Content of physician referrals to physical therapists at clinical education sites in Indiana.

The capacity to solve problems has been described as one of the defining characteristics of a profession.[1] Problem solving is exhibited by physical therapists when they make independent diagnosis and treatment decisions. The level of decision making required by physical therapists can be demonstrated in several ways. Decreasing proportions of physical therapists work in settings in which physicians are readily available to assist with decision making. In 1978, 47.1% practiced in hospital settings; by 1990, this percentage had decreased to 29.6%.[2] Physical therapists today are called on to make independent diagnosis and treatment decisions when they see clients without physician referral. In 1982, physical therapists could see patients without referral in only 3 states; by 1992, they could do so in 28 states.[3]

Another indicator of decision making relates to the content of referral to physical therapy, when a referral exists. Two indirect indicators of the level of decision making required of a physical therapist are the percentage of physician referrals to physical therapy that indicate the client's diagnosis and the proportion of referrals that indicate a specific treatment that the physical therapist should administer. Despite anecdotal reports of increasing levels of decision making by physical therapists through referrals without diagnoses or treatment orders, these two factors have not been studied systematically in the United States since 1969.[4]

In 1969, Worthingham examined physical therapy referrals in a nationwide study of three types of practice settings (clinical education, public health, and private practice facilities) to determine the "initiative and judgment required of the physical therapist"[4(p990)] in response to the physician referral. Fewer than half of the referrals contained "specific" diagnoses. In addition, 81% of referrals to physical therapists in clinical education facilities, 39% in public health facilities, and 75% in private practice facilities specified a type of treatment.

Three other studies have examined the types of treatment specified in referrals to physical therapy. Seventy-six percent of the 151 physicians studied by Silva and associates[5] in California in 1981 stated they used physical therapy services on a prescriptive, rather than a referral or consultative, basis. A national study of 243 physicians by Uili and colleagues[6] in 1984 indicated that all the physicians preferred prescriptive referral of patients to physical therapy. In contrast, a 1987 study of referrals to private practitioners in Victoria, Australia, showed that only 45% of referrals contained some form of treatment suggestion or prescription.[7]

Thus, based on the existing literature, it appears that a majority of patients referred to physical therapy do not have differential medical diagnoses and that many are sent to physical therapy without specific treatment orders. These findings indicate that physical therapists are frequently required to make decisions about the nature of the patient's complaint and about the best way to treat the patient.

Because the content of referrals to physical therapists in the United States, including therapists working in settings used as clinical education sites, has not been studied directly in over 20 years, we wondered whether current clinical education sites used within our entry-level master's degree program in physical therapy receive referrals that require students to use the type of diagnostic and treatment planning skills emphasized in our curriculum. We therefore designed a study to accomplish the following purposes:

1. To determine the frequency with

which referrals to selected clinical

education sites in Indiana specify a

differential diagnosis.

2. To determine the frequency with

which referrals to selected clinical

education sites in Indiana contain

specific, general, or open treatment

orders.

3. To determine the frequency with

which referrals to selected clinical

education sites in Indiana contain

different combinations of the diagnosis

(diagnosis present or diagnosis

absent) and treatment (general,

specific, or open) variables.

4. To determine whether these frequencies

differ based on whether

the referral was for an inpatient or

an outpatient.

Based on anecdotal reports of increasing decision making by physical therapists and the diversity of clinical facilities, we hypothesized that few referrals would contain diagnoses and specific treatment orders and that referrals for outpatients would provide fewer diagnoses and specific treatment orders than would referrals for inpatients.

Method

Sample

To ensure statewide representation and a balance between inpatient and outpatient facilities, 20 clinical education facilities associated with the Krannert School of Physical Therapy at the University of Indianapolis were selected. Of the 20 clinical education facilities, the directors of 17 facilities agreed to participate in the study. These 17 facilities were 9 hospitals ranging in size from 83 to over 1,000 beds and 8 outpatient facilities. We limited our sampling to sites in Indiana because we believed that greater accuracy in recording the required information would be attained if we worked closely with a small number of clinical sites with directors who were known to us.

Procedures

Inpatient and outpatient data-collection sheets were distributed to clinic directors. Inpatients were defined as hospitalized patients and those residing in extended care facilities; outpatients were defined as nonhospitalized individuals, including home care patients and children seen in school systems. The data-collection sheets had spaces for the date, diagnosis(es), and treatment order(s) for each new patient referral. The department directors were asked to compile lists of the exact wording for all new patient referrals received during 1 calendar month.

Data Reduction

Initial examination of the information obtained revealed that the determination of whether a differential diagnosis was given was too subjective to be made by a single examiner. Therefore, a panel of evaluators was assembled. The panel consisted of two physical therapists, one with 7 years and one with 4 years of experience in inpatient and outpatient settings; a board-certified specialist in internal medicine; and two board-certified primary care physicians participating in a primary care fellowship in sports medicine. The primary care physicians shared their responsibilities for the determination of diagnosis category. Each panel member was given a list of the diagnoses collected in the study. The panel members individually indicated whether they believed each diagnosis was a differential medical diagnosis. We compiled the definitions of the term "differential medical diagnosis" found in three medical dictionaries-10 and instructed the panel members to use the following definition as a basis for their decisions:

Differential medical diagnosis is a

diagnosis determined by systematically

comparing and contrasting clinical

findings to determine which one of

two or more diseases or conditions is

producing the patient's symptoms, as

determined by the referring

practitioner.

The results of the team members' votes were compiled for each diagnosis. Because each diagnosis was rated by four individuals, ties were possible, in which case the primary investigator (ALC) cast the deciding vote.

Following the analysis by the panel, we noticed that many diagnoses had not been identified as differential medical diagnoses because they were actually designations of surgical procedures. We therefore expanded our definition of differential medical diagnosis to include surgical procedures, renamed it the more general "differential diagnosis," and reclassified the surgical procedures as differential diagnoses.

Because determining whether a treatment order was specific, general, or open was easier than determining whether a differential diagnosis existed, the primary investigator categorized the treatment-order variable independently. A referral with a specific treatment order was defined as one in which the physical therapist would have limited opportunities for decision making about the type of treatment to deliver, although the characteristics of the particular types of treatment did not have to be specified. General treatment orders were those that specified some treatments, yet allowed for a measure of independent decision making about types of treatment by the physical therapist. For example, "ultrasound" was considered a specific order because the decision about what form of heat to use was not left to the therapist's discretion. Very few of the specific orders contained any more specific language than the type of treatment. For example, none specified specific dosage levels for ultrasound. "Heat" was considered a general order because the therapist would have discretion about the type of heat modality to provide to the patient. Open treatment orders either specified "evaluate and treat" or gave no treatment order beyond "physical therapy." Table 1 provides further examples of responses that were classified as differential and nondifferential diagnoses and examples of the three levels of treatment orders.

[TABULAR DATA 1 OMITTED]

Data Analysis

Analysis of the data consisted of the tabulation of frequencies of referrals (1) with and without differential diagnoses and (2) with general, specific, and open treatment orders, and the cross-tabulation of these two variables. Chi-square tests for independence were performed to determine whether the percentages of referrals with differential diagnoses, treatment orders, and their combinations were distributed equally between inpatient and outpatient referrals. We set the alpha level of significance at P=.05 for each test and used the StatView II package(*) to run the analyses.

Results

All 17 directors who indicated a willingness to participate in the study completed and returned their data-collection sheets. The total number of inpatient referrals was 880, with a range of 2 to 243 referrals per facility. The total number of outpatient referrals was 1,387, with a range of 20 to 182 referrals per facility. The total number of referrals studied was 2,267. These referrals contained 1,177 unique diagnoses.

Table 2 indicates the number and percentage of the various diagnosis and treatment categories and combinations of categories for the total group and for the inpatient and outpatient subgroups, For the total group, 39.6% specified a differential diagnosis and 32.6% contained specific treatment orders. When compared with inpatient referrals, outpatient referrals contained significantly lower percentages of differential diagnoses 56.0.% versus 29.1%, [[chi].sup.2] = 162.87, df=1, P=.0001), specific treatment orders (39.5% versus 28.2%, [[chi].sup.2] =50.31, df=2, P=.0001), and the combination of differential diagnoses and specific treatment orders (24.8% versus 9.0%, [[chi].sup.] = 196-58, df=5, P=.0001).

[TABULAR DATA 2 OMITTED]

Discussion

Both of the research hypotheses--that few referrals would contain diagnoses and specific treatment orders and that inpatient referrals would contain more information than outpatient referrals--were supported. The lack of differential diagnoses accompanying referral to physical therapy indicates a majority (60.4%) of patients in these clinical education sites in Indiana are being assessed and treated by physical therapists without a diagnosis from the physician. Thus, this lack of diagnostic information from the referral means that physical therapists at these sites are called on frequently to make decisions about the nature of the patient complaint.

With respect to the professional relationship between physical therapists and physicians, this finding may be interpreted in a variety of ways. When physicians refer patients without diagnoses, this may mean that they believe that physical therapists will use professional judgment to determine which patient problems can be addressed by physical therapy. An alternate interpretation, however, is that the absence of a diagnosis, particularly in the presence of specific treatment orders, is an indication that physicians believe that physical therapists are technicians who need not be informed of anything but the treatment to be performed. Overall, only 15.1% of referrals contained both a diagnosis and a specific treatment order.

Only 32.6% of referrals contained specific treatment orders. This finding indicates that therapists at these sites often make treatment planning decisions autonomously or with minimal guidance from the referring physician.

Additional results of this study suggest that physical therapists who see outpatients are called on to make more diagnostic and treatment decisions than those who see inpatients. This finding indicates to us that students should have broad exposure to both inpatient and outpatient environments if our goal is to provide opportunities to communicate and negotiate with physicians who write very specific orders as well as to make diagnosis and treatment decisions for patients who have very general referrals.

Although we found significantly more diagnoses and treatment orders for inpatient than outpatient referrals, we do not believe these findings should be interpreted to mean that physical therapists in inpatient settings do less challenging work than therapists in outpatient settings. Intuitively, it seems that inpatient diagnoses are more often known than outpatient diagnoses. We expect that physicians will share diagnoses, when they have determined them, with colleagues to whom they refer patients--whether those colleagues are physical therapists or other physicians. In addition, the acuity of patient problems in the inpatient setting lends itself to greater specificity of treatments by physicians, particularly of contraindications such as those related to cardiopulmonary status or postsurgical weight bearing. Our results imply that physical therapists who treat inpatients may not be required to make as many diagnosis or treatment decisions as those who treat outpatients, but we believe they are likely to make more immediate decisions related to tolerance for treatment and readiness for discharge than do therapists who treat outpatients. In addition, even when diagnoses and treatments are specified, therapists may exercise diagnostic and treatment planning skills by discussing new diagnostic findings with physicians and negotiating different treatment plans than those specified in the referral.

Two weaknesses of our study limit the usefulness of our findings. First, determining when a diagnosis was present proved difficult. When it became apparent that the primary investigator alone could not make good judgments about whether a diagnosis was present or absent, we convened a panel of judges consisting of two physical therapists and two physicians. Although this led to a situation in which tied votes were possible, we chose not to convene an odd-numbered panel to prevent overloading of the panel with either physical therapists or physicians. Unfortunately, approximately one third (33.7%) of the diagnoses represented within the study received two panel votes as a differential diagnosis and two panel votes as a nondifferential diagnosis. The primary investigator then acted as a tiebreaker for the diagnosis. Of the equivocal diagnoses, she determined that 36.5% were differential medical diagnoses and 63.4% were not. Based on this information, readers should be aware that the proportion of referrals without diagnoses may be inflated by the votes of the tie-breaking investigator.

Second, the facilities that participated in this study were purposively selected clinical education facilities in indiana. The proportions reported in this study may not be representative of other geographic regions or of facilities that do not participate in clinical education of physical therapy students.

Summary

Fewer than half of referrals to selected clinical education sites in Indiana contained differential diagnoses, fewer than one third contained specific treatment orders, and fewer than one in six contained both a diagnosis and a specific treatment order. Inpatient referrals contained significantly more differential diagnoses or specific treatment orders, or both, than outpatient referrals.

Acknowledgments

We thank the facility directors who participated in the study and the panel members who classified diagnoses. We also thank Harriette Bashi, PT, and Jamie Shellenberger, PT, who assisted in the compilation of the diagnosis list and results.

References

[1] Houle CO. Continuing Learning in The Professions. San Francisco, Calif: Jossey-Bass Inc Publishers; 1980. [2] 1990 Active Membership Profile Report. Alexandria, Va: American Physical Therapy Association; 1991. [3] Taylor TK. Historical perspective on direct access to physical therapy services. In: Domholdt E, Clawson AL, Flesch PW, Taylor TK, Direct Access to Physical Therapy Services: An Education Module. Alexandria, Va: American Physical Therapy Association; 1991. [4] Worthingham CA. Study of basic physical therapy education: V request (prescription or referral) for physical therapy, Phys Ther 1970; 50:989-1031. [5] Silva DM, Clark SD, Raymond G. California physicians' professional image of physical therapists. Phys Ther, 1987;61:1152-1157. [6] Uili RM, Shepard KF, Savinar E. Physician knowledge and utilization of physical therapy procedures. Phys Ther. 1984;64:1523-1530. [7] Dennis JK. Decisions made by physiotherapists: a study of private practitioners in Victoria. Australian Journal of Physiotherapy, 1987; 30:181-191. [8] Dorland's Illustrated Medical Dictionary. 25th ed, Philadelphia, Pa: WB Saunders Co; 1974. [9] Dorland's Pocket Medical Dictionary. 24th ed. Philadelphia, Pa: WB Saunders Co; 1989. [10] Stedman's Medical Dictionary. 23rd ed, Baltimore, Md: Williams & Wilkins; 1976. (*) Abacus Concepts Inc, 1984 Bonita Ave, Berkeley, CA 94704.

AL Clawson, PT, was Assistant Professor, Krannert School of Physical Therapy, University of Indian Indianapolis, IN 46227, at the time this study was conducted. She currently resides at 21407 Crystal Greens Dr, Katy, IX 77450 (USA). Address all correspondence to Ms Clawson.

E Domholdt, Edd, PT, is Associate Professor and Dean, Krannert School of Physical Therapy. A portion of this paper was presented at the Annual Conference of the American Physical Therapy Association; June 11-15, 1989; Nashville, TN.

This article was submitted October 16, 1992, and was accepted December 7, 1993.