Today’s blogpost comes from CPN member Hazel Horobin. Hazel is a Senior Lecturer in Physiotherapy at the University of Brighton in the UK.
I warmly welcome Jonathon Kruger as the new CEO of the WCPT. What an amazing job he steps into, representing physiotherapy/physical therapy globally. I guess though that one of the issues he will struggle with most is the national variations in professional recognition. This concept is frequently encapsulated as professional ‘autonomy’ and I would like to explore this.
Our treatments are frequently thought of as being the consequence of reasoning processes (Norman, 2005). However, sociologists talk about issues of ‘structure’ and ‘agency’ when considering people’s actions. Agency then means the individual physiotherapist’s freedom to choose what to do. However clinical reasoning, when it is couched solely in terms of individual thinking, fails to recognise that treatments are frequently shaped through the structural issues that contain our lives: the political, financial and relational contexts within which we work and that lie beyond our individual control. They include for us as physiotherapists issues such as the number of sessions funded for given conditions; the beliefs, values and customs of our profession; and the expectations of the community we work with – both our clients and the other professions with which we share our working arenas.
An example of structural control in the UK (from where I write) can be seen perhaps in the involvement of physiotherapists in ‘return to work’ projects for the long term unemployed (DfH, 2008). Foucault (1988) suggested that the function of professions was to work with governments to construct acceptable behaviour and develop tools of subjugation. This may appear somewhat extreme, until one considers that such employment related programmes are designed, at least in part, to act as a brake on a rising costs of health and social care. Dave noted the dominance of a ‘work’ ethos in physiotherapy practice in his blog on 7th June, and government influence on our practice, perhaps explains why. In removing the need for doctor referral, we seem to have omitted the ‘middle’ man between ourselves and the state.
It is not only government that controls, but also our relationship with other professions (Freidson, 2001). Medicine forms a key comparator for physiotherapy. Indeed, in many parts of the world regulatory control is exerted by the medical profession. UK physiotherapists might feel that they ‘won’ the right to first contact care in 1977 (DHSS, 1977), but this example of professionalisation has everything to do with efficiency in health care provision. In less well-resourced countries the structural drivers for physiotherapy development are limited. This is as a consequence of a high proportion of medicine occurring in the private sector, where productivity is not an imperative (since there is a surfeit of medical staff for those that are able to pay) (Bhat, 1999). Additionally, community expectations are relatively low re standards of practice (Brugha & Zwi, 1998) and the population is youthful and therefore less likely to require rehabilitative health care. This context makes any extension of AHP autonomy in those countries likely to be blocked by the vested interests of medical staff, which remain unchallenged, subsequent to a lack of financial (and therefore political) imperative.
Viewing practice through the prism of structural control, we may be surprised to discover the confines of autonomous decision making as well as a potential paradox: there may be, in reality, less ‘day-to-day’ autonomy in better resourced healthcare systems than those traditionally viewed as lacking decision making capacity. Here, in apparently prescriptive health care environments, coexisting poor professional governance (Sachan, 2013) permits greater levels of autonomy than the regulatory system suggests.
So, autonomy is always incomplete. Physiotherapy frequently has little or no say in national, professional recognition, and this recognition may have little bearing on our actual autonomous approach to work anyway. So the binary view of ‘autonomous’ or ‘not autonomous’, is perhaps a rather insensitive yardstick with which to judge ourselves. We need to recognise the structures that shape and contextualise all our worlds, because when we do this, we are enabled to celebrate, and embrace, the variety of decision making that is ours.
Bhat, R. (1999). Characteristics of private medical practice in India: a provider perspective. Health Policy and Planning, 14(1), 26-37.
Brugha, R., & Zwi, A. (1998). Improving the quality of private sector delivery of public health services: challenges and strategies. Health Policy and Planning, 13(2), 107-120.
DfH. (2008). Carol Black’s review of the health of Britain’s working age population ‘Working for a healthier tomorrow’ [online]. . Retrieved 14th August 2010, from http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_083560
DHSS. (1977). DHSS (DEPARTMENT of HEALTH and SOCIAL SECURITY) (1977). Report of the Sub-group on the Organisation of the Remedial Professions in the NHS. London: HM Government.
Foucault, M. (1988). Technologies of the self: A seminar with Michel Foucault: Univ of Massachusetts Press.
Freidson, E. (2001). Professionalism, the third logic: on the practice of knowledge: University of Chicago Press.
Norman, G. (2005). Research in clinical reasoning: past history and current trends. Medical education, 39(4), 418-427.
Sachan, D. (2013). Tackling corruption in Indian medicine. The Lancet, 382(9905), e23-e24.
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