McKenzie practitioners have a unique perspective on the topic of autonomous practice because the "thinking" of MDT fits in to the Direct Access paradigm. It is important that MDT be at the forefront of this discussion and we have dedicated this issue to this topic to encourage your dialogue and action.

Guest Commentary 1
     Direct Access and the McKenzie Practitioner
 Erik van Doorne, PT, DPT, Cert. MDT

Direct access is not a new topic for our profession. It has been an important part of the Vision Statement of the American Physical Therapy Association (APTA), who has been fighting for the rights of patients to see physical therapists without having to obtain a physician's referral for almost 30 years. It has been a battle fought and won on the state level, resulting in 48 states and the District of Columbia who have eliminated the physician referral requirement for patients to access physical therapists for an evaluation, while 44 of those states and DC also allow access to some form of physical therapy treatment without referral.

The battle continues at the state level, but has now gone to the federal level to achieve direct access under Medicare. The APTA introduced the Medicare Patient Access to Physical Therapy Act (HR1829) on March 31, 2009 and will soon follow with its senate companion bill. This is a very important goal for our profession and a big step in lowering the barriers for patients to receive our care. This direct access bill would allow Medicare payment for the services physical therapists provide without a physician's referral or signing of the plan of care.

But is it safe? The answer is a resounding yes. Clearly, a growing number of states have achieved direct access, and the evidence from the federation of State Boards of Physical Therapy and Health Providers Service Organization (HPSO), a leading liability carrier, shows no increased risk to patients in states who have direct access. HPSO does not rate a physical therapist as a higher risk because they practice without a referral.

Another problem is that patients normally have to wait to get an appointment for a referral to go to physical therapy, leading to an unnecessary delay in care. A study by Dr. Jean Mitchell and Dr. Greg de Lissovoy of Georgetown University and Johns Hopkins University, respectively, found that reimbursement under direct access will realize cost savings of approximately $1200 per patient episode of care. So, not only does it provide quicker access to our services, it also saves money.

Furthermore, a study published in April 2002 in the Journal of Bone and Joint Surgery (JBJS) by Kevin Freedman, MD, MSCE and Joseph Bernstein, MD, MS showed clearly that there is inadequate musculoskeletal training in medical schools. Our profession is more than ready for direct access in every setting with every patient in every state.

Now, I can hear you thinking, "What does all of this have to do with me, the McKenzie MDT practitioner?"

We should be leading this battle for direct access. I cannot think of a better trained practitioner to be that entry point for musculoskeletal injuries. Certified McKenzie practitioners - that is, credentialed and diplomaed - have received, in addition to their regular physical therapy education, unique advanced assessment and treatment skills. The McKenzie Method has provided us with a structured, evidence based, logical and safe method to assess patients with musculoskeletal injuries. Therefore, MDT clinicians are very well trained to look for the pathology and the red and yellow flags. We know when the assessment doesn't make sense, or when red flags come up and when we need to refer a patient to their physician for additional medical care or diagnostic testing.

How many times do you still look at the referral when a patient comes in? Or do you grab your McKenzie assessment form and start from scratch and at the end come to a conclusion and treatment plan?

The McKenzie Method is proven to be a safe and valid, well researched method of assessing and treating patients. We have passed the test as Credentialed MDT practitioners and even more extensive and grueling training in the McKenzie Method for Diploma holders. I think we are the physical therapists who should feel most comfortable with direct access because of our advanced training and skills.

Just as we empower our patients, we must do so with ourselves and our profession. So, this is my challenge to you: If we consider ourselves professionals, we should at least be a member of our professional organizations and get involved to help create change. Become a member of The McKenzie Institute because they give us the method, the continuing MDT education, and the ongoing support to provide the best care for our patients; and also become a member of your professional association (APTA, CPA) who fight for the PT profession to make sure our patients can come to us without unnecessary hurdles. I think we owe such a modest investment to our patients.

References
Freedman, KB, Bernstein, J. Educational deficiencies in Musculoskeletal Medicine. JBJS (American) 2002;84: 604-608.

Health Providers Service Organization, in a March 22, 2001, letter to the American Physical Therapy Association, on file at APTA .

Massey, BF Jr. 2002 Presidential Address: What's all the fuss about direct access? Phys Ther. 2002;82:1120-1123 .

Mitchell JM, de Lissovoy G. A comparison of resource use and cost in direct access versus physician referral episodes of Physical Therapy. Phys Ther. 1997;77:10-18.

Click here for Guest Commentary 2 by Susan Bamberger, MPT, Cert. MDT