Monday, February 11, 2008



As promised, I am presenting my response to James Scifers comment regarding the NATA's lawsuit against the APTA. I will attempt to address all of the, in my opinion, important positions James Scifers wrote in his comment to the "NATA Attacks Our Profession" post.

James Scifers said:

Finally, as a professor who holds each of these credentials and teaches both entry-level athletic training and entry-level physical therapy students, I can honestly state that in terms of their ability to perform an evaluation and differential diagnosis of both orthopedic and non-orthopedic dysfunction, I see absolutely no difference in abilities between graduates from the two programs in which I teach.

Furthermore, given the choice to be evaluated and treated for an orthopedic condition by either group of graduates, I would, without a second thought, select the entry-level athletic training professional. The depth of their knowledge regarding the evaluation, differential diagnosis, treatment and rehabilitation of orthopedic conditions is far superior to that of most physical therapists.

First, this is just one man's opinion. I think red heads are the best physical therapists, hands down. But, unfortunately, that is just an anecdotal claim. However, in terms of evaluation and diagnosis, we do know that:

Experienced physical therapists had higher levels of knowledge in managing musculoskeletal conditions than medical students, physician interns and residents, and all physician specialists except for orthopaedists.

So, while my opinion is just that, research can help speak for a physical therapists skills in managing musculoskeletal conditions compared to a wide variety of other healthcare professionals.

James Scifers said:

Additionally, students in the entry-level athletic training program receive a far more extensive education in terms of therapeutic exercise, therapeutic modality selection and application, orthopedic assessment (including a full course of evaluation and treatment of the spine) and diagnostic imaging than the PT students at the same institution.

Don't know how to address this statement really. I know what my education was, but my alma mater did not have an ATC degree program for me to compare against. I did look into Seton Halls curriculum and course descriptions for the DPT and MATC programs. Things I do know:

1. Seton Hall DPT must be real new as board pass rates are not available

2. The clinical imaging class is the same for both the DPT and the Masters ATC

GMED 6017 Clinical Imaging
This course emphasizes imaging of musculoskeletal connective
tissue, central neural tissues, and peripheral vasculature. Survey
of current technology used in structural and functional imaging
of the body is discussed as well as interpretation, documentation,
and communication of clinical imaging information.
2 credits

3. Seton Hall MATC Therapeutic Ex vs Seton Hall DPT Therapeutic Ex

GMED 6022 (GMED 4022) Basic Rehabilitation Procedures
Provides the student with an introduction to the principles of
patient care. Topics include: Patient interviewing, documentation,
monitoring of vital signs, positioning, transfers and the
use of assistive equipment for ADL activities. Students will also
be introduced to physical examination skills including:
goniometry, range of motion, manual muscle testing, reflex
testing and sensory testing.
GMED 6018 Therapeutic Exercise
This course provides a foundation of knowledge and skills used
to manage the majority of musculoskeletal problems using
appropriate exercise principles and rehabilitative techniques.
Additionally, this course will examine current concepts in
strength and conditioning designed to assist individuals in
achieving maximal performance without incurring injury.
VS.
GDPT 6445 Therapeutic Exercise
Therapeutic exercise is one of the key tools that physical therapist
utilize to restore and improve a patient’s neuromusculoskeletal
well being. This course provides a foundation of
knowledge and skills used to manage the majority of neuromusculoskeletal
problems using appropriate exercise principles
and techniques. Using a problem-solving model, patient care
intervention for musculoskeletal dysfunction includes medical
screening, physical evaluation, and goal setting. Students will
develop skill in therapeutic exercise techniques and learn how
to integrate these techniques with other therapeutic modalities.
GDPT 6030/PTFY 4030 Clinical Skills I
This course will promote skills acquisition in basic elements of
patient services. Emphasis is placed on basic physical handling
skills, health care record information collection and documentation,
general screening for all systems, and essential of
patient-practitioner interaction.
GDPT 6031/PTFY 4031 Clinical Skills II
The course promotes skills acquisition in basic elements of
patient services. Emphasis is placed on basic handling skills,
health care record information collection and documentation,
general screening for all systems, and essentials of patient- practitioner
interaction. The course will prepare the student to
integrate elements from examination procedures into basic
treatment approaches.

4. Seton Hall Modalities MATC vs. Seton Hall Modality courses DPT. Wait...again, same course for both:

GMED 6013 (GMED 4013) Therapeutic Modalities
This course emphasizes the use of heat, cold, compression,
traction and electrotherapeutic techniques in the management
of patients with impairments and functional limitations due to
a variety of orthopedic, neurological and medical conditions.
This course will stress a problem solving approach for the selection
and application of appropriate procedures to manage pain,
edema, limitations in motion, muscle weakness and wound
healing.

So, from the information I can access, the statement that Seton Hall MATC students receive a greater amount of therapeutic exercise and modality education seem unfounded.

Finally, James Scifers says:

This is only one example from one University in the country, but I think it illustrates the need to allow each profession to practice according to their educational competencies and professional qualifications and not according to title alone.

and

Joint mobilization is not physical therapy.
Fair enough. I cannot argue with those statements.

I'm not convinced by any stretch of the imagination that the average MATC graduate tomorrow has the same, and definitely not superior, skill set of an average DPT graduate tomorrow in regards to patient evaluation and differential diagnosis. That doesn't mean they won't get as good results with joint mobilization (including the spine) that a PT would. Joint mobilization as a skill is not a magical tool at all. The skill is knowing when, and more importantly, when not to utilize it.

In the end, I guess, the profession that proves itself to the general public and healthcare policy makers, will ultimately be held as the first choice in treating neuromusculoskeletal conditions. No amount of blogging will change this.

It's unfortunate that a much needed and skilled profession such as Athletic Trainers (ATC's) feels the need to waste everyones time and money with an unfounded lawsuit. Instead, maybe spend the money on research on ATC manual skills and outcomes.

5 comments:

Anonymous said...

In addition, most entry-level ATC's are at an undergraduate level as well. Shoot they just stopped the internship model less than 7 years ago. An entry level Masters in athletic training is not the norm. Generally I know we have more Masters programs for PT than Doctorate; but it would be interesting to compare over the past 5 years or so how many doctorate level PTs we have at entry level and Masters level ATC's.

Dan Rhon said...

Jason,
I thought that was a good response. Just wanted to mention there are other articles in addition to John Childs 2005 (you referenced) that add to the strength of clinical comptetence of Physical Therapists:

http://www.ncbi.nlm.nih.gov/pubmed/17484321?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

http://www.ncbi.nlm.nih.gov/pubmed/15773564?ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

http://www.ncbi.nlm.nih.gov/pubmed/16355913?ordinalpos=428&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

http://www.ncbi.nlm.nih.gov/pubmed/17138843?ordinalpos=9&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

These are just a few... there are many other editorials that summarize/reference these and the one you mentioned as well. Some may show areas that need improvement across the board, but overall they at least establish a baseline. Maybe its true anectodally, but I think you would be hard-pressed to take what is in the literature and make an argument that AT's "depth of knowledge" is "far more superior" than that of physical therapists.

Anonymous said...

Jason,

Thank you for posting my initial comments so prominently on your website. Also, I appreciate you taking the time to feedback to my original comments.

First, the research article you reference does not compare the skills of the PT to the ATC so it really has little to no bearing on my initial argument. Additionally, the research design is flawed in that it has PT faculty scoring the responses to questions. Obviously, each profession is going to provide different answers to these questions based on their content expertise. PT faculty members are certain to score PT responses higher than MD or medical student responses. If the "judges" had been physicians, would the physical therapists have scored the same? Finally, the cases presented in the "exam" are not representative of what orthopedic physical therapists or athletic trainers encounter on a daily basis. Although an interesting study, I would argue that, like many research studies, it creates more questions than it answers.

Second, I would like to suggest that you re-read my original post since many of my comments were taken out of context.

All comments referencing the skills and knowledge of new PT and ATC professionals was in reference to the programs in which I teach, not in reference to Seton Hall. As I stated earlier, I would not presume to evaluate another institution’s curriculum without having significant knowledge of course content, delivery, assessment, etc. All of the comments regarding specific knowledge and application of evaluation and treatment skills were referenced to my institution only. Additionally, all of these comments were in regard to orthopedic assessment and intervention techniques only. As I mentioned in my initial posting, athletic training students focus the majority of their attention on the musculoskeletal system while physical therapy students invest a great deal of time on other systems in addition to the musculoskeletal system. This variation in the educational curricula provides each group of graduates with unique areas of expertise, yet similar skill sets.

Finally, I agree that each profession has its place in the evaluation and treatment of orthopedic and non-orthopedic conditions. I also agree that further investment should be made in (collaborative) research to benefit the patients who seek out our collective rehabilitation services and expertise.

So, although many clinicians would welcome the chance for ATC and PT to work side-by-side and even to compete for patient self-referral and physician referral in an open healthcare market, it is the APTA who opposes allowing this to happen through numerous legislative initiatives (including limiting AT practice patterns through state licensure laws, proposing changes to the CMS Incident-to Billing regulations, preventing dually-credentialed individuals from teaching courses to athletic trainers, etc).

Ultimately, the playing field is not level for each profession. Physical therapists enjoy a much longer history of acceptance into the traditional health care market, have enjoyed third-party reimbursement privileges for years and possess far more lobbying power in Washington. As a result, regardless of educational level, clinical competence or clinical outcome studies, physical therapy will continue to prosper…and athletic trainers will continue to fight for the right to practice the basic clinical skills that their entry-level education clearly qualifies them to provide.

Anonymous said...

It is called encroachment. ATC's are not satisfied with their current niche and naturally desire a need to expand. Are there too many ATC schools graduating a large number of ATC's? If there are no jobs for a new ATC, I understand their need to try to delve into other practice areas. This would be devastating for PT's if the ATC's pull this off. They are cheaper and the PT salary would suffer.

Andrew NIcholson, MS ATC said...

Jason,

I just spent extensive time reading your blog. I am impressed, you have a very fine product going. I will just make 2 quick comments regarding the NATA and APTA lawsuit.

First, would M.D.'s say that PT's are trying to expand into their field.
"This is just another example of people wanting more than they are willing to go to school and get the education for."
If PT's want to diagnose, treat, have direct access without a referral, should you not under your own argument go to Med School?

Second, I know that this is out of your control but the comment that was made below brings up several points worth discussion.

"It is called encroachment. ATC's are not satisfied with their current niche and naturally desire a need to expand. Are there too many ATC schools graduating a large number of ATC's? If there are no jobs for a new ATC, I understand their need to try to delve into other practice areas. This would be devastating for PT's if the ATC's pull this off. They are cheaper and the PT salary would suffer."

Point One: Generally, I do not think that most PT's know or bother to find out exactly what the education and training of other similar professions entail. It gives the impression PT's think and act like they are better than every other medical profession. You have done some homework and I applaud you.

Point Two: ATC's have been working right along side preforming the same duties as PT's for over 20 years. I have work in hospitals, clinics, colleges and high schools. This is not a new expansion we have always been there.

Point Three: Where is the discussion about what is good and best for the patient or the entire health care field? Are most PT's worried about their salaries or worried about a little competition?
There are several studies posted on the NATA website that provide evidence that ATC's patients; return to work quicker, at less cost and with better patient satisfaction than patients that did not work with an athletic trainer.

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