Monthly Archives: April 2017

Physio Will Eat Itself

PWEI physio2

I suppose this is about change. We might be doing ourselves irreparable damage you know, as a profession. I just read Dave Nicholls’s Should we give up physiotherapy? , and I just saw Kettlebell Physio Neil Meigh’s Facebookey Livey thingy, and I’ve been concerned about the de-commissioned physiotherapy services in Nottingham  and been interested in the proliferation of “myth busting” initiatives (all good stuff BTW, except for the de-commisioning) and wondered about a tone and trend being witnessed within the profession, perhaps best exemplified by posts like this:

Meakins LBP

Now before Meakins gets all “oi you little barrrstid, that’s right proper fackin’ science that is you old spanker” on me, I’m not saying this is bad/wrong/evil/or anything – in fact the opposite. It’s lovely. Meakins’ post is, as always, a provocative and grounded signal to make all of us sit-up and think a bit more about what we are doing and who we are. There are two dimensions to this post, first something about treatment of LBP (but it could be any are of practice), and second something about the quality, or state, of practice. Both essential areas to continually be reflecting upon in the light of new evidence.

Dave Nicholl’s blog asks us a critical question related to Sir Meakin’s first point: “if it were in the best interests of patients or the healthcare system as a whole, for us to disestablish physiotherapists, would we do it?”

Kettlebell Neil talks about not just the quality of practice, but also the extent of practice – wondering if we are spreading ourselves too thinly in some sort of desperate professional attempt to shift our allegiances and pretend to be things we are not.

These two points are of course related. If the evidence starts to question the utility of what we do at the moment, does it not make sense to become involved in other areas? The move from multi-modal, structure-based interventions for LBP, for example, might be taken as we see more evidence in favour of simple exercise based interventions. Or indeed no intervention at all.

So what is the issue with all this?

[OK, USUAL DISCLAIMER: I am of course wholeheartedly in favour of implementing the best evidence to ensure the best outcomes for people we engage with (what constitutes ‘best evidence’ is, however, a discussion for another day), blah, blah, blah. So before you try and use the “you don’t like change or science” argument, au contraire mon ami. In fact, during a recent office clear out, I happened upon this letter I sent to Frontline in 1999 advocating for change and science (and referring to Bob Dylan):

Frontline letter 1999 3

So there. Get over it].

The issue is, I think, one of professional identity, and what this means for the people we serve. The increasingly active dialogues which happen within the profession (perhaps the SoMe Echo Chamber is the best example, although these dialogues do occur elsewhere) are forever encouraging us to think, challenge our own beliefs, reflect, and progress. And quite rightly so. But whilst this is happening, there is an emerging phenomenon which seems to be getting ignored – how do we look from the outside? I wonder if anyone outside the profession knows who we are or what we do. In fact, I wonder if many from within know these things.  What is our identity? What is our USP? Who even are we?

Here’s one part of the problem. Our (possibly ever-so-slightly overly) enthusiastic attitudes to “new evidence”, which soon turn into vitriol:

“. . . you are such a loser for still doing foam-massage-mobilisation-needle-specific-electro-release techniques when this n=17 uncontrolled trial in Anals of a Physiotherapist’s P-value says it may or may not be better than tele-instructed stair-walking whilst reading a pamphlet about pain and pretending not to be frightened and I stopped doing what you’re doing like yesterday and now I’m better than you because I watched a well-produced slightly humorous video of a popular and charismatic physio god probably from Australia or America or somewhere like that with 11,000 Twitter followers who doesn’t do any grade III+ mobilisations anymore but uses metaphors instead and who I think represents the very best of science although I haven’t actually read it myself but he/she’s got a tan and a nice smile and is from abroad so it must be true and anyway I’ve read a pop-sci/psych/phil book so I know what a fallacy is and you do all of them and now I actually work as a Band 17b Advanced-Extended-Diagnostic-Rehab-Strengthener-Specialist-Wish-I’d-Been-a-Doctor-Consultant and I can do injections and prescribe Haliborange and do advanced metaphorical squats and minor surgery on gerbils so there you creepy practice-based-on-your-own-experience bastard fuckwit of a no-hoper.” (Author’s personal communication)

In goes without saying that both parties here are right and wrong in roughly equal measures. However, this vitriol soon turns into grand claims about what we should or shouldn’t be doing as a profession, and whilst all this is happening our public and our employers and our commissioners peek cautiously through the gap in the door and think “who the twattin’ ‘ell are this bunch of jokers?”.

Of course evidence and debate and progression are critical to the functioning of a profession. But this should be done with not only an understanding of the data, but also with a meaningful understanding of the sociocultural context in which such data are intended to be used. Humans and societies do not change quickly, even in the presence of over-whelming evidence that they should. Whilst we try and initiate rapid change in what we do, we risk alienating those we serve. If people are unsure who we are, they won’t sit around with their pain and their money and their contracts waiting for us to come to a consensus on whether we should do a squat with or without our bellies pulled in. No, they will seek the care and services of those they recognise and have confidence in. As they drift away, they leave us bickering and squabbling between ourselves, slavering with excitement at a few more Facebook likes, eating ourselves until we are no more.

Then that’s it. The end. Finito.

Be careful what you wish for peeps. Stay focused. Bridges not walls eh.

For a more considered and erudite argument related to this matter, I have recently had the joyous experience of writing a chapter with the incredible Fiona Moffatt for the remarkable Dave Nicholls’ astonishing CPN’s startling forthcoming anthology on Physiotherapy. Watch that space. But while you’re waiting.

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