By Allissa Haines
It’s a super big pet peeve of mine in online massage communities. Someone will post a question about clinical contraindications . . . and roughly 32 people will chime in and say, “Get a doctor’s note.” This breaks my heart every time, and here’s why.
Doctors don’t know what massage does to the body.
Most massage therapists aren’t even sure what massage does to the body. A doctor cannot and should not be expected to make safety decisions around a modality they do not practice and very likely don’t know much about. Most MDs don’t get training in what various soft-tissue modalities do to the body or when they are or are not contraindicated.
Specifically, any given doctor won’t know what your massage does to the body. A doctor’s knowledge could be limited to one cruise massage they got 10 years ago that was super light touch and had lots of lavender. So, if a client with a clot in their calf says, “Is it safe for me to get a massage?” that doctor thinks, “Sure! That’s safe. Go get your massage.” We know we really shouldn’t be working on the leg of someone with a clot, but the doctor doesn’t necessarily know that.
Or a physician might think all massage is just like very specific work they once got at physical therapy after they tore their rotator cuff. PT-related massage is dramatically different from the kind of work I do. My slow, deep work would not be appropriate for a person with certain health issues, and that physician could be giving a thumbs-up on a dangerous situation.
A note does not absolve you of liability if the client is harmed.
“A doctor said it was OK, here’s a note” is not going to help you in court if you knowingly gave a deep massage to a hot, swollen thrombosis. And I doubt that a note is going to help you sleep at night if you hurt someone.
It’s not a doctor’s job to decide if massage is safe.
It is our job to decide whether we can apply a safe and effective massage to a person with any particular medical complication or issue. It is our job. We are the ones with the massage training. We are the ones who can and should know how to adapt a massage to be safe.
It’s helpful to consider all the factors you can before you reach out to a medical provider. Let’s consider an example. How does this client challenge their body on a regular basis? Are they walking up and down stairs with a full basket of laundry comfortably? Are they exercising? Are they vigorously working out? If a vigorous workout doesn’t cause angina complications, then your simple medium-pressure massage with a goal of relaxation probably won’t either. Nor would a light massage with some specific deeper work to the low back.
There are times when we may need to communicate with a client's medical provider in order to help determine safety and adjustments. That doesn’t mean you write a note or an email or you call a doctor’s office and talk to a receptionist and say, “I need to know if Dr. Smith thinks it’s OK for me to massage their patient.” We are not looking for permission, we are looking for information.
Getting that information starts with a conversation with your client and getting appropriate permission and documentation to reach out to their provider. In connecting with the medical professional, we should present the needed information about our massage so they can give their thoughts on safety. “This is what my massage looks like. Here’s an example of the pressure. This is how it might challenge the body. The client is otherwise challenging their body this way on a daily basis. Are there any other factors I should consider in determining how to adjust this treatment?”
Sometimes we need to ask a medical professional about medications.
And sometimes it can be hard to get in touch with a doctor. Enter: your community pharmacist. It’s good to know your local pharmacists or have some relationship so you can call and say, “Listen, I got this client on this medication. And I’m pretty sure it means I need to watch for a drop in blood sugar/bruising/edema. Would you agree with that?” But we’re still not asking for anyone’s permission or for any other provider to take responsibility for what our massage could do.
Ruth Werner has beat the drum about this for years and makes the point really well on a recent podcast episode about clots. She says, “In order for a massage to take place, only two people have to give permission—the massage therapist and the client. You know who doesn’t have to give permission? The doctor. I’ve said it before. And I know I will say it again. It is not a doctor’s job to determine whether your work is safe. That’s your job. And you are the only person who can do it.”
It is so important to consider your responsibility and really remember what it is you do, and how you were trained. If you were not trained to handle this kind of clinical reasoning, then take some more classes, dive into pathology. Or just get used to referring out more complicated clients. But asking a doctor for permission and assuming that permission makes your massage safe is not a thoughtful or ethical approach to providing massage.
My hope is that after reading this piece, the next time you’re tempted to say, “Get a doctor’s note,” you change that to a more refined and thoughtful line of questioning:
- What is the client’s normal activity level?
- Would your massage challenge the body more or less than that?
- Are there things about this illness or medication that you feel warrant a conversation with a medical provider to clarify your understanding of the issues?
As massage therapists, we are the practitioners who often spend the most time listening to and putting our hands on clients. We owe it to them to do the critical thinking to provide them with the best possible care.
Allissa Haines can be found at massagebusinessblueprint.com. Enjoy her weekly Massage Business Blueprint podcasts with Michael Reynolds.
You'll still need a doctor's note if you're billing insurance
You make some excellent points, Allissa. I just wanted to point out something your article doesn't mention: getting a doctor's note for insurance purposes.
Many clients have insurance plans that cover massage therapy AND their plan says "self-referred...no doctor's referral needed". The problem with this is, without a doctor's referral/note/prescription, which should include a diagnosis on it (ideally in ICD-10 code), a massage therapist cannot bill to medical insurance. Why? Because we can't diagnose, it's out of our scope of practice. A physical therapist told me once that you can bill with a pain diagnosis, such as "knee pain", which is basically the client diagnosing themselves, but he also said these codes are frowned upon by insurance companies and often lead to denial of treatment (and payment). I've rarely used pain codes except sometimes as a supplemental code. So getting someone with proper diagnostic authority, such as a doctor, will go far to allow for a positive rehabilitation experience (smoother, less interruptions) for both the client and practitioner.
I have talked to several health insurance companies about this. For example, referring to a specific patient's insurance plan, I asked, "So you're saying that this patient doesn't need a doctor's referral in order to see me as a massage therapist?"
"That's correct," the CSR said.
"So if I send you a bill for services rendered that has no diagnostic code on it, you're going to pay that?"
"Ok, so the problem here is that a massage therapist has no diagnostic authority, so we are always going to need a doctor's referral with a diagnosis code on it. I do hope you can pass on this message to the right people to change this policy that's confusing to both clients and practitioners."
I've had new potential clients actually get a little testy when I told them they needed a doctor's referral and I wouldn't work with them until they had it, because they insisted that they didn't need one. They weren't wrong as it was in black and white print in their policy. They were thrilled to have a plan that gave them more freedom and I certainly appreciate that, but in this case, that freedom isn't really there.
I wish the system was different and I wish clients/patients did have more freedom in their choice of care without excessive red tape of the system, but that's the cards at the moment.
The bright side of this situation is when the client returns to their doctor (the referring one) after a number of treatments and mentions or demonstrates how much better they're feeling and doing, it helps educate the doctor as to the effectiveness of our work. As you mention, many doctors simply are unaware or even misinformed as to what massage therapy is and how it can be useful in health care and our clients can be our best allies in educating their doctors.
Two dIfferent things
Hi Jason. What you are talking about is a whole other matter. Yes, people may need a referral or prescription for insurance coverage. I did not forget or leave that out, it's just not what this article is about (it's about the 'permission' issue specifically).
But your comment is very thorough and will be super helpful for people who deal with insurance or may want to start doing that!