Prescribing Physios

I posted on Twitter how I was NOT in favour of the recent proposal to change the national regulations for physiotherapists in the UK to prescribe and modify stronger pain medications such as Codeine and Gabapentin here. This created a lot of mixed reactions and so I thought I would expand on this a bit more here.

To put this as clearly as I can I don't think its the role of ANY physiotherapist to prescribe ANY medications let alone strong analgesics with potentially serious side effects and harms. I do understand and recognise that the physio profession must adapt and progress to help those we see in pain within an ever-changing healthcare system. I just don't think prescribing medications is the way we should be doing this.

Distracted

In my opinion, the physiotherapy profession continues to be distracted by the biomedical world of pain management, with many physios focusing on the medical management of pain with injections and medications rather than other alternatives that can be just as effective and far less harmful.

This is not to say that I don't think injections or medications can't and shouldn't be used to help those in pain when indicated; I just don't think it's within the role of the physiotherapy profession, and I say this as a trained and qualified 'injection therapist' myself.

I know this sounds hypocritical, but as an Extended Scope Practitioner working in a busy Trauma and Orthopaedic department, it was essential that I had the training and ability to administer ultrasound-guided corticosteroid injections under a local patient-guided directive. And as much as I love working in this role, I do not enjoy this aspect of my job.

Dilution

I am all for advancing skills in physiotherapy but I think there are some lines that should not be crossed. Mixing the physio and medical roles too much I believe leads to both confusion and dilution of the effectiveness for patients.

Just as I wouldn't expect a doctor to spend the time designing and prescribing an individually tailored rehab program for a patient after an MSK injury, I wouldn't expect a physio to prescribe and administer medications to a patient after an MSK injury.

Personally, I believe all physios who currently inject and/or prescribe medications, and I include myself here, do a far less effective job at advising, educating and more importantly rehabbing patients back to good robust functional levels.

This is simply because they have far less time to plan and implement rehab programs, discuss lifestyle modifications, and give behavioural and motivational advice with patients, as they are instead discussing the pros and cons of injections, medications, or surgery, which from my own experience takes a lot of time and effort.

Don't get me wrong I think advising patients about the pros and cons of injections and medications is a worthwhile use of time, even if it's not the most rewarding, I just don't think physios need to be trained in the administering or prescription of medications them to do this.

Longer ≠ Better

The main argument for physios to be trained in prescribing medications is that they're better placed to advise patients as they see them more and for longer than doctors. This is believed to make them better judges of what and how much mediation is needed. But I call bull shit on that.

Spending longer with patients doesn't automatically mean you get to know them any better, or make you a better judge of what the issues may or may not be. In fact, I think spending longer with patients can sometimes cloud and affect your professional judgement as you develop personal attachments that can make you prone to over or even underestimating things in patients.

Advising ≠ Administering

The other argument for physios to prescribe medications is that they are often asked about medications by patients and because they are not trained to prescribe them they can not give any advice about them. Again I call bull shit on this.

I absolutely 100% agree that all physios do need more training on pharmacology and medications, and this should begin at the undergraduate level. The time spent learning massage, manipulations, or spinal segment motion palpation could be spent better on learning drug physiology, mechanisms, and interactions.

If physios had more basic training and education on pharmacology, they could be better placed to give patients recommendations without the need to prescribe or modify them, and this is no different with any other factor such as diet, stress, or smoking. Giving advice about something doesn't mean you have to administer it.

Faster ≠ Better

Finally, one of the main arguments for physios to prescribe more medications is that it's more convenient for patients, and avoids any delay of them being in pain, as well as easing the pressure on doctors appointment schedules and time. But again I call bull shit on this.

Yes, many doctors are under huge pressure on their time and appointment schedules, and yes many patients do find it difficult to make appointments to see them, and yes there are often delays. But this is due to ineffective healthcare management and infrastructure at a national governmental level and will not be easily fixed nor impacted on significantly by more physios prescribing medications.

I also think there are some very good and well-justified reasons why there should be some inconvenience and delay between a lot of patients with non-acute, non-traumatic pain and their ability to access strong pain killers like Codeine and Gabapentin. Faster, quicker, more readily available access to treatment doesn't always equal better quality of care.

Advocating a delay in accessing pain control can come across as cold, uncaring and discompassionate, but I think it can be beneficial for some patients for a number of reasons. First, it simply allows for a short period of time to see if pain naturally reduces. It can also allow an individual to experience a brief exposure to an unpleasant stimulus which could help them develop more resilience and robustness against it. And finally, it can help put off and deter those looking for medications for secondary gains and of course avoid the complications and risks this has.

Now I'm in no way advocating that we let patients suffer unnecessarily or needlessly for extended periods, just that popping a pill or having an injection immediately at the first hint of pain isn't how or why they should be used.

More = Better

Around this argument is the complaint that it's often difficult for physios to get in contact with doctors to discuss patients medications, and so if they can independently prescribe them this avoids this issue and will be better for patients. Again, I call bull shit on this.

I don't deny that it is often very difficult if you work outside of a multi-disciplinary team environment to get in contact with doctors and other healthcare professionals, it's difficult at times even working within one. However, avoiding and circumnavigating this communication issue is NOT the answer to help patients, in fact, it could have the exact opposite effect.

One thing I have learnt after 20 years working in healthcare is the more connections, links, access, and communication you can have with other clinicians the better it will be for you and your patients. If your ability to contact another healthcare provider to ask for some advice or guidance is difficult or obstructed, I would strongly urge you to improve this as quickly as you can, NOT avoid or ignore it.

All healthcare professionals, including physios, need to stop thinking and working in their little isolated silos thinking they can help patients all by themselves. All clinicians should be looking to work and integrate more with other clinicians, as this allows each to help, support, and more importantly, learn from each other, which ultimately helps patients and avoids duplication, error, and confusion with their management.

Summary

So once again I do NOT support the idea that more physios should be prescribing or modifying more medications. I do understand the arguments of quicker, faster, more convenient pain control for patients, but as I have argued above I think these are not justified.

I do support the notion that all physios need to learn more around medications to be able to offer simple advice and guidance to patients. However, I don't think they need to prescribe or modify them as this can cause confusion for patients and lead to potential barriers and disagreements between doctors and prescribing physios.

Finally, I think ALL physios should be focusing on other ways and means to help patients in pain away from medications and injections. I think more physios need to look to specialise and advance in things we do best, which is getting patients moving more, making lifestyle modifications, and long term behavioural changes.

As always thanks for reading.

Adam