Do what is best for the patient and not just what the doctor says!

I come from an extended family of doctors/physicians and I have high respect for their profession and knowledge. But we all know that doctors are only human and they are not perfect. They may not necessarily know all the time what is best for the patient. Since I work with and see the patient more often than they have seen their doctor, I may be in the position to know what is better for the patient with regards to their Physical Therapy needs. I had a recent issue with my managers insisting that we physical therapist should follow the doctor's order regardless of what the circumstances are. That is simply idiotic and cowardice. Just because they are afraid for the doctor to yell at them is not reason enough not to do what is best for the patient.

The situation was regarding a 60 yo man with severe OA of both knees with flexion contractures and a pain level of 7/10. Doctor CP wrote "aggressive PROM" on his/her order. For the first 6 sessions of treatments, I modified the order to be mostly active stretches and home low load stretch so as to not cause more pain. No improvement on extension ROM was noted after the first 6 sessions. So my supervisor told me to do tibial pressure because Doctor CP insists on it. I complied and did 3minutes of grade III tibial AP oscillatory joint mobs instead because I believe this will be better tolerated and yet achieve the same effect as the sustained tibial pressure. Joint mobs also allow us to have more time to address the strength and pain issues of the patient. After the following additional 6 sessions of treatment with Tibial AP grade III, we achieved a 5 degrees improvement in extension. That is a very good result clinically considering is diagnosis and age. I firmly believe that if I did any more aggressive physical stretch on this patient, he would have more pain and I would have done more harm to him. My belief was confirmed during that one time when I did not put a bolster under his knees during his E-stim to have that sustained extension stretch with very low load force. The patient complained of more discomfort on the knee after the E-stim. And during that other PT session, after I was chastised for not following the doctor's order to the letter, I did the aggressive stretching (as adamantly instructed) and the sustained tibial pressure and sustained prone knee hang with weights. Patient complained of increase pain post treatment from 5/10 to 8/10. He also was not able to tolerate the full 10 mins of the sustained tibial pressure and prone knee hang so it was cut short to 8 mins.
These two instances clearly confimed my belief that the "aggressive PROM" order of the doctor was the best approach for this patient since it caused him more pain. My approach not only increased ROM, it also improved strength and decreased pain.

My treatment approach was clinically sound, ethically correct and better than the doctor's order since it treated the patient as a whole and not just his knee ROM. Since management has had run in with Doctor CP in the past, they have adopted the unspoken policy of doing what Doctor CP says regardless of it being the best for the patient or not. And what is worse, they choose to chastise me instead for using my better ethical judgement to modify the doctor's order to better manage the patient. That is just wrong!