned he fractured his distal fibula 4 months ago at work and was dealing with a non-union injury. He was trying to avoid surgery, and had been receiving PT over the past 2 MONTHS! He also mentioned this was a work comp injury. My question is this: what the heck are you doing with a fractured ankle for 2 months in a PT clinic? His range seemed fine, so last time I checked it needed rest, protection from a boot and possibly a bone stimulator. The boot was removed after 4 weeks, no bone stimulator, and the PT clinic kept treating him with band exercises, stretches, and ice and electrical stimulation. As a reminder, I work for one of the "substandard quality of care POPTS" and this person was being seen by a PT working at a PT owned and operated clinic. That obviously has everything to do with quality of care.... but I digress.
- Anyway, I told the guy that non-union fractures don't need exercise they need protection, a bone stimulator trial, and making sure his calcium/ vitamin D intake was at recommended levels (which it wasn't since he didn't like to drink milk). He agreed, and was wondering why the clinic kept doing the same things over the past 2 months despite his ankle not getting better. I told him it really wasn't a PT issue until that bone starts healing. Did the clinic need the business that badly to max out this guy's work comp benefit? Or is it simply another case of negligence? The nice second part of the story will be that when it comes time to gait train this guy and work on his significant leg atrophy, he will have used up his 24 visits the state provides and be left out of the clinic during the time he needs this benefit.
- In both cases, I walked away feeling queezy about our profession. I think it is time we start looking for ways to guarantee that our PT work force is up to date and weed out the dead wood. Yes, that might mean we have to take board exams on regular intervals similar to what MD's do. We are trying to talk about ourselves as doctors right? Well, maybe it is time we do a little more from within our profession to improve the care we are providing as a whole which would only strengthen our argument for direct access. When I hear these stories, I wonder if my brethren are really qualified for direct access responsibilities? Think about the PT's in your clinic, would you trust them to treat your mother as a primary care provider? How about PT's you encountered during your clinical education or from your PT program? The number I would trust are counted on one hand, maybe two.
Anyone else out there seeing these types of problems? If so, I would like to hear the ideas and possible solutions to this significant problem you have come across. It's a discussion that obviously warrants more attention from the PT profession.
