Ep 312 – Standard of Care, Scope of Practice with Ruth Werner

A person sits at their desk talking on their phone while working on a computer.

A client with a complex health challenge can benefit from a conversation between their massage therapist and their health-care team. But, a conversation isn’t the same as permission. In this episode of The ABMP Podcast, Kristin and Darren speak with Ruth about massage therapists’ inclinations to get a doctor’s permission before treatment, whether a doctor’s note protects MTs, and what consulting a health-care team looks like.


Read Ruth’s article in Massage & Bodywork magazine: http://www.massageandbodyworkdigital.com/i/1488451-january-february-2023/56?

Author Images: 
Ruth Werner, author of A Massage Therapist's Guide to Pathology.
Darren Buford, editor-in-chief of Massage & Bodywork magazine.
Kristin Coverly, director of professional education at ABMP.
Author Bio: 

Ruth Werner is a former massage therapist, a writer, and an NCBTMB-approved continuing education provider. She wrote A Massage Therapist’s Guide to Pathology, now in its seventh edition, which is used in massage schools worldwide. Werner is available at ruthwerner.com.   

Ruth is also the host of the podcast I Have a Client Who . . . which runs each Friday on The ABMP Podcast Network. And, if that wasn’t enough, Ruth is a columnist and frequent feature writer for Massage & Bodywork magazine.


Darren Buford is senior director of communications and editor-in-chief for ABMP. He is editor of Massage & Bodywork magazine and has worked for ABMP for 22 years, and been involved in journalism at the association, trade, and consumer levels for 24 years. He has served as board member and president of the Western Publishing Association, as well as board member for Association Media & Publishing. Contact him at editor@abmp.com.

Kristin Coverly, LMT is a massage therapist, educator, and the director of professional education at ABMP. She loves creating continuing education courses, events, and resources to support massage therapists and bodyworkers as they enhance their lives and practices. Contact her at ce@abmp.com.



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Full Transcript: 

0:00:00.2 Speaker 1: Thanks to the support of generous sponsors and all the folks who paid it forward, Healwell is excited to announce it's offering its online symposium Within Reach, the Quest for Information and Research for 50% off. That's $160 for two incredible days of education and engagement that will transform the way you relate to not only research but all information. Join us February 25th and 26th, for this highly interactive virtual symposium. Learn more at healwell.org. Are you ready to thrive in 2023? Join the free five-day Thrive Challenge so you can achieve what you're aiming for this year, the biggest roadblocks holding many therapists back right now are consistent client numbers, time balance, and knowing exactly what to do next when the world still feels a little crazy. In this free challenge, you'll discover the solutions and get a head start to thrive in your best year yet. Go to massagechampions.com/challenge to join now. 




0:01:23.2 Speaker 2: I'm Darren Buford. 


0:01:24.5 S1: And I'm Kristin Coverly. 


0:01:26.3 S2: And welcome to the ABMP podcast, a podcast where we speak with the massage and bodywork profession. Our guest today is Ruth Werner, Ruth is a former massage therapist, a writer, and an NCBTMB approved continuing education provider. She wrote a Massage Therapist's Guide to Pathology, now in its seventh edition, which is used in massage schools worldwide. Ruth is available at ruthwerner.com. Ruth is also the host of the podcast I Have a Client Who, which runs each Friday on this very ABMP podcast network, and if that wasn't enough, Ruth is a columnist and frequent feature writer for massage and bodywork magazine, which brings us to our topic today. We're excited to dive into Ruth's feature article in the January-February 2023 issue of Massage and Bodywork Magazine, helping clients with complex conditions. Why get a doctor's note isn't good enough, and what is better. Hello, Ruth, and hello, Kristin. 


0:02:16.4 Speaker 3: Good morning my friends. How are we today?  


0:02:19.6 S1: We are excited to have you on our pod today. [chuckle] It's always a great day when we can pull Ruth over onto our pod as well as her own. So, we're really excited to talk to you about this actually really interesting topic, Why Get a Doctor's Note Isn't Good Enough and What Is Better? So let's start at the beginning. Ruth, what was your inspiration to write this article?  


0:02:42.0 S3: It seems like such a simple question, but I think this article... And I have now created my own online continuing education class about it, have been rattling around in my brain, probably since very... Certainly since very, very early in my practice. And I mentioned in the article, and it's absolutely true, that when I was in massage school, if we ever... Which was 125 hours, my first go-through. The advice we were given was, "If you have questions about whether a massage is a good idea or not, just call the client's doctor." And I knew then that that was absolutely a non-starter. It just that's not gonna go anywhere. And I ended up, through weird circumstances, I ended up developing a clientele of people who are probably younger than I am now, but they seemed elderly to me at the time, the parents of a lot of my friends, who had a lot of physical issues. They'd had knee surgeries, and osteoporosis, and diabetes, and all kinds of things that I was not prepared to work with, and that's part of what drove me to become interested in pathology, but also part of what... And a driver for that was how do we figure out what's safe?  


0:03:57.1 S3: What are the decision points where we figure out how to make our work as safe as possible? And it became clear to me that we're the only ones doing that, there's no one... There's no authority who can do that for us. So, in my work with Massage and Bodywork, every now and then we have a meeting where we talk about what are some things that you wanna take on. And I think the article that I did, which had came out a little more than a year ago on critical thinking, was a starting place for this. We were brainstorming ideas, I said, "I really wanna do something where we go through a process of decision-making." And I'm just coming to this conclusion in this moment, I think this article about a doctor's note and deciding whether our work is safe, is sort of the culmination of that critical thinking article. We may be placed in a room with a person who has a complicated medical history, we have the information that is available to us in that room, and we have the time while they're preparing for us to enter that room, to make some quick decisions about our work. And that is sometimes... As we know, it's very complicated. But I get very frustrated when I see people suggesting that we can offload the responsibility for that decision by asking someone who seems like a more important or more trustworthy authority, because none of that is true. 


0:05:32.5 S3: We can't offload that responsibility, and as I say over and over and over again, it is not a doctor's responsibility to know whether our work is safe, and even if the doctor or surgeon, or home healthcare nurse or whatever... Even if the medical professional to whom we ask for permission says, "Yeah sure, go ahead." If something goes wrong, we are still at fault. It may be that that blame can be shared a little bit, so there's legal responsibility and there's ethical responsibility, and when we decide to be a massage therapist, we take on the ethical responsibility of determining whether our work is safe. 


0:06:13.3 S2: Ruth, I know you have mentioned this in the article, but you see this pop up all the time on social media. You put some really awesome examples in the article, but it's a little terrifying for me when you sent the article into us, that I just see how often this pops up and how often it is constantly... The information is constantly shared to other MTs that this is the starting place. We probably don't have an answer for this, but where did this just originate? Do you think it's just because of the disparity between the education, possibly between massage therapists and MDs or needing it as a crutch or just feeling better? I get it, it's probably really scary for somebody to come in and proceed with something that you're not familiar with. 


0:07:00.0 S3: As the place of massage therapy has evolved in the American healthcare culture, from an occasional treat to something you do to help you cope with a long-term challenge, that has raised the... I think that's probably increase the number of people with long-term health care challenges who pursue massage. And that means we... Our responsibility is also raised, and that's a drum I beat in almost every setting, in the podcast, in my CE classes, in the book, in the articles. We have a responsibility to offer safe and effective work, that's my favorite phrase, safe and effective. 


0:07:40.8 S1: Okay, Ruth, I think we all are on the same page, that it's often a fear-based response. Like, "I don't know what to do with this situation, here is my default, because I will feel protected if someone else who I view as more educated or a higher authority is giving me permission to do my work." But here is the real question, does having a doctor's note or permission actually protect a massage therapist, if something doesn't go right in a session?  


0:08:10.8 S3: So, from a legal point of view, if you have... Especially if you have it on paper, some indication from a medical person, a doctor, a chiropractor, an osteopath, a whatever that, "I think this client should receive a massage. And the client definitely should not receive a massage." If that person is injured, the massage therapist is still at fault. What the massage therapist can try to demonstrate, because once in a while, a terrible thing will happen, and someone will have an adverse event, and hopefully it won't be a life-threatening adverse event. But the reason we stay within our scope of practice, and the reason that we deliver an appropriate standard of care, and we can define those terms if you wanna go down those rabbit holes. And the reason we record what happens is to demonstrate due diligence, that we have done what's within our power to be professional and to offer safe work. A doctor's note demonstrates that someone else thought this would be safe as well, but if it wasn't safe, the client still got hurt, and we can't offload that responsibility. 


0:09:22.4 S3: Legally, that doesn't work. You might be, as I mentioned earlier, some of that responsibility may be spread out some, but the rubber hits the road where the hand hits the skin. And if you're the one who massaged the extremely painful unilateral calf pain of the person who just got off an airplane, even though their doctor said, "Yeah, sure, go ahead and get a massage." And the person has a DBT, and then has a pulmonary embolism, and then may or may not make it, that is still the responsibility of the message therapist. And if someone wants to make a stink about that, the massage therapist is squarely in their sights. 


0:10:04.7 S2: Ruth, let's shift the conversation here to what we're referring to as, "getting a doctor's note or permission", versus having a conversation with a client's healthcare provider. Can you dive into that a little bit and tell me what the difference is?  


0:10:20.3 S3: Here's what getting a doctor's note looks like, "Dear Dr. X, your client... Sorry, your patient, Mrs. Y wants to receive massage for her recent shoulder surgery, is that okay with you? Signed P Trisage." What is the doctor supposed to do with this? They don't know what massage is, they don't know what kind of work you do, they don't know how often or how deep. They might know how recently the surgery was, but the real decision points are not shared. By contrast, "Dear Dr. X, I'm a massage therapist, I specialize in shoulders. Your patient who had this shoulder surgery six weeks ago wants to receive a massage. I have some concerns, because I noticed that her scar has not completely healed yet, that seems a little slow. I don't intend to stretch the skin around this, but I wanna make sure that anything else I do is not going to disrupt her healing process. Can you give me some feedback about this? Can you give me some feedback about this? Can you... Do you have an opinion about her risk of complications? Do you feel that it would be safe for this client to stretch her arm in whatever direction?" 


0:11:40.5 S3: These are the kinds of questions that are gonna allow a physician or a surgeon or a whoever to have an informed opinion, and that's really, really different from, "Is it okay if she gets a massage?" And that's the point of the article, and that's the point of the CE class, is outlining the differences between these two things, and then providing some... There's a template that's in the article that is pretty applicable for lots of different circumstances, so you can fill in some of these blanks. Making sure that whoever it is you're communicating with has enough information to make a judgment about whether they think your work is a good idea or not, or in alignment with their treatment goals or not, or however that conversation needs to move forward. 


0:12:28.3 S1: Yeah, and listeners, just so you know as you're hearing Ruth say, "Oh, there's some sample content that you can learn from and adapt and use for your own practice." If you've got sparked up about that, know that yes, it's in the article and there are links there, but also, it's on ABMP.com. And we'll put that link in the show notes for this podcast, so it's easy for you to find. But Ruth, you and Allissa Haines of Massage Business Blueprint, worked together to create a sample letter that you might give to a client to share with their doctor or physician or their healthcare team. Can you tell us a little bit more about that?  


0:13:05.6 S3: Yes, thanks. I really was hoping to be able to talk about that. So, part of the impetus for writing this article now at this time, was because Allissa and I were both noticing a lot of these conversations and both of us getting a little heartburn over it. So we combined our creative energies, and one of the things that Allissa and Massage Business Blueprint have done, is they've created a whole e-book, and in this e-book which is available for free, they'll ask for your email address, and then that... And that's it. But in this e-book, there are several templates, I think there are at least four, for different kinds of situations, that people can adapt for their own use. The one that is available through the article and that you just said will be posted is completely open to whatever the underlying condition might be. But Allissa wrote one about... Oh gosh, lymphedema, and there's one about long-Covid symptoms, and there's one or two more. And in addition, Allissa also wrote a sample verbiage that we can give to clients, because it's the client that needs to be our carrier to get this doctor's note, this inquiry, this invitation for a conversation into the doctor's hands, and that it turns out to be a complicated process. 


0:14:34.2 S3: So, the video that goes along with our article is Allissa and me talking about, "How do we get this in front of a doctor's eyes?" And there are a few options, and some of them require that our clients do some of this for us. And so, in this e-book, that pathway has been made as easy as possible. We're really just trying to reduce the friction points to getting this kind of conversation set up. 


0:14:58.1 S2: That's perfect, Ruth, 'cause my thought, my 10,000-foot view here is, "I can't even get my own doctor on the phone and communicate. What are you talking about? How am I gonna do that for my client? That seems like such a huge hurdle." 


0:15:08.9 S3: Yeah, and this is where the institution... And not everybody has this, but the institution of electronic health record portals, ends up being really, really, really helpful. Because you can give a communication to your client in an electronic form, and ask them to upload it to their doctor, and I have found, just on my own behalf, that ends up being a pretty good way of getting some communication going. And fill in that, we can print it out, give it to the client and ask them to take it into their next appointment. Or we can print it out, put it in a sealed envelope with the doctor's name on it, and walk it into the office ourself and, "Please put this in the person's inbox, or mail it or whatever." But what we can't do is email it, because that does not... That is not compliant with privacy laws. 


0:16:03.6 S1: Let's take a short break to hear a word from our sponsors. Anatomy Trains is excited to invite you to our latest in-person Fascial Dissection workshop, April 10th through 14th, 2023, in Boulder, Colorado. Join Anatomy Trains' author, Tom Myers and master dissector, Todd Garcia, on this voyage of discovery. Visit anatomytrains.com for more information. Are you a massage therapist who loves to problem-solve? Do you see clients with challenging musculoskeletal issues? If so, then studying precision neuromuscular therapy will help to sharpen your decision-making skills and achieve better client outcomes. Our emphasis is on the problem-solving process, rather than the teaching of a singular technique or approach. Led by founder Douglas Nelson, each PNMT instructor is a busy clinician with decades of practical experience. Visit pnmt.org to explore our offerings of live seminars, online courses, or the video resource library, the PNMT portal. That's pnmt.org. Let's get back to our conversation. 


0:17:23.7 S2: I think you mentioned it in the article, but I foresee one of three things happening in this kind of instance. MTs giving a very light-touch massage, because they're afraid of the condition that's been presented to them by the client, banning the massage altogether and referring the client to someone else, because taking the time to seek out a client's physician to have this conversation may seem hard or intimidating. Or maybe worst case scenario, jumping right in because they took that weekend class in X, Y and Z. 


0:17:50.6 S3: The scope of practice issues end up being a really interesting part of this conversation. Because, no matter where you are... Oh, gosh, now that I've said this, I'm not 100% sure it's true. But I bet that there is no state massage law that says, "You must get a doctor's approval before you work with a client." And so, when we look at the legal definition of scope of practice, it really comes down to two things, one is competence, that you only do things that you are actually capable of doing, that you're educated enough to do. And a weekend workshop in manual lymph drainage is not enough to be competent to do manual lymph drainage for someone with a very complex situation, so competence. And the other aspect of scope of practice is permission, and that permission is given by the client, which means we need to get it... We need to obtain informed consent. And the permission is also related to what your local regulations are. So, nowhere in that decision-making process is the voice of the doctor saying, "Yeah, sure, go ahead." I wanna speak to your first scenario which is, "I'll just go really light, so I don't disrupt anything." And truthfully, I think that that's not a bad plan in terms of safety, when we look at wanting to be both safe and effective. 


0:19:14.2 S3: It's not a bad plan in terms of safety, and the effectiveness is gonna be related to how relaxed our client can be, while we're there with shaky hands being really, really nervous about disrupting something. However, I think our clients might deserve our being able to know enough about their situation maybe to offer some more directed kinds of work, when it's appropriate. Sandy Fritz often talks about how the more complicated your client's healthcare situation is, the simpler the massage needs to be. And I actually really, really agree with that, I think that's a really nice phrase, a really nice idea. But sometimes people have complicated things that could really benefit from targeted, directed, well-informed massage therapy, if the massage therapist knows enough to be safe. But all of those elements have to be in place, about having permission from the client and local regulations. So if you live in a state where you're not allowed to work inside the mouth, even if you're really good at working inside the mouth, and the client really has a problem and they want you to receive work inside the mouth, if you do it, you're out of scope, because you're no longer in compliance with your regulations, so permissions and competence. And if we can demonstrate that those pieces are in place, then we're working within our scope of practice. 


0:20:37.9 S1: Okay, Ruth, we started the conversation talking about the reflex to say, "Oh, my gosh, I better get a doctor's permission" is fear-based. We've talked a lot about how we could shift from saying, "We need doctor's permission" to "Let's have a conversation with the doctor or healthcare team." But really it's up to us to be competent in our scope of practice and educated to work with whatever condition the client is presenting with. But someone can be agreeing with us and on that train, but still the fear exists, that original fear is still there. So, let's talk about and give some advice for someone listening who said, "I am on board, but yet if that situation presents itself, I might still feel the fear, now what?" So what advice do you have for someone who's in that situation, how do they step by step, kind of work through that?  


0:21:35.6 S3: My first response to that is fear is good. Because what it tells us is we are aware that something might go wrong, so let's take steps to make sure that that doesn't happen. And the steps we take are to run through the thinking processes about identifying what are the variables that are really gonna play into this decision. Maybe getting more information before we pursue anything further, and if we can't put together enough information to feel pretty safe, then it might be time to initiate a conversation with that person's providers. My favorite piece of advice for someone, who's stuck there, is to... And this is not new or innovative, it's basically to go slow, be conservative. If there's a part of their body where you're not sure your work is appropriate, don't work on that part of the body until you get more information. 


0:22:35.1 S3: And then incrementally, perhaps, increase the demand for adaptation that your massage presents. If someone is recovering from a knee surgery and their knees are really swollen, but it's not infected, and you don't happen to be educated in manual lymphatic drainage, let's leave that side alone for a while, maybe help them pump their leg a little bit as they're going through their recovery process, work elsewhere, see how that goes, next time maybe institute a little bit of gentle touch, see how that goes, next time go a little further. 


0:23:16.4 S3: And that's just one goofy example, if you're gonna be working with post-surgical clients, you should probably get some training in lymphatic drainage, and I know a place where that can happen, that's an ABMP class that was recently aired. But I love the idea of working incrementally, and I definitely don't love the idea of aiming for great, big, miraculous results in a short period of time, because those are the results that tend to backfire. 


0:23:45.2 S1: Yes, and I love the E word that you mentioned in that answer too, educate yourself. If you're presented with something, you feel overwhelmed, I loved, too, that you said, start incrementally. But also, if it's something you really want to learn, so that you can practice confidently and work with clients in these conditions and presenting with these situations, seek education, grow, expand what you know. So the next time this happens, you feel confident, you have the skills, it's in your scope of practice to give safe and effective treatment and care to the client, right?  


0:24:23.3 S3: Yes, absolutely. And the wonderful continuation of that virtuous circle, is that if you end up having great results with this client and their particular kind of situation, because you have accrued good information, and you've developed some new skills and care, is that that person is gonna refer more people. And so by... Not necessarily by accident, but through diligence, this is the kind of thing that can really solidify a person's practice. 


0:24:55.3 S2: Kristin, have you had scenarios where somebody's come in and you feel stumped at the beginning and like, "Oh, my God, I don't know about this, I need to research this more or look into it more." And is that something that you would do on the spot and tell the client, or you would delay the session? I'm just curious from a client perspective. 


0:25:14.0 S1: Yeah, that's a great question. In my private practice, later in my career, I usually have those conversations before the client comes. So I kind of... As I'm texting with them, getting it set up, I say, "Anything specific we're working on?" So I can do that prep in advance. But when I started and I worked in a clinic, I worked with a lot of car-accident victims, and so sometimes it was in the moment like, "Oh, this is happening today. Okay, great, let me do some consultation, let me reach out and get some information." So, yeah, so I've had all scenarios kind of present themselves and you do, you have to take a breath, get the information you can, and make smart choices using critical-thinking processes to work with that session in the moment and then plan for further sessions. Get the information you need, reach out to your support group, your other massage therapists, that hopefully you have a little group where you can talk about these situations that come up and support each other as you're decisions and moving forward. 


0:26:18.3 S2: That's so important, Kristin. I just wanted to hear that from you, because I wanted to make sure listeners hear that permission that you're saying. That permission to pause, to research, to critical think, that Ruth talked about earlier. And I'm just thinking, scratching my head a little bit here, does a ABMP have a resource that people could use for that? Do either one of you know what that resource is?  


0:26:40.4 S3: There were a database of pathologies that you could... 


0:26:47.5 S2: Oh, yeah. 


0:26:47.7 S3: Look something up really fast and get at least a starting point of some strategies. Gosh. 


0:26:56.3 S2: Listeners, were referring to Pocket Pathology, which is the app that we developed with Ruth on this topic. Incredible, ABMP members, access that app. And if you're not an ABMP member, just make sure to become a member so you have access to that. 


0:27:09.6 S1: Yeah, I will jump in and say, it's a great resource. So in the moment, if something presents itself as a surprise, which sometimes can happen as clients come in, and they're like... And usually it's an, "Oh yeah, I forgot to tell you... " X, Y, Z kind of thing during your oral health history check-in. While the client's getting ready, you can very easily pull out your phone, go to Pocket Pathology, type in the pathology, and you get a lot of incredible content immediately. So, it is worth looking at, and hopefully you don't always have to use it in an emergency situation, it's also great just to go in and learn while you have time, when you're not in that stressful situation but just as great continuing education and knowledge, super helpful. 


0:27:56.8 S2: I wanna thank our guest today, Ruth Werner. For more information about the articles we discussed, visit the notes section of this podcast or visit massageandbodyworkdigital.com. And for more information about Ruth and the good work that she is doing, visit ruthwerner.com. Thanks Ruth, and thanks, Kristin. 


0:28:14.0 S3: Thanks everybody, always great to see you. 


0:28:16.5 S1: Ruth, thank you for another incredible conversation about a topic that's really important to practitioners, and the way that they run and succeed in their practices. We appreciate you. 




0:28:34.1 S1: Members are loving ABMP Five-Minute Muscles, and ABMP Pocket Pathology, two quick reference web apps included with ABMP membership. ABMP Five-minute Muscles delivers muscle-specific palpation and technique videos, plus origins, insertions, and actions for the 83 muscles most commonly addressed by body workers. ABMP Pocket Pathology created in conjunction with Ruth Werner, puts key information for nearly 200 common pathologies at your fingertips and provides the knowledge you need to help you make informed treatment decisions. Start learning today. ABMP members log in at abmp.com, and look for the links in the featured benefits section of your member home page. Not a member? Learn about these exciting member benefits at abmp.com/more.


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