This is an interesting thread and it's good to see all the discussion it has generated. It's also nice to see it has not degenerated to a lot of name calling and personal insults.
I work with PTs both in-house and out - private practice and hospital based. I have a good working relationship with a lot of therapists around town and I talk to them on the phone and have lunch with them to discuss patient cases. I also educate the patients about PT - that they should be having mostly "Active" PT and not so much time on modalities and passive PT. I also tell them that if they are one of eight other patients being multiplexed with modalities, to run. If they only see the PT for the evaluation then work with a PTA the rest of the time, I tell them to call me. I rarely approve requests for TENS units and home traction units from PTs. I also will change PTs if the patient doesn't see some kind of improvement within 4-5 sessions. I dont' like patients wasting their time and money on PT that lasts on and on.
I have had some therapists blatantly ignore my prescription - I ask for McKenzie method, they send me a note with nothing about directional preference, derangement, restrictions, etc. I even have patients call to ask if the therapists do McKenzie therapy and they will lie and say yes. I have pulled patients out of therapy because of this. I have had patients quit PT crying because although I asked for aquatherapy (because the patient has a lot of somatic issues and has a lot of myofacial pain and she likes the water) - they insisted on land based PT and even went as far as having an internal pelvic therapist talk about internal PT for her SI pain. The therapist apparently told the patient that the doctor doesn't know anything that they decide what they want to do. They are so used to docs just writing eval and treat that when they do get a detailed script, they just disregard it assuming I don't know anything about PT.
I do think that PCPs in general do not get educated about MSK issues enough. I teach CME courses to PCPs on MSK topics and peripheral injections. During that lecture, I educate them on what to look for in a PT, to not blindly sign off on requests for DMEs, and to not renew a PT script unless the patient is making progress. In practice, I send a detailed note back to the PCP for each referral and will follow up with a phone call as needed.
The PTs I work with - whether they are for or against direct access - appreciate that they don't have to explain everything on their report and I basically hand them a patient on a "silver platter". I also get the patient to "buy in" to the PT process prior to starting - which helps the therapist since the patient is more motivated. 80-90% of my spine patients get better without surgery. Most don't even need injections. I rarely write for opioids and manage most patients with NSAIDs, muscle relaxants, neuropathic pain agents, and medrol dose pak. I tell the patients that medications and injections are temporary but the benefits of PT will last long term.
That being said, I have diagnosed conditions such as OPLL - which would have been missed by most PTs and chiros - who had to be referred to surgery immediately. I have also diagnosed multiple myeloma and other oncological processes causing back pain, Compression fractures with posterior retropulsion causing radicular pain, high grade unstable spondylolisthesis, etc.... All of these patients would not be good candidates for PT. There are quacks in every healthcare field including medicine and patients who are vulnerable or gullible will fall for them. There are PTs who own gyms/spas where they do nothing but sell devices, charge for modalities, and keep patients for months and months on "maintenance" PT by a PTA.
If patients choose to go to a therapist or a chiropractor or an acupuncturist, or a herbalist and there is delayed diagnosis or catastrophic outcome, then those specialists and patients have to deal with the consequences. I will have no problems testifying about a missed radiological finding or physical examination/history element. Patients should be educated about the risk they are taking by avoiding a physician - but the same patients who would go to a PT first without seeing a doctor will also go see a chiro, an acupuncturist, a holistic healer, etc. without first seeing a doctor as well. So to me, direct access doesn't mean much. The patients who know to see me first will continue to see me first. The referring docs who know to refer to me first will continue to refer to me. If a therapist or anyone else for that matter wants to call him/herself a "doctor" and defraud the system, let him/her deal with the consequences.