"Physical therapy is not a subspecialty of the medical profession and physical therapists are not medical doctors; we are a separate profession that provides a unique service that physicians are unable and untrained to provide."

Letter to the AMA from the APTA, Dec 2009

Tuesday, January 13, 2009

Do You Understand Physical Therapy?

"Do you understand?"

"Does that make sense?"

You might think I'm asking you about Obama's new health care plan.

I'm really showing you how I speak to my physical therapy patients every day as I explain their diagnosis and ask for their 'buy-in' for their plan of care.

What I'm actually doing is asking many of my patients to make commitments to lifestyle changes that take their money, attention and time.

Patients with arthritis, hip replacement surgeries, sports injuries and car accident victims all depend on an accurate physical therapists' diagnosis.

Head nods are nice but I need commitment to get patients to adhere to their home exercises.

I'm asking my patients to commit to action-plans that I have made based on my decisions in my physical therapy diagnosis.

What's a Physical Therapy Diagnosis?

Doesn't the doctor do that?

The doctor makes the diagnosis, orders therapy and the therapist follows the orders, right?


What if the diagnosis is "Low Back Pain" (a symptom, not a diagosis) and the orders are "Evaluate and treat"?

Then the physical therapist needs to make a decision.

The physical therapist needs to make a diagnosis.

Different than the Doctor?

The physical therapist may arrive at her decision differently than the doctor.

Ian Edwards, an Australian physical therapist, studied clinical reasoning strategies in physical therapists.

Clinical reasoning strategies are...
"...a way of thinking and taking action within clinical practice."
Edwards was able to divide reasoning strategies into two groups:
  1. Diagnosis

  2. Management

Diagnosis was further divided into two groups:
  1. Diagnostic reasoning - linking physical impairments to disability (see the ICF model)

  2. Narrative reasoning - listening to patient 'stories', beliefs and cultures.

Management was divided into six groups:
  1. Reasoning about procedure - selecting interventions.

  2. Interactive reasoning - establishing patient-therapist rapport.

  3. Collaborative reasoning - setting patient goals and progression of activities based on consensus.

  4. Reasoning about teaching - assessing the patient's receptivity to and understanding of the therapist's findings.

  5. Predictive reasoning - 'envisioning future scenarios with patients', eg: getting better.

  6. Ethical reasoning - ethical and practical barriers to achieving all of the patient's goals.

What's the point?

Physical therapist decision-making can also be divided based on its intended purpose:
  1. Treatment

  2. Documentation

Physical therapists, I believe, treat their patients using the following of Edward's reasoning strategies:
  • Narrative reasoning

  • Interactive reasoning

  • Collaborative reasoning

  • Reasoning about teaching

Physical therapists document their findings and write their notes and charts using the following of Edward's reasoning strategies:
  • Diagnostic reasoning

  • Reasoning about procedure

  • Predictive reasoning

  • Ethical reasoning

The physical therapist's diagnosis is important for the patient's final outcome. Make the wrong diagnosis and the patient doesn't get better.

The physical therapist's notes and charts are important for legal and audit protection, accurate reimbursement, peer communication and patient progress.

Make the wrong decision while writing in the chart and the therapist doesn't get paid, or worse.

Do you understand?

Does that make sense?

Free Tutorial

Get free stuff at BulletproofPT.com

Tim Richardson, PT owns a private practice at Medical Arts Rehabilitation, Inc in Palmetto, Florida. The clinic website is at MedicalArtsRehab.com.

Bulletproof Expert Systems: Clinical Decision Support for Physical Therapists in the Outpatient Setting is a manager's workbook with stories, checklists, charts, graphs, tables, and templates describing how you can use paper-based or computerized tools to improve your clinic's Medicare compliance, process adherence and patient outcomes.

Tim has implemented a computerized Clinical Decision Support (CDS) system in his clinic since 2006 that serves as a Reminder, Alerting, Prompting and Predicting CDS using evidence-based tests and measures.

Tim can be reached at
TimRichPT@BulletproofPT.com .

"Make Decisions like Doctors"

Copyright 2007-2010 by Tim Richardson, PT.
No reproduction without authorization.

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Consistent with the American Physical Therapy Association Vision Statement for Physical Therapy 2020, the American Physical Therapy Association supports exclusive physical therapist ownership and operation of physical therapy services.