JUNE 1979 P H Y S I O T H E R A P Y 27 PATIENT R E F E R R A L AND T H E PHYSIOTHERAPIST P R E S ID E N T IA L A D D R E S S BY M R J. C R A IG T hro u g h o u t the w orld the present dependent system of referral o f patients by the m edical profession to physiotherapists is u n d e r scrutiny and the question arises w h eth er this system is in keeping w ith to d ay ’s situation. It was a fte r reading articles by P ru e G alley 0n this subject published in the A u stralian Jo u rn al of physiotherapy th a t I thought it w ould be w orthw hile for us to give som e consideration to-day to this aspect of physiotherapy practice. I have draw n heavily on points m ade by P ru e G alley; I am sure she w ould have no objection to this as I have no do u b t th a t she would be anxious fo r th e subject to have as w ide an airing as possible. She m akes the point th a t th e physiotherapy profession has in recent tim es m ad e a special study of n orm al and bnorm al hum an m ovem ent patterns. In consequence, Me profession has developed a very considerable exper­ tise p articu larly w here this relates to th e indiv idual’s movem ent p roblem an d is in consequence in th e best position to decide w h eth er physiotherapy w ould help in any p articu lar case. T his being so, it seem s illogical that only m edical p ractitioners are presum ed to possess the know ledge to decide w hether physiotherapy w ill be beneficial to th e p a tie n t o r not. Surely th e decision w hether physiotherapy can be used is a physiotherapy decision, not necessarily a m edical one. In recen t times, th e developm ent of m edical know ­ ledge has been such th a t m edical u n d erg rad u ate an d p ostgraduate training cu rricu la have becom e so intensive that nothing m ore th a n a basic know ledge o f w hat physiotherapy has to offer is ever included in th e ed u ­ cation o f m edical practitioners. T his can h ard ly be regarded as an ad eq u ate basis f o r decisions regarding their patients w here physiotherapy is concerned. Physiotherapy is rapidly assum ing a m uch higher level of professional activity, an d in consequence physio­ therapists m ust assum e m uch g re a te r professional responsibility. T herapists, th erefo re, can m ake th e greatest co ntribution by using th e ir skills o f evaluating, guiding th erap eu tic exercises an d directing fu nctional training. D etailed treatm en t prescriptions given to therapists lim it th e p o ten tial c o n trib u tio n o f highly trained, well qualified specialists w ho need to be given \m u c h g reater responsibility in the care of th e patient. ^ P h y sio th e ra p ists a re m ost effective w hen given responsibility in evaluating each p atien t by perform ing specific tests; planning a treatm en t p rogram m e as a result of the evaluation; presenting a treatm en t p ro ­ gram m e to the physician fo r a p p ro v al w hen necessary; carrying out the treatm en t program m e an d reporting the p a tie n t’s progress an d need fo r change w hen this is A T T H E 13th N A T IO N A L C O U N C IL M E E T IN G necessary; instructing n on-professional w orkers an d relatives in carrying out specific procedures a n d super­ vising th e ir w ork; and instructing com m unity health agencies such as P ublic H e a lth N urses a n d D istrict N urses w ho are follow ing a p a tie n t’s fu n ctio n al achieve­ m ent at home. F o r econom ic reasons th e present referral structure encourages the p atien t to seek h elp fro m sources u n ­ connected w ith trad itio n al m edicine rath er th a n physio­ therapy, because o f easier access. H e can m ake direct contact w ith these no n -trad itio n al sources. I f he wishes to be treated by a physiotherapist on th e o th e r hand, he m ust first p ay a visit to his m edical p ractitio n er before he can receive th e p h ysiotherapy he desires o r believes th a t he needs. T h e disturbing aspect o f this situ atio n is th a t once the patients opts fo r no n -trad itio n al m edicine, he is rem oved fro m the benefit o f tra d itio n a l m edicine in ­ cluding access to physiotherapy. I t is im p o rtan t to realise th a t physiotherapists do not regard them selves as being an alternative to the m edical profession, b u t ra th e r th a t th eir m ethods o f treatm en t are com plem en­ ta ry to those th at are the prerogative o f th e m edical practitioner. W ith these thoughts as a background, let us now consider possible alternatives to th e present m ethod of patient re ferral to physiotherapy. T h e m odel I am ab o u t to present is in essence th a t suggested by P ru e G alley. It allows at least tw o points of en try into th e system of trad itio n al m edicine — thro u g h th e m edical p ractitio n er o r th e physiotherapist. By m aking entry to th e sphere o f accepted m edical care easier, th e suggested system m ust surely be m ore acceptable b o th to p atien t an d m edical p ractitio n er th an th a t at present in op era­ tion, provided th a t adequate guidelines to cate r fo r th e physiotherapists’ lim itations in term s o f differential diag­ nosis are introduced. P R IM A R Y METHODS OF R EFERRAL TO THE PHYSIOTHERAPISTS The Patient is Seen by the Physiotherapist Only T his direct contact situation is th e one w hich appears to cause concern am ong physiotherapists w ho a re u n d er­ standably loath to accept responsibility in areas in w hich th eir training has been inadequate. F o r this reason it is not a m odel w hich w ould be accepted by all physiotherapists, bu t this is no reason f o r it to be totally discarded. Contents — Inhoud Patient Referral and the Physiotherapist .............. 27 U.C.T. — 150 Academic Festival ... ... ................ ... 28 Some Philosophical Considerations on Pain ... ... 29 The Nature of Acute Pain .......................................... ... 39 The Psychology o f Pain ............... ...................... ... 41 The Role of the Radiotherapist in the Control of Pain ...................................................................... ... 43 The O rthopaedic Surgeon and Chronic Pain ... 44 Pain Symposium — W orkshop ......... ...................... 44 Chronic Pain ............................................. ..................... 45 News from Special Interest Groups ......... ... ... 47 Branch News/Taknuus .......... ..................................... 51 Classified ..'.................................................................. 52,53 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 28 D u rin g th e course of training, th e physiotherapist becomes adm irably equipped to identify m ovem ent an d p o stu ral problem s an d also has a know ledge of the m ethods by w hich som e of these can be avoided. T his being so, in th e com m unity m edicine situation w here a m edical diagnosis is n o t in a ll cases necessary, the physiotherapist can assum e a p rim ary preventive role acting as an adviser in industry, schools and th e hom e. In o rd e r to m ake this possible, the present referral stru ctu re w ould have to be altered so th a t p h y sio th era­ pists could act in this way. P ru e G alley suggests th a t the “first c o n ta c t” m odel just described w ould be the m ost suitable fo r these circum stances. I t w ould also increase the scope of em ploym ent o p p o rtu n ity w ithin th e profession. The Patient Comes to the Physiotherapist, but is Referred to his D octor T his situ atio n w ould arise if a m edical p roblem is found to exist w hich requires the atten tio n of a m edical practitioner, o r w here p h y sio th erap y is contra-indicated. The Patient com es to the Physiotherapist, who con­ sults with the Patient’s D octor T his m ethod of co n tac t w ould ap p ear to have the w idest ap p licatio n in th a t it allows fo r th e physio thera­ pist to be a p rim ary contact practitioner, b u t a t the sam e tim e p rotects th e p a tie n t from m isdiagnosis by virtu e of th e fact th a t th e th erap ist consults w ith th e p a tie n t’s d o cto r when necessary. This p rocedure o f course also protects th e physiotherapist from the consequences o f m isdiagnosis. F u rth e rm o re , the doctor has w ider co n ­ tacts should it be necessary to refer the p atien t to other m edical resources. M any o f the p atien ts coming to the physiotherapist as first co n tac t m ay w ell require access to such o th er m edical resources as the radiographer, pharm acist, etc. This fo rm of re ferral is reciprocal in th a t if the prim ary contact is th e physiotherapist, th e th erap ist m ay consult w ith th e p a tie n t’s d o c to r while if the p atien t in the first instance contacts th e d octor, th e p a tie n t m ay be referred to the physiotherapist. T his system provides the p hysiotherapist w ith a choice as to how he o r she wishes to act professionally. Physiotherapists wishing to retain th e p rotection afforded by m edical referral m ay opt to accept only patients referred by m edical p ractitio n ers and this they are free to do. O th er nhvc' therapists m ay w ish to act as first contact practition within th eir lim itations, w ith the way still beine l Is open to them to consult the p a tie n t’s m edical pra«- tio n er should this be necessary. T his m ethod of c o n s.!' tatio n betw een physiotherapist and d o cto r w ould affn the physiotherapist an o p p o rtu n ity of educating th medical profession ab o u t physiotherapy and w hat it h to offer. T h e physiotherapist w ould be in contact wit*! a w ider group o f m edical p ractitioners, m any o f whom m ay no t have considered physiotherapy if th e ir patient had m ade th em th e ir first p o in t o f contact.. CONCLUSION W h at is being suggested is a change in attitude tow ards the physiotherapist’s role, fro m th a t of depend ent, to th a t o f responsible independent. If this step taken, how ever, the profession m ust not lose sight of th e fact th a t it w ould be involved in increased respon sibility, greater dedication an d self discipline front all concerned. T h e p resen t ethical code o f th e society k not ad eq u ate to guide m em bers as to w hat would hJ considered responsible behaviour should th e p rim a ri contact principle be ad opted an d it w ould b e necessary to introduce into th a t ethical code guidelines imposing constraints w here professional conduct is concerned. T he advantages o f responsible independence fo r the profession w ould be to im prove the professional status o f the physiotherapist, to m ake know n to a wider body o f th e m edical profession w hat physiotherapy has to offer by way of com plem enting m edical measures as such, an d by way o f channeling into trad itio n al medicine m any patients w ho are c u rre n tly m aking practitioners of non -trad itio n al m edicine th eir first point o f contact. A s in all things, how ever, th ere are also shortcomings and th e greatest of these w here independence is con­ cerned is increased responsibility w ith w hich goes an increased m easure o f legal liability in th e litigation conscious w orld in w hich we live. References G alley, P rue (1975): E thical P rinciple an d P atient Refer­ ral. A u st. J. P hysiother., 21. G alley, P ru e (1976): P atien t R eferral and the Physio­ therapist. A u st. J. P hysiother., 22, 117- 120. JUNIE 1979F I S I O T E R A P I E U .C . T . — 150 ACADEMIC FESTIVAL Plans are progressing fo r th e A C A D E M IC F E S T IV A L w hich the U .C.T. M edical F a c u lty is arran g in g in o rd e r to celebrate th e 150th A nniversary of th e U n i­ versity o f C ape- T ow n. T h is w ill take the fo rm of R E F R E S H E R C O U R SES in the variou s disciplines. T h e dates are 3rd to 8th D E C E M B E R , 1979, an d a cordial in v itatio n is extended to all physiotherapists to attend. PRO VISIO N AL P R O G R A M M E planned by D EP A R T M E N T o f PHY SIOTH ER APY Monday. Setting the Scene — a panel discussion on recent developm ents in p h y sio th erap y and to indicate areas to be covered b y subsequent sessions. In tro d u c ­ tion to m o b ilisatio n and m an ip u latio n techniques. Tuesday. In tro d u c tio n to neuro treatm ents. Sym posium on p aed ia trics w ith special reference to cerebral palsy. Wednesday. In fectio n s — In te rd isc ip lin a ry meeting. R eu n io n of U .C.T. diplom ates and graduates. T hursday. R ecent advances in orth o p aed ic and physio­ th erap eu tic treatm en t o f hip s an d knees. M o b ilisatio n and m a n ip u la tio n techniques. Friday. T echniques and a p p aratu s used in chest and intensive care physiotherapy. ACC O M M O DA TIO N : Block bookings have been m ade at hotels and Uni­ v ersity residences b u t early bookings are essential to av o id disappointm ent. SOCIAL PRO GRAM M E: F o r delegates and spouses will include sport (golf, bow ls etc. and a d o cto rs’ 10 km run at 0700 on S a tu rd a y 8th) and the usual attractio n s o f th e Cape, e.g. Wine- lands tour. Class reunions will take place on W e d n e s d a y night, D epartm ental D in n ers on th e T h u rsd ay night and a Buffet D in n er w ill follow the Festival O ration by P ro fesso r Jan n ie L ouw on the F r id a y night. E n q u iries: T h e Secretary, Postgraduate E d u c a tio n C entre, M edical School, O bservatory, 7925. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )