"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

Monday, February 8, 2010

Physical Therapy Students Take on Direct Access

Samantha SooHoo, president of the Pre-Physical Therapy/Occupational Therapy club at the University of California, San Diego is energizing the discussion on direct access to physical therapy services.Samantha SooHoo, physical therapist student

If anyone would like to provide another answer to Samantha's questions please reply in the comments section below.

Here are Samantha's questions and my responses:

1. Tim, In your opinion, how would direct access to physical therapy be beneficial for the US Health Care System as a whole?

How would it benefit patients, physicians and therapists?

Direct access to physical therapists has the potential to lower costs: consider a typical course of treatment for simple lower back pain.
  1. patient has initial episode that fails to resolve within two weeks

  2. patient sees primary care MD and receives NSAIDs and a follow-up in two weeks

  3. patient follows-up and is distressed - medical decisions may be made based on pain severity rather than physical findings - in this case a referral for an MRI and a neurosurgical consult is made (2 weeks)

  4. MRI is negative and the neurosurgeon refers to PT (2 weeks)

  5. PT sees patient after 2 months, 3 physician visits and an expensive imaging scan.
Could this have been handled better? I think so - Samantha has touched on how we can do better in her follow-up questions.

2. What implications would direct access have for practicing physical therapists right now? Would there be additional training or continuing education required?

Routine use of medical screening tests for suspected pathology would need to become part of the standard of care for outpatient physical therapy patients.

Unfortunately, I do not see 100% of my PT/PTA employees performing medical/pathology screening. Where I can, I train my staff but more needs to be done.

I have hired 2 DPT's in the last year and neither one of them demonstrated in their notes signs of routine screening for pathology, clinical prediction rules or other use of evidence-based practice.

These practice patterns vary individually and across settings as I know physical therapists in Skilled Nursing Facilities (SNFs) that do routinely screen their patients.

Physical therapists are undergoing a cultural shift as we transition to a doctoring profession. Again, this isn't just about training new techniques but an attitude that we, not just the physician, are ultimately responsible for the welfare of our patients.

3. What aspect of physical therapy field needs improvement as it heads towards the direction of Direct Access?

Education does not seem to be the answer - if more education were the key my DPT employees would routinely exceed the performance of my non-DPT employees but that is not the case.

I find the difference is attitude - some people are just more willing to change their practice style when presented with evidence that the old way is less effective. What needs to change is the uncritical acceptance of many of the 'techniques' taught to us in physical therapy school.

Skepticism is important.

Don't worry, this problem afflicts medical doctors as well - unwarranted practice variation and idiosyncratic local 'standards of care' often have more to do with where you went to school than with the current state of the evidence.

4. Opponents of direct access argue that physical therapists may overlook serious medical conditions because they may not be able to refer a patient directly for diagnostic testing and are not trained to make medical diagnoses.

Tim, What is your response to this claim?

To continue the example from above: (LBP) expensive, sensitive imaging tests are often used to confirm that the patient is a surgical candidate rather than to rule out suspected occult pathology.

Physical therapists can employ evidence-based screening tests and findings from the history to test for suspected pathology. Patients who test positive on the screening tests can then be referred for diagnostic imaging.

The promise of clinical prediction rules is to distinguish the high-risk patients from the low-risk patients for these and other conditions:
  1. dizziness
  2. pneumonia
  3. acute chest pain
  4. DVT
  5. lower back pain
  6. Incidence of falling down
  7. and other common, high-cost drivers in health care.
Physical therapy is not a high cost driver in health care but it has a high growth rate - which means that scrutiny is applied to our highest volume codes (eg: 97110 Therapeutic Exercise et al).

Physical therapists use exercise in the prevention of disability and so the ability to make a medical diagnosis (eg: cervical radiculopathy) seems irrevelant.

Why not make a physical therapist's diagnosis oriented along a disablement model that focuses your decision making towards prevention and future risk reduction?

5. If direct access was indeed implemented, how would communication between physicians and physical therapists look differently than it does now?

Samantha, the fact is that I enjoy direct access (and payment) now in Florida and in 47 other states.

Patients will gain improved access to physical therapists with Medicare direct access - which is really what this discussion is about.

Again, physical therapists would be a primary entry point for patients and would take on responsibility for their patients welfare. Physicians who recognize these behaviors in physical therapists now tend to refer more patients because they see us as a resource.

Physicians owning physical therapy tend to drive up costs with an uncertain impact on outcomes - there is no evidence that they provide better care.


Samantha, PT has a lot to offer and the future looks very bright for patients and for society. Our profession has been on an exponential growth curve over the last 10-15 years from the standpoint of evidence and opportunities.

Don't let the current political morass (eg: the Massachusetts Massacre) get you down. PT may be better off without fee-for-service but there are too many vested interests preventing that from happening overnight.

Thanks for your contribution.

Samantha SooHoo is the president of president of the Pre-Physical Therapy/Occupational Therapy at the University of California San Diego. The club has about 60 members and their blog is available here. Samantha volunteers at Scripps Memorial Hospital in La Jolla in the outpatient rehabilitation services clinic.

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