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For a high proportion of our clients, the first time they come to see us is the first time they have been to see a physiotherapist. For some clients it is also the first time they have seen anyone about their particular injury/pain or problem. For them, coming to see a physiotherapist can be a leap into the unknown.

A recent comment from a client is perhaps an example of the perception of the general public of physiotherapists as a whole. They began their sentence with ‘I appreciate you do not have medical training but…’. Initially at the time, my first instinct was to be protective of the profession we have all worked so hard to protect. However, I did not challenge or question this person’s belief and answered their question. Afterwards it has make me think and it provided an interesting topic and inspiration for this blog.

Where does a physiotherapist sit in the ‘medical tree’?

If you have a musculoskeletal problem what are your options? Having thought about this client’s comment I appreciate that this is actually a really tricky question for you to answer….

In the first instance, the most obvious answer is you could see your GP. A GP generally has a 7-10-minute window to assess and decide on a plan for your management moving forward. This is not very long – I take my hat off to any doctor who decides to become a GP. It is often a thankless task in a very time and money restricted environment.

What I would be looking for my GP to do if it were me? Firstly, I would want to be to listened to. Secondly, if they didn’t have the knowledge to further assess/diagnose my problem. Then I would want to be referred to someone else who has the expertise to further assess me and possibly initiate treatment. This could be a physiotherapist (osteopath/chiropractor/sports therapist) or a specialist doctor.

Your other option is to go directly to a physiotherapist (or other ‘therapist’) or a specialist doctor.

What’s the difference between a Physio and GP?

There are four main differences:

Cost:

A physiotherapist’s time is generally cheaper than a doctor’s time. A fact recognised by the NHS which has lead to the introduction of physiotherapists into primary care in the UK. First Contact Physiotherapists (FCP’s) have been introduced into an increasing number of GP surgeries. The purpose of which is to assess patients who present with musculoskeletal problems. (As many as 1 in 5 patients presenting to the general practice). Freeing up the GP to deal with more general medical problems.

Access to prescribed medicine:

As a physiotherapist I have had to default any prescription of medication to a doctor colleague. However, there were changes to legislation in 2012 – physiotherapists were (with additional training), allowed to begin prescribing a small group of clinically relevant medicines independently. There is, however, still only a small proportion of physiotherapists registered to do this.

Access to further investigations:

For example, Imaging (ie x-rays, MRI, CT scans, ultrasound scans) or blood tests. Again, this is changing with many physiotherapists now able to refer directly for scans and blood tests. However, this is complex. Within the NHS an ‘Advanced Practitioner’, ‘Extended Scope Practitioner’ or as mentioned earlier, FCP’s would be able to refer directly for these tests.

However, in a private setting, physiotherapists can refer you directly for these, but only privately. If your scan or blood test needs to be undertaken by the NHS, then a private physiotherapist is unlikely to be able to give you a referral for this. Although they may write you a letter to take to your GP to explain why he may want to refer you for said tests.

Time:

Perhaps the most important factor of all is the fact that a physiotherapist will, at worst, spend 30 mins assessing your problem. For the majority of NHS and private physiotherapists this would more likely be 45 mins to one hour, compared to the the roughly ‘7-10’ minutes that you would get with your GP.

Again, there are exceptions to this if your GP has a particular interest in musculoskeletal medicine or  have completed further training in the area. A specialist doctor would spend 30-60 minutes assessing your problem (but usually at a much higher cost).

The question: ‘medically trained’ or not?

Let’s look at the Oxford Dictionary definition:

Medicine:

  1. The science or practice of the diagnosis, treatment, and prevention of disease (in technical use often taken to exclude surgery).
  2. A drug or other preparation for the treatment or prevention of disease.

Medical:

  1. Relating to the science or practice of medicine.
  2. Relating to medicine as distinguished from surgery, psychiatry, etc.

Physiotherapy:

  1. The treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery.

Having read the definition of physiotherapy I have to admit I am horrified at how out of date this definition is – but perhaps the profession is to blame partly for this. A quick look at the Chartered Society of Physiotherapy website provides a better definition here (if not a bit more long-winded!).

Personally, I am still not happy with this definition (I am sure I am not alone). The biggest differences are the omission of ‘the diagnosis’ and ‘the prevention of disease’. Hopefully you would struggle to find a physiotherapist that would tell you that prevention is not part of their overall treatment approach. Once you have recovered from your injury then prevention of further injury would be part of the treatment plan. This is something that should definitely be included in both definitions!

Diagnosis

The question of diagnosis is where it gets a bit trickier. From the pure definitions then this is the stand out difference between a ‘Medical Doctor’ and a Physiotherapist. However, for the majority of physiotherapists, ‘diagnosing’ people’s problems are part and parcel of their everyday work.

A physiotherapist will ultimately give you a ‘diagnosis’ of what they think is ‘likely’ to be the problem. Most of our patients come with this exact expectation. Physiotherapist’s will go through the same process as the doctor with a few limitations.

Their first aim is to make sure that your problem is a truly musculoskeletal issue. The aim of their questioning is to work out if there is likely to be an underlying condition. Specifically, one that requires ‘medical’ treatment or further assessment. If it’s decided you need further assessment, they, (like a good GP), should advise you on who is the best person to undertake this further assessment. Some physiotherapists who have undertaken additional training, (much like a GP or Specialist Doctor) may have direct access to imaging or blood tests. They will be able to refer you for these tests directly. But again – not all physios have this additional training.

What’s A ‘Working’ or ‘Differential’ Diagnosis?

What should be understood and made clear is this type of diagnosis is termed a ‘working diagnosis’ or ‘differential diagnosis’. This means until those further investigations have been carried out and the ‘working/differential diagnosis’ has been confirmed or corrected. Then it should not be treated as a ‘definitive diagnosis’ and is subject to change! The examination tests available to physiotherapists are not specific and sensitive enough to be used as a tool for an accurate diagnosis. This should be explained by the examining physiotherapist. We can never be 100% sure of a ‘diagnosis’ until it has been investigated and confirmed. Even then, it could be argued, there is always room for doubt!

Conclusion

So in conclusion, coming back to ‘medically trained’…. From a purely ‘definition’ perspective then the answer would have to be: – ‘Some’ physiotherapists could be classed as ‘working medically’ but this would be purely on an ‘environmental/circumstantial’ basis. If they have undertaken additional training and have direct access to the relevant further investigations, then they would be able to independently confirm or refute/correct the diagnosis.

For the vast majority of physiotherapists however this is not the case. Even if they have the relevant knowledge often a lack of direct access to further investigation means they need to refer back to a GP or on to a specialist doctor to initiate this.

Does that make us less qualified to ‘diagnose’ than a doctor with direct access to all of the relevant investigative channels? That’s a subject for another blog!

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Paul King

Paul, Physiotherapy Lead at Chancery Lane, specialises in assessment and treatment of shoulder problems, hip and groin, knees, lower limb biomechanics, running assessments, cycle assessments and sports injuries, rehabilitation, strength and conditioning. He also has an interest in Ergonomics and work station optimisation.

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