As a new physical therapist, I have been unsure of when to refer patient out for a serious pathology. A weekend course with Dr. Boissonnault brought more clarity to my understanding. This becomes especially relevant with direct access. I’d like to share some pearls I learned from this class.
1) Think about “what’s the worst thing that the patient can have?”. Once I am aware of this, I will have a clear idea of what questions to ask to clear that condition. Most of the time, a serious pathology can be cleared out pretty quickly. Doing so will also help retain my knowledge for differential diagnosis. Because as the saying goes, if you don’t use it, you lose it.
2) The screening process for PTs vs MDs are very similar. For example, it's difficult to diagnose with a certainty that a tumor is causing patient’s low back pain. However, we can screen to see if the patient is appropriate for further imaging or blood work studies. Here are some examples. PTs and MDs would use the cluster 1) history of cancer, 2) age> 50, 3) unexpected weight changes 4) failure of conservative treatment as a way to screen out cancer causing back pain. Ottawa cervical spine rules can be used to determine if a plain film is indicated after a neck trauma. This leads to my 3rd point because disease has its own schedule...
3) If the patient is positive for screening (ex: back pain with history of cancer, weight loss, night pain), but has already seen their physician, then what? Ask...
a) Is the physician aware of these findings?
b) What tests have been done so far?
c) If they saw their physician a while ago (like 2 months ago), compare the symptoms now vs when they saw the physician. Has it significantly worsened? Are there new onset of symptoms?
If these questions are positive, and your objective testing doesn’t seem musculoskeletal, then referral to physician is warranted.
4) A mechanical pain pattern (movements, posture relation to pain) does not rule out serious pathology. It does help to differentiate visceral/systemic origins of pain because these are not affected by movement. Early on, pathological conditions (skeletal cancer, RA, stress fractures) frequently present in a mechanical pain pattern. They would use common musculoskeletal descriptors such as dull ache and intermittent.
5) Determine how urgent the referral is: ASAP vs in a week vs at the patient’s convenience. For example, signs of DVT is an urgent referral as in they have to go to an ER now. However, if you see an abnormal looking mole on your healthy patient with shoulder pain, you can recommend that they make an appointment and get that ruled out as soon as they can. Certainly, it’s not an emergency here.
6) As a rule of thumb, plain films (x-rays) are very specific but not sensitive tests for most of these serious pathologies. Let’s use cancer as an example. Once you see something abnormal on the x-ray, such as a mini golf ball growing in patient's spine, that would be positive for cancer. But if you don’t see anything, then that doesn’t mean you can rule out cancer. Another common example is that x-ray will be normal for first 10-14 days with stress fractures.
7) The way you communicate to your patient and their doctor is very important. The doctors are very busy. When I call them, use words that describe patient’s unusual findings to grab physician’s attention. Back it up with all the findings that support my suspicion. If I am having the patient call the doctor themselves, I need to educate them how to report their symptoms. For example, instead of saying, “I have a neck pain”, the patient needs to say, “I have a throat pain, that radiates to my chest and to my face, and I have been having difficulty swallowing”.
7) Lastly, we cannot force a patient to do anything! We can recommend that it’s in the best interest to do x,y, and z (example: go to an ER) but ultimately, it’s their choice. We cannot force their family members either, or their dog, Willy.
Stay tune for an interview with Dr. B in a few weeks!
-Kay Lin, DPT, CSCS