One of the reasons I chose to specialize in physical medicine and rehabilitation (PM&R) was influenced by Puerto Rico’s distinctive regulations governing physical therapy. At the time I trained, a physical therapy practice could not legally operate without a physiatrist’s license on file. Only a physiatrist could refer a patient to physical therapy, and only a physiatrist’s credentials permitted the clinic to function, as defined under Puerto Rico’s physical therapy statute. That requirement has since changed to allow other medical specialties to fill that role as well, but during my training years, the physiatrist held that ground alone.

This policy was intentional and reflected a key principle: Physical therapy is a medical treatment, and medical treatments require a medical diagnosis, ideally made by the physician most qualified to provide it. In Puerto Rico, that physician was the physiatrist. As a result, a common business model emerged in which physical therapists and physiatrists collaborated closely, frequently meeting to discuss patient progress.

This regulatory structure also influenced the entire career trajectory of a PM&R physician, and it contributed to my decision not to practice physiatry in Puerto Rico. Observing where my co-residents secured employment after graduation revealed the limitations of that career path. The majority accepted positions as the physician of record for physical therapy clinics, not as a formality, but because the clinics could not legally operate without a physiatrist’s license. The prevailing job market favored physicians signing on to a PT practice, maintaining its operations, and effectively supporting another professional’s business rather than establishing their own. I recognized that this path offered limited opportunities for professional growth, which motivated me to seek further training on the mainland rather than remain in Puerto Rico.

Upon relocating, I encountered a markedly different system. Any licensed physician, including internists, urgent care providers, or even those with limited recent musculoskeletal experience, can refer patients to physical therapy. Frequently, referrals consist solely of a generic directive such as “evaluate and treat,” sometimes issued after minimal patient contact. This leaves physical therapists with insufficient diagnostic information, requiring them to perform initial screening, differentiate between mechanical and nonmechanical pain, and determine appropriate interventions, tasks that ideally should have been completed by the referring physician.

An exception to the issue of vague referrals is found among orthopedic surgeons who perform joint replacements or spine surgeries. These specialists typically provide highly detailed protocols specifying weight-bearing status, range of motion, postoperative timelines, and approach-specific precautions, often in documents several pages in length. Surgeons maintain this level of control over rehabilitation because they possess comprehensive knowledge of the surgical intervention and its potential complications. This approach most closely resembles the Puerto Rico model, in which the referring physician has thoroughly examined the patient and provides actionable guidance to the therapist. The challenge is not the feasibility of such specificity in American medicine, but rather that it remains optional for most referring physicians, except surgeons seeking to safeguard their operative outcomes.

In contrast, chiropractors have always operated as independent health care providers, requiring no physician oversight. Previously, this asymmetry highlighted the distinction between physical therapy, which required physician authorization, and chiropractic care, which did not. However, recent legislative changes have altered this landscape. As of last year, all U.S. states permit some form of direct access to physical therapy without a physician referral, unrestricted in twenty-one states and time- or visit-limited in others. In Florida, where I currently practice, a licensed practitioner must approve the plan of care within thirty days or after eight visits. The Prevent Interruptions in Physical Therapy Act was introduced as a temporary measure to allow Medicare patients to continue accessing therapy. The central issue is no longer gatekeeping, but rather the substantive content required for a referral to be meaningful.

This is the question that my training in Puerto Rico addresses more effectively than the current system. A physiatrist’s referral was more than a signature; it originated from a physician specifically trained to conduct comprehensive examinations of the spine, joints, gait, and neurologic function, and to develop a precise treatment plan for the therapist. This included identifying which structures to load or protect and recognizing red flags that necessitate imaging or surgical consultation before initiating therapy. In contrast, an “evaluate and treat” script from a physician who has not performed a thorough examination lacks these critical elements. Such a referral is nominal and shifts diagnostic responsibility to a professional whose scope of practice, in most states, does not include ordering imaging or establishing a differential diagnosis.

This diagnostic gap becomes evident whenever a patient reports that physical therapy “didn’t work.” I frequently encounter individuals who diligently completed their exercises and attended every session, yet experienced no improvement in symptoms. While it is tempting to attribute this to a refractory condition, I will first consider whether the patient received an accurate diagnosis prior to referral or was sent with a generic “evaluate and treat” script, leaving the therapist to address symptoms rather than underlying causes. For example, patients with discogenic back pain, facet-mediated pain, or early hip osteoarthritis presenting as low back pain each require distinct exercise regimens, which a generic referral cannot specify. Apparent treatment failures may, in fact, reflect unaddressed diagnostic errors made before the referral.

I do not advocate for a return to the Puerto Rico model, in which a single specialty controlled access to physical therapy clinics. Direct access is supported by evidence demonstrating faster care, reduced costs, and no indication of compromised patient safety when therapists are properly trained to identify cases requiring further evaluation. Direct access is effective because physical therapists are equipped to recognize when a case exceeds their scope and to refer appropriately. In contrast, a vague “evaluate and treat” script allows a physician who has not conducted a thorough examination to delegate diagnostic responsibility without first narrowing the differential diagnosis.

If I could integrate one aspect from the system in which I trained into my current practice environment, it would not be the physiatrist’s exclusive authority over physical therapy referrals. Rather, it would be the underlying standard: A referral to physical therapy should be based on a thorough physical examination, a well-considered differential diagnosis, and sufficient clinical reasoning to inform the therapist of the specific problem to address. Regardless of whether the referral originates from a physiatrist, an internist, or is made under direct access, the critical factor is not who signs the referral, but whether a comprehensive evaluation was conducted beforehand.

Francisco M. Torres is an interventional physiatrist specializing in diagnosing and treating patients with spine-related pain syndromes. He is certified by the American Board of Physical Medicine and Rehabilitation and the American Board of Pain Medicine and can be reached at Florida Spine Institute and Wellness. 

Dr. Torres was born in Spain and grew up in Puerto Rico. He graduated from the University of Puerto Rico School of Medicine. Dr. Torres performed his physical medicine and rehabilitation residency at the Veterans Administration Hospital in San Juan before completing a musculoskeletal fellowship at Louisiana State University Medical Center in New Orleans. He served three years as a clinical instructor of medicine and assistant professor at LSU before joining Florida Spine Institute in Clearwater, Florida, where he is the medical director of the Wellness Program.

Dr. Torres is an interventional physiatrist specializing in diagnosing and treating patients with spine-related pain syndromes. He is certified by the American Board of Physical Medicine and Rehabilitation and the American Board of Pain Medicine. He is a prolific writer and primarily interested in preventative medicine. He works with all of his patients to promote overall wellness.