I support the concept of access to Physical Therapy Services without discrimination based on Covid-19 disease, Covid-19 vaccination, or “masking” status in general. However, I oppose elements of this petition for regulation change as a means to achieve access ends they fail to accomplish therapy access ends while creating other service provision problems. While I assume and appreciate the intention of this petition to ensure access to physical therapy services for all Virginians without discrimination based on personal healthcare decisions and status, I oppose this petition as worded because it creates the following (assumed unintended) negative consequences which may result in as much or more public harm than safety:
1. Creates conflict of interest ethical dilemmas for therapist providers.
Physical therapists are already bound by their Code of Ethics to treat patients without discrimination as to the “patient’s health condition.” as stated in section 3D. However this petition fails to consider that therapists can and have a duty to remove themselves from patient care (making appropriate transfer or referral of care) when the therapist’s status results in a conflict of interest that poses an ethical dilemma (in which one deeply held set of values is in conflict with another, namely the best interest of the patient) as stated in section 3D of the Code of Ethics, “Physical therapists shall not engage in conflicts of interest that interfere with professional judgment.” Therapists have resolved these conflicts ethically as a matter of course throughout the pandemic to accommodate their need to provide patients with access to treatment with their need to minimize infecting others. For example, at one place where I work, one vaccinated, healthy, male therapist with no vulnerable household members volunteered to treat a patient who was COVID positive, who could not tolerate a mask, and was otherwise scheduled with a pregnant therapist close to her due date. The pregnant therapist (to whom the patient was originally scheduled) instead treated one a COVID-negative patient originally scheduled with the male therapist. They might have done the same kind of therapist swap for non-mask or Covid issues (if the pregnancy prevented safely lifting the patient’s weight, or if the assigned therapist was not fit-tested, or was allergic to the vaccine, or had a history of Guillian-Barre). In this case it was the therapist’s status, as opposed to the patient’s status that was the cause for care reassignment. This type of everyday, common, prudent, ethical problem-solving based on clinical expertise would be undermined, disrupted, and perhaps even precluded should this petition go into effect as worded.
2. Fails to assure non-discrimination in that it conflates patient access with patient status and tries to solve a hypothetical access problem with a status solution. It falsely assumes that only one behavior on the part of the therapist is the best and only option for access, and erroneously labels patient’s status as opposed to inaccess as the discriminatory element of concern. This point is nuanced, but significant in that the petition as worded creates a logical fallacy of syntax. In other words, the wording makes it a violation of regulation to refuse service to a patient for any reason (e.g. abusive behavior, non-payment, no-shows, etc.) if they just incidentally happen to also refuse to wear a mask.
Perhaps the intended concept could be more accurately worded as “to patients or prospective patients for those individuals or their accompanying representatives refusal to wear masks” or “to patients or prospective patients based on the individuals or their accompanying representatives refusing to wear masks” or “refusing mask-wearing” more accurately conveyed syntax than “to patients or prospective patients if those individuals or their accompanying representatives refuse to wear masks” as stated in the policy proposal. Also, I recommend reconsidering the negative, judgmental connotation with the word choice “refuse” and consider the appropriateness of replacing “Physical Therapy Assistant” with “Physical Therapist Assistant.”
3. Creates unnecessary and less robust duplication of effort as therapists are trained in implementing clinically expert infection control procedures and ethics at the individual, precision, patient level of care (some might say precision medicine), which far exceeds the standards of patient-centered of a general public policy and is far more precise in meeting individual patient needs than the petitioned regulation would. Access, as a standard of care issue, is already addressed in infection control guidelines, regulation, education, and practice act standards elsewhere. As an ethical issue, access is already addressed in the APTA Code of Ethics, which is industry standard. (Emphasis added below.)
“Principle #1: Physical therapists shall respect the inherent dignity and rights of all individuals.
(Core Values: Compassion and Caring, Integrity)
1A. Physical therapists shall act in a respectful manner toward each person regardless of age, gender, race,nationality, religion, ethnicity, social or economic status, sexual orientation, health condition, or disability.”
“1B. Physical therapists shall recognize their personal biases and shall not discriminate against others in physical therapist practice, consultation, education, research, and administration.”
“Principle #2: Physical therapists shall be trustworthy and compassionate in addressing the rights and needs of patients and clients.”
“2A. Physical therapists shall adhere to the core values of the profession and shall act in the best interests of patients and clients over the interests of the physical therapist.”
“2B. Physical therapists shall provide physical therapist services with compassionate and caring behaviors that incorporate the individual and cultural differences of patients and clients.”
3. Item 2 creates a regulation with potential legal and ethical conflict with other oversight regulatory agencies or standards of care in a dynamic environment sowing confusion about regulatory oversight. Any mention of other authoritative institutions should clearly state the difference between those which provide laws and regulations to which therapists are bound versus those which are merely informational in consideration of the Code of Ethics “Principle #5: Physical therapists shall fulfill their legal and professional obligations. (Core Values: Accountability, Duty, Social Responsibility) 5A. Physical therapists shall comply with applicable local, state, and federal laws and regulations.”
4. Item 4 is at conflict with a physical therapist’s ethical and standard of care requirement to take a history and Review of Systems, and to refer when necessary. For example, if a therapist suspects an adverse vaccine event, referral to a neurologist or PCP before treating the patient could be construed as refusing treatment under this petitioned regulation proposal.
5. Creates a specific disease category of discrimination not enumerated elsewhere. We already have oversight devoted to non-discrimination based on behavior and health status in general. There is no more need to enumerate Covid-19 and masks than there is any other disease, vaccination, or behavior, or health choice.
6. As worded, this petition seems to have a Covid-19 disease bias that fails to consider other infectious disease transmission and regulatory considerations as well as the OSHA hierarchy of hazard controls and NIOSH PPE distinctions that set standards for infection control including and beyond Covid-19. I object to the term “mask” in professional regulation without operational definition. Therapists are educated about specific PPE that fall into categories of N95 respirators, surgical masks, face coverings, face shields, PARPs and other NIOSH definitions. Use of wastebasket, non-specific terms such as “mask” reflect a standard of care that is non-expert, sows confusion about infection control principles, and undermines public education and confidence.
7. What evidence exists that such a regulation is needed and not covered elsewhere?
Any physical therapist or physical therapist assistant licensed by the Board or practicing pursuant to a compact privilege, as defined in § 54.1-3486, approved by the Board shall be considered guilty of unprofessional conduct if he:
2. Knowingly and willfully commits any act which is a felony under the laws of this Commonwealth or the United States, or any act which is a misdemeanor under such laws and involves moral turpitude;
4. Conducts his practice in such a manner as to be a danger to the health and welfare of his patients or to the public;
A. A practitioner shall not:
3. Engage in an egregious pattern of disruptive behavior or interaction in a health care setting that interferes with patient care or could reasonably be expected to adversely impact the quality of care rendered to a patient; or
4. Exploit the practitioner/patient relationship for personal gain.