Autonomy and the future of physiotherapy.
ABSTRACTWhile the roots physiotherapy are surely in prehistory with touch,
massage, manipulation, heat and ice, the first organizations that could
truly be referred to as physiotherapy arose in 18th century Scandinavia.
Then it was essentially masculine and independent of medicine and thus
autonomous. Subsequent events in Scandinavia and elsewhere led to
medicine dominating physiotherapy where it existed. Medicine then
dictated the educational content, granted licensure, and controlled
access to patients with a prescriptive relationship. Referred to, in
modern times, as "allied health professions", physiotherapy
along with other so labelled disciplines were often and some still
remain subservient to the medical establishment.
Today however, in most western nations, the emerging profession of
physiotherapy finds itself at varying degrees of autonomy and
preparedness for professional independence. With the advent of the
clinical doctorate in the USA the profession needs to reflect on
preparedness to be a profession whose practitioners hold a clinical
doctorate, it's the scope of practice, evidence-based research and
action needed to address any shortcomings.
Our profession is at a crossroads. Does it shuffle along meeting
expectations and accountability as defined by others, or does it take
the step of an in-depth assessment of a future role; a role designed
that would assure that we become the profession of choice for all
citizens when it comes to the restoration, maintenance and enhancement
of the physical functioning? In taking such a step we must prepare for
resistance and must be prepared to self promote our proven abilities.
This paper will advocate that we take such a course for it is in the
best interest of the client/patient.
INTRODUCTION
Thank you It's certainly an honor to be invited to be a
keynoter, It is one of special significance to me to be speaking to you
here in Dunedin, the city of my birth and education which led to my
becoming a physiotherapist--a decision I have never regretted.
Many moons ago when I agreed to give this address, it seemed that
to speak on 'autonomy and the future of physiotherapy' should
be a natural given my years of working for autonomy and my international
involvement in practice, teaching, consulting and in holding office in
professional organizations.
But then I began to question my ability to speak on this here in
New Zealand (NZ) for while I am one of you I am at the same time not one
of you. Thus I became concerned that my words on the future of
physiotherapy, especially some critical remarks, might seem like an
outsider coming in and perhaps giving unwelcome advice. I trust this
will not be the case--but know at least that I am sensitive to it.
It has been said that "those who cannot remember the past are
condemned to repeat it" (Santayana 1905). Therefore I shall begin
with some physiotherapy history here in NZ and then abroad in order to
see just how far some nations have come and others have not, and how
much we have gained in autonomy and thus responsibility. This will set
the stage for what I think is desperately needed at this time and that
is once again a thorough practice analysis so that we can better make
many of the decisions for our future. In the process I will cover
aspects of practice, education, research and marketing all in order to
better define who we are and who I consider we should be in order to act
in the best interests of the client/patient.
HISTORY
I have been a physiotherapist for exactly 50 years. My father
before me was the first male graduate of the school here in
Dunedin--then I believe called the School of Massage and Medical
Electricity.
My father was what I would now call autonomous practitioner in that
he received referrals, rarely a prescription. His doctors knew him well
and he knew his limitations. Thus his relationship with physicians were
ones built on trust and mutual respect.
At the hospital clinics here in Dunedin it was a little different.
While physicians on the whole may have known little of physiotherapy,
they saw it as their responsibility to prescribe it and were so assisted
by one of their own creations, namely specialists in physical medicine.
When I was a student the contrast between how my father practised and how most of the staff practised was troubling. It occurred to me
that the only way I wished to practise was in the manner of my father.
It seemed to me, however, that our lack of an academic degree, and
graduating instead with a diploma and with no areas of recognized
specialization as was present in medicine and surgery--we had a long way
to go to become a full profession with the autonomy that should
accompany such a status.
So what is autonomy?
Autonomous is defined by the Physiotherapy Board of NZ as "to
be able to work independently of others appropriate to their
education." (Physiotherapy Board of New Zealand 1999) This
definition is quite unique and I would like to know where it came from.
By contrast Dorland's Medical Dictionary defines autonomy as
"the state of functioning independently, without extraneous influence." (Dorland's 1994).
During my studies as a student, I met with other leading therapists
throughout the country including, Johnny Meney of Hamilton, the
impassioned Len Ring of Auckland and Keith Ritson of Wellington. I noted
that they on an individual basis had reached the same degree of autonomy
as had my father--They were respected for their judgment; doctors sent
patients to their practice and left it open for them to decide what
treatment was in the patients' best interests. But they were
exceptions and there were few able to practise with that degree of
independence.
It was also apparent that as a profession we needed to advance
clinical specialization. Only if we offered specialized skills akin to
those in medicine and surgery, would we be able to bring the best of
care to patients. Clearly we need generalists as does medicine, but we
also need specialists. In the 1950s and 60s there was no means for
identifying and recognizing who if any had those advanced skills.
It thus seemed to me that to advance the profession we needed
autonomy to construct a profession that would have a degree on entry,
advanced degrees for faculty and a means of recognizing specialized
skills for the practitioner.
While a student at the school I had a life-shaping experience when
conducting a class for back pain patients. One man had difficulty in
getting one leg over the other while lying on his back. I simply flexed
up his knee and gave him a little shove. Although the gym was busy with
several classes going on at that time, it seemed there was no other
noise to be heard when, from his back on the resonating wooden floor,
there was a loud 'crack' for all to hear.
I was immediately disciplined in front of my class and the class
nearing the end of the session was dismissed. My patient limped away. It
was a Friday. I worried all weekend. On Monday he did not show up to the
class--but then some ten minutes later he swaggered in, shook my hand
and thanked me for "fixing" his back.
The instructor was still not impressed but it was time to talk to
my father. He shared with me his collection of Mennell and Cyriax
volumes and said that if I wanted on graduation to study this work and
bring it to physiotherapy he would financially support it. He then
recounted the many times that patients with whom he had on occasion
limited success might go to a chiropractor and receive the relief they
sought. My future was now clear to me. I would specialize in the spine.
On graduation I was allowed to specialize in treating spines in the
outpatient department. One such patient, whom I assisted with a self
taught Cyriax manoeuvre, was Dr John Fulton, then Chairman of the Otago
Hospital Board. He was suitably impressed and grateful. When he said
"I don't know how to thank you", I suggested a way that
he could thank me--in fact, several! You see I had just read a book by a
26 year old author with the title "My Early Life". The author
was Winston Churchill (Churchill 1930).
In that book Churchill outlined a philosophy to which I subscribe.
I pass on to you today, especially to the younger persons present, that
there are people in positions of power and influence who wish to mentor
and help along younger men and women--however they are rarely asked to
do so, but will jump at the opportunity if so asked. To further
paraphrase Churchill's message, he went on to say that before you
ask make sure you are prepared to receive the favour and never, never
let them down..
Dr Fulton obtained for me a grant from the Workers'
Compensation Board that introduced me to the leading lights in my field
in Europe--such as Drs James Cyriax and Alan Stoddard of England, Robert
Maigne of France and physiotherapist Freddy Kaltenborn of Norway. The
list in America included spine surgeon Dr Paul Harrington and the deans
of some osteopathy and chiropractic schools. I was well on my way to
specializing in the spine, not just in its treatment by manipulation but
by all means, including the study of biomechanics.
Those years were 1960 and 1961 and I was only 23 years of age.
Those embossed and important letters of introduction sent on ahead to
make study arrangements were essential to the opening of doors for my
learning.
At that time to become a teacher of physiotherapy here in Dunedin,
it was the practice to go to England and undertake an apprentice-like
training. There you were taught to teach The curriculum in those days
held few references, little evidence for practice and required few if
any visits to a library and did not seem to promote specialization and
expansion into developing fields.
During this period, 1960-61, I saw physiotherapy practised in a
half dozen nations working for the most part under medical control and
prescription with little chance for conducting a patient assessment and
modifying the treatment accordingly. It became obvious that if
therapists were not allowed to evaluate their patient and make treatment
decisions--how could they ever specialize? The knowledge they would gain
would place their understanding in advance of most of those who would
make referrals. This of course did not concern osteopaths and
chiropractors who had direct access. So I added direct access to my list
of what we needed besides autonomy, professionalism, degrees, and
specialization.
But I also saw that in Norway, clinicians of Kaltenborn stature,
were as autonomous as was my father, whereas in England physiotherapists
were mostly technicians, except perhaps at St Thomas' where Cyriax
would proclaim that "my girls know what to do." I was never
sure where that left me!
Some time later I would learn of an interesting history in Sweden
where in the early 1800's there were actually two primary
healthcare professions. One was medicine, which of course was in its
infancy given the absence of antibiotics and other life-saving and
life-extending pharmaceuticals available today, and the other profession
was best described as remedial gymnastics and physiotherapy. This latter
group was principally made up of the sons of noblemen and thus had great
influence on society. These therapists, as I shall call them, were
directly able challenge medicine of the day with their approach to
fitness and health. However the physicians felt threatened and after a
long and bitter struggle lasting many decades, the physicians prevailed
and managed to open the schools of physiotherapy to high school
graduates, mostly females. Soon the profession was demasculanized and
lacking its connection to nobility came under the control of the medical
profession. So there was a case of autonomy--autonomy lost (Ottosson
2007).
In 1963, after a two year absence which had included looking after
our Olympic Team at Rome--a position I had attained by once again doing
what Churchill advocated and simply asked for the opportunity of serving
the team little realizing they would make me a full member and that I
would march on in the opening ceremonies--I returned to New Zealand.--I
now wished to specialize in the spine and to use my acquired skills in
manual therapy including manipulation.
A condition of my scholarship from the NZ Worker's
Compensation Board was that I to teach upon my return. But this
presented a problem because, quite understandably, the teaching faculty
at the school objected to my teaching since I had not taken the
customary teacher training that they, the other faculty, had taken in
England. Due to these concerns I was appointed by the Medical School to
the Physiotherapy School to be the Lecturer in Spinal Treatments.
I am sure I was less than diplomatic in my reasoning as to why I
thought such training in the UK was out of date, a vestige of
colonialism; that our future in teaching lay in gaining advanced
academic degrees from a University;, and that practicing clinicians
should play a much larger role in the teaching at the school.
Unfortunately New Zealand would be one of the last Western
countries to offer a degree to its graduates and to require advanced
degrees and/ or experience for faculty. It would not be until 25 years
later in 1993 that New Zealand students would graduate with a
bachelor's degree.
I have to suspect that part of the reason for the delay was that
we, as a profession in New Zealand, were well satisfied with our
position within the health sciences. We enjoyed a respected relationship
with our medical colleagues and the community.
Additionally no doubt, we were torn between the profession being a
clinical profession and it becoming an academic discipline. Even a
cursory glance at the American system would show that when physical
therapy education went from the hospital to the university there was a
decrease in emphasis on, and proximity to clinical practice. There was
even discussion that physical therapists should become the evaluators of
the patient and that the physical therapist assistants should be the
clinicians!
In an article I published NZ Journal of Physiotherapy in May 1972
(Paris 1972) I compared Boston University education with that offered by
the then New Zealand School of Physiotherapy. One point of comparison
was that the New Zealand school had more than three times the patient
contact hours before graduation than did Boston University students.
Clinically, I was able to operate a back pain service at the
Dunedin hospital and to have an active and successful private practice.
But it was not easy to practise as a specialist physiotherapist in New
Zealand in 1962 when many of those who spoke officially for medicine and
therapy felt that only the doctor could make the diagnosis and decide on
the treatment. I called what I did a "clarifying examination".
I vehemently defended the right of therapists to perform joint
manipulation so that patient would not have to leave the orthodox
medical arena to go visit a chiropractor to receive manipulation when
indicated.
General medical practitioners in Dunedin supported that view and my
practice with my father flourished. I rightfully denied that what I was
doing was chiropractic and argued most strongly that it was part of
practice in England and Norway. However our Journal declined two
articles from me on the subject of manipulation. It was the NZ Medical
Journal that published, in 1963, my first article following a
presentation I gave on manipulation at their national conference (Paris
1963).
Alarmed, the Chiropractic Board of New Zealand sued me for
practicing chiropractic. I sought legal assistance and it was not
encouraging. A leading light on the Physiotherapy Board of NZ, namely
Keith Ritson, advised my father that I was on my own. The Board could
not support the practice of spinal manipulation and, even if they should
choose to do so, they did not have the financial resources that would be
needed.
I reasoned that the Society was no doubt in a similar position. How
was I to defend the right of a physiotherapist to practice manipulation
at a time when such practices were chiropractic considered chiropractic even at our
only school? No matter the history that Hippocrates performed
manipulation and so did Drs Mennell and Cyriax, both of whom instructed
therapists in the techniques,--I was on my own here in New Zealand. So I
wrote the Chiropractic Board stating that I would leave New Zealand and
that they should--and they did--drop their charges.
Now my agreeing to leave New Zealand must have seemed like a
retreat--and it was. But I saw as a strategic retreat for I had already
planned to go to the United States to gain a PhD in biomechanics. I
planned to return, to hopefully be appointed once again by the medical
school to the physiotherapy school, As a medical school faculty member,
I would be in a better position to withstand chiropractic efforts and be
able to defend our right to practice spinal manipulation. But alas it
was not to be. My domestic situation required that I remain in America.
But before I left--therapists such as Joan Derbidge of
Christchurch, arranged for me to give a seminar. Others, such as Gordon
Oldham, Brian Mulligan and John Meney asked that I conduct a series of
two week long courses in each of the major centers. This I did. Some 85
therapists attended--almost 10% of the then therapists in New Zealand.
Just two years after my departure, the interest by physiotherapy in
manipulation had grown to the point that in 1968 a group formed the
Manual Therapy Association. I was thrilled. Then, in 1972, another
important event in our path to recognizing special interests and needs:
the Private Practice Association was formed.
No doubt, with these two groups organized and focused, this enabled
the Society to be ready when, in 1978, the Government formed the
Committee of Inquiry into Chiropractic. The society over the objections
of the NZ Medical Association, presented its own case to the inquiry
and, as a result, many feel that this was when physiotherapy in New
Zealand came of age (Scrymgeour 2000). By making its own independent
submissions and using its own expert witnesses, physiotherapy proclaimed that it was a fully-fledged profession--it had exercised the basic
tenant of autonomy--self responsibility and independence.
The situation in the United States with regard autonomy was not as
good as in New Zealand. Here in New Zealand individual therapists and
the profession have, as a whole, always been held in high regard and
with respect by the medical profession. There has been little discord or
efforts to control and limit our growth. This is very evident in talking
to New Zealand physiotherapists and physicians. No doubt gaining
university status has enhanced this attitude and the common pursuit of
evidence-based practice. But it is something very precious and it did
not exist, as a rule, in the United States in 1978.
For instance just last month in California, a bill that would have
granted direct access to physical therapy, now a profession with
qualifications at the doctoral level, was defeated in the state
legislature. Why? It's simple. The group that led the charge to
defeat the bill were orthopaedic surgeons who still today much prefer to
hire their own physical therapists and refer to them such that they can
reap any profit from their referral-for-profit activities. This practice
is unfortunately widespread amongst an increasingly greedy American
medical profession.
But I'm getting a little ahead of myself and would like to
give a little history on progress, and the lack of it, in America. In
the 1960's and 70's we were, in the United States, very much
under the control of the medical profession. The medical profession
accredited the schools and thus dictated the curriculum, and on
graduation they controlled the registration process. We were considered
technicians and expected to behave as such. The code of conduct actually
said that when a doctor entered the room we were 'to stand and
smile sweetly'. Incidentally, male therapists were a rarity. In all
of Massachusetts I was one of only three male therapists.
On the faculty of Boston University and with a clinical position at
Massachusetts General Hospital I soon established orthopaedic support
and entered private practice. My practice eventually grew to 34
employees.
We changed the Practice Act in Massachusetts in a way that slipped
by the awareness of most physical therapists and medical practitioners
at the time. We simply added the phrase that "physical therapists
would be responsible for the treatments they gave." Legal
interpretation--we now had the responsibility to examine our patients
and determine the most appropriate treatments. You would think the
medical profession would see this as a sneaky trick to break their
control. Perhaps some did. Surprisingly however it was the physical
therapists that objected the most. They did not, in 1971, want that
increased degree of responsibility. Yet gaining responsibility is the
first step to professional autonomy.
We had some additional success with advancing clinical
specialization. While the American Physical Therapy Association (APTA)
did not wish specialty clinical interests groups within its umbrella,
our 942 member manual therapy academy forced a change and won for us an
Orthopaedic Section. This overnight became the largest special interest
group within theAPTA.
I then moved to Atlanta Georgia and while on the faculty of Emory
University made a big push to establish an advanced specialty
master's degree for graduate therapists. Therapists were entering
the profession with a bachelor's degree but there was little to no
opportunity for those wishing to be faculty to gain a degree in an area
of specialization--other than education. I thought it essential that the
profession had qualified faculty with identifiable advanced clinical
competencies. This was not the first time I had made such a proposal.
The first was in Boston while at Boston University, and there it was the
Medical Advisory Board that said specialization was not needed in
physical therapy. At Emory University it was the Dean of Allied Health
who rejected the proposal. The plan was denied without any opportunity
for me to appear before them and argue the case. More discouraging was
the fact that the chief therapist at Emory University asked that I not
pursue it further, as "it might upset things." With such a
request we were neither being treated, nor were we asking to be treated,
as professional colleagues.
But I had chosen Georgia for a reason--Georgia had liberal
education laws. So, in 1979, I founded the nation's first
proprietary school of physical therapy, and at the post-graduate level
(or what we refer to as the 'post professional level') we
issued a licensed but non-accredited MHSc in Orthopaedic Physical
Therapy.
Graduates of my non-accredited and thus non-recognized degree had a
hard time getting jobs in academia but some managed and they made the
changes. They won respect for their knowledge and skills and so in 1993,
14 years later, my school was fully recognized and accredited by the
United States Office of Education. I relocated to Florida, and four
years later we became the University of St. Augustine. This now houses
the largest physical therapy--and the third largest occupational
therapy--school in the nation. In addition we have two other campuses:
one in South Florida and one in San Diego, California.
The Future
Thus far in my presentation I have outlined by way of my experience
in New Zealand and overseas, principally the United States of America,
my observations of our movement from technician to a professional status
depending on the nation. But the process remains far from complete and
could unravel if progress is not continued and consolidated.
I earnestly believe that we are on the brink of achieving greatness
as a profession, societal recognition that might have only been dreamed
of half a century ago. You may think we are already there and I would
not wish to argue against such thoughts. However just as in Sweden a
century ago there were two equal health care providers--medicine for
disease and physiotherapy for the physical functioning--that day may
come again, but this time cooperatively and in the best interests of the
patient.
New Zealand--as you well know--is a small country. Being small has
/many advantages. You have just two schools whereas the USA has 211
schools, you have one association, and one set of national laws and one
national Board. Contrast this with the United States where the 50 states
at times behave like 50 countries each with their own powerful
legislatures, licensing and practice acts. In comparison with
physiotherapy in NZ, in the USA the profession of physical therapy has
to work with numerous bodies. It is easier for you to go work in
Australia than it is for me to work in an adjacent state.
You have the opportunity here to show the rest of the physiotherapy
world exactly how to prepare for the future. And by the rest of the
world I refer to all of Asia and South America as well as to much of
western and all of eastern Europe. In those nations autonomy is just a
dream. If they can look to NZ as a model, if NZ puts forth that model
and assists other nations to so develop this will be a significant
contribution to healthcare.
In looking at this future there are many areas that could be
addressed and in the interests of time I have chosen five of them.
1. The first is to once again define our scope of practice
2. Next, backing up practice with meaningful research
3. Then educationally we must consider the best way to put together
a clinical doctorate
4. And of course we must further develop our will and ability to
market our profession
5. And finally maintain our autonomy
Let me begin with:
1. The need to define our scope of practice.
In the USA, due in a large part to full employment for physical
therapists, we have consistently failed to be concerned and thus to
define our full scope of practice.
As a result of a chronic shortage of physical therapists--currently
by some estimates to be in excess of 5,000 ...
* we lost pre and post natal care to nurses
* We lost sports physical therapy to athletic trainers
* we lost acupuncture to acupuncturists
* We lost chest physical therapy to inhalation therapists [now
respiratory therapists--Ed].
* and we have lost certifying authority in the area of hands,
aquatics and weight training.
* No doubt we will also lose veterinary physical therapy
There are lessons from the above for us here in New Zealand. If we
do not define our full scope of practice, and ensure that we practice to
our full scope, and provide adequate numbers to meet those needs, others
will arise to meet the demand. Our voice as big as it may be now, will
only be one of many that compete for media and legislative attention.
Sustained periods of job security breeds apathy and consequently an
over-dependence on payers such as the ACC. If you are comfortable with
what it provides today, you can be lulled into a complacency concerning
tomorrow. Then when reimbursement changes negatively you will be hurt
because of your dependency on one source. Nothing is constant. History
shows that.
Instead we should constantly redefine and expand our scope of
practice, scout for new opportunities and find new and competitive
methods of delivering our services and being paid for them. So I
advocate that we define a very broad scope of practice--or at least
consider it. It begins with a definition of who we are. How we define
physiotherapy to the world we serve, is at the heart of our scope of
practice. May I suggest, for discussion, that we define ourselves as the
profession of choice, the primary care practitioners for the
restoration, maintenance and enhancement of the physical functioning of
the individual.
The three words--restoration, maintenance and enhancement are of
course not new but they do allow us to consider the full scope of
practice.
By restoration we speak of our traditional and principle area of
practice be it treating injured knees, spines or rehabilitating of the
stroke or cardiac patient. Certainly we are the masters at physical
restoration.
With regards maintenance--an area of increasing importance--what is
our position? Maintenance speaks to wellness and maintaining the quality
of life rather than losing it. Increasingly today health care management
is passing from medical model of disease and medicine, to dysfunction and behavioral models of prevention and care.
While medicine may save lives no profession will speak to the
quality of those lives more than does physiotherapy. Do we say
"yes", we are the wellness practitioners, but are then not
seen in health clubs, golf clubs, and gymnasiums and in the schools
instructing and advising on health care? And will we ourselves be
examples of a healthy and productive lifestyle? There has to be a better
way than that offered by medical technology where spines are
increasingly being fused and joints replaced. Our challenge is to show
that physiotherapy is a better alternative and can provide and maintain
a healthy, active and satisfying lifestyle.
As to enhancement this area is most typified by sports
physiotherapy. Athletes may need restoration but they also seek
enhancement. Do we have a role and to what extent? Are we not the best
qualified to be the trainers and to work with the coaches on enhancing
performance? Is that research in our journals or does it lie elsewhere?
It seems to me that there are more questions than answers. It is of
course a challenge for the profession that we should engage. It's a
challenge especially to the young, for it's their future. But who
decides? Does the motive for change come from the clinicians, the
Society [NZSP], academia or from the Board [New Zealand Physiotherapy
Board]? Clearly it's all of these including our colleagues in
medicine and the lay public.
2. Research
There can be no argument that research, especially research that
shows our clinical efficacy, is not only essential to our future but
also will determine the direction our future takes. Who should do this
research is a big question.
At my University we have broken with tradition and do little in the
way of research We are now of the opinion that the average faculty
member and student is today incapable of producing papers of sufficient
quality to make a difference to practice. This is because the bar, for
those papers that will be considered in the meta-analysis and in forming
the practice guidelines, has been raised beyond their reach. We have
spent hundreds of thousands on research and have little to show for it.
Our literature is full of papers that grind out minor variations of
established thought--how many more papers do we need on knee
isokinetics--or of the transverse abdominus as a trunk stabilizer?
Enough already!
Thus our University has taken the position that only research
projects that are well funded, directed by and carried out by experts in
the field will have any chance of being considered to carry sufficient
weight to influence the future of our profession. For this reason, we
actively support the national Foundation for Physical Therapy, which is
sponsored by the American Physical Therapy Association. Our philosophy
frees our faculty to do what they are impassioned to do--and that is to
teach hands-on ready-to-go skilled professional clinicians. The future
employment of our faculty depends not on the research funds they bring
in or papers they publish, but more on student and employer satisfaction
with our product.
Supporting a research center is at least for us a much better
alternative than requiring faculty and students to do research.
Here in New Zealand, the University of Otago has, I am sure you are
aware, broken new ground by having achieved significant funding for the
type of research that will determine our future. The study headed by Dr
Haxby Abbott and Professors Baxter, Campbell, Robertson and Theis,
wherein they will look at the long-term effect of physiotherapy to the
hip and knee, is truly a first for physiotherapy. Studies of this nature
are sadly lacking in our literature.
Medicine is full of such long-term outcome studies but few indeed
are the studies in physiotherapy that show our effectiveness beyond a
few weeks. It is one thing to show that six weeks of physical therapy as
opposed to six weeks of medication can better reduce pain and disability
returning the patient to work and recreation--but what at three years,
five and ten years? As yet we simply do not know.
Where are the studies that show that physical therapy given
intensely at first, with monitoring and boosting sessions over the
decades that follow, not only results in less pain, more function, a
better quality of life and less surgery but, above all, increased
patient satisfaction and at less cost? This is what the New Zealand
study will attempt to do.
3. The Clinical Doctorate
Here in New Zealand you have begun to discuss the clinical
doctorate. Australia already has two programs up and running. You have
an opportunity to study what the USA and Australia has done and to come
up with a better plan by learning from their experience; and I trust
that you will.
But first, why have a clinical doctorate at the entry point into
the profession? Is it justified by the body of knowledge unique to
physical therapy, and at a level that justifies the doctorate, or is it
the inevitable consequence of degree inflation?
In the late 1990's physical therapy in the USA began to debate
the topic of becoming 'a doctoring profession': i.e. that the
entry-level professional qualification be at the clinical doctorate
level. In a debate before the APTA, I was asked to take the position of
being opposed to doctoral education at the entry point into the
profession. I thus argued that a Masters degree was a sufficient degree
and that the doctorate should only be conferred on those clinicians who
demonstrated advanced clinical competencies. To my thinking, although we
had a sufficient body of knowledge distinct to physical therapy, we did
not have the evidence for that knowledge and we lacked and still lack a
rigorous system to measure advanced clinical competencies as do exist
within medicine with their respected specialty boards. I still hold to
this position but, as a pragmatist, once the association voted to move
to the doctorate my school was one of the first, if not the first, to do
so.
Unfortunately many schools did not make substantial changes to
their curriculum in terms of clinical content. Many tended to add that
with which they were comfortable, such as research, and in the view of
many, failed to emphasize that it is a clinical degree--a degree which
should have little if any academic standing. It is a professional degree
which ranks in academia as it should: below that of a post-professional
masters.
Worse still: efforts to provide what we call a transitional
doctorate--that is a doctorate in physical therapy for all those who in
earlier years graduated with a diploma, bachelors or masters--was an
abysmal failure. While we came up with a "consensus" on what
that transitional program should entail in the way of course work and
experience, the universities anxious to provide the degree to their
graduates often watered down the requirements to where they became easy
and inexpensive to acquire. Consequently, even some of the more P
rigorous programs had to change course toward this lower common
denominator in order to remain competitive.
I would suggest that you consider that graduating at a
master's level might be sufficient with the clinical doctorate
being awarded when sufficient graduate studies and clinical skills had
been proven. Perhaps the College would play a role here.
4. Marketing
I am sure many of us in this room can remember a day where to even
mention marketing in a health science profession would be to raise a
considerable ethical issue. Well today we are in competition: we are in
competition for the hearts and minds of doctors, patients, legislatures
and of course the media. We are also in competition with chiropractors
and those surgeons who would rather operate than rehabilitate.
We can win or we can lose in this arena but we must accept that we
have to market our product and services in order to succeed and survive.
In the United States, in late 1998, in a last minute effort to
balance the budget the Senate randomly removed $6 billion from physical
rehabilitation: overnight we saw 20% unemployment in physical therapy.
Never had we had unemployment and it happened without warning. Our
research has simply not proven that we are essential.
Be aware also that, in the United Kingdom, less than 30% of last
years graduating physiotherapy class are employed and this percentage is
expected to grow worse. While education has been funded--employment has
not.
Had we had the studies that show our effectiveness, had we marketed
those studies effectively, thus proving our value to the public and
legislatures, I have to believe that these events in the USA and the
United Kingdom would not have occurred. It could happen again--it could
happen here.
So it's about marketing. It's about marketing our
effectiveness, but it's also about research; for without the
evidence that we are effective and that we are essential, we have little
to market. Therefore we should direct our research towards outcomes,
cost savings and quality of life.
5. Finally maintaining and advancing our autonomy. This is at the
core of a profession such as ours.
I am a firm believer in autonomy and have spent much of my career
striving to achieve it for myself, for my profession and for my
educational institution. Only when we free the therapist to evaluate the
patient and to make the decisions as to treatment, and then require that
they take responsibility for those decisions, do we free the
therapist's mind and practice to grow and develop and thus better
serve the patient/client.
But what role will we have in being able to prescribe
pharmaceuticals, order lab tests and imaging studies, make referrals
that enhance our efforts and hopefully save on health care costs by
unfettered and complete direct access of patients to our services? Of
course you have gained some of these services, more so than any other
country of which I am aware.
However autonomy gained can unfortunately become autonomy lost. In
the United States the medical profession, out of 'financial
greed', is undermining much of the autonomy we have gained. Quoting
from the American Journal of Bone and Joint Surgery, March 2008
"Medicine is no longer considered by a growing number of
practitioners to be a profession but, rather, a business. It is
dictated, governed, and discharged in the same manner that traditional
businesses are conducted. Profit is becoming its raison d etre."
(Sarmiento 2008)
Over the last decade there has been an explosive growth in physical
therapy practices owned by orthopaedic surgeons who then refer
exclusively to their clinics often much more than they did when they did
not serve to profit from self referral. They usually hire new graduates
who are impressed to work in such an environment, but this drives out of
practice many established, experienced and well qualified private
practitioners--since when did health care become all about money and not
about the value of what we offer? Referral for profit is certainly not
in the best interest of the patient. I believe you would be mistaken if
you thought it could not happen here in New Zealand.
Unfortunately all is not well here in New Zealand with regards
autonomy. While you enjoy as much, if not more, independence than any
other country clinically--the front door if you wish--your own
profession is threatening to regulate you into a second class status at
the back door. Autonomy can be hurt by over-governing bureaucracies no
matter how well-intended So, in our policies on governance, we must
continually strive to be involved in the decisions that decompression therapy affect our
practice. Here I refer to certain requirements by the New Zealand
Physiotherapy Board of which many of you may not be aware. The
Physiotherapy Board has the responsibility to protect the public against
unscrupulous and unqualified practitioners and practices, as does the
Society. No question. However the Board is in danger--in my view and
that of other speakers who have presented here in the recent past--of
restricting your access to theories and practices that might advantage
your future growth. Let me explain.
I have spoken in many countries and to many organizations. It is
customary, once invited by a Society or organization, to provide the
title of the presentation, an abstract for advertising, and a resume for
the introduction. These I am happy to provide. That is as it should be.
But never before have I been told that as a speaker I needed a temporary
licence from the Physiotherapy Board before I would be allowed to speak
before you here in New Zealand. A licence to speak to you, my
colleagues?
Not sufficient that your Society--of which, incidentally, I am an
Honorary Fellow--invited me: the Society had to apply on my behalf to
the Board in order to obtain and pay for a licence for me to speak. What
an embarrassment to them, and such an affront to me and other
international speakers.
What nonsense. But it did not stop there. I was asked to provide
the Physiotherapy Board: a copy of my passport; a copy of all my
practice licences; and the evidence for what I was about to present. The
Board has even asked an American therapist for a copy of her marriage
certificate!
When I failed to provide more than a copy of my passport the Board
turned down your Society's application for me to speak at this
conference. The Board asked for more information, such as (no doubt) my
speech, but I refused to hand it over for I am a fervent believer in
free speech and would never submit a non-scientific paper to even the
suggestion of censorship.
But there is more. I was informed by the Board that should they
grant me this temporary licence, it would not cover me for other
speaking engagements in New Zealand. In other words I am not permitted
to speak to students at either of the schools or to a gathering of
therapists in, for instance, your clinic, as I am not licensed to do so
while here in New Zealand.
This is an outrage.
It is censorship, it's a violation of academic freedom and a
violation of free speech--it is a huge loss of professional autonomy.
[applause--Ed.] It must be addressed by this Society; and vigorously.
[prolonged applause--Ed.]
Throughout history well-meaning governments and regulating
authorities have set laws and regulations not in the best interests of
the citizenry. This is such a time.
The Society, I know, is embarrassed by these events and has been
unable to change them. But change them they must and we must support
them in their efforts.
New Zealand, I know, has a history of over-regulation. That is why
in 1963 I joined the New Zealand Constitutional Society because of the
restrictions to free speech that are ever present in New Zealand.
Whether, as in the 1950's, it was restricting the music we could
hear on the radio and bring into the country, or as it is today in
restricting speakers like me, or as reported in the New Zealand Herald,
telling our athletes what they can and cannot say before during and
after the Beijing Olympics. Not so the Australian and British Teams, who
have refused to be stifled and insist on the rights to free speech
(Korporaal 2008).
In my mind the right to free speech is essential to a robust
democracy and serves as a safeguard to society. No one has ever
successfully restricted me from speaking out on manipulation--but turn
the clock back to 1960's and I suspect the Physiotherapy Board,
with today's rules might well have endeavored to do so. Likewise
Robin McKenzie and Brian Mulligan would never have been allowed to
spread their theories and innovative treatment approaches to the
betterment of patient care worldwide if other countries adopted such
restrictive rules as requiring a licence to speak. I am sure this
embarrassment will be addressed. I hope I have helped.
Summary and Close:
So ladies and gentlemen let me now summarize and close.
Physiotherapy continues to have a bright and wonderful future. We have
come a long way in just one generation where we were technicians under
the control of the medical establishment to the present where we are
partners in health care and the recognized experts in the restoration,
maintenance and enhancement of the physical functioning.
We must carefully defend our autonomy while at the same time seek
to define and expand our scope of practice and to develop the research,
education and leadership that will be needed to advance our present
position to where the recognition we accord ourselves is shared by the
universe at large.
Thank you
[standing ovation--Ed.]
REFERENCES:
Churchill WS (1930): My Early Life. London: Schriber's Sons.
Dorland's (1994): Dorland's Illustrated Medical
Dictionary 28th Edition. Philadelphia: Saunders.
Ottosson A (2007): The Physiotherapist--What happened to him? A
study of the musculinization and demasculinization of the physiotherapy
profession 1813-1934. ISSN: 100-6781--a doctoral dissertation. Goteborgs
Universitet. 424 s.
Korporaal G (2008): Let the blogs begin, AOC tells Olympians. The
Australian Feb 18th.
Paris SV (1972): American Physical Therapy and New Zealand
Physiotherapy Education Compared. New Zealand Journal of Physiotherapy,
May.
Paris SV (1963): The Theory and Technique of Specific Spinal
Manipulation. New Zealand Medical Journal 62:371
Physiotherapy Board of New Zealand (1999): Registration
Requirements Competencies and Learning Objectives. Wellington:
Physiotherapy Board of New Zealand. ISBN 0-478-09418-3. p.93.
Sarmiento A (2008): Is Socrates Dying? J Bone Joint Surg Am.
90:675-676.
Santayana G (1905): Reason in Common Sense. In Santayana, G. The
Life of Reason: Or, The Phases of Human Progress. P284.
Scrymgeour J (2000): Moving On: A History of the New Zealand
Society of Physiotherapy. Wellington: New Zealand Society of
Physiotherapy: p. 63.
Stanley V. Paris, PT, PhD, FAPTA, FNZSP (Hon.), NZMTA (Hon. Life
Member), FIFOMT (Hon. Life Member), FAAOMPT (Fellow
and Hon. Life Member)
University of St Augustine for Health Sciences, St Augustine,
Florida, USA
Response: Physiotherapy Board of New Zealand
Response to: Paris, SV (2008): Autonomy and the future of
physiotherapy. New Zealand Journal of Physiotherapy. 36(2): 67-75
The Physiotherapy Board appreciates the opportunity to respond to
aspects of the keynote address delivered by Professor Paris above. That
address contained comments about the difficulties Professor Paris
encountered with the registration process as a physiotherapist visiting
New Zealand in a professional capacity.
The Board fully recognises the importance of having internationally
respected physiotherapists visit New Zealand for the purpose of
presenting lectures, courses and workshops and has no desire to put
unnecessary obstacles in the way of professional development and
progress. Nor has it ever sought to stifle professional growth by
restricting access to the best of knowledge imparted by respected
scholars and clinicians. It is timely therefore to explain the reasons
for regulation of visiting presenters before clarifying the Board's
current position and intentions in this regard.
It is easy to envisage shortcuts for high profile reputable people.
The Board has however a duty and the ultimate responsibility of
protecting the public from doubtful practitioners and others who might
represent themselves as having competencies in physiotherapy outside the
scope that their peers would recognise. In so doing, the Board also
protects the profession from those who might denigrate or destroy the
image of a physiotherapist.
Parliament, through the Health Practitioners Competence Assurance
Act 2003 (HPCA Act) set up regulatory authorities to protect the health
and safety of the public by ensuring that health professionals are
competent and fit to practice. It did this by a strictly defined
registration system which also, incidentally, protects each health
profession by ensuring its reputation does not suffer at the hands of
incompetent practitioners.
The legal advice taken by the Physiotherapy Board prior to the
inception of the HPCA Act indicated that visiting presenters required
registration by the Board under the HPCA Act because they would be
"practising a profession" by virtue of their delivery of
physiotherapy services. In the early days of the new legislation,
following that advice and desirous of correctly carrying out its duties
under the new Act, the Board developed policies and procedures that with
hindsight, saw the regulatory pendulum swing toward a stringent
registration system. This robust system was designed to protect the
public and the profession from poor practitioners and charlatans
circulating in our country and purportedly promoting physiotherapy
knowledge and skills.
In the light of experience some modifications were made prior to
the 2006 NZSP conference with a positive response to the changes being
expressed later. Since the latter half of 2007, the Board has been
reviewing the requirements further. Benchmarking against other
regulatory authorities in New Zealand and overseas has produced
confirmation that a degree of registration for visiting presenters is
required by many other regulatory authorities. It has become apparent
however, that a less stringent approach is possible, a stance supported
by more recent legal advice. Further modifications are being evaluated
and the pendulum is now poised to swing toward the other direction. The
Board will keep in touch with the profession as it seeks a balance
between its current policies and a more modified approach that continues
however, to protect the public and the profession.
The Board agrees with Professor Paris that physiotherapy has a
bright and wonderful future. The Board too, supports the concept of
autonomy. The confidence that the public and the profession has in its
regulatory body is one reason that the profession has autonomy. The
Board believes there is no tension between its duty of accountability to
the public, including the profession, and that of the growing maturity
of the profession.
Hilary Godsall
Chair, Physiotherapy Board of New Zealand
Response: New Zealand Society of Physiotherapists
Response to: Paris, SV (2008): Autonomy and the future of
physiotherapy. New Zealand Journal of Physiotherapy. 36(2): 67-75
Thank you for the opportunity to respond to Professor Stanley
Paris's keynote address. The New Zealand Society of
Physiotherapists Inc continues to working positively with the
Physiotherapy Board of New Zealand for the benefit of the profession
overall and the patients we treat.
In our discussions we recognise the differing roles of the two
organisations. The society promotes a self-regulating and advancing
profession. The Board is required by the Health Practitioners Competence
Assurance (HPCA) Act 2003 to protect the health and safety of the public
by providing mechanisms to ensure that health practitioners are
competent and fit to practise their professions. The differing roles do
cause tensions, particularly in regard to the autonomy of the
profession. These tensions are not confined to the physiotherapy
profession and are being highlighted by other professional groups too,
in the current Ministry of Health review of the HPCA Act.
The Society will continue to advocate that the requirements placed
upon the profession under the HPCA Act be set at a level which takes
into account both the self-regulation of the profession and an
assessment of any potential of risk to the public.
Jonathan Warren
President
New Zealand Society of Physiotherapists