PTs: what are we good at? what needs work?

Physical therapists (PT) are extremely knowledgeable in their respective specialties. As a matter of fact, Childs et al. (2005) performed a cross-sectional study where they compared the musculoskeletal knowledge of physical therapists and physicians. A standardized written examination was given to all the participants for accurate comparison. These PTs were compared to physicians from a variety of backgrounds: orthopedics, family medicine, OBG, psychology, interns, residents, etc. With a maximum score of 100, these were the top 5 scores from each profession/specialty:

1. Orthopedic Physician: 94

2. Physical Therapist [board certified in orthopedics (OCS)/sports medicine (SCS)]: 81

3. Physical Therapist (no specialty): 74

4. Physical Therapy student (doctoral level): 68

5. Physical Therapy student (master level): 64

As it turns out, orthopedic physicians and board certified physical therapists received the highest ranking on the examination. These results are a testament to the level of knowledge that PTs have as it relates to musculoskeletal conditions. When I finished my residency in orthopedics and became board-certified in 2015, I had great pride in my ability to evaluate, diagnose, and treat patients with orthopedic and sports related conditions. However, at that point in time, my knowledge was sensitive and specific to orthopedics and sports medicine. I was able to rule in treatable orthopedic conditions and rule out conditions beyond my area of expertise. However, due to my narrower scope of practice, I was unable to rule in medical conditions outside the musculoskeletal system.

Much of that has changed since nursing school. Nursing has given me a skill set that I did not have two years ago. In essence, the experience has helped to fill the gaps in knowledge that previously existed. My short time in the ED has taught me how to administer medication, insert IV lines, interpret labs and diagnostic tests, monitor and analyze EKG rhythms, and assist with advanced cardiac life support. By no means have I mastered any of these areas yet. However, being on the other side of the spectrum, it does make me wish I had learned some of these skills more in PT school. Not all of them are entirely relevant to being a PT. Though, I do believe that certain skills need to be taught better within PT school so that graduates are more readily prepared to be autonomous providers. So what do we need to work on? Here are a few things:

1. Differential diagnosis (DD) curriculum needs to be improved. Outpatient clinicians need to know when to appropriately refer patients to providers when the treatment is beyond their scope of practice. Differential diagnosis is imperative for the patient’s safety and well-being. Is the low back pain you’ve been treating for 10-12 weeks actually musculoskeletal? Or is it something else? The education I received for orthopedics (Guy Simoneau, PT, PhD, FAPTA) was phenomenal. My professor for DD was outstanding (William Boissonault, PT, OCS, DSc, FAAOMPT). However, the DD curriculum should have been way longer than it was. If PTs want to have direct access and be first-line providers of musculoskeletal care in every state, the education needs to be even better. I entered a full-time orthopedic residency that helped shape me into a more well-rounded clinician. However, the vast majority of PTs who graduate go straight into practice. A residency-trained PT is significantly more prepared than a PT who is fresh out of graduate school. A PT is qualified to practice after their doctoral training; however, PTs who undergo residency or fellowship training will be much better than their counterparts.

2. PT students need to know how to perform a thorough physical assessment of all other organ systems. There is no doubt in my mind that PTs are excellent with their musculoskeletal and neuro exam. However, I have found that many PTs grossly lack the ability to assess the cardiovascular, respiratory, and gastrointestinal system. It is important to understand these systems, as it helps us identify potential problems that need to be addressed by a specialist or primary care provider (PCP). Unfortunately, the majority of PTs I have encountered know little to nothing about how to perform a physical exam on other body systems. PTs do not have to be experts in these areas, but they should at least have a basic understanding of these systems.

3. PT students need to be taught more by other healthcare professionals, not just by PTs. In my opinion, professionals like nurses, physicians, respiratory therapists, speech pathologists, etc. need to be included. Why? Because PTs who work in the inpatient setting work with patients who are being treated by a variety of healthcare professionals. Many of these patients are higher acuity,  making it vital that PTs adequately understand medications (ex. use, side effects, adverse reactions), IV line equipment (ex. if the IV pump is beeping, why is it doing that? Which lines can be disconnected while the patient is ambulating? etc.), respiratory equipment (ex. nasal cannula vs. venturi mask vs. non-rebreather mask), EKG rhythms, and lab values. There is no one better to learn from than the professionals themselves. We will be better clinicians by directly learning from the experts.

What are your thoughts? Do you agree or disagree? I would love to hear your thoughts!

Resources:
Childs, J.D., Whitman, J.M., Sizer, P.S., Pugia, M.L., Flynn, T.W., & Delitto, A. (2005). A description of physical therapists’ knowledge in managing musculoskeletal conditions. BMC Musculoskeletal Disorders, 6(32), 1-7.

Kearns, M., Ponichtera, N., Rucker, T., & Ford, G. (2014). Physical therapists as practitioners of choice: consumer knowledge of practitioner skills and training. Journal of Physical Therapy Education, 28(1), 64-72.

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