Doctor said my 6mo needs PT

@gbredr This! My son was early and had some difficulties. He is in OT, PT, and Feeding therapy. His therapists are all great and give us awesome tips. I honestly don’t know how things would be without them.

As for sitting up, the Fischer price sit me up has been a game changer! He freaking loves that thing and it allows him to work on his strength while also being able to relax when he’s tired.
 
@springwillow I'd rather intervene early than late personally. Wait lists can be ridiculous, and I appreciate providers who are proactive about these kinds of early interventions.
 
@lwh Yes this! Everyone around me thought I was crazy for seeking speech therapy for my older son, and my old ped was recommending a “wait and see” approach. Low and behold I self-referred and his delay was bad enough to warrant “immediate” services (I.e. we got to skip the wait list). I hate to think of where we would be if we had waited!
 
@springwillow Having done PT with my LO I can say it is super fun and you learn so much! Can I ask why you think it’s extreme? It’s like a bay gymnastics with a personal trainer who helps move baby and plays with baby to get certain muscles engaged in certain ways.

I bet she did the referral so you could have it if you needed it. Also the wait lists are super long so calling now would mean an initial intake appointment ins 4-6weeks in some areas.
 
@risensoul It's just so soon to recommend it imo. If he was 8 mo I'd understand but it was a bit concerning to hear. I felt like it meant he was delayed or there might be something wrong, and my mind instantly turns to guilt and self blame.
 
@springwillow This might be some tough love, but I personally don’t see the benefit to your child from keeping them from getting evaluated. The only person that is helping is you and your own feelings.

If there is something wrong (and if there is, that’s OKAY!! It doesn’t mean you did anything wrong!) keeping them from getting evaluated and getting early intervention, if appropriate, is going to make things worse for your child in the long run because these delays build on each other.

My son has been in speech therapy since 18 months, and started physical therapy and occupational therapy at 3 and he’s grown leaps and bounds in his abilities since then.

Best case scenario, you get them evaluated and the NP was wrong. Worst case, they need a little bit of PT. There’s no downside here other than you feeling embarrassed.
 
@theoden This. PT doesn’t mean something is “wrong” with your kid. PT is a tool, which the parent as the chief advocate for the child, can use to help the child develop into the best version of themselves. Accessing care is an act of love, not an admission of flaw.
 
@theoden This comment is accurate. Why are you going to argue with a doctor … when you aren’t a doctor. PT is amazing for so so many things. And many of them are just preventing an issue from getting worse.
 
@theoden I'm not embarrassed to get my son PT nor get him evaluated 😂 I don't understand why you would think that, I have no problem getting him PT if he needs it, and I understand he can only benefit from it. But it felt concerning to hear without any explanation that my baby boy MIGHT need physical therapy. It sparks the train of thought of "well if he needs physical therapy, is there a delay in his motor functions? Is something wrong? Is there anything I could've done to prevent this? To help this? Is the nearest pt going to be 3 hours away in my state capital where it is dangerous to travel?" I'd love to get him PT if he needs it, it sounds fun, in fact I've been researching ways I can help him at home without having to travel hours away to find a decent PT for my child. But I wish NP and I would've communicated more, gonna have to call up there and make another appointment just to have a conversation
 
Not saying that I DON'T want my son to go to PT or that I'm trying to keep him from it, I just wanted to see if I wasn't the only one who thought it seemed a tad early to be concerned. I have NOTHING against physical therapy and EVERYTHING against the way that the appointment went with the NP. There was no explanation from her as to why she would think he needed pt, and as a FTM I couldn't help but feel anxious.
 
@springwillow I don't know why you're getting downvoted, what the NP recommended was outside of her scope of practice and, based on the information you've provided here, not accurate anyway.

I'd suggest posting this on r/noctor, which is about mid-level scope creep and inaccuracies, and asking the MDs there if they think the NP was practicing outside of her scope of practice and if they would agree with her assessment. You could also post on r/askdoctors. But I think you are in the right to question what the NP said, it's not wrong, they unfortunately frequently over-prescribe and over-refer, you are right to question if that's medically necessary.

As an aside, I'm an attorney, and mid-level scope creep and the harm caused by inaccuracies, neglect, or recklessness by midlevels is a growing issue in medical tort law. This is a growing issue that people are starting to collect more and more data on and even publish books about, which is why I'm so skeptical. Please ask on one of those other subs at least if you can't get in with the actual pediatrician soon.
 
@brianball Generally curious how it's outside of a NP scope of practice to recommend early intervention services? I work in early intervention and NP's provide us referrals all the time.
 
@annie9824 Totally get it! I'm a bit busy at the moment getting the baby to bed and packing for a big trip, so I'm going to try to remember to come back later tonight and edit with more info and details, but I'll try to say something relatively short now.

So, I'm not a doctor, not in health care at all. But I am an attorney and have an MA in an area related to economic policy. My understanding is coming from a political and public health perspective. Back in 2010, Obamacare was passed, which led to a sort of national panic with the underlying question of: if medicine becomes more affordable, more people will want to go to the doctor, but we don't have enough doctors for all these people. What do we do? At that point and going forward, a number of state legislatures, particularly in Republican states, started to roll back regulation on NP and PA practice. NPs and PAs used to be part of a physician-led health care team, but state legislatures started to give them more and more practice authority, and you also started seeing insurance using terms like "provider" to refer to NP's, which has now trickled into the mainstream.

Prior to 2010, you basically wouldn't have gotten referrals exclusively from an NP without physician oversight since they weren't allowed to practice without physician oversight. Moreover, and then as exacerbated by Covid, we also started rolling back educational requirements for NPs. You used to basically need a decade or more of RN experience before an NP program would accept you, and in such programs, you were required to have a ton of hands-on experience. But now, requirements for have lessened and a number of online "NP diploma mills" have cropped up, which again, a number of state legislatures argue will fill some sort of gap, but these programs, in addition to lax admittance requirements, often don't require any in-person training, or barely any.

So you might still wonder, well, what's wrong with just taking up that NP on her referral? This is, I think, what is bugging me about the comments here, but I know it shouldn't since this isn't widely known. Basically, these comments are boiling down to, "well, it doesn't seem developmentally worrisome, but it's better safe than sorry, no harm from seeing a PT!" But is there no harm? I'm thinking here about negative externalities. It can be extremely hard to get in with a pediatric physical therapist, or really any, who actually takes insurance. In the US, specialists, not just therapists but anyone from neurologists to ENTs or what have you, can have long wait times for appointments, and be expensive. When you are taking a spot that's not really necessary, that's taking a spot from someone else.

Now you might think, "but that is just one person!" But the problem is, with growing NP independent practice and scope creep, it's not. For example, studies referred to by the American Medical Association show that non-physicians order imaging at 400% the rate of physicians. That's just for imaging in the quickest one I could Google at the moment, but it's a common complaint across doctors and specialists, and even ER doctors, I know: they tend to get super wasteful referrals from NP's that would have been avoided had that patient been seen by an MD and not an NP, saving the patient significant time, money, and emotional stress, and allowing patients who actually needed those spots to get seen sooner.

In terms scope of practice today, it really depends on the state's legislatures, but I don't know a single MD who wouldn't be horrified at NP's diagnosing children, especially with something as silly as saying that a child needs PT for not hitting a milestone when the time for that milestone hasn't even been reached yet. That causes stress to the patient, wastes the patients time and money, (will they need to take off of work for that appointment?), wastes the PTs time, and takes the spot away from someone who needs it. At the very least, the OP should see a doctor first, as I am almost 100% confident that they would not reach the same conclusion as the NP based on what OP wrote here.

If you ask in r/noctor, they'll be able to give you a much better rundown from a medical perspective of why it's outside their scope of practice. I just gave the political summary of how it is only recently that such a thing is even legally allowed in some states.

Also, the reason for the MD shortage has to do with a shitty Congressional bill in the 1990s limiting funding for residencies, which basically limited how many students medical schools could take in per year, and has artificially shrunk our pool of doctors in this country. I'll find a link about that after dinner if you'd like to read more.
 
@brianball It’s not all about money and insurance, or a shrinking pool of doctors due to one congressional bill. The shortage of medical professionals is multi factorial which is for a whole other post. It has just as much to do with Americans in particular being sicker, living longer, in addition to healthcare workers as a whole being burnt out and leaving the profession for better working conditions or opportunities—MDs, mid level providers, nurses alike—among many other reasons.

Not disagreeing with any of your points really, there’s valid aspects to each one. But, as a pediatric NP with over a decade of experience…..there are kids that would go without a primary care “provider” if I, along with my fellow peers, weren’t an NP or a PA. I totally get the over referral, over ordering, over prescribing aspect of what you are getting at; there are many with my same degree/medical decision making privileges that would “err on the side of caution” rather than not, and would make these soft calls to CYA if you will. Who wants a law suit?? Oh….

There’s certainly an art to medicine that takes not only education but also expertise and skill to master and those soft calls usually originate from lack of one or all of these things. The diploma mills you speak of are a real problem however most mid level providers I know do not have degrees from these places, most actually have very reputable education experience and most I know also have doctorates (DNP—doctor of nursing practice or equivalent).

To note regarding your study link about the 400% imaging rate of mid level providers vs MDs, I work for a physician group with 6 MDs, and NOT ONE of those 6 have personally ordered a single X-ray, CT, MRI or lab in the last 10+ years because they have a NP to do it for them. And don’t even get me started on prescriptions. I get asked on a weekly basis to call in their own prescriptions and this is not just something my physician group does. Lol that study is a tad inflated there, at least in my experience.

As someone that is from a very rural state with several gaps to access in care, there are kids that would go without if there weren’t more NPs/PAs. I know one rural family medicine doctor that was seeing 40 pediatric patients a day, averaging less than 5 min per patient in an 8 hour day and had a 3 month long waitlist for a new patient (usually meaning parents will just not take their child unless there’s a pressing issue or find an urgent care for what they need which is a whole other issue). They hired an NP and were able to see 50% more patients and increase the access to care for their area by a large margin. All this to say—there’s sometimes a reason why seeing an NP may be necessary, that’s all. Im not saying this is OP’s situation by any means, only saying this in response to your very thorough reply.

For the record, my child sees an MD and we are happy with that. But if we lived in an area where access to care was somewhat limited or my son needed to see a provider when his regular pediatrician was out and they were non-physician, we’d be happy to see whatever provider was available, even if that meant possible soft calls on certain things.

Like I said, there’s some validity in each of your points. But to generalize a whole group and undermine the profession as whole, just no. There’s some shitty and sleazy attorneys out there too taking peoples money and causing harm with law degrees from “(insert city’s) school of law”…..but do I think as a whole attorneys are like this? Absolutely not.
 
@kylon Sorry I don't have much time at the moment to respond, but I'm sorry if it seemed like I'm shitting on the profession as a whole, I'm more shitting on scope creep or people jumping into it with online diploma mills and the lowering of educational standards, plus the issues of independent practices being bought up and understaffed.

And that one bill in the 90s was significantly detrimental as we basically haven't reversed it and Congress is doing nothing about increasing resident funding, which limits med school admissions. Also, as to your point about the study, I haven't read the study in full but I would assume that they would control for what you suggested as a factor and are focusing on independent practice as to when MDs are.overseeing. Finally, I'm super sympathetic to the plight of rural areas suffering without MDs, but to me the solution isn't for state legislatures to rewrite the scope of practice for non-physicians, but for us to increase funding on a federal level plus incentives for MDs taking positions in rural areas, which again won't happen without increasing resident funding. But there are plenty of incentives that would draw many out there, from salaries comparable to or higher than city salaries, remote work/telehealth options for when in person isn't necessary, loan forgiveness after a certain period of time working, better work-life balances and more PTO, etc. We can build the funding and incentives and subsidies into producing and staffing more MDs, we just choose to deregulate instead.

But I do 100% believe in and am supportive of the role that NPs play in our health care system, just as with any profession. Of course there are shitty attorneys and those people suck too. Like do not even get me started on how fucking depressing law school was at recognizing the full extent of how corrupt our judiciary is and how basically all that matters is money when it comes to the rulings in a number of sectors, like how much antitrust has been rewritten over the years. That doesn't mean I hate FTC regulators or antitrust attorneys, just that the system is broken.
 
@brianball I agree, those are all great solutions, in a perfect system with no flaws. If only. My oldest brother is a physician and most of those incentives were offered when he took his first job (particularly loan forgiveness) which ultimately was his main reason for taking that job. One of the bigger medical schools in my state has started a rural admittance program allowing them to increase their total number of students admitted to medical school, under the condition that some of these students will be family medicine doctors in rural areas for X number of years upon graduation. Funding from our state legislature has helped with this. Great strides in the right direction, but a long way to go.

I believe NPs should always work in direct collaboration with their physician partner (team based decision making with autonomy escalating with experience) and I am lucky that my job situation supports this. I wish this was required across the board and also wish for standardization of NP/PA/mid level provider autonomy on a federal level….but I digress. I do appreciate your perspective from a legal standpoint. All in all, in both our respective career fields, we are navigating a broken system.

Anyway, sorry OP for hijacking your post! I do agree that this is a very very very soft call and would seek a second opinion before going forward with a referral. If by 9 months there is still concern, this is when I would seek a referral especially if any other milestones are not yet met. Wish you and your little one the best! You are doing great.
 
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