Acute PT and the Physiatry Conflict..Brewing Trouble.

There is this patient under my care with classification of non-solid tumor of the hematopoeitic system. As is well known, these patients are particularly vulnerable to severe deconditioning, with high levels of morbidity in the adult population. What is worse, a significant number of these patients are too sick for traditional physical rehabilitation. I have been involved with the care 0f this patient through some critical illness, during course of this hospitalization. Fortunately, as of yet, this patient has been progressing reasonably, though, still with significant medical issues.

Physical therapy in the acute inpatient setting is progressively consultative, with limited hands on intervention. I am not even going to begin extrapolation on this. However, with less than 5 FTEs' serving a larger than 350 bed population, a frequency of no more than 2-3 visits a week is inevitable, sometimes even less. After all, the patients are in the hospital for a critical illness first. If they are truly in full rehab mode, it would be so much more appropriate to be in a rehabilitaiton setting that could accord much more directed care consistent with their philosophy. In this case, it just made good clinical sense to get this patient over to an inpatient rehabilitation unit (IPR) as soon as medical stability was achieved. Given the acuity of this patient's status, a sub-acute IPR seems most logical. However, owing to a complex referral relationship (more of preference/convenience, than necessity), the primary heme-oncology service is favorable to send these patients to acute inpatient rehab setting whenever feasible.

Acute IPR is a hospital. Traditionally, in the grand scheme of things, PM&R and the medical body have reserved privileges for admission under their own control. While I have nothing against their admission privileges, it is highly insulting for our PT community to be dictated on, concerning our therapeutic judgment and decision making. Much as I anticipate colleagues denying this, I know for a fact the MO (of how PM&R sweetly circumvent criticism for writing out explicit details of intervention management in the IPR setting - as if, we have no idea of how to evaluate for, or set plan of care!). Yet for sake of immediate patient need, I requested physiatry to be consulted and be on board. Interestingly, I always have my doubts of such patients being either appropriate, or be accepted for acute IPR admission.

PM&R did come on board the case, late as usual. They had no helpful input, just as usual, instead, focusing on the Physical Therapy consultation as their pivotal criteria. And from the word go, decided against accepting the patient, just as I had suspected. At this point, consider the facts. The patient has been mine as a consultant, first. I got PM&R on board. As stated, they have no useful input. Yet the PM&R resident remarks in his notes, "recommend Physical Therapy daily", as their only suggestion.

I am astounded by their presumptive superiority complex. They dare refer my own patient, back to me! When I was the one suggesting them to come on board. And if they had no useful input (primarily to accept the patient), I guess, I have enough clinical acumen to keep my own advice of when and how to see my own patients. Frankly speaking, physiatry in the acute care consultation service, rarely do have any unique examination method, or recommendation, that would be above and beyond what an expert acute PT provides. I hear echoes of this thought from scores of internists and surgeons, who cannot even begin to fathom how it would be helpful to even get physiatry on the case, since they cannot ever make a recommendation, sans the PT recommendations!

Which brings me so often to the point of whether it is at all a necessity to have physiatry be involved in hospital inpatient settings? The PTs are already providing the last detail of the patient diagnostics and status on the neuro-musculo-skeltal status on these patients. The medical piece that these rehab doctors introduce in their consultations are purely copies of the internist documentation and the H&P. The musculos-skeletal/neuro exam, is frequently the copy of the neurologist or PT documentation. And for heaven's sake, I do not understand how a rehab physician does not know how to do a functional status exam! I do concede to their ability to organize the information that they compile from all sources, but where is the novelty of their specialty in that? Don't PTs do that as well?

And insurance companies for once, have wizened to the fact that PT impressions are pivotal in authorizing for inpatient rehabilitaiton. That leaves just about no role for a physiatrist in a hospital rouding role. I propose that we as PTs should capitalize on our strengths and gain the recognition for our expertise in the acute care setting. Acute care PTs are already neck deep in the responsibilites and liabilities of being primary care for the neuro-musculo-skeletal health of our paitents. We should therefore be able to command the salaries that these Physiatrists are getting, and at least not have to copy the notes of other professionals!

In closing, I hope these PM&R mean well where patient care is concerned. But the high road they are travelling to keep PTs from usurping their own practice is blatantly self-serving. They have deep pockets and strong lobbies. But the power of truth is larger than just deep pockets. They have the nerve to suggest that they make the decisions when we provide the logistics? PTs are not the messenger people for physiatrists. The sooner they recognize this the better. Otherwise, I am looking forward to their conceit being their nemesis, at least in acute care practice. What do you, my readers, think? Stay tuned for more on this....

Cheers all.
AcutePT