Don’t write a script for physical therapy: refer them to a physical therapist.

You have heard it countless times: “I’m going to refer you to physical therapy (PT)” or “What you need is physical therapy.” While I understand that these statements are said with good intentions, I do have some issues with the phrasing. My physician assistant (PA) colleagues are similarly unsatisfied with the term “physician’s assistant.” It is physician assistant, not physician’s assistant (with an ‘s). The “‘s” implies ownership of some kind: it also implies that they are merely an assistant to the physician. A regular medical assistant is not the same as a PA. Referring someone for physical therapy sounds as silly as referring someone to medicine, dentistry, or law. Have you ever heard someone say “I’m going to refer you to medicine” or “I need to refer you to dentistry”?

Semantics is the study of linguistics and the meaning associated with words. PT is a noun, just like medicine, dentistry, or law. These phrases put more emphasis on PT as a verb and less on the therapist implementing the actions. Just as every orthopedic surgeon is not created equal, neither are physical therapists. There are really bad physical therapists, just as there are bad apples in other professions. It is pertinent for providers to refer patients to a physical therapist that they trust, someone who is up to date on evidence based practice and consistently has solid patient outcomes. Too often, I have seen providers arbitrarily write a script for PT with no thought of referring the patient to a specific therapist. Would you choose any random orthopedic surgeon to perform your knee replacement? Or would you want someone giving you a referral to a specialist who has outstanding end results? The collaborative relationship between therapists and other providers is extremely important. It has often been said that successful return to function is based on surgery and rehabilitation, with both being equally weighted (at the very least). PT is a combination of exercise prescription (EX), manual therapy (MT), use of modalities, and education of all kinds (pain management, pathophysiology, functional biomechanics, etc.). PT is not synonymous with exercise or physical activity. It is so much more than that.

Referring someone to PT without knowing their skill level is unwise and less beneficial for the patient. How do you know if the therapist is using evidenced based practices (EBP) or if the therapist is proficient with MT techniques? As a physical therapist, my decision to refer patients to a specific orthopedist is based on patient testimonies, the clinician’s involvement in EBP, and the degree to which patients smoothly progress and return to their prior level of function (PLOF). When I hear these phrases, it makes me believe that providers are under the impression that all physical therapists provide the same level of care. That simply is not true. Not providing therapist recommendations is a disservice to all parties involved, especially to the patient. If a provider does not refer a patient to a specific therapist, it can only mean a couple things: (1) the provider believes that all physical therapists provide equal care; or (2) the provider is too busy to care and/or does not personally know any therapists. Regardless of the reason, it undermines the value of the clinician and disregards the clinical decision-making of the therapist.

All parties need to be educated about the following concepts:

1. Physicians need to be aware that not every therapist has the same skill level. Research has demonstrated that a combination of EX and MT leads to the best outcomes. Ask about the therapist’s training and credentials. Are they APTA board-certified? Have they completed a residency or fellowship? While these credentials do not guarantee that you are seeing a superior therapist, it proves that they committed themselves to training beyond their graduate degree (ex. similar to a physician completing a residency and fellowship). For the most part, these types of therapists have a certain level of skill that other therapists may not possess.

2. Physical therapists must communicate with providers about mutual patients. Therapists need to inform providers that the patients are getting better under their care. Many patients will leave PT after feeling better and will not touch base with the provider who referred them. This leaves the provider in the dark, making it unknown whether the patient improved or worsened. Providers are much more likely to send patients to a therapist who has successful outcomes.

3. Patients need to do their homework and understand that there are many companies to choose from. While convenience is a huge factor, don’t make that the primary reason you choose a particular clinic. Read the biographies of the physical therapists and see what kind of experience they have.

I will eventually practice as a primary care provider (PCP); as a nurse practitioner (NP) (and being a therapist), I will not halfheartedly write a random script for PT.  I will be judicious with my referrals and make sure that they are seen by a proficient physical therapist. Sending a patient to a mediocre physical therapist does nobody any favors. Patients need to be referred to a physical therapist, not physical therapy. A proficient physical therapist will use a combination of treatments to optimize patient function. This will ensure that patients are receiving the best possible care.

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