A diversist? That’s not even a word! Yes, diversist is indeed not a word. It is a made-up word, a word none the less that could have meaning. For example:
‘the condition of having or being composed of differing elements’
or
‘Diverse people or things are very different from each other’.
It might also be viewed as a means of classifying a designation. Compare this to the word specialist. A simple definition would be:
‘possessing or involving detailed knowledge or study of a restricted topic’
or
‘a person with great knowledge or skill in a particular field’
A specialist is also a designation, certainly one that is more commonly used. Examples might include nail technician specialists, tea specialists or carpet specialists.
In New Zealand the physiotherapy board has, since 2016, developed a specialization process similar to that of the UK extended scope practitioner role (here). The application process is strict (applicants must have postgraduate training at a Masters level), costly and rigorous with a view to gaining the “prestigious” title of physiotherapy specialist in a specific clinical area. So, in physiotherapy a specialist might mean you have a particular area of interest in a competency such as respiratory or musculoskeletal. In musculoskeletal this is usually reduced to a specific body part such as the shoulder, spine or knee. Currently, we have 8 physiotherapy specialists most of which are in the musculoskeletal field.
I have to ask a couple of questions:
Are we trying to flog a dead horse?
Is it worth it?
What are the opportunities that come from being a specialist?
What if I have other qualifications?
What does the HPCAA say?
Are we trying to flog a dead horse?
Ok, so possibly not a dead horse but certainly a dying one. What do I mean? Specialism in healthcare is a designation given to a clinician that essentially knows a lot about a little. Like, an orthopaedic specialist or gastroenterologist. These doctors are without doubt incredibly skilled and competent clinicians in these areas of medicine. Perfectly suited to medical reductionism, these approaches are based upon a model that separates the mind from the body, that views the body metaphorically as a machine and reduces it into its respective parts. Physiotherapy is different it needs to evolve. I have discussed why here, here and here.
Interestingly, research has shown that healthcare professionals with specialist experience and who feel like experts are less likely to react to negative news about a particular practice they have specialised in. Meaning they would be less likely to adapt their practice, despite what the evidence might suggest. Similarly, individuals who are around peers with more experience are more likely to imitate and side with the choice of the perceived expert (Staats, Diwas, & Gino, 2018).
This may come down to the specific training and reasoning processes that healthcare professionals have developed through their education. Biomedical reasoning is inductive, meaning it follows a particular course of reasoning from obtaining clinical data from say a subjective history to ascertain a diagnosis. Specialists or experts tend to favour the use of this method as it provides greater odds of diagnostic success (Coderre, Mandin, Harasym, & Fick, 2003). It is reasonable to say that attempting to achieve diagnostic success has not exactly lead to the best in healthcare outcomes (Deyo, Mirza, Turner, & Martin, 2009).
So, when we are faced with problems that we believe we’ve encountered in the past and that we have the proper knowledge to solve, we feel a sense of comfort and confidence. This feeling can lead us to approach situations mindlessly rather than thoughtfully. If we are adopting a particular type of diagnostic reasoning looking for specific patterns to confirm our suspicions, we may overlook important and necessary information. Hence my feelings on using an alternative approach when using reasoning. I have written about this before here
Physiotherapy has had an affinity to medicine since the early 1900s aligning itself closely through subjects of anatomy, physiology and pathology. Physiotherapists, identified as the professionals in understanding movement, adopted a biomechanical approach as their model of choice (D. A. Nicholls & Gibson, 2010). The understanding that faulty movement patterns or postures lead to pain and injury, which as we know lack validity (Lederman, 2010; O’Sullivan, Smith, Beales, & Straker, 2011). Adopting a biomedical / biomechanical perspective provided physiotherapists with opportunities to specialize in specific areas of the body – back, knee, shoulder. Yet, the principles of biomechanics have become somewhat warped with claims of “optimal body alignment” will lead to optimal body movement and minimize pain and injury. This is not supported by the evidence (Lederman, 2010).
This may make sense from an acute injury perspective, but we are now all too familiar that pain and tissue damage do not correlate and that this is even less so when viewed from a chronic perspective (Butler & Moseley, 2003). So where the biomechanical model has served a purpose for a considerable period of the professions existence, times are changing and the model no longer serves the needs of society as does the profession (Nicholls, 2017).
Pain and injury should not start and end at a tissue level or a joint level or location level. A human is attached to the injured body part and whether acute or chronic, has a thinking reasoning and emotional brain attached to it (Gifford, 2014).
Considering we are at a time in healthcare where the rates of disability in musculoskeletal disorders continue to increase (Vos, 2015; Vos et al., 2012), reductive uni-dimensional approaches are being brought into question (Eriksen, Kerry, Mumford, Lie, & Anjum, 2013). That biomedical reasoning methods are ontologically flawed, focusing on the disease rather than the human (Low, 2017). That people living with location specific MSK conditions are potentially living with other co-morbidities or medically unexplained symptoms (Tomasdottir et al., 2013) and that with specialisation, professionals become introspective having a limited view of colleagues work and the broader MDT (Susskind & Susskind, 2015). Do we really feel that specializing in a specific area of musculoskeletal practice is beneficial towards our career development?
Is it worth it?
The application process costs a hefty $5341.10 for starters, the board are reviewing the cost of a practical clinical assessment, which is likely to send the cost up so your guess is as good as mine. So, is it worth it? Considering that there is no clear career development pathway for physiotherapists, no identifiable salary tier, the main funder of physiotherapy services does not recognise physiotherapist specialist titles (and does not intend to in the near future) and pays a flat rate, it seems that there is no incentive or return on the cost. In addition, in order to be registered on the specialist register you must have a Masters degree as a minimum qualification (there is rumour that this is changing to PhD). This alone can cost up to $6000 (not factoring the loss of earnings) and adds minimal gain on an already limited career progression. I also have it on good authority, that other health professions such as psychologists are not subjected to the same scrutiny if they wish to use additional titles.
What are the opportunities that come from being a specialist?
It would seem there are relatively few opportunities and those that do surface demonstrate a shocking consideration of what a physiotherapist has achieved throughout their career.
I bring your attention to a recent position advertised on the popular jobs website – Seek.co.nz
The position was for an assistant research fellow position within the school of physiotherapy at the University of Otago. The ad described an attractive opportunity for any enthusiastic physiotherapist to break into the research field, until reaching the essential requirements. The successful applicant should have a PhD in a recognised field of study. Now, I don’t know about you but working towards a PhD takes years of study, lots of stress and can be costly. The real ball breaker though was the salary – 0.5EFTS of $48-66k NZD a year for 3 years. No that is not a typo! For those of you reading in a foreign country that’s between $32-44k USD and around £24-33k GBP. Now, I know that funding for research comes from grants and I also realise how tirelessly researchers work, but this salary is less than a new graduates wage in New Zealand. I suspect the response will be, “well, that’s academia!”
I realise that there is possibly a false equivalence of phd to specialist. One being academic and the other clinical. Yet, it begs the question that for a clinician that has achieved so much in their clinical career (advanced qualifications and practice), is there any further advantage?
What if I have other qualifications?
Well, it would seem, irrespective of other qualifications you might have (strength & conditioning for example) you are prevented from using the word specialist, if you are practicing as a physiotherapist. It is a rather depressing and shitty state of affairs that if you possess a physiotherapy title you are also penalised by it.
What does the HPCAA say?
I have read through a number of sections of the HPCAA act and whilst it does state that professional titles are protected it does not state anywhere about specific titles such as specialist.
7 Unqualified person must not claim to be health practitioner
(1)A person may only use names, words, titles, initials, abbreviations, or descriptions stating or implying that the person is a health practitioner of a particular kind if the person is registered, and is qualified to be registered, as a health practitioner of that kind.
It does however state in section 11:
11Authorities must specify scopes of practice
(1)Each authority appointed in respect of a profession must, by notice published in the Gazette, describe the contents of the profession in terms of 1 or more scopes of practice.
(2)A scope of practice may be described in any way the authority thinks fit, including, without limitation, in any 1 or more of the following ways:
(a)by reference to a name or form of words that is commonly understood by persons who work in the health sector:
(b)by reference to an area of science or learning:
(c)by reference to tasks commonly performed:
(d)by reference to illnesses or conditions to be diagnosed, treated, or managed.
So, whilst the HPCAA act have not made any specific regulations around additional titles they have left it to respective authorities. Therefore, can it be concluded that whilst the physioboard are recognising physiotherapists working at an advanced level, this is also elitist? There is a risk that this may lead to marginalising the public. With such an expensive and rigorous process, physiotherapists who hold the “specialist” title will undoubtly cost more. This risks perpetuating further instability within the profession in NZ that is attempting to reinvent itself based on influential changes taking place in healthcare (D. Nicholls, Reid, & Larmer, 2009).
So, is earning the title “specialist” prestigious or beneficial towards further career development? Well, I think we should do a numbered summary. What the hell, 1) with the interesting research around experts reacting to negative news, 2) reasoning models with a focus on diagnosis of disease, 3) the state of opportunity to further a professional career, 4) the changing healthcare landscape and 5) the poor financial return doesn’t seem to balance out for the time, cost and effort that a physiotherapist puts in to attain such a title. It’s hard to motivate oneself to work towards such a elitist title. I really fail to see the attraction.
What’s the alternative?
Let’s look back at the definitions I gave for a diversist. The first was a definition of diverse. If we consider the metaphorical and ontological meaning of this statement then it fits with those that we support everyday – people not tissue, with a diverse set of biological, psychological and social characteristics that need to be viewed from a position of holism and not reductionism.
The second definition related to diversity. People are different from each other, no two people are the same and whilst a shoulder, a knee or a back might look the same, the biology, psychology and sociology associated with that body part may be very different. As such, the research gold standard of an RCT lacks the ontological world view and is reductive epistemologically (Kerry, Eriksen, Lie, Mumford, & Anjum, 2012). As a profession, we need to explore the broader perspectives beyond the biomedical into the social sciences.
So, rather than following the herd and filling the pockets of bureaucrats I suggest an alternative approach. Be a non-conformist, be rebellious and doing things against the grain. Embrace your inner creativity and adapt to the needs of society and not the desires and demands of bureaucracy. This is a direction that physiotherapy and physiotherapists could consider rather than following an ever dwindling and decaying model of healthcare. Otherwise we continue to let the powers that be to – keep showing us the way not to be.
Be a non-conformist, be a rebel, be creative!
Thanks for having a read
TNP.
References
Butler, D. & Moseley, L. (2003) Explain Pain. Noigroup Publications, Adelaide, South Australia.
Coderre, S., Mandin, H., Harasym, P. H., & Fick, G. H. (2003). Diagnostic reasoning strategies and diagnostic success. Medical Education, 37(8), 695–703. https://doi.org/10.1046/j.1365-2923.2003.01577.x
Deyo, R. a, Mirza, S. K., Turner, J. a, & Martin, B. I. (2009). Overtreating chronic back pain: time to back off? Journal of the American Board of Family Medicine : JABFM, 22(1), 62–68. https://doi.org/10.3122/jabfm.2009.01.080102
Eriksen, T. E., Kerry, R., Mumford, S., Lie, S. A. N., & Anjum, R. L. (2013). At the borders of medical reasoning: aetiological and ontological challenges of medically unexplained symptoms. Philosophy, Ethics, and Humanities in Medicine : PEHM, 8(1), 11. https://doi.org/10.1186/1747-5341-8-11
Gifford, L. (2014). Aches and Pains. CNS Press (Aches and Pains Ltd. ISBN-10: 0953342352
Kerry, R., Eriksen, T. E., Lie, S. A. N., Mumford, S. D., & Anjum, R. L. (2012). Causation and evidence-based practice: An ontological review. Journal of Evaluation in Clinical Practice, 18(5), 1006–1012. https://doi.org/10.1111/j.1365-2753.2012.01908.x
Lederman, E. (2010). The fall of the postural–structural–biomechanical model in manual and physical therapies: Exemplified by lower back pain. CPDO Online Journal, 1–14.
Low Msc, M. (2017). A novel clinical framework: The use of dispositions in clinical practice. A person centred approach. Journal of Evaluation in Clinical Practice, 1–9. https://doi.org/10.1111/jep.12713
Nicholls, D. A., & Gibson, B. E. (2010). The body and physiotherapy. Physiotherapy Theory and Practice, 26(8), 497–509. https://doi.org/10.3109/09593981003710316
Nicholls, D., Reid, D., & Larmer, P. (2009). Crisis, what crisis? Revisiting “possible futures for physiotherapy.” New Zealand Journal of Physiotherapy, 37(3), 105–114.
O’Sullivan, P. B., Smith, A. J., Beales, D. J., & Straker, L. M. (2011). Association of Biopsychosocial Factors With Degree of Slump in Sitting Posture and Self-Report of Back Pain in Adolescents: A Cross-Sectional Study. Physical Therapy, 91(4), 470–483. https://doi.org/10.2522/ptj.20100160
Susskind, R., & Susskind, D. (2015). The Future Of The Professions: How Technology Will Transform The Work Of Human Experts. Oxford University Press. Great Clarendon Street, Oxford, UK. ISBN 978-0-19-871339-5
Staats, B. R., Diwas, S. K., & Gino, F. (2018). Maintaining Beliefs in the Face of Negative News: The Moderating Role of Experience. Management Science, 64(2), 804–824. https://doi.org/10.1287/mnsc.2016.2640
Tomasdottir, M. O., Getz, L., Sigurdsson, J. A., Petursson, H., Luise Kirkengen, A., Krokstad, S., … Hetlevik, I. (2013). Co- and multi-morbidity patterns in an unselected Norwegian population: cross-sectional analysis based on the HUNT Study and theoretical reflections concerning basic medical models. European Journal for Person Centered Healthcare, 2(3), 335–345. https://doi.org/10.5750/ejpch.v2i3.734
Vos, T. (2015). Global , regional , and national incidence , prevalence , and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries , 1990 – 2013 : a systematic analysis for the Global Burden of Disease Study 2013. The Lancet, 386, 743–800. https://doi.org/10.1016/S0140-6736(15)60692-4
Vos, T., Flaxman, A. D., Naghavi, M., Lozano, R., Michaud, C., Ezzati, M., … Moradi-Lakeh, M. (2012). Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: A systematic analysis for the Global Burden of Disease Study 2010. The Lancet, 380(9859), 2163–2196. https://doi.org/10.1016/S0140-6736(12)61729-2
The Naked Physio / The curiouser 
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