Are physical therapist students adequately prepared for primary contact practice?

Abstract

Background: In the United States (US) health care system, patients in most states have the option to obtain physical therapy services through direct access without a physician referral. This primary contact care (PCC)with a physical therapist results in decreased: physical therapy visits, utilization of diagnostic testing, physician consultation and improved patient satisfaction and outcomes. Barriers to PCC include lack of insurance reimbursement, lack of patient awareness and concerns about therapist qualifications. However, studies have demonstrated that with increased training in entry-level physical therapy programs, physical therapists have the tools tomedically screen, diagnose and appropriately refer patients who may have conditions outside the scope of physical therapy practice. Purpose: To evaluate development of clinical reasoning and differential diagnosis skills amongst physical therapists and physical therapist students in a PCC model compared to a physician referral (PR) setting. Factors examined included: clinical reasoning, differential diagnosis, medical screening and perceived barriers to primary contact care. Methods: This was an exploratory study utilizing qualitative methods and semi-structured interviews. Participants included physical therapists (n= 4) and physical therapist students (n= 4) completing clinical education experiences at a private practice utilizing both PCC and PR practice models. One on one interviews were conducted by the authors to assess if and how physical therapist practice changes with PCC versus PR episode of care. Interview transcripts were analyzed using a constant comparison process of analysis for areas of contradiction or consensus. Results: All respondents reported utilizing skills equally in clinical reasoning, differential diagnosis and medical screening in both practice models. Physical therapists reported applying the same level of diligence in their diagnostic skills andmedical screening to all of the patients under their care, regardless of practicemodel. Physical therapist students recognized thatmany patients referred by physicians do not have a specific diagnosis, thereby already necessitating diagnosis by the physical therapist. However, students selfreported reduced confidence in a PCC setting and required more confirmation from their clinical instructors regarding diagnostic skills. All students felt academically prepared to work in a PCC setting, but reported requiring consistent exposure to this setting to feel confident in their clinical reasoning and diagnostic skills. Respondents noted a lack of patient awareness of PCC as the main barrier to this practice model. Conclusion(s):All respondents felt that they had the skills required to practice in the PCC setting however, there are limited opportunities for students to practice in this setting. In addition, patients are not aware of physical therapists’ role as primary contact providers for patients with musculoskeletal conditions. Implications: A goal of physical therapists in the US health care system is for patients with musculoskeletal disorders to have improved access to physical therapy. To meet this challenge, it is imperative that educational experiences provide the opportunity for students to improve confidence in their clinical reasoning and differential diagnosis skills. Academic and clinical educators should seek more collaborative opportunities for students in PCC settings, to meet local and global health care needs for expanding primary practice roles for physical therapists.