March 2016

Ethics Corner

Kamal Ibrahim, MD, FRCS(C), MA
Ethics and Professionalism Committee Chair

Dear SRS members,

The Ethics and Professionalism Committee will continue to publish potential ethical problems and conflicts in the newsletter and ask for the members’ input. Therefore, the Committee encourages members to submit to the committee any ethical conflicts they may face for further discussion. The following potential ethical conflict is submitted by John Lubicky, MD. Although it is a knee problem, the issue can apply to spine physical therapy (PT) care.

Is this an ethical issue?

Parents who have children that have even mild M-S injuries or who have relatively simple surgery seem to believe that formal physical therapy will be needed. It’s almost an obsession. In all honesty, most of these kids can do simple exercises taught us and supervised by the parents. But those who are sent to formal  therapy, once in the hands of some PT’s, begin a seemingly endless plan of care that seems unreasonable and unnecessary. Consider the following scenario.

A normal 14 y/o girl with recurrent patellar subluxations undergoes a double bundle MPFL reconstruction. The surgery is uneventful and her operated knee is placed in full extension in a knee immobilizer for three weeks. On exam in the office, the wounds are healed, there have been no complications and the girl is having no pain. Her knee is a bit stiff so a prescription for PT is written indicating she should have PT two times per week for four weeks. A few days later the PT sends his own prescription outlining the plan of care for physician approval. Four weeks after the first post-op visit the girl returns, walking normally, with normal ROM of the knee and no obvious quad atrophy. The girl says her knee feels fine,  she tells me the PT wants to continue therapy and sends along a request to extend the program for an additional eight weeks. The request was denied and the patient was told to discontinue formal PT. The PT sent an unhappy response to the denial. This is not an isolated example of this kind of PT directed care whether it involves extremity or spine surgery or injuries.

There may be an ethical issue for the PT as extending therapy is clearly a conflict of interest. Continuing the therapy visits is in the best interest of the PT. In some cases, the PT will insist on continued care until all the insurance coverage is exhausted. Shouldn’t we as physicians determine the need for therapy or should we allow the PT’s free reign? Since many PT’s now hold the title of DPT, it may become more difficult to deal with this issue.

Please send your opinion to The committee will review all responses and publish their summary in next newsletter in June 2016.

Chair: Kamal N. Ibrahim, MD, FRCS(C), MA Committee: Brian G. Smith, MD; Oheneba Boachie-Adjei, MD; Paulo J.S. Ramos, MD; M. Wade Shrader, MD; John P. Lubicky, MD, FAAOS, FAAP; Hilali Noordeen, FRCS; Timothy S. Oswald, MD; James M. Eule, MD; Timothy A. Garvey, MD; H. Robert Tuten, MD