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When we stop and send you to a physician
Direct access means we are frequently the first clinician to see a problem. The skill that matters most in that position is recognising the problems that are not ours.
When to stop and see a physician the same day. Some things are not ours to treat, and the useful skill is recognising them quickly. Unexplained weight loss, night pain that does not change with position, fever with back pain, a sudden change in bladder or bowel control, progressive weakness, a history of cancer with new bone pain, or trauma with a suspected fracture all mean we stop and send you to a physician the same day. We would far rather make that call ten times unnecessarily than miss it once.
Most back pain is mechanical. Most shoulder pain is a tissue that has been overloaded. Most dizziness that reaches a physical therapist is coming from the inner ear. That is what the base rates say and it is what almost every appointment turns out to be.
A small number of presentations are something else, and some of those are serious and time-sensitive. Because New York lets us treat you without a referral, the responsibility for spotting them sits with us rather than with a doctor who saw you first. It is the reason the direct access law requires three years of licensure, and it is the part of this job we are least willing to be casual about.
What we screen for, at every first appointment
Unexplained weight loss. Night pain that does not change with position — pain that wakes you and stays regardless of how you lie is different from pain that hurts when you roll onto it. Fever alongside back pain.
A sudden change in bladder or bowel control, or numbness in the saddle area. This one is an emergency, not a referral: it means an emergency department today, and we will tell you so and help you get there.
Progressive weakness — not pain, weakness, and getting worse rather than staying put. A foot that catches on kerbs, a grip that keeps dropping things, a leg that gives way.
New bone pain in somebody with a history of cancer. Trauma with a suspected fracture. Calf pain and swelling that could be a clot. Chest symptoms, or an arm pain with features that are not musculoskeletal at all.
What happens when we find one
We stop. Not “finish the session and mention it at the end” — we stop treating and we deal with the referral, because a treatment given to somebody who needs a physician is at best a delay.
Then we telephone. Not a letter and not a note for you to carry: we ring your physician's office while you are still here, or we direct you to an emergency department if that is what the picture warrants, and we write down what we found and why it concerned us so that the person who sees you next is not starting from nothing.
And we do not charge you for the visit. Being screened and sent onwards is not a treatment and we are not going to bill it as one.
The false-positive rate, stated honestly
We refer out considerably more often than the referrals turn out to be necessary. Most of the people we send for a physician's opinion come back with nothing serious found, and go on to do perfectly ordinary physical therapy.
That is the correct trade and it is worth being explicit about why. The cost of an unnecessary referral is an appointment and some worry. The cost of a missed cauda equina syndrome is permanent and it is measured in hours. Any screening rule set to avoid the first cost will eventually pay the second, so ours is not set that way.
If we send you to a physician and they find nothing, that is a good outcome rather than an embarrassing one, and we will not be sheepish about it.
The other kind of referral: not urgent, just not us
Some problems are perfectly safe and simply outside what physical therapy does well. A shoulder that genuinely needs a surgical opinion. A pain that turns out to be a rheumatological problem needing medical management. A dizziness that is not vestibular. A pelvic floor problem with a component that needs a physician.
We will tell you at the first appointment where possible, rather than treating for six weeks and arriving at the same conclusion with your money spent. A practice that never says “this is not ours” is not being thorough; it is being commercial.
In order
How this works in practice
Screening happens at the first appointment
Before treatment, as part of the history rather than as a form you fill in.
Anything urgent stops the session
We do not finish the hour and mention it at the door.
We telephone while you are still here
Your physician's office, or directions to an emergency department where the picture warrants it.
You leave with it written down
What we found and why it concerned us, so the next clinician is not starting from nothing.
We do not bill the visit
Being screened and sent onwards is not treatment.
We follow up
If you come back to us, we want to know what they found — including when the answer is nothing.
Questions we are actually asked
When we stop and send you to a physician — frequently asked
What are the warning signs that back pain is serious?
Unexplained weight loss, night pain that does not change with position, fever with back pain, a sudden change in bladder or bowel control or saddle numbness, progressive weakness, and new bone pain in somebody with a history of cancer. The bladder and bowel one is an emergency rather than a referral — that means an emergency department the same day.
Will you tell me if physical therapy is not the right treatment?
Yes, and at the first appointment where we can. Some problems are surgical, some are medical, and some need a different profession entirely. Treating somebody for six weeks to arrive at a conclusion we could have reached in the first hour is not thoroughness, it is billing.
Do you charge for a visit where you refer me out?
No. If we screen you, find something that needs a physician and send you there, that is not treatment and we will not bill it as such.
How often do you refer people out unnecessarily?
Often, by design. Most of the people we send for an opinion come back with nothing serious found. That is the correct trade: the cost of an unnecessary referral is an appointment and some worry, and the cost of a missed cauda equina syndrome is permanent.
Can you talk to my doctor?
Yes, with your consent, and we would rather do it by telephone than by letter. Where a surgeon has set post-operative restrictions we work to theirs rather than around them, and where we think a restriction is holding you back we ring them rather than quietly ignoring it.
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The booking page shows each therapist's own diary rather than a generic grid, so a slot you can see is a slot that is genuinely free. Most people do not need a doctor's referral to start — New York's direct access law runs to ten visits or thirty days — though Workers' Compensation, No-Fault and Medicare each need one from the first visit. If you are not sure which of those you are, telephone and we will work it out before you book.