As a profession, we find ourselves at a critical inflection point. We hold a doctoral degree (DPT) and have fought for and won direct access, legally positioning ourselves as the primary entry point for musculoskeletal care. Yet, an identity crisis bubbles just beneath the surface, one that every outpatient practitioner feels daily.

Are we Doctors, autonomous diagnosticians who manage the full spectrum of patient care? Or are we Therapists, highly skilled experts in executing a plan of care?

The truth is, the modern outpatient clinic demands we be both. The tension arises when we let our “therapapist” legacy overshadow our “doctor” responsibility, especially in the most complex cases. This isn’t just an MSK issue; this spectrum of practice is visible across our entire profession—from ortho and sports to pelvic health, neuro, vestibular, pediatrics, geriatrics, oncology, and the myriad of other specializations we inhabit.

The Spectrum of Our Professional Identity

Our “Doctor vs. Therapist” identity isn’t a simple binary; it’s a spectrum. We live on different ends of it, often in the same patient.

• The “Specialist-Treater” Role: In many cases, the primary diagnosis is already established. This is the world of post-surgical orthopedics and much of neurologic PT. A patient arrives with a known “post-op rotator cuff repair,” “stroke,” or “Parkinson’s disease.”
  Let’s be clear: this is not a simple, “recipe-following” role. The critical thinking required to manage tissue healing against a surgeon’s protocol, or to apply the principles of neuroplasticity to a patient with a TBI, is immense. It demands a high-level specialist-treater. The primary challenge is how and when to progress, not what the underlying pathology is.
• The “Diagnostician-Treater” Role: This is the other end of the spectrum. This is the world of the non-surgical MSKpatient, the vestibular patient, and much of pelvic health.
  Here, the patient walks in with no referral, pointing to a vague “shoulder pain,” “dizziness,” or “pelvic pain.” This is the “doctor” moment. This is a diagnostically demanding setting in our profession.
  In this role, we carry a dual burden:
  1. First, be the “Doctor”: We must perform the differential diagnosis, identify red flags, rule out systemic disease, and decide whether to treat, co-manage, or refer.
  2. Second, be the “Specialist-Treater”: We must then design and progress a complex plan of care for the condition we just diagnosed.
• Pelvic health therapists live this dual role daily, often acting as the primary diagnostician for conditions many other providers overlook, while also managing complex post-surgical cases (like post-prostatectomy) in the “specialist-treater” role.

A Parallel Path: The DPM’s Identity Transformation

This tension is not unique to us. The podiatry profession faced this exact same crisis—and solved it.

We can see a direct parallel in their evolution. The “chiropodist” of the early 20th century was, in essence, a “foot therapist.” Their role was treatment: the technical, hands-on application of skills to treat corns, calluses, and bunions.

Their transformation into the “DPM” (Doctor of Podiatric Medicine) was a deliberate, multi-decade strategy. It began in the 1960s when they standardized their degree to the DPM, a 4-year post-baccalaureate program. This wasn’t just an academic upgrade; it was a fundamental identity shift from treater to diagnostician. They mirrored their curriculum on MD/DO schools, ensuring they were trained in basic sciences, systemic disease, and differential diagnosis.

Armed with this new doctorate, they began their campaign. They secured federal “physician” status under Medicare in 1967. They fought state-by-state to expand their scope, allowing them to diagnose and manage conditions far beyond the skin.

But the real key—and the most crucial lesson for us—is what they did with their post-graduate training. They proactively trained their residents in advanced rearfoot and ankle surgery even before it was universally legal. This created a powerful “scope-training gap” they could leverage.

This culminated in their 2011 mandate: all DPM graduates must now complete a mandatory 3-year, hospital-based surgical residency (PMSR) with rotations in internal medicine, general surgery, and orthopedics. This mandate was their final trump card. It gave them the undeniable proof of competence to win full hospital privileges (like performing H&Ps) and secure their identity. They are no longer “foot therapists”; they are physicians and surgeons of the foot and ankle.

Possibilities for Our Profession

We are currently living in the “doctor vs. therapist” tension that podiatry resolved. We have the doctoral degree, but we have not yet, as a profession, fully and systemically embraced the advanced practice model that solidifies our “doctor” identity in the eyes of the public and payers.

The DPM’s story isn’t a prescription, but it is a powerful case study. It illuminates possibilities for how we can also resolve our tension and elevate our “doctor” role.

• Possibility 1: Financially Rewarding the “Doctor” Role What if our payment models reflected the profound difference in clinical complexity? Imagine a specialist-tier reimbursement A DPT with board certification (like an OCS) managing a complex, direct-access diagnostic case would be reimbursed at a higher rate. This would create a powerful financial incentive to master the “doctor” role, especially as we move toward value-based care.
• Possibility 2: Formalizing Advanced “Doctor” Practice What if we created new, legally protected tiers of advanced practice, just as the DPMs did with surgery?
  • Primary Provider for Primary Pain: Envision a DPT who, armed with advanced training in pain neuroscience, becomes the primary (and best) provider for managing primary pain conditions like fibromyalgia, complex regional pain syndrome, and other central sensitization states.
  • Primary Provider for Metabolic Health: What if a DPT, with specialized training in lifestyle medicine, becomes the primary provider for managing metabolic conditions? We are the experts in prescribing exercise, especially for people in pain. We are uniquely positioned to manage the intersection of diet, pain, inflammation, and metabolic disease (like Type 2 Diabetes).
  • Interventional Practice: A DPT could become the primary provider for MSK injections (e.g., ultrasound-guided trigger points or corticosteroid injections), a natural extension of our anatomical and diagnostic expertise.
  • Primary Fracture Management: Envision a DPT with specialized training who can diagnose stable fractures, order and interpret all follow-up imaging, manage casting, and clear the patient for return to sport—owning the entire
  • Expanded Neurologic Diagnosis: In neurologic PT, this could mean moving beyond treating a given diagnosis to being the diagnostician for complex or emerging conditions, perhaps leading to new pathways for managing degenerative diseases.

The evolution of both professions shows a commitment to growth. The DPM’s journey highlights a key lesson: to be seen, paid, and respected as doctors, we must not only claim the title but also universally embrace the advanced training and diagnostic responsibilities that come with it.

The non-surgical MSK patient, the complex vestibular case, and the direct-access pelvic pain patient all need a “doctor.” The post-op, stroke, and MS patient needs an expert “specialist-treater.”

The question is, will we, as a profession, build the systems that fully empower and reward us to be both? And, as I hope we will, will we have the foresight to, like the DPMs, make advanced residency training the standard we all strive for?

This post was created by Nick Rainey, with assistance from Gemini (AI) for sourcing, wording, and theme development.

Sources

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