Some of the discussion following the release of the CSP’s recent video A new vision for physiotherapy prompted some interesting thoughts about the constant tension we face if we are to anticipate the future for our profession (link). A couple of issues surfaced from the blogpost and the comments that followed that prompted me to think about the link between physiotherapy, politics and evidence-based practice:
- Firstly, in defence of the CSP, it cannot be easy being a professional body these days. Social media has opened up great opportunities for communication and sharing of ideas, but it has also made a critic of everyone. This is perhaps one of the most important and challenging aspects of a social media landscape where n0-one has to obey anyone else’s code of conduct and can say pretty much whatever they want. As someone deeply invested in the idea of critical thinking, my hope is that groups like the Critical Physiotherapy Network help stimulate critical debate about the profession and function as ‘a positive force for an otherwise physiotherapy.’ More than anything, I hope we can engage in debate that is serious, constructive, respectful and a never-ending act of opening.
- In the discussion following the blog about the video, @HelenOwen3 made the very valid argument that ‘we need to stick true to our goal of improving patient care,’ and I think everyone can agree that that is vital. But it only represents one half of the primary function of a professional group – the other half being that it must always remain ‘relevant’: relevant to the government that provides the bulk of its funding and legislative protection; relevant to other health care professionals; and relevant to the public at large. Health care professions are ‘political’ not only because they influence politicians to spend money in different ways, but because being a professional is inherently a political act. Imagine if physiotherapy decided that it did not want to be ‘political,’ and decided to ignore the government’s concerns about the future cost of healthcare, the ageing population and the prevalence of long-term illnesses and lifestyle disorders. It wouldn’t be long before we were replaced by another profession that were happy to tow the party line, leaving us with the luxury of practicing our long-established model of care in unsubsidised clinics treating short term conditions that don’t cost too much to resolve, in competition with people with a weekend’s training in massage and underwater basket-weaving.
- A lot of physiotherapists believe that strategies like evidence-based practice will protect us from this fate, but I suspect that’s because they are wedded to a biomedical/biomechanical philosophy of practice and don’t see that all practice is inherently political. Thus they believe that it is enough for EBP to inform their clinical decision-making but fail to see that it will not help the profession decide whether it should be evidence-based in the first place. There is now an enormous body of literature suggesting that EBP may constrain as much as it enables (link), but to locate this literature, one has to step out from underneath the cloud of EBP that now saturates physiotherapy practice, and this is not easy to do if treating the body-as-machine is the beginning, middle and end of your practice philosophy.
- Evidence from the profession’s history points to the fact that the greatest successes have been achieved without any recourse to EBP. Physiotherapists did not establish their legitimacy with EBP – they did it by imposing rules that convinced the government, the medical profession and the public that they could be trusted (link). We did not establish our role as the providers of orthodox health care with the weight of evidence for the efficacy of our sling suspensions and effluerage. No, we did it by demonstrating that we could be trusted professionals allied to medicine. History teaches us that the future vitality of physiotherapy is unlikely to be achieved by the weight of evidence for the efficacy of our practice, but rather our ability to anticipate the prevailing political climate and adapt accordingly.
- That is not to say that evidence-based practice is not important in the current tug-of-war over healthcare resources. Clearly it is. But some people seem to be quite selective about the kinds of evidence they want to support (which is quite ironic given that EBP is supposed to transcend such subjective judgements.) There is almost overwhelming evidence now, for example, that social determinants of health (poverty, poor housing, access to services, substandard education, etc.) are the most important contributors to people’s health – far more significant to behavioural interventions (link).
‘One of the problems with contemporary health care is that it focuses on ‘soft target’ risk factors ‘such as physical activity, nutrition and weight control that target individuals rather than environments and structural conditions that in turn, are causal pathways for heart disease, diabetes and cancer’ (Keleher & MacDougall, 2009, p. 28).
- But social determinants demand political action, sometimes against the directions taken by the governments that ‘sponsor’ us. They require coordinated, sometimes centralised action to transfer power away from the hands of professionals and put it in the hands of clients/patients, families and communities. And they demand that we do this while at the same time advocating for people who otherwise would be voiceless. This is not the approach we are ‘sold’ today though. What we are told to believe in is the power of individual responsibility, behaviour change strategies and the importance of making people independent. Clearly EBP is not as ‘neutral’ as some suggest.
Keleher, H., & MacDougall, C. (2009). Understanding health : A determinants approach. Australia: Oxford University Press.