It seems odd for a supposedly patient-centred profession to still have special interest groups that perpetuate the idea that the body can be carved up by systems and structures, and that I could be a cardiorespiratory, neurological or musculoskeletal physiotherapist and not a physiotherapist for the whole person.
Special Interest Groups (or SIGs) are historically significant divisions within the profession that owe their structure to the guilds that formed in the Middle Ages, when blacksmiths, printers and jewellers tried to protect the interests of their members and promote their speciality (see Farr, 1997 or Smith 2004). But SIGs may now be creating more problems than they resolve, and may have become a barrier to our profession’s ability to respond to the changing economy of health care in the 21st century.
If the logics of patient-centred care – which decentre the traditional power base of the health care professional – are combined with the growing desire to see collaborative and inter-professional practice, then what place for the specialists in women’s health, mental health or sports?
It isn’t hard to see why physiotherapy adopted special interest groups. They are after all, reductive, and reductionism one of biomedicine’s cardinal principles (alongside specific aetiology, experimentation, germ theory, etc.). But even if this still functions as a justification for having a paediatric special interest group, per se, it surely creates some contradictions that are worthy of exploration:
- Why do we have special interest groups that are based on body systems and not different cultures, religious beliefs, or political affiliations?
- Why do we have special interest groups that focus on only some modalities of treatment and not others?
There are 12 subgroups in the WCPT (acupuncture, animal practice, cardiorespiratory, EPAs (electrophysical agents), manual therapy, mental health, neurology, older people, paediatrics, private practice, sports and women’s health), all constituted by serious, hard working professionals, who believe passionately in their area of expertise. Their role is largely to promote the interests of their members and lobby for recognition within the wider community. They achieve this, in part, by showing that their area is distinct from the others, thus perpetuating the idea that this or that body system rules other body systems or is, at least, worthy of special interest.
This seems an odd mythology in the 21st century, when most people have long since given up the idea that the muscles are disconnected from the nerves, which are disconnected from the brain, which is disconnected from the lungs, and so on.
What is, of course, deliberately excluded from the idea of the Special Interest Group (could it have a more pernicious name?), is the whole person, the embodied, complex, richly diverse person that is rapidly becoming the future of physiotherapy practice. The days of us treating single, acute, self-resolving injuries and illnesses are nearly over, and we are being shifted slowly into a much more interesting space. But this space is populated by people, not pathologies, so perhaps it is now time to recognise that the Special Interest Groups of the 20th century have had their day, and a new (sub)structure for the profession is needed.
SIGs say a lot about the profession’s focus. They reveal where the profession looks to direct its specialists, and where its leaders provide direction for its novices to follow. And here is one of the problems. Many of the people who run and organise SIGs have achieved recognition because of their specialty, and naturally see this as essential to the future health of the profession.
We see this in teaching departments, where specialists believe passionately that no graduate would be qualified for practice without their particular knowledge of shoulder impingement or pelvic floor pain. But you only need a handful of such specialists and the curriculum starts to become bloated and fragmented.
Isn’t it time to end the artificial division between SIGs?
Isn’t it time to start thinking about patient-centred physiotherapy practice and not clinician-centred specialties?
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On a side note, it seems odd that some countries have some SIGs and not others.
The American Physical Therapy Association has 18 SIGs, there are 16 in Australia, 14 in Canada, 12 in New Zealand and only seven in Singapore.
Most of the variation relates to the local politics of the region (America, for instance, has Federal, Health Policy and Administration, and a Home Health SIG while others don’t). But regional variations can’t explain why America has Education, Research and electrophysical SIGs while others don’t.
References
Farr, J. R. (1997). On the shop floor: Guilds, artisans, and the european market economy, 1350-1750. Journal of Early Modern History, 1(1), 24-54.
Smith, P. H. (2004). The body of the artisan: Art and experience in the scientific revolution. University of Chicago Press.
The International Federation of Manipulative Physical Therapists, a subgroup of WCPT since 1978, considers subgroups essential in the further development of our profession. Medical doctors have specialists with specialised knowledge in a specific area. Surely there is a need for specialised areas within physiotherapy? The definition of Orthopaedic Manual Therapy as defined in our constitution encapsulates our view and shows quite clearly that we are committed to giving patient centred care.
“Orthopaedic Manual Therapy (OMT) is a specialised area of physiotherapy / physical therapy for the management of neuro-musculo-skeletal conditions, based on clinical reasoning, using highly specific treatment approaches including manual techniques and therapeutic exercises. Orthopaedic Manual Therapy also encompasses, and is driven by, the available scientific and clinical evidence and the biopsychosocial framework of each individual patient. “
Hi Annalie
Thank you for your thoughtful comments. I’ve been fortunate to have quite a lot to do with IFOMPT over the years. I interviewed Stan Paris, Ian Searle, Brian Mulligan and Rob McKenzie as part of our NZ Centenary History project a few years ago, and curated Ian’s records of the first years of IFOMPT when he was secretary of the organisation after 1973. I say this because I can understand entirely the position that IFOMPT has fought for for so many years. The competitive environment that manual therapists have operated in over the last half century are quite particular in physiotherapy, and I know how much time and energy some of our colleagues have given over to the search for professional recognition.
That notwithstanding, my question was not so much about the wisdom of dividing the profession into specialties, but rather what our historical divisions tell us about our profession’s historical affinity with biomedicine, and how this might be constraining as much as it is enabling. Biomedicine has, and no doubt will continue to have, an important role in future physiotherapy, but it is not without its problems – not least, as you put it, medicine’s ‘specialised knowledge [of] a specific area.’ You will have noticed from previous posts that many people in the CPN find this a problematic concept.
It’s interesting that you cite the definition of OMT in your constitution, because to an outsider it has always seemed to me to be problematic. To talk of being patient centred, and to invoke the much critiqued notion of ‘the biopsychosocial framework,’ whilst holding to the idea that your focus is restricted to neuro-musculo-skeletal conditions seems to be contradictory.
This is a challenge not just to IFOMPT but for all subgroups that focus on body parts and systems, and it’s a debate without an obvious short term solution. So I’m really grateful that you took the time to comment and offer your opinion.
I’m sure you disagree with what I’ve said above, so it would be good to keep the debate going in the hope that others can think about how they are positioned in the discussion.
Thanks again.
Dave Nicholls