State of the Union: Who are we and where are we going?

Physiotherapy
I’ll make no bones about it; I have certainly had my doubts about remaining in the profession. I’m sure this resonates with other young physiotherapists in my position. Generally, physiotherapists (NOTE: this does not apply to me) are graduating from university coming from families of high achievers and are owners of immensely high secondary-school leaving scores, good social skills and athletic ability to match. I generally would attest that most physiotherapy graduates nowadays could have been anything they wanted to be; thrilling that they have chosen physiotherapy. Like me, some of these graduates may have witnessed a glass ceiling fly rapidly toward them. But what is buoying, is that this glass ceiling is continually smashed and replaced ever higher by those pioneers of the profession. And I would like to reiterate my total and utter support for this wonderful profession, as I have had a slight renaissance in my own career, helping me realise how much value it can provide both to every patient, to society at large and to ourselves. I am using this particular post to reconcile some of the thoughts and feelings that may be commonplace in our profession, especially amongst the younger generation of our profession, but not verbalised amongst peers. Thoughts that I have certainly had, and worked through, to help me fall back in love with the profession as a whole. So who, for that matter, are we? And where are we going? I will work through these questions from an average physiotherapist’s perspective.

Like every post in this blog, this should create more questions than solutions, in contrast to the norm in today’s blog-logged media-sphere. Don’t look for solace here.

Out of the primordial soup.. And to the…trees?

I’m sure I’m not alone in feeling pride of being part of a profession that has carved out an immense reputation from a position of subservient lackeys in rehabilitation hospitals; physiotherapy has certainly solidified its place on the face of healthcare. Starting out in the 19th century, originally working as mainly massage therapists, physiotherapy has now grown into the beast it is today. Multifaceted, evidence based, respected and even, well, even treating beasts. We are now independent primary care mavericks, capable of accurate diagnosis and case management that is, in my opinion, unparalleled by other professionals who sit in the sphere. We are capable of doing and being much more than a pair of therapeutic hands to patients; we can change lives through real behaviour change and let’s be honest, even the best surgeons can sometimes be guilty of perpetuating damaging health beliefs. But we mustn’t kid ourselves; the medical profession has about 4000 years on our own development as professionals. And so, we are truly in the infancy of a burgeoning profession. My guess is as good as yours as to how much development can continue, but we hope it’s a lot. These are some points currently on the table regarding extending scope of practice and my take:

  • Prescribing rights; in order for our profession to grow I think these must become part of experienced clinician’s practice. If a clinician is well-trained and maintains an adequate standard of knowledge in physiology, pathophysiology, pharmacology, pharmacokinematics and side effects then I don’t see a difference in what profession prescribes medications ( RefRef). An experienced professional that has specialised in that particular area would be a more efficient prescriber of a particular medication than someone who sees everything else. In fact the APA espouses cost savings of nearly $7 million to government and $2 million to patients if the reigns are handed over to physiotherapists (Ref). I’m sure I’m not alone in considering this only a matter of time and am waiting with baited breath. I don’t consider it to make us better practitioners, but to improve the system as a whole; it just makes sense.
  • Imaging rights; potentially a slightly moot point because any good physiotherapist I know uses imaging to their fullest potential. It is a necessary part of our diagnostic process and physiotherapists are shown to be the most frugal users of R-type x-rays. We are efficient and skilled in diagnosis; it is just frustrating that the circular referral system isn’t abolished altogether. Possibly the reason this issue has not moved far in the past 7 years (Ref) has a monetary basis also; why increase government spending for improved patient outcomes when most private patients can generally pay and put some nice wads into private radiology practices? And let’s be honest, the public patients can probably just wait… We need a good cost analysis of the extra amount of rebates spent, in both the public and private systems, due to circular referrals. Again though, it just makes sense to me that the rebates are aligned with current practice and every patient has the appropriate access to necessary images when referred by a skilled physiotherapist.
  • Referral rights; I won’t linger, because essentially it is the same argument. The APA has done a cost analysis for this issue and it is estimated to save Medicare $13.6 million, and patients $2.175 million if physiotherapists are also included in referral of patients to specialists or consultant physicians (Ref).
  • Specialisation; the continual growth of our profession requires a well-regulated specialisation platform. Again I take my hat off to what physiotherapy has already achieved in this, but I think we have some ways to go to develop pathways closer to those in the medical field (Ref). There is a lot more to this discussion and I’ll save that for a later post. In the future I see a more experienced-based titling and specialisation system, one that resembles fellowships of the colleges of specialty in medicine.

From out of the primordial ooze physiotherapists have thrived into the adolescents we are now; more simian than human at the moment. But in the future, we should be recognised as a primary care giver with no equal, a central contact point between all the specialties and other avenues for care. That is what I see at least.

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The darlings no more? Exercise or die!
From such a positive note, I’m going to give my spin on where I see the profession currently. Not so positive.

With the failings of manual therapy and with the electro-crazed practice of the 80s and 90s slowly diminishing, we seem to be moving into another era of physiotherapy. Gaining back what is rightfully ours.. exercise right!? We should be doing this better than any other professionals because we originally started out in hospitals doing rehabilitation exercises right!?

Well I hate to be the bearer of bad news, but I sucked at exercise prescription coming out of university because we did a whole one course on the entire prescription and program design malarkey.. I am now a strength and conditioning coach purely because I recognised my failings in one of the most valuable assets to any physiotherapists arsenal; exercise prescription. The majority of our profession just don’t have the adequate knowledge in this area to apply it efficiently.

There may just be some professionals that have and always will do this better than us. Namely those that actually do specialise in exercise.. as their ONLY form of treatment. I’m talking the exercise physiologists, the strength and conditioning coaches (the true ones, not the pretend ones like me). Possibly we can all work together in the future in a lovely rose-coloured, barbell-infused, chalk-exuding erotic future but maybe some professionals may lose out. I’d like to wager that with numbers on our side, it probably won’t be physiotherapists. It does leave a slightly bitter taste in my mouth that professionals who specialise in exercise are being encroached upon by professionals who once specialised in putting sound waves into your skin; somehow magically vibrating a meniscal repair into repairing itself like me boogying to the Beibs.. Come on, it’s OK to like Beiber. But for now physiotherapists are amongst the leading professionals dealing out the panacea with gusto and in the future I see most professionals becoming more like coaches than the traditional manual therapists. See my previous blog on ‘The placebo effect’ for more on my take about manual therapy’s place in the profession (REF). Physiotherapists are already wonderfully placed to use manual therapy sparingly to enhance patient trust and confidence in their own bodies. No other exercise profession has this ability. Put together with our diagnostic capabilities and developing exercise prescription abilities, I do see a rosey future indeed for physiotherapists. Teenage years are tough though..

The art in the profession…
I don’t succumb to the clinician and researcher dichotomy, but there is evidently still a divide between research and clinical practice (Ref). Without a doubt, though, physiotherapists are amongst the best professionals with utilising and adopting research in clinical practice (Ref). We have always been less ‘art’ than most other professions, and we are getting better all the time. Critical analysis of evidence and integration into clinical practice has, and will, always be a strength of the profession. In fact, current clinical practice seems to be more closely aligned with research practice that it ever has been. And certainly, cutting edge clinical practice, seems to have vastly outstripped any research quantification when it comes to exercise practice. Maybe now, we need research to catch up to clinical practice and investigate or debunk some of the things we see in popular media formats every day.

Getting social.. The Wild West
Which brings us to novel technologies and media.. This would seem to be the main reason as to why clinical practice and research are so closely tracking nowadays. Never before has current evidence been more available, literally at your fingertips. The never-ending barrage of information from the interwebbings, twitter, Instagram, Snapchat and Facebook has armed an entire generation with… well information. It is still up to the clinician to utilise their own critical analysis skills in these spheres; to adapt and adopt as they see fit. I’m not going to say every bit of information is useable.. Because it’s just not. In fact, I do have some reservations about this new ‘wild west’. The volume, speed and directness of the information on various social media platforms do make me think it is slightly more difficult to apply typical critical analyses. The problem, in my mind, comes from a conclusion made and applied to peer-reviewed research by a second-hand source online, which then duplicates and infiltrates practice. There is not so much need to go directly to the source anymore, and potentially judgement errors based on another’s false conclusions could become more of an issue than ever before. Third-party social media posts are a student’s wet-dream, but can also be problematic purely because they may be followed without question. But then again, we all must learn and I have certainly been guilty of this.

It truly is the Wild West for most of the profession; particularly our more respected and experienced clinicians. The dearth of their knowledge remains untapped outside the realm of cyber space and it continues to be a case of the loudest voice gets heard the most. Meaning the most eye-catching and engaging posts are those made by clinicians who are ‘good’ on social media, tending to be the youngest (generalising here). Generally these posts don’t offer much in the way of truly practice-shaping information. Posts that would be of more value are those made by clinicians with many more years’ worth of experience but they sure as hell wouldn’t be as sexy and naturally my feed wouldn’t include these… In the future, I do see the older generation of clinicians, those worth learning the bulk of clinical know-how from; putting out some hyper-sexy eye-catching posts (the APA has even written a guide to help! Eek; Ref). I also would like to see some more regulation of student’s social media-learning and content designed specifically for social media; potentially courses that sound like, ‘Online critical analysis and social media research methodology; TWEETER1111’ will be commonplace in various health degrees.

No conclusions.. Just dance. https://www.youtube.com/watch?v=fRh_vgS2dFEwho-0_orig

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