Prior Authorization

A clinic. DECLAN, a rugby player in full kit, sits on an exam table. His left shin bends a little in the middle. JOANNE, a nurse practitioner, scrolls a tablet.

DECLAN When do I see the doctor?

JOANNE Dr. Hale only sees patients who’ve failed physical therapy.

DECLAN I heard it snap.

JOANNE A lot of people hear things. Pain on a scale of one to ten?

DECLAN Five.

JOANNE (typing) Okay, so not broken.

DECLAN I play rugby. A five for me is a fifteen for a normal person.

JOANNE We go by the scale. Broken legs present as an eight or above. Honestly, you’re lucky. The evidence for PT is incredible. Patients who do PT first avoid spinal surgery forty percent of the time.

DECLAN Wow. That’s amazing. But I don’t think I need spinal surgery.

JOANNE (delighted) Exactly. You don’t.

DECLAN Okay, so if it’s not broken, what is it?

JOANNE The physical therapist will do a full assessment.

DECLAN (relieved) Oh. Okay. Good.

A PT gym. BRETT, a radiantly enthusiastic physical therapist in a quarter-zip, holds a clipboard. DECLAN hops in on one leg.

BRETT Welcome! Can I just say, you made a great choice.

DECLAN I didn’t choose it.

BRETT Nobody does at first. Let me tell you something. Twenty years ago, people with back pain were getting spinal fusions. Knee scopes for everything. Cutting people open when all they needed was a stronger core. And we were the ones who said, wait. Have we tried glute bridges?

DECLAN That’s genuinely great. I think I just need a cast.

BRETT Ooh, I’d be careful with casts. Casts and spinal fusions have the same problem. They make it really hard for us to work on your strength and mobility.

DECLAN Isn’t that the point of a cast?

BRETT (warmly) See, that’s the old way of thinking. Let me walk you through what we do here. In PT, we assess weakness, mobility deficits, and stabilization issues. Then we build you a program to get you stronger.

DECLAN Okay, cool. That sounds really useful for later. But I’m pretty sure my bone is broken. Can you tell me if it’s broken?

BRETT Oh, buddy. No. (slowly) See, the thing with broken bones is that you can’t always tell from the outside.

DECLAN You can tell with mine.

BRETT So what they do is this special kind of imaging called an X-ray. It takes a picture of the inside of your leg, so the doctor can actually see whether the bone is broken. That’s not what physical therapy is for.

DECLAN Great. Can I get one?

BRETT Oh, that’s a doctor thing. You’d have to ask Dr. Hale.

DECLAN I can’t see Dr. Hale until I fail PT.

BRETT (shrugging) I just get the referrals.

BRETT Okay, let’s walk.

He takes one step and collapses.

BRETT (writing) Significant gait asymmetry. Push against my hand.

He pushes. He screams.

BRETT I’m going to note some pain behavior there.

DECLAN It’s not behavior. It’s pain.

BRETT Here’s what I want you to hear. Your right leg is incredible. Whatever you’re doing with the right, just do that with the left.

DECLAN The left is in two pieces.

BRETT And that’s the mindset we’re going to work on. Strength lives on the other side of discomfort.

DECLAN I’ve had a 120-kilo prop stand on my face. Discomfort is my whole personality.

BRETT Then this’ll be easy! I’m starting you on our foundations program. Seated marches. Ankle alphabet. Sit-to-stand from a chair. Use your hands if you need to, no shame. Pain up to a four is fine.

DECLAN It’s a five sitting here.

BRETT So we’ll work on getting that down.

Week two. A group class. DECLAN sits in a folding chair beside DORIS, 81, who is crushing her seated marches.

BRETT Great work, Doris! Declan, where’s your knee lift? Pain?

DECLAN (sweating, shaking) Seven.

DORIS You have to push through it, dear.

BRETT Doris had a hip replacement three weeks ago and she’s on the blue band.

DECLAN What band am I on?

BRETT (gently) You’re on yellow, bud.

Week four. DECLAN’s foot now points slightly sideways.

BRETT So we’re seeing some rotational compensation.

DECLAN My shin has a corner.

BRETT That’s swelling.

DECLAN Swelling is round.

BRETT Pain?

DECLAN Ten.

BRETT (writing) Pain trending up despite intervention. Some concerns about compliance.

Week six. DR. HALE, a brisk woman in her fifties, enters for the first time, holding an X-ray. The bone is clearly snapped.

DR. HALE Congratulations. You failed physical therapy, which unlocks me and an X-ray.

BRETT I just want to say, he didn’t fail. He didn’t really try. Doris tried.

DR. HALE It’s a fracture.

DECLAN Thank you. Can I have a cast?

DR. HALE (scrolling through Brett’s notes) Hmm. You came in at a five. Six weeks of seated marches, and now you’re a ten.

DECLAN Because it’s broken.

DR. HALE It was broken at the five. The leg didn’t change, Declan. Your relationship to it did.

DECLAN My foot points sideways now.

DR. HALE Doris is on the blue band.

BRETT (quietly) She’s on green now.

DR. HALE I think what we’re looking at is low pain tolerance. I’m referring you for CBT.

A therapist’s office. DECLAN sits with his leg propped on a pillow. DR. PRICE, a soft-spoken therapist, holds a notepad.

DR. PRICE Welcome. You should know you’re part of something really exciting. For years, people in pain just got handed opioids. Look where that got us. CBT is the breakthrough. Opioid prescriptions in our network are down ninety percent.

DECLAN Because CBT works?

DR. PRICE Because you need twelve sessions before Dr. Hale can prescribe anything. Nobody’s ever finished twelve sessions.

DECLAN Why not?

DR. PRICE They’re not willing to do the work.

DECLAN What’s the work?

DR. PRICE Mostly sitting with discomfort.

DR. PRICE So let’s examine the thought, “My leg is broken.” What’s the evidence for it?

DECLAN holds up the X-ray.

DR. PRICE Okay, that’s one piece of evidence. What’s the evidence against?

DECLAN There isn’t any.

BRETT pokes his head in.

BRETT His right leg is incredible.

DR. PRICE Good. So for homework, every time you think “my leg is broken,” I want you to write down a more balanced thought.

DECLAN Like what?

DR. PRICE Like, “My right leg is incredible.”

BRETT gives a thumbs-up and holds up a yellow band. Lights out.