The CSP has just released a new video titled The vision for UK physiotherapy, which is in a similar vein, and follows closely on from the Physiotherapy Associate of British Colombia’s recent Choose to move video, which I wrote about recently (link), and the APTA’s call for a ‘transformative year in physical therapy (link).
Each of these calls carry a similar message about the transformative possibilities of physiotherapy and the importance of physiotherapists reaching beyond the narrow confines of the body-as-machine. It’s hugely significant that physiotherapists are now recognising this and seeing that unless they can connect people to the bigger, more emotive aspects of their health, they risk being sidelined as (albeit very skilled), expensive body technicians and, in all likelihood, replaced by people who do not need a four year undergraduate training, a masters degree or a doctorate.
What is a little less reassuring though, is the broadly political and social message that is carried by these calls – messages that may appear to be obvious and taken-for-granted on the surface, but are, all the same, no less problematic.
It seems to me that there are three broad criticisms one can make of these calls: that they focus too much on the individual, on independence and on population health. Taking each of these in turn:
The focus on individual Health care today is dominated by messages about personal responsibility. Who could argue with the logic that we should all sit less, do more exercise and eat better food. But while these messages seem obvious, we should remember that they are a relatively recent ‘invention.’ Not so long ago, health services were organised around the things that governments felt responsible for: the casualties of war, poverty, poor housing conditions causing the spread of communicable diseases, etc. This was the model of the welfare state. Governments have long since realised that this model of health care is unaffordable, however, and so have looked for ways to shift the burden away from the state. The preferred method seems to be to shift the responsibility on to us.
Rose Galvin’s paper Disturbing notions of chronic illness makes this point brilliantly. She argues that at no time in our history have we been so saturated by health information. We can find advice on what to eat, what to drink, how much exercise to take, when to check for lumps, when to know we’re stressed, etc. She argues that there are good reasons for this, and it may not be what you think. The real virtue of all of this knowledge, Galvin argues, is that it serves an important political function. When, in the future, we go to the doctor complaining of hip pain and ask for physio, or a hip replacement, the doctor will be able to say “if you had followed our advice years ago, you wouldn’t have hip problems now. Clearly you didn’t, so you must be responsible. If you are responsible, you must pay.” Galvin calls this ‘culpability in the face of known risk’ and it is a powerful driver of health education and ‘behaviour change’ in the developed world.
So where do we fit in? Clearly government ministers can’t walk the streets handing out health advice to people (although many of them would like to!) No. Governments ’empower’ agencies like doctors, nurses and physiotherapists to do this, and in return they get access to special treatment denied to other professions (legislative protection, access to patients in the public health system, etc.). Our role is to ensure that we anticipate the government’s political motives and comply. We are the ones who uncritically push messages about personal responsibility and sell these ideas on the basis that they are common sense and obvious. Critical thinking is about challenging the taken-for-granted obviousness of these beliefs however and asking if they are quite so benign as they first appear. Importantly, critical thinking is not about saying these ideas are either simply good or bad, only that they are dangerous.
The focus on independence The messages about independence might also be seen as problematic in these calls. Autonomy and independence are central to western ideas about health, but they are also fictions. Watch the video and you will see anything but independence. You will see people who are dependent on other people, people dependent on feeding tubes and prosthetic limbs, neighbours and friends, therapists and carers. Dependence has become a dirty word in health care because it suggests that the person is a burden to the state (and thereby you and me, the taxpayer and voter). Physiotherapy has long functioned as a social practice designed to alleviate this burden. Much of its credibility has been gained by returning people to work and reducing the burden of care that falls on the taxpayer, the state, families and communities. Think, for example, of how much investment went into physiotherapy after WWI as a cog in the new field of re-habilitation.
So it may be logical that physiotherapists champion ‘independence’ but is it a good idea for a profession that claims to also be an advocate for the needs of the ill and injured? Independence stigamtizes. Those who are ‘dependent’ on others (children, frail elderly, disabled people, etc.) are marginalised because they cannot be independent. Physiotherapists struggle with these populations in some ways, because our practice is so heavily ‘biomechanical’ that we prefer cure over care; fixing things to supporting things; working on rather than working with. New messages about the importance of independence do nothing to change this. Should we not look to the idea of positive dependence, where everyone’s connections with the people and things they need to live a meaningful life are acknowledged instead, and look to challenge the uncritical acceptance of independence as an obvious good?
Focus on population health Finally, and briefly, the focus on population health. Simply put, physiotherapy has never had a model of population health and so to claim it now seems more of a political move than a reality. Unlike doctors, nurses, even dentists, who have always been invested in mass screening programmes, public health drives and global health initiatives, physiotherapy has preferred to focus on the individual body beneath our hands. In fact our almost obsessive focus on the body beneath us has meant we have allowed ourselves to ignore all of the cultural, economic, political and social explanations for health and illness, and concentrate only on the body-as-machine. For that reason our work has always been one-to-one. There are no published models of population health that overlap directly with physiotherapy, in the same way there are not models of primary health care that relate directly to us. It has never been our focus, so to claim it now seems disingenuous. To summarise this rather lengthy post, critical thinking, for me at least, is not about being able to systematically review research articles, but about asking deeper questions about why things are the way they are, and how might they be otherwise. Hence the strap line for the Critical Physiotherapy Network states that we are ‘a positive force for an otherwise physiotherapy.’
Karl Popper once argued that the task facing the scientific community was not to support the latest thinking, but to try with all our might to refute it, with the best ideas being the ones that survived the onslaught of criticism. I really do applaud the CSP (and the PABC and APTA) for their efforts to promote physiotherapy – particularly where they identify the transformative possibilities of our practice.
I do think though that some of the messages now appearing sound some alarms about how the profession will develop in the coming months and years and more critical insights are definitely needed.
Dave Nicholls (AUT University, Auckland, New Zealand)
Galvin, R. (2002). Disturbing notions of chronic illness and individual responsibility: Towards a genealogy of morals. Health, 6(2), 107-137.