The New Patient Who Wants More Than Therapy
Daniel R. is a licensed physical therapist in the District of Columbia. His 2:00 p.m. patient, Ms. K, is a 54-year-old attorney with three weeks of cervical pain and tingling in the right thumb and index finger. She walked in without a referral and asks Daniel to do three things: 'crack' her neck the way her chiropractor does, order a cervical MRI because her insurance may require one before approving more visits, and give her a few sample lidocaine patches from the clinic's sample closet. She also hands him a disability parking form and asks him to certify that she is 'totally disabled.' Daniel has completed continuing education in manual therapy and has a colleague who is a chiropractor. The clinic manager tells him that ordering imaging and signing the form are 'good customer service' and that the chiropractor next door will sign the form if Daniel will not. Daniel has not examined Ms. K yet.
1. Which of Ms. K's requests may Daniel lawfully fulfill as a DC physical therapist, and which are outside his scope or prohibited? Explain the line between physical therapy evaluation and manual therapy versus medical diagnosis and medical orders.
Read the worked answer
Daniel may evaluate Ms. K and provide manual therapy, including joint mobilization or manipulation, if it is within his education, training, and competence and he has obtained informed consent. The Act regulates the practice of physical therapy-examination, evaluation, treatment, and instruction to prevent or alleviate physical disability-not chiropractic or medicine. He may not diagnose cervical radiculopathy as a medical disease, order an MRI, or dispense lidocaine. A PT may identify signs and symptoms that require medical evaluation, but the medical diagnosis and the imaging order belong to a physician or other provider authorized by DC law. The request to 'crack' her neck should be handled as a request for manual therapy: assess first, explain what he can and cannot do, and do not advertise or hold himself out as a chiropractor. If cervical manipulation is contraindicated or beyond his competence, he should not perform it.
2. How should Daniel respond to the MRI request and the lidocaine samples, and what should he do if Ms. K's symptoms suggest a condition requiring medical diagnosis?
Read the worked answer
He should tell Ms. K that he cannot order the MRI or provide the lidocaine patches. He should document the reason and refer her to her primary care physician or a neurologist for evaluation of radicular symptoms. If she has progressive weakness, gait disturbance, bowel or bladder changes, or bilateral symptoms, he should treat it as an urgent red flag and direct her to emergency care. He should not accept the samples from the clinic's closet or ask the chiropractor to order imaging based on his examination; either would be an improper workaround. He can send the physician a copy of his objective findings to support the referral.
3. What are Daniel's obligations regarding the disability parking form and the clinic manager's suggestion to have the chiropractor sign it?
Read the worked answer
The parking form asks for a medical certification of 'total disability,' which is outside the PT's scope unless DC law specifically authorizes PTs to certify that condition. Daniel can provide objective functional findings-gait speed, balance, endurance-but should not sign a certification that requires a medical diagnosis. He should explain this to Ms. K and refer her to a physician. He should also decline the manager's suggestion to have the chiropractor sign based on Daniel's examination. That would be aiding a misrepresentation and could violate the prohibition on false or misleading certification. He should document the request and his refusal.