Ever since the beginning of physical therapy as a profession, physical therapists have been viewed as an ancillary service or extension of the doctor. In years past, this was absolutely true. The training of a physical therapist was far inferior to that of a medical doctor. More recently, the education requirements of physical therapists have increased, leading to a push for access as primary care. Physical therapists are clamoring to be viewed on or near the same level as the medical doctor. Should this be the case?
Whether or not physical therapists are prepared for this is debatable. In general, one of the requirements in switching to the doctoral degree was to improve the differential diagnosis skills as a physical therapist. While this has without a doubt improved, the consistency of being able to recognize non-musculoskeletal disorders may not be as great as desired. This can be improved with residency training. Ideally all PT's would go through residency training; however, not nearly enough residencies are available. Maybe there can be some alternative step after PT school that could simulate what doctors go through in their residency training, but be more accessible to PT's.
If we want to be viewed on the same level as medical doctors, I believe there is a bigger issue that needs to be addressed - how we treat pain. Much of the recent research regarding pain science has consistently showed a lack of correlation between anatomical "pathology" and pain. There have been numerous studies showing asymptomatic individuals with pathological findings in their spine and other joints. I bring this up, because many doctors (not just orthopaedic surgeons) continue to attribute pain to the pathoanatomical theory. The relationship between pain and the nervous system is inconsistently understood. Many practitioners misinterpret that pain is a sensation (via "pain fibers") and not realize that it is actually a perception. The studies showing inconsistencies in imaging findings are taken but then interpreted that the findings are only significant if they match the patient's pain complaints. While this is a step in the right direction, it continues to have a pathoanatomical basis. If this were completely true, a patient with L-sided radicular pain would not have complete resolution with repeated loading on the involved side! The pain patients experience is more associated with a hypersensitization of the nervous system and can be managed by finding a way to down-regulate it.
Why do I bring up the pain issue? Because the AMA holds a monopoly on the development of health care policy, it is more so the medical profession that must be convinced of physical therapy's ability to increase their direct access. Before we can convince others organizations, we need to have consistency amongst our profession. Many of the "top physical therapists" build their therapeutic model off the pathoanatomical theory as well, leading to professional organizations promoting these ideas. Even as research regularly is coming out that should push us away from that model, many PT's cling to it. There is success with treating via the biomechanical approach, but is it the most effective? In trying to increase the relevance of physical therapy as a profession in primary care, we need to promote the same ideas and philosophies if we expect to be the provider of choice for musculoskeletal pathology.
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