The response to the formation of our Critical Physiotherapy Network has been amazing, and it’s made me think about some of the reasons why physiotherapy is now ready for a group like this.
1. Health care is increasingly complex
The sheer size and complexity of the health care system is profoundly challenging the old medical model. Writers like Bryan Turner, Simon Williams, Debbie Lupton, Chris Shilling, Nick Fox, Alan Petersen and others have shown that biomedicine has brought about many great achievements, but it has also contributed to the present dysfunction in the health system. As the old system is slowly dismantled (and with it, many of the principles that have underpinned physiotherapy in the past), we will need help to navigate our way to new models of practice. Critical thinkers in physiotherapy won’t be the only people to do this, but they will certainly be important.
2. The breadth of physiotherapist’ current knowledge isn’t enough
Physiotherapists’ training has long been focused on treating the body-as-machine. That approach has worked up to a point for most of the last century, but it will not be sufficient for the future. If physiotherapy is going to be more than it has been in the past, we will have to engage in lengthy discussions about how we will change, what we will gain and what we will relinquish, and what our future role will be. The profession will need its historians to remind us of the lessons of the past; it’s philosophers to help us decide how we might adapt to the new world; and our social theorists to map a course to a better future. We will not be able to do any of this if we don’t engage our students teach our students to be historians, philosophers and social theorists as well as capable clinicians.
3. Without critique, we can’t really know our limits and possibilities
Our professional ignorance of ‘other’ ways of understanding the world of health and wellbeing now presents one of the greatest barriers to our progress as a profession. How can we move forward without the right vocabulary to help us define our future? The language of history, philosophy and sociology is so alien to physiotherapists that we have come to think of critiquing as meaning only that a student can review a research paper and tell you whether it is methodologically sound or not. We are going to need much greater depth of insight than this, or the change we bring to the profession in the coming years will be limited by the breadth of our insight and imagination.
4. The government and the public is increasingly demanding more the health professionals it supports
The ‘technical rationalism’ that is the hallmark of orthodox health professions (Schön, 1987) is out of step with what the public and our state governments now want from us. It has long been known that our practices are too focused on short term, acute models of cure (not care), and not on the complex problems that beset our modern health care systems. We cannot hope to retain our relevance if we don’t adapt to what the government and the public now want from us. Physiotherapy has a long history of responding to political pressure. Look, for instance, at the role physiotherapy played in establishing a nationwide rehabilitation service after World War I. The changing economy of health care is now calling for another seismic shift from the orthodox health professions, as non-communicable diseases and the burden of chronic illness threaten to overwhelm our health care systems.
5. Knowledge is no longer fixed
We live in uncertain times. No-one trusts doctors, judges or priests the way they used to. Physiotherapy, for its part, is based on quite fixed ideas about the body, movement, function and ability, that we like to think are stable and unchanging. The truth is, however, that none of these concepts are immutable. As we move away from the mind-body splits towards a more embodied or holistic view of health and illness, we have to reject many of the reductive ways we have previously learnt to approach the body. This means revising the central role that anatomy, biomechanics, kinesiology, pathology and physiology play in defining our practice; replacing them with more patient-centred, socially-responsive, complex and nuanced understandings of the body in health and illness. It will take a great deal of skilled effort to move traditional physiotherapists away from their positions of past strength.
6. Our clients/patients are all unique after all
Despite our affinity for biomedical understandings of the body, we have always known that each one of our patients is unique – just as we are unique people as well as physiotherapists, parents, joggers, and whatever else. So student physiotherapists have always had to go through a kind of transformation – usually after graduating – to allow them to make sense of the real world of practice. The transformation takes them from the pure, rational world of the body presented in their textbooks (where one hamstring is pretty much like the next), to the messy, ambiguous, and uncertain world of clinical life. Sadly, most of us have had to endure that experience of transformation: of realising that our training was woefully inadequate; of realising that we had been given no help to transition into professional practice. This will need to change in the future if we are to better prepare the next generation of practitioners for the real world of work.
7. Critical thinking is now well established in other health professions, so why not ours?
Lest we think, for a moment, that the idea of a Critical Physiotherapy Network is a new one, we should reflect on the fact that critical philosophical and social theory has been a feature of health professions like medicine, nursing, psychology and occupational therapy for decades. We can benefit from this because others have shown us how it might be possible to adapt, but we must also learn from their lessons. The debate around the future of nursing, especially, has shown us that we need to concentrate as much on creating a safe, supportive environment for critical thinking, as it is about arriving at a final answer. There is not one right answer to the problem of physiotherapy’s future, only an ongoing engagement with the problem to hand. What matters most then is that we can nurture our colleagues to engage in the debate and never stop wanting to improve their work without fear of being marginalised or persecuted for speaking truth to power.
8. Our student education has been poor
We could do worse than begin by acknowledging that the educational philosophies we have applied to physiotherapy in the past have been poor. Didactic, often reductive, and designed around knowledge translation rather than critical thinking, we have systematically robbed the profession of critical voices that could have been the drivers of change now. And so we are forced to play catch-up – hoping to use the experience of others to accelerate our progress and make the necessary changes to prepare our profession for the 21st century. We have to accept this, but we should at least consider how we perpetuate the poor practices of the past, and look to ways to correct ourselves, so that we don’t limit the chances for future generations to act critically in the face of profound change.
9. Our university trained practitioners, researchers and teachers are branching out
Fortunately, physiotherapists are dynamic, pragmatic, inspirational people, and – despite their training, rather than because of it – have taken wholeheartedly to change, not least in the move from the old training school system to university education which promises to yield a cohort of critical thinkers with the skills and credibility to drive change in the profession. We now have a number of professors, senior academics and postgraduate students who are pushing the boundaries of physiotherapy knowledge and driving change for the future of the profession. We could not have contemplated making this change 30 years ago (maybe even 15 years ago!), but now the time is ripe for these people to come together to help their colleagues respond to the pressures they now face in everyday practice.
10. We have the people
Looking at some of the profiles of the people now in the Critical Physiotherapy Network, it’s plain to see that we now have the people who can lead the profession into the next century and provide the critical voice that the profession has long since needed. Over the next few months and years we will be working to support these people so that they, in turn, can do what they do best and provide critical commentary on physiotherapy. Our hope is that this opens doors to the possibility of an ‘otherwise physiotherapy.’
Vive la revolution!
Schön, D A. Educating the Reflective Practitioner : Toward a New Design for Teaching and Learning in the Professions. San Francisco: Jossey Bass, 1987.