The Façade of Patient Safety Advocacy

• “Physical therapists shouldn’t see patients without a referral from a physician.  Your back might hurt because you have cancer.  Physical therapists don’t treat cancer.”
• “Physical therapists shouldn’t be permitted to do dry needling.  They aren’t trained as acupuncturists.  An acupuncture needle can be dangerous in the wrong hands.”
• “Physical therapists shouldn’t perform high velocity low amplitude thrust manipulation to the spine.  Spinal manipulation is an advanced procedure.”

Health care providers will inevitably compete for potential patients and certain interventions since the legal and practical boundaries that separate medical professions can be blurry.  The divisions that do exist are often more political than pragmatic.  The easiest way to discredit another political party is to portray it as soft on national defense and formulate a doomsday scenario whereby terrorists will rule the earth if said group assumes power.  Similarly, the best way to vilify another medical profession is to allude to all the undiagnosed malignant tumors, punctured lungs, and severed spines that would ensue if a particular group of providers expanded its scope of practice and professional autonomy.  In other words, shared interventions can be to medicine what terrorism is to politics.  The difference in medicine, however, is that the villains are professions with a weaker political lobby and lesser resources, not every potential competitor.  In medicine, we only pick the fights that we can win.  Consequently, many of the dialogues that occur between medical professions are just as mindless and futile as those that occur between politicians.  Lots of words are exchanged but nothing is actually said.

To be fair, physical therapists aren’t always the victim during these exchanges.  The fluid overlap between rehabilitation, fitness, and athletic training can make physical therapists uneasy.  Many physical therapists, especially those who identity themselves as “manual therapists”, become hypertensive the second they see a personal trainer at the gym rub a client’s leg with a rolling stick.  “Personal trainers can’t do soft tissue work”, these physical therapists declare.  Therefore, physical therapists are just as susceptible to fear-based professional myopia as everybody else.  The scare tactics employed by various health professions are contingent upon certain assumptions.  Some of these assumptions are:

1. There is an epidemic of preventable cancerous deaths attributable to direct access physical therapy.  Conversely, primary care medical doctors are less likely to be duped by systemic problems masquerading as local pain syndromes.
2. Thrust manipulation is an “advanced technique” because it actually modifies joint position and induces lasting structural changes.
3. The act of penetrating the skin with a small needle requires hundreds of hours of training devoted strictly to acu (needle) puncture and “energy” medicine.
4. Our bodies are sufficiently fragile and plastic that manual therapists routinely alter soft tissues with their techniques. Non-clinicians lack sufficient histological expertise to work with devices like foam rollers and lacrosse balls.

Each of these assumptions justifies a blog post in itself.  In the interest of time, there is no evidence to suggest that any of them are true and yet these are the very assumptions that divide many professions.  More importantly, they decrease the pool of potentially competent providers who might be of service to people in need; the supposed reason most people get into health care in the first place.  Practitioners that throw accusatory stones from a theoretically baseless house might consider resting their arms to reevaluate their framework.  Typically, this is not the case in medicine.  When one considers the actual mechanisms whereby the aforementioned contentious techniques achieve a therapeutic effect, things like acupuncture/dry needling, spinal manipulation, and “soft tissue” work emerge as much less mystical and proprietary.  While each of these tools can provide relief in certain contexts, their mechanism of action does not warrant the divisiveness they create.

In addition to running a private physical therapy practice in New York City, I also work as a Pararescueman in the Air Force.  Pararescuemen provide personnel recovery and technical rescue capability in non-permissive environments for the U.S. military.  They are trained to independently stabilize and treat injured servicemen and women for up to 72 hours without access to advanced medical facilities.  Consequently the scope of practice for Pararescuemen is extensive relative to other prehospital providers and includes training in chest tubes, surgical airways, rapid sequence intubation, regional and general anesthesia, blood transfusions, intravenous and intraosseous narcotic administration, and advanced cardiac life support.  The initial medical training for a Pararescueman lasts eight months, way less time than civilian medical providers with a similar scope of practice take to legally perform the same procedures.  Many Pararescuemen don’t have college degrees and are more proficient medically than military and civilian counterparts with more formal education.  While the military is certainly not devoid of politics, Pararescuemen generally do not engage in turf wars with other providers because treating patients with bullets and explosives around doesn’t appeal to many people. In many ways, military medical training demonstrates how drawn out and antiquated the civilian educational system can be.  Prehospital providers in the military master legitimately invasive procedures in less time than some people insist is necessary to rub somebody’s leg with a stick, superficially puncture the skin with a 28 gauge needle, or produce an audible cavitation in the proximity of a joint. Preparedness and clinical competency are achieved through high quality training, not an arbitrary number of hours. 

During my first semester in physical therapy school, my classmates and I could identify every major anatomical structure in the body from memory.  The actual efficacy of something like dry needling notwithstanding, do we really require an additional 400 hours of acupuncture instruction to appreciate that we shouldn’t stick a needle between somebody’s ribs or into an artery? Despite the inescapable overlap between different health-care professions, the boundaries that do (and must) exist should be based on reasonable and objective clinical standards.  Clearly, people who aren’t trained as surgeons shouldn’t do surgery.  

Nonetheless, dry needling, spinal manipulation, and manual therapy don’t warrant the same scrutiny as an organ transplant.  This distinction is not as obvious as it may seem when professions seek to establish relevance to the public.  All health care providers are patient safety advocates.  Patient safety concerns are not always political and financial interests disguised as advocacy.  However, the façade of patient safety advocacy is transparent.  Most professions would be wise to fix their own internal issues before marketing themselves at the expense of others.  Sometimes sharing information and embracing professional redundancy is in the patient’s best interest.  Professional self-interest can interfere with patient care.  Remember that the next time a health care provider with skin in the game predicts the next medical malpractice plague.  True patient advocacy might mean refusing to walk the wheel with our colleagues.