Autonomy for Physiotherapy

No its not about the moniker

A four-year program in Physical Therapy (PT) was established to produce therapists with a foundation in scientific knowledge and proficiency in patient management. While it's understood that completing a bachelor's degree doesn't entail a comprehensive understanding of all aspects of the field, it does aim to equip graduates with the skills to effectively treat common conditions encountered in daily practice. Typically, this includes familiarity with around five musculoskeletal conditions, three neurological conditions, and three cardiorespiratory conditions. Okay don’t jump on me for saying the truth, we do study very little. It's worth noting that while we may study extensively, the focus is on being prepared for real-world scenarios, not becoming experts in every sub-specialty, such as ICU care or post-operative hand surgery, spinal cord injury rehab, etc. These specialized areas are often learned on the job within a month or two.

Regrettably, despite transitioning the profession to a graduate degree program, little seems to have changed in terms of patient care. Therapists are still frequently handed treatment plans that may include ineffective or unnecessary interventions, often prescribed for a standard duration, such as ten days. Despite the introduction of buzzwords like Evidence-Based Medicine (EBM), high-value care, and patient-centric treatment, substantial improvements have not materialized.

Okay, we all and bitch and moan about it. No this is not me bitching about it. okay a little. However, I think most of us think the solution is autonomy in practice. By the way, what I mean by autonomous model is not first contact practice. It means the therapist will make independent decision regarding PT and when needed in consultation with the medical team. However, I'm skeptical that autonomy alone can resolve the issues at hand.

Let me elaborate on my skepticism:

My doubts arise from observations of college Outpatient Departments (OPDs). Many colleges operate autonomous OPDs, and some even practice a first-contact model. Nevertheless, I would like to ask an honest question: do any of these settings not witness the same outdated practices? Do they not frequently encounter cases where patients any pain are subjected to ten days of interferential therapy (IFT), any brain lesion stretching, and passive movements? Or crying children stretched and made to do circus on a ball ? Isometric exercises for osteoarthritis of the knee—are they not part of the routine? Why have we not changed? I have gone to apartment colleges to national institute- sorry nothing changed. of course there are always some black swans- but they are black swans not the norm.

Let's consider my clinic as an example. My primary objective is undoubtedly financial gain, followed by more financial gain, and so on. You might wonder, "What about patient outcomes? Isn't that important?" Well, in the world of capitalism, it's all about the market—the survival of the fittest. If I don't demonstrate positive changes in my patients, they won't choose to come to me. But here's the interesting part: for most patients, a 10-day treatment regimen often yields improvement. Of course, there will be exceptions where some patients don't respond as expected, but that's okay. The law of averages is in my favor. I can afford to have a minority of patients who don't experience significant improvement.

So, you might ask, "If the evidence says no to certain treatments like interferential therapy (IFT), how will I convince patients to commit to 10 days of therapy?" Or, "How can I ensure that stroke patients will return for treatment if I adopt a more active approach?" Or even, "Will patients continue seeking my services if I don't give them the sensation of me doing something 'to' them, like placing stickers on them, massaging for 15 minutes on specific points, or stretching athletes before their events?". Hmm I thought I got insecure after I became clinical depressed

These are the questions that drive my decisions because, ultimately, my livelihood and my ability to provide for my family, including sending my son to study in the USA, depend on them. I often find myself leaning on cognitive biases to absolve myself of responsibility, attributing it to the system I operate in, all in an effort to get into the right side of God. Forget evidence-based treatment; in my world, it's all about the revered minimum, 10-day regimen of hands-on therapy on the patient.

So, what’s the solution- you negative nelly, thought you are not going to moan and bitch.
Well, I don’t know 😂 but I think these are the solutions. I know I will come across a leftist or a dreamer- but here they are:

1. If you are a clinical - the solution is fairly simple- add high value care ( evidence based treatment which is usually exercise) with low value care

2. If you are in government set up and treating 100 patient and there are 2 therapists- I don’t know what to do. I suppose- keep on pushing for autonomy- so that you can triage patients and treat accordingly

3. If you are a teacher- grow balls- men and women. just a tiny one. Show some guts and read a book ( no no not the one which you read when you went to college you ignoramus) before teaching and treating.

4. Please remember you are selling your knowledge- not the machine or some manual work. So have a confidence to “make patient” do therapy not take physiotherapy (one of the sad things I hear is “I took PT for 10 days last time I had LBP” . I could love to hear- I did do PT as per his/ her advice. So, be confident in your knowledge.

5. I do believe social medicine is the only way to promote EBM- otherwise it will be money money and money.

6. Remember, reading is fundamental. Continuously educate yourself by reading and staying updated. Don't accept information blindly; always seek critical experimental evidence to support what you learn.

7. Have a reflective practice- ask yourself am I doing because this is what I know or is this the best treatment.

8. Don’t be afraid to say I don’t know.

9. Burn the syllabus- it is 99 percent absolute rubbish and 1 percent pure rubbish

10. along with it keep on fighting for autonomy- we will go there- my hair is complete white- we will be there before it all falls off my head.

I know WCPT tells us to post world PT day with photos- what I usually see is- Rangoli, some pretty girls in the best dress, some “camp” (just sad) and sometimes the easiest to show we have done something substantial (like what I do) - conduct a seminar (low hanging fruit). No, i want to post what you have changed- from low value to high value care, teach us how you did it, that is a f@#$ing PT day celebration.

As for autonomy- the only goal which will make PT valuable for Patient- otherwise just a ritual the patient gets when they get better. For that we need to change

Happy PT day folks- you are part of a great profession just wanting to come out from the mud it is stuck.

With so much of love
Hariohm