Have Scientific Experts Lost Their Voice in Influencing Healthcare Culture?
“Shouldn’t our goal, as healthcare practitioners, be to decrease dependency and promote improved long-term outcomes?”
When I began consolidating these thoughts, between bear calls, on my mountain bike, I had no intent to share or publish; but figured I ought to at least write them down as a therapeutic outlet for my daily frustrations. But, what use is there in a therapy that only brings short term relief? So, I hope instead that my words might prompt a more long term solution by elucidating the key problems at the core of our current healthcare status quo.
As a private practice Physiotherapist amongst an ocean of private healthcare practitioners (Chiropractors, Massage Therapists, Osteopaths etc.), whose differential roles are blurred from the perspective of community members, I have observed a major flaw in our chief metrics of efficacy. Specifically, it seems that our impact and utility is measured by schedule saturation and frequency of client return. In practice, however, these metrics seem to be an indication of our complacency as cogs in the wheel of a healthcare model epitomized by capitalist ideology versus scientific consensus?
Specifically, I aim to shed light on the critical mass of manual practitioners whose practice thrives on a homogenous caseload of returning clients led to believe that they are “getting better”, and thus feel dependent on weekly or bimonthly manual interventions (manipulation, massage, IMS, Ultrasound, ART, acupuncture etc.) with their guru. But what if a care model consisting of manual interventions offering short term relief without a complimentary progressive exercise program begets a chronic need for manual interventions, both in lieu of pain psychology and reinforced deconditioning? In short, it’s a numbers game.
To clarify, this rebuke is not meant to discredit the role of manual interventions altogether, only to reinstate their role as part of a holistic approach that centralizes exercise. Instead, I observe their use abused as a primary intervention, next to which, exercise takes a back seat; or in many instances, is completely disregarded. If the evidence unanimously supports movement and exercise as more effective at addressing pain and injury than manual interventions alone, and yet collectively, private healthcare practitioners continue to valourize a healthcare model of dependency, have scientific experts lost their voice in influencing public health?
Why are we not seeing a mass shift towards an active care model? Shouldn’t our goal, as healthcare practitioners, be to decrease dependency and promote improved long-term outcomes?
Could it be that we tend to allow patient expectations to weigh in too heavily in our clinical decision making and treatment delivery? Practitioners continue to dish out the short term relief option, instead of tackling the much larger task of dismantling traditional cultural beliefs around rehabilitation and rebuilding a value system that favours movement. After all, the traditional model yields caseload saturation and thus, financial stability in an increasingly competitive market. Unfortunately, within this model, our utility, and thus financial stability is only realized within a thriving economy, which was made abundantly clear during and post-pandemic.
So, what’s the alternative? Speaking as a Physiotherapist, I believe there are several. One viable option is a transition to a relatively fixed public practice salary and an agreement to practice within the constraints of the public health authority. Unfortunately, current allocation of public funding limits our reach to acute and sub-acute care within these roles. Specifically, preparing patients for discharge by facilitating independence and ambulatory capacity following an acute injury, illness or surgery requiring short or long term hospitalization post-surgery. Outside these roles, a large majority of the population with injuries and chronic pain are left to seek private practitioner support. Currently, government funding subsidizes a negligible $23 of a private physiotherapy visit ($90-150/visit) for individuals with an annual income of approximately $30,000 per year or less, limiting our impact to middle and upper class citizens with private healthcare benefits.
Instead of simply waiting for a drastic shift in the allocation of public resources, another viable option is to have private healthcare practitioners ally to bring about this much needed change in public knowledge and healthcare culture toward an active care model. In theory, this pathway should help decrease public healthcare expenditures in lieu of decreased preventable illness and injury, perhaps expediting a shift in public funding distribution towards proactive healthcare services.
The challenge? Capitalism values the Layman’s ever evolving wild goose chase for the next magic wand and thus, through rampant campaigns, reinforces dogmatic narratives that further support immediate and short term solutions- from massage guns to shockwave therapy. Novelty wins over the widely acknowledged, but less buzz worthy scientific opinion. Complexity wins over simplicity.
For example, in 2023, one of the largest benefits providers announced restrictions to coverage for Physiotherapy and Kinesiology services for the purpose of “exercise”, otherwise known as, injury prevention, further substantiating a dependent and reactive healthcare model versus one projected to cut costs long term.
Further, albeit anecdotal, it’s worth pointing out that strength and conditioning experts and personal trainers rarely seek healthcare practitioner guidance for pain and injury. Why? Perhaps because a diversely active lifestyle is less injury prone, combined with the fact that there is often a parameter-specific exercise, or program, to replace the short term benefits of any manual intervention. In the case that I’ve led you to the false conclusion that our role as Physiotherapists and other private healthcare practitioners is obsolete, allow me to redefine my vision for our place in the community.
Regulated private healthcare practitioners (Physiotherapists, Chiropractors, etc.) who act as primary care practitioners for musculoskeletal injuries and pain, should prioritize their role as an educator and facilitator above all else. Following a thorough assessment that accounts for lifestyle factors and past medical history, patients should be provided a clear understanding of their current presentation along with a realistic and well-defined pathway to recovery. A “well defined pathway to recovery”, should both empower patients to play an active role in the process and promote self-efficacy.
Frequency of follow-ups should be individualized and prioritize re-assessment of progress measures and program revision or progression as appropriate, versus, arbitrary manual interventions that chase pain versus pain origin. Active interventions, and recovery practices should be considered the central focus and should be dose-specific no different than any prescription medication. Disempowering narratives that foster a sense of fragility and incapacity like, “bad”, “unsafe” and “incorrect” exercises and movement patterns, should be discarded in favor of positive language. Plateau’s in progress, including a patient’s perceived need for repeat interventions, should be acknowledged, and serve as an opportunity to re-direct interventions, or seek the perspective of another healthcare professional. A practitioners’ role and its limitations should be acknowledged.
We should also serve as liaisons and communicators to help patients navigate the complexities of the public healthcare system, while simultaneously helping to mitigate growing exhaustion of public healthcare resources and personnel. This entails fostering improved two-way communication with general practitioners and specialists, specifically concerning further medical investigation and surgical considerations, both of which seem to take liberal precedence over conservative pathways, as is exemplified by growing waitlists.
Finally, there is a massive absence of continued care for patients with sub-acute and chronic neurological conditions (Traumatic brain injury/Stroke, Spinal Cord Injury, Parkinsons, etc.), once discharged from the public system. We should expand our knowledge and reach to better extend our support to this patient population with the aim to facilitate their improved quality of life and independence.
We are, or should be, in effect, a “guidance counselor” versus “provider” of physical health.
In summary, employing a healthcare model that aims to empower independence and self-efficacy through education does not have to yield schedule scarcity. The tide lifts all boats. If we unite to channel our skills and experience towards the goal of improving long-term health outcomes, honestly and scientifically, our daily scope of practice might change but our value and utility in the community can only be enhanced.
Written by Jenny Lehmann
Co-signed by Josh Lehman