Dear Physicians and Surgeons
This service is offered to not only help patients but also to help physicians and surgeons.
One of the most common problems cited by family physicians is; what do you do with a patient with persistent joint pain who has failed to see improvement? When a patient then raises the question of whether they need an MRI or to see a surgeon or not, it’s almost impossible to answer unless you’re a surgeon. Should you order an MRI? What do you write in a referral letter to a surgeon? Which surgeon do you refer to?
This system of referring patients to an experienced physiotherapist in orthopaedic triage assessments is designed to offer family physicians another option rather than putting a patient on a lengthy waiting list with hope of a surgical solution that may never materialize.
Although a physician is critical in the differential diagnosis process, more and more centres around the world are recognizing the expertise of experienced orthopaedic physical therapists in determining whether a patient has truly been engaged (compliant) in a well designed active rehabilitation program specific to their diagnosis. Just because a patient has been treated for a condition doesn’t mean the treatment or exercises have been appropriate for the specific diagnosis. Put another way, one size of treatment or exercise does not fit all diagnosis.
A New Model: Towards A Higher Standard of Patient Care
This new model is designed to reduce premature or incomplete referrals to an Orthopaedic Surgeon unless the patient has been triaged as a high quality referral by an physiotherapist experienced in Orthopaedic triage assessments and the patient has failed to see functional progress following appropriate non-operative rehab strategies, specifically functional exercise for a period of three months or longer.
Before writing a referral letter premature or incomplete referral you need the following information.
(1) their working diagnosis of the condition (injured tissue, severity).
(2) confirmation that the patient has been engaged and compliant in an appropriate home based rehab exercise program for three months.
(3) a written description of treatment they received from all healthcare professionals including a list of the rehab exercises the patient has done,
(4) a statement that the patient has failed to see functional improvement in their activities of daily living or quality of life measures.
(5) a measure of joint severity (i.e. disability indexes).
If you don’t have this information included in your referral letter, there is a high probability that a patient who needs surgery, will be incorrectly ranked as a low priority, with the consequence that they may never see a surgeon and/or go to develop chronic MSK pain and diminished capacity to live independently.
Our model is designed to help Family Physicians
As family physicians, if you have a patient who has persistent joint pain and is questioning whether they need an MRI or need to see a surgeon, then I encourage you to consider referring your patient to our office BEFORE making a final decision and creating false expectations for your patients.
The consequences of a premature referral are creating false expectations in the patient’s mind that;
(a) they need to see a surgeon
(b) surgery can fix their problem
(c) they will see a surgeon soon
(d) surgery is the only solution, nothing else will help.
In reality, if a surgeon rejects a referral or denies surgery (after waiting two years) , the majority of your patients will likely become depressed, gain weight, become less active and compound the impact of other concurrent physical and mental health issues – ALL because of the false expectations created by a premature referral.
We offer Family Physicians an alternative to limit false expectations.
Once we have conducted an initial assessment we will forward a written report and our recommendations to you (family physician)
If we believe your patient needs to see a surgeon, we will write a comprehensive referral letter to the most appropriate surgeon.
If we believe a referral to a surgeon is premature, we will provide your patient with recommedations on treatment and rehab strategies that may prevent the need for a referral altogether. Don’t forget that even with complete tears on MRI’s, 70% of patients can improve to the point where they don’t require surgery IF they follow an appropriate treatment and rehab plan.
We do not require a written referral to conduct an initial assessment, however the more information available to us, the better.
- A plain x-ray is required to rule out conditions such as a osteosarcoma, chondrosarcoma or Ewing’s sarcoma
- An MRI is not required nor recommended.
Our model is designed to help Orthopaedic Surgeons
Patients who need surgery, should see a surgeon ASAP.
Patients who don’t need surgery, still need help to improve the quality of their life.
In addition to helping improve the quality of referrals received by surgeons, there is a larger audience of patients who don’t need surgery and need direction.
Rather than leaving family physicians without direction on how to handle their non-surgical patients, I invite you and your triage team to refer these patients to me.
For 25 years, my role has been to provide this patient population with direction on non-surgical options to improve their functional capacity for activities of daily living and quality of life.
Below is sample text that you can include in your letters back to referring family physicians to give them direction on how to handle their patients as well as how they can help reduce the number of incomplete or premature referrals to your office.
Dear Referring Physician;
While we respect your referral to our office, what is not clear from your letter is whether or not your patient has in fact been engaged in an appropriate and supervised home rehab exercise program for a period of no less than three months.
Based on this information, we believe your patient may be able to improve their < insert joint > function and avoid surgery through participating in a home based rehab exercise program under the guidance of an experienced physical therapist.
We would recommend that you refer your patient to one of the Physical Therapists listed below, who is (1) familiar with our triage criteria, (2) will instruct your patient on an appropriate home based rehab exercise program and (3) monitor their engagement and compliance over a three month period.
The Physical Therapist will re-assess your patient at three months and if they believe your patient has been engaged and compliant with our program, and still requires a surgical consult, the Physical Therapist will re-refer the patient back to our office and copy you with their assessment findings.
Respectfully yours,
< Insert Surgeon name here >
____________________
Terry Kane, Physical Therapist
637-11th Avenue SW, Calgary, AB
Appointments: Online Booking at www.calgaryorthopaedics.com
I look forward to working with you on behalf of your patients.
If you’re looking to improve the quality of referrals you receive, I would welcome the opportunity to help your triage process in whatever way I can.
Since this service is designed to help you and your patients, I welcome any feedback that you think would help.
If you have any questions or comments, please complete form below to send me an email. I will contact you ASAP.
Thank you for your time.
Terry Kane, BPHE, BSC(Physical Therapy)
Registered, College of Physical Therapists of Alberta # 1726
PRAC ID# 2886-01108
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