A recent book review for a book titled ‘Towards a Critical Medical Practice: Reﬂections on the Dilemmas of Medical Culture Today‘ made me reflect on one of the prevailing questions facing physiotherapy in the 21st century. The review said this:
The study of the postcolonial Indian healthcare system with its manifold sociocultural complexities and incongruities offers rich cross-cultural perspectives; the interplay between the legacies of colonialism and the shifting priorities of a vibrant but bureaucratically entrenched state apparatus reveals that it has over the decades succumbed to pressures from neo-liberalism and the free market, and that its initial commitments to providing care to the economically disadvantaged or marginalized poor have at best been ambiguous. As with other facets of national development, India since 1947 has been straddling two wide-ranging policy alternatives: creating a worldclass medical infrastructure staffed by superspecialists and equipped with the latest cutting-edge technologies that cater to the needs of the wealthy and the powerful, while at the same time delivering basic curative services to the masses.
What struck me was that we too face a difficult challenge in the future. Do we move away from our traditional affinity with social welfare (in which we have historically been a profession for all the people in New Zealand), and move towards a profession of specialists?
The appeal of the specialist model is obvious. There are clearly not going to be enough physiotherapists to address all of the physical co-morbidities that are coming our way in the next few decades, and the slow dismantling of tertiary care, legislative protection of title, and the vertical encroachment into traditional physiotherapy skills point to a much less diverse role for us in the future.
That being said, are we ready yet to give up on large sections of the population to become specialists?
Graduate entry masters programmes are now established in some centres in Australia, USA and UK, and these privilege the idea that graduates will command higher salaries and more ‘consultant-like’ positions in the future. (Why else would students take on greater debt and longer periods of study?) And we are certainly seeing more of these kinds of roles emerging as the profession diversifies. But the people who will be able to afford these super-specialists will primarily be working-age adults with some disposable income.
So who will be the therapist for the family with the child with CP? Who will be the therapist for the man with a stroke living at home with his elderly partner? Who will develop innovative practices in the ‘Cinderella’ areas of practice like mental health?
Will ‘consultant therapists’ be the ones at the front of the queue when governments had out money for diabetes care, rehab for cancer survivors, obesity management, or accident prevention? I doubt it. Not least because it seems, at the moment, that we’ve so concerned to tell people to lose weight, stop smoking and get more exercise, that we’ve forgotten that there is actually a complex health problem underlying each patient’s presentation that is going to be missed.
I believe absolutely that physiotherapists should be the people at the front line when money for government health priorities is handed out, but that doesn’t seem to be in the forefront of the profession’s mind as it currently drifts in a miasma of indecision.
Sooner or later, we will have to decide if we want to remain a profession for all the people, or a specialist niche operation. We don’t have the numbers to do both. It would be better, I think, if we decided this for ourselves, rather than having the decision foisted on us by circumstance.