Last week, I had an amazing opportunity to shadow a physical medicine and rehab doctor (PMNR). The experience has shed a new light on my understanding of what patients may encounter when going through our health care system.
Overall, the MD had a very good rapport and at times, therapeutic alliance with the patients. They do have a long term relationship with the chronic population as they frequent them every 6 months or so. Here are some philosophical differences between PT and MDs.
1) Heavy use of pathoanatomical cause to explain patient’s pain: with all the patients, he educated their condition using the scans from imaging and the findings. For example, the MD showed the normal hip x-rays and compared it to the degenerated spine x-rays. Then reassured patient that the symptoms are not coming from the hip, but rather it’s coming from the back. For other patients, he explained that the patient is having pain is because they have too much degeneration in their facet joints or there is significant decrease in disc space. After shying away from pathoanatomical based approach to treating patients, it was an eye-opener to see that the MDs educate patients heavily on imaging findings correlating to their pain.
As a PT, when I educate patients, I emphasize on reassurance and structural integrity of the human spine. If the patients ask about their imaging findings, I tend to educate patient on how the imaging findings have low correlation to their condition. I may have been toward the opposite spectrum of deemphasizing the imaging findings. Also, patients have been ingrained with the pathoanatomical approach from a very credible referring MD. I should reconsider learning about what patient already has learned about their condition and have a more gradual way of educating patients now. As appropriate, I will need to gradually shy patient’s beliefs away from pathoanatomical model when they see us for PT. Patient education in regards to imaging findings is still something I continue to work on.
2) Lack of referral to the PTs if he suspects that it’s structural problem: if the imaging demonstrates stenosis, severe degeneration, etc, he will elect to put patients on medication regimen or surgical referral.
3) I did not see CRPS taking into account, when many patients demonstrate signs of that. No referrals to PT is made if MD suspects that the problem is a result of structural changes (for example, lumbar stenosis). This is troubling since this approach has failed our patients and contributed to opioids pandemic. Articles like this shows that PTs should be integral part of managing chronic pain population.
Later I had a talk with one of the PMNR doctors, who agrees that correlation between low back symptoms and imaging is poor. He explains that he has attempted to convince his patients countless number of times without having much success. If patients are not buying the MD's education, it's hard to imagine that a PT can convince the patient otherwise. I think the main source of patients’ beliefs on pathoanatomical causes of low back pain is from media and google searches: pages like this is the first link that patient sees when they google “low back pain".
Kay Lin, DPT, CSCS