Professional Accountability

You are a physiotherapist registered in Ontario who has been working in the United States for the past 10 years. You have recently returned to Ontario and are seeking employment as a full time physiotherapist. Your experience has been in private practice settings working primarily with patients who have orthopedic conditions.

Since sending out your resume, you have been contacted by a number of multidisciplinary clinic owners to be interviewed for a position in their clinics. These clinics are owned by a variety of individuals: physiotherapists, other regulated health practitioners or business owners. The majority of the patients attending these clinics were injured in a motor vehicle accident. Frequently during these interviews, the position that you are being interviewed for is described as "a consultant role." The clinic owner indicates that the physiotherapist is expected to assess the patient only and the kinesiologist or athletic therapist working at the clinic will do the treatment. You have been offered a job in several of these clinics at a very competitive salary.

You find this role different from what you have experienced in the past. You feel you need to reflect more upon the job offer before you make a decision.

Response

Prior to accepting an offer of employment from a potential employer, the College recommends that registrants consider a number of issues for the purpose of determining whether or not they are able to fully comply with their professional obligations as described in the Standards of Practice for Physiotherapists and other relevant College documents. Registrants should proactively ensure that their employment obligations are not in conflict with their regulatory obligations.

Issues to consider

What are the patients' expectations as to who will be providing the physiotherapy treatment?
What are the payors' expectations as to who will be providing treatment when the billing is for physiotherapy services?
Is it appropriate that complete treatment plans for all patients assessed by the physiotherapist be carried out by the kinesiologist or the athletic therapist?
Is the physiotherapist assigning a portion of the physiotherapy treatment or is the physiotherapist referring the patient to another health practitioner?
Does the employer understand the professional obligations of the physiotherapist?

It is important that the physiotherapist clarify with the patient the role the physiotherapist has in the patient's care before beginning treatment. This dialogue is an essential component of the process physiotherapists engage in for the purpose of fulfilling their professional obligation to obtain informed consent from the patient. In other words, if the physiotherapist is not going to provide the treatment but will assign the treatment to another practitioner, the patient must be informed of this and agree to the involvement of the other practitioner in their physiotherapy care. The patient also needs to understand that physiotherapists refer their patients to other practitioners when the situation warrants a referral. The patient should understand that there is a difference between assignment of a portion or all of the physiotherapy treatment to a support person and a referral to another health practitioner. The College considers a referral to be separate from the care provided by a physiotherapist. When treatment is assigned, the Standard on the Use of Support Personnel by Physiotherapists applies.

What are the payors' expectations?

Physiotherapists must comply with the contractual obligations around billing described in the agreement with the payor and also ensure that they are not in a conflict of interest situation. They must understand the expectations of the paying agency and ensure that they can comply with these expectations while adhering to their professional obligations. They are responsible for how their registration number is used for billing. This includes monitoring for situations that do not comply with the contractual arrangement and taking steps to rectify the situation.

Is it appropriate for the physiotherapist to only assess and not treat?

In some instances, it is very appropriate for a physiotherapist to limit their role to assessment only. For instance, when doing an independent assessment for a third party, the physiotherapist has been retained to function as an assessor or provide a second opinion. However, in the scenario described here, one can reasonably presume patients will be presenting with a variety of signs and symptoms with varying levels of complexities associated with their presenting problems. Physiotherapists have an obligation to place the needs of their patients ahead of their own and to provide quality care to their patients. There are likely to be patients who, because of the breadth and complexity of their problems, require direct care from the physiotherapist. Physiotherapists make individual decisions about the management of their patients and need to have the freedom to provide the type and level of care that is required for each patient they assess. The employment agreement between the employer and the physiotherapist has to provide this level of autonomy to the physiotherapist who is responsible for the care provided to each patient receiving physiotherapy services.

Recommendations

As self-regulating health professionals, physiotherapists are obligated to manage their practice in a way that allows them to deliver ethical and quality care.

The College recommends that, when faced with this type of employment opportunity, registrants discuss and negotiate an agreement with the employer that allows the registrant to:

provide direct treatment to those patients who require treatment from a physiotherapist;
establish some type of mechanism by which they can monitor how their registration number is used for billing; and
clearly distinguish between those patients for whom a portion of the physiotherapy treatment has been assigned and those patients who have been referred to another practitioner. When the physiotherapist refers to another practitioner, it is not appropriate for that practitioner to bill the payor for "physiotherapy" services.