This post is the first from a new blogger on the site. Cath Cruse-Drew’s first post explores the use of categories in physiotherapy. There’s some more information about Cath at the bottom of this post.
I have often wondered why Physios, Physio educators and Physio managers align our profession with the categorisation of illness and disability. Thomas Sydenham started the diagnostic ball rolling in his ‘Observationes Medicae’ in 1676, his ‘carving nature at its joints’ was thought to be a methodically sound and scientific approach that matched the ideas of the biological sciences of the day in the classification of plants and animals. Thus, the idea of difference in medicine began. Diagnoses were separated from each other and over time became culturally sanctioned and eventually embedded in the International Statistical Classification of Diseases and Related Health Problems (ICD) now in its 10th revision. This has given us a technical and categorical way of applying treatment, from which ‘pathways’ and ‘protocols’ are born, outcomes and cost measured.
I can’t help feeling we are missing the point.
The very structure of the system ignores the lived experience for the patient. Ironic for a profession whose main aim is to help people function how they want to function, which is an entirely lived experience. In Andy Clark’s ‘Surfing Uncertainty’ he describes a model in which cognitive short cuts serve to limit processing demands, making efficiency its goal whilst sacrificing, sometimes vital, information. Cognitive short cuts based on previous experience, probability and prediction could be responsible for some well-known illusions such as the McGurk effect (if you’ve never seen it, look it up on utube, its really cool!) It occurs to me that segregating patients into broad categories like respiratory or neurology, or filling in an assessment form that demands a diagnosis and a ICD10 code, might be a consequence of the way this predictive model works. Are we the product of a combination of cultural and computational brain-washing? Are we missing vital information by succumbing to a diagnostic illusion? I can’t think of a patient in the last 25 years who fitted neatly into any category. Why am I doing it then?
It’s a question that challenges many facets of Physiotherapy, from the structure of our degree courses, to the structure of our departments and how we interact with our patients at a personal level.
Segregation and specialisation of services seems a convenient and relatively straight forward way of dealing with substantial numbers of patients. Similarly, using diagnostic codes to cost outcomes provides a ‘bottom line’ for those in charge of Physiotherapy purse-strings, but if it’s not reflected in clinical reality for us, or life reality for our patients, we need to glue nature’s joints back together, put a gentle hand over the mouth of medical history, loosen the grip of categorisation, de-code and re-think.
Some further reading
Clark A, Surfing uncertainty : prediction, action, and the embodied mind (New York : Oxford University Press 2015).
Hacking I, ‘Between Michel Foucault and Erving Goffman: between discourse in the abstract and face-to-face interaction’ [Taylor & Francis] 33 Economy Society 277 (I love the quote on pg 279: ‘Classifying changes people, but the changed people cause classifications themselves to be redrawn.’ I think it’s a beautiful summary of the predicament underlying the categorisation of patients).
Haslam N and Ernst D, ‘Essentialist beliefs about mental disorders’ 21 J Soc Clin Psychol 628.
Hohwy J, ‘Delusions, Illusions and Inference under Uncertainty’ 28 Mind and Language 57.
Kirkengen AL and others, ‘Medicine’s perception of reality – a split picture: critical reflections on apparent anomalies within the biomedical theory of science’ 22 J Eval Clin Pract 496.
Introducing Cath Cruse-Drew
I’ve worked with people with acquired brain injury for the majority of the last 25 years in various settings, including acute units, day care, community, case management teams, rehab units and Headway; also in a variety of roles, from the underestimated role of tea-making to setting up new services, clinical specialisms and team leads. I was one of the first Physios in the 90’s to work in the traditionally nursing role of Stroke Liaison Sister. I am currently studying for a MA in Medical Ethics and Law at the King’s College London Law School, where it’s an enormous privilege to be able to think about and apply academics’ work to the challenges facing the Physiotherapy profession.