A lot is said about physiotherapy being biomedical and following ‘the biomedical model’, but what exactly is this, how and why does it underpin physiotherapy?
Over the next few blog posts, I’ll try to explain the idea of the biomedical model in a bit more detail and show why and how it has influenced physiotherapy.
I’m going to tackle 7 key aspects of the model. There are more, of course, but these are considered by most people to be the main ones.
- Specific aetiology
- Germ theory
- Cartesian dualism
- Objectivity and experimentation
Understanding something about these will give you a stronger sense of why they’re so important to physiotherapists, but also why they might be problematic.
1. Specific aetiology (etiology in North America)
Aetiology means ’cause’, so is perhaps one of the most important features of modern, Western biomedicine in that it seeks to identify the specific cause of a person’s presenting signs and symptoms.
Crucially, in modern medicine the emphasis is not so much on treating all the signs and symptoms a person presents with, but rather, finding out what has caused them in the first place.
Most medicine does this in a stepwise fashion.
Starting with all of the patient’s various signs and symptoms, the diagnostician (doctor, physiotherapist, etc.) deduces that symptoms A and B are being caused by a single problem – X, and that B and C are being caused by something else, Y.
Without going into the whole question of what deduction, induction and abduction are, the idea is to keep going with this process until you arrive at the single cause for all of the patient’s problems. Their specific aetiology – or the specific reason why they are now ill.
The logic of this is that you should focus your attention on diagnosing the cause of the patient’s problems rather than treating all of their different signs and symptoms.
This is why many good clinicians spend 90% of their time working out what not to do, rather than just jumping in and treating whatever comes, literally, to hand.
You might think that this idea is as old as medicine itself, but it has only been possible for diagnosticians to think this way with the advent of reliable diagnostic technologies like histology and imaging, and so the deductive reasoning so familiar to biomedical practitioners is perhaps only slightly more than a century old.
The search for specific aetiology required patients to come to specialised centres for assessment, and so was partly responsible for the radical shift from doctors visiting (wealthy) patients at home, and relying on what is called ‘heroic’ medicine to exert their power, to patients coming to clinics and hospitals to receive care.
David Armstrong has written brilliantly on this in his papers Decline of the hospital and The rise of surveillance medicine.
How does this relate to physiotherapy?
One of the hallmarks of modern physiotherapy is its pursuit of first contact status, or the ability for the public to see physiotherapists without a doctor’s referral. This can only be achieved if physiotherapists are trained as diagnosticians because, without a doctor’s initial assessment, the patient could conceivably present with any problem, and the therapist has to be able to work out what’s going on.
Hence why so much more of our training now goes into assessment and diagnostics.
In countries where physiotherapists still receive work from a doctor’s prescription, there is less need to focus on specific aetiology, because the doctor (you hope) has done that work for you. And so training focuses much more on the practical skills and places less emphasis on testing.
The adoption of specific aetiology as a practice principle could, therefore, be said to have radically changed the nature of physiotherapy practice over the last half-century. It has allowed us to share in some of the social capital society affords doctors, and allowed us to remain close allies not only to the language of medicine but also its ways of thinking and doing things.
Next: Germ theory