Monday, September 8, 2014

Grad School!

A few months ago I started grad school. This is has affected my posting schedule and will continue to do so for a while. But grad school is awesome, so it's okay.

I am attending the MGH Institute of Health Professions. Technically, the MGH does not stand for anything. In reality it is there because the school was created by Massachusetts General Hospital i.e. MGH. MGH can also stand for Man's Greatest Hospital, since MGH is one of the best hospitals in the world, both from a clinical, patient standpoint and also for research.

Dr. Steven Hirsch

Well, a doctorate in physical therapy (DPT). In our profession we don't normally call ourselves 'doctor'. But it's a three year program with a residency to cap it all off. A doctorate in PT means that patients do not need a referral to be seen - they can self-refer. In turn we are required to have the knowledge to know when a person needs a different kind of care - such as a surgical consult or neurology.

My favorite part of the Institute's program is the strong clinical focus. My first patient experience will be in only the second semester of the program (a month from now). And my first full-time clinical placement is just one year in. 

Brains! and the rest of the Body

The first class this summer was Gross Anatomy, which is  a full human cadaver dissection. We spent five hours at a stretch, two days a week, for eight weeks, teasing a cadaver apart. From head to toe. From the skin all the way through the bones. Every muscle. Nerves, blood supply, organs. Just about everything. It was great!

With an undergrad degree in exercise science I already had a good handle on the musculature, but it was still incredibly informative to go through and see every part. How it connects, how it works. To look at a tendon and say, "do you think these are the finger flexors?" And then find out by grabbing them and pulling on them, to watch the fingers actually flex.

Now I also have a mind-numbingly detailed picture of the nerves and blood supply for every muscle. A useful set of information for the diagnosis of all sorts of movement related problems.

Why a Doctorate?

First, because it's required now. Everyone graduating 2014 or later has to have a DPT and every current PT has to upgrade by 2020.

More importantly is the value of self-referral. 

I worked in a primary care office for four years, as a medical assistant. When folks came in with musculoskeletal complaints we did one of three things for them:
  1. Refer them to PT
  2. Refer them to Ortho for a surgical consult
  3. Prescribe conservative treatment because it wasn't severe enough to warrant a referral
Of those, the PT referral was the most common. Around 90% it seemed. This wasted the patient's time. This wasted the patient's money. This contributes to the overwhelming and growing cost of healthcare in this country.

And it did nothing for the patient. 

Maybe we printed out a pre-made set of exercises for them to do until they got to PT. But the doctors, PA's and NP's who worked in internal medicine didn't have the expertise to say which of those exercises any particular person should do. 

One time as a patient I was handed a sheet describing exercises that required thera-bands to do. But that office doesn't have any bands and they didn't mention where to get them. And they certainly couldn't tell me which color to use. Luckily for me I happen own a set already, but I'm not most patients.

PCP's just aren't set-up for handling musculoskeletal injuries. That's not a criticism. At Harvard Vanguard Medical Associates, where I worked, the department was actually called Internal Medicine, instead of something like general practice or primary care. And that accurately described what we were good at. The diagnosis, treatment and management of diseases of the internal organs are a big part of healthcare especially as individuals age.

If a patient may need surgery or other non-PT treatment, then a doctor of physical therapy can refer them appropriately. If a patient doesn't need a course of PT then the physical therapist can still provide a better diagnosis and basic treatment info than a PCP. Perhaps just a handful of PT visits will be much better than no follow-up but not as costly and time-consuming as the typical 2-3 times per week for 8-12 weeks that is standard for outpatient PT.


If you can, then skip the primary care office and go straight to a DPT for any musculoskeletal injury. This is mostly a question for your insurance company. It is still the case that many insurance plans require a referral before they'll cover PT. 
But you can always call and ask your regular doctor and see if you can skip the visit and just get a referral. Especially, if you've been seeing the same doc for a while and have needed PT before. And tell them you're an athlete, this will make them more likely to trust your instincts on the matter and to expect that your needs exceed their capabilities.

So, that's what I'm doing and why.

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