Not so long ago, physiotherapists had a very close, perhaps paternalistic, relationship with the medical profession. But it seems now that our quest for professional autonomy is pushing us further away from physicians and surgeons. There are few in the profession, I think, that would dispute the obvious benefits of greater independence for physiotherapists, but this is a critical ideas blog, so I’m going to do just that.
Physiotherapy has, for much of its history, been wedded to medicine. Indeed, the modern physiotherapy profession only survived and later prospered because its founders made subservience to medicine a condition of entry. Memberhip of the Society of Trained Masseuses (STM) – formed in 1894 and the forerunner of all physiotherapy professional bodies around the world – required that everyone sat the STM’s stringent examination. Doing so cost a lot of money and effort, at a time when anyone could practice as a masseuse with just half-a-day’s training. So why did people submit to the Society’s exam? The answer is that the STM had secured the patronage of many esteemed medical men, so that members of the Society could be assured of legitimate ‘health’ cases to treat, and could distance themselves from quacks and prostitutes (see Nicholls and Cheek, 2006).
Medical patronage served the profession well during both World Wars; the epidemics, economic depressions and medical advanced of the inter-war years; and the birth of the welfare state, but by the 1970s, people within the profession wanted more control over their own professional affairs. Moving training from national health budgets into higher education and the growth of profession-specific research hastened the separation, and now, today, physiotherapy finds itself at something of a crossroads.
With diminishing funding having such a profound impact on health services in many developed countries, questions over the evidence underpinning many (bio)medical therapies, and people being much more skeptical about medical authority (see this, and this, for instance), the Chartered Society of Physiotherapy (CSP) in the UK this week complained that ‘NHS patients needing physiotherapy are being forced to attend millions of unnecessary GP appointments for a referral’ (link).
In the press release that accompanied the report, ‘Prof Karen Middleton, chief executive of the CSP, said: ‘GPs are facing ever-increasing pressure yet out-dated rules mean they are still forced to see and refer patients who should instead be seeing a physiotherapist as the first point of contact’ (ibid).
There are clear and compelling arguments that patients should have direct access to suitably qualified physiotherapists (i.e. those who train in differential diagnostics and have a broad medical-based training; a training that is not available in every country). But might there be something to be gained from taking the exact opposite route?
Physiotherapy faces many of the same pressures it prospered under more than a century ago: competition for clients; horizontal and vertical encroachment from other variously qualified practitioners; challenges to its specialised knowledge; etc. Its answer 100 years ago was to align itself with the profession that it thought could carry it forward. Certainly it marginalised some ways of thinking and practicing in tying itself so closely to biomedicine, but it gained others, and those ‘others’ helped make physiotherapy the profession it is today.
Certainly moves to ‘share’ in the work of medicine (as in this, for example), illustrate that physiotherapists still see themselves as primarily biomechticians (a new word I think I might have just invented). So perhaps now might be a good time to rethink our separatist agenda, and look to our past to find new ways to align ourselves with biomedicine in order that we can secure the profession’s future for the next century or more?
Nicholls, D. A., & Cheek, J. (2006). Physiotherapy and the shadow of prostitution: The Society of Trained Masseuses and the Massage Scandals of 1894. Social Science & Medicine (1982), 62(9), 2336-2348. doi:doi:10.1016/j.socscimed.2005.09.010