Vignette-Based Triage Decisions in Musculoskeletal Care Among Physiotherapists, Physiotherapists Licensed for Direct Access, and Physicians in Germany: An Online Cross- Sectional Survey

Why It Matters

The study highlights that expanding direct‑access physiotherapy in Germany may be premature without improving triage competence, as low accuracy threatens patient safety and influences health‑policy decisions.

Key Takeaways

• Overall triage accuracy hovered around 35‑43% across professions
• No significant difference in accuracy between PTs, licensed PTs, physicians
• Vignette 7 and 10 showed especially poor classification rates
• Physicians displayed stronger opposition to direct‑access models
• Findings stress need for targeted training and clear referral guidelines

Pulse Analysis

In many health systems, physiotherapists are increasingly positioned as first‑contact providers for musculoskeletal complaints, a model known as direct access. Germany, however, retains a more physician‑centric pathway, with statutory direct access limited to a few settings. Accurate triage—identifying red‑flag conditions and deciding when to refer—remains the cornerstone of patient safety in this context. The recent vignette‑based survey offers a rare glimpse into how German clinicians across three professional groups actually perform this critical decision‑making step.

The survey of 110 participants revealed an overall triage accuracy of only 35‑43 %, with no statistically significant gap between conventional physiotherapists, Heil‑praktiker‑licensed physiotherapists, and physicians. Accuracy plummeted on specific cases, notably vignettes 7 and 10, suggesting that certain clinical presentations are consistently challenging regardless of training background. Such uniformly low performance raises concerns about the readiness of any group to assume unsupervised first‑contact responsibilities, underscoring the urgent need for targeted educational interventions and simulation‑based assessments.

From a policy perspective, the findings bolster arguments for clearer referral thresholds and standardized triage protocols before expanding direct‑access rights in Germany. Physicians’ stronger opposition to direct access may reflect perceived risks to patient outcomes, while physiotherapists’ willingness signals professional confidence that could be harnessed through structured up‑skilling programs. Future research should explore real‑world outcomes, longitudinal training effects, and the impact of decision‑support tools, ensuring that any shift toward broader physiotherapist autonomy safeguards both clinical quality and health‑system efficiency.