Doing too much

A recent short paper in the journal Sociology of Health & Illnesshas offered some important insights into overdiagnosis and overtreatment (Armstrong, 2021).

For some years now, health service managers have argued that there is ‘too much medicine’ in healthcare, and have used the language of cost containment and ‘Choosing wisely’ to increase professional accountability. But health professionals have themselves been concerned with too much reliance on expert advice, and have criticised other competing professions for encouraging patients’ dependence on the therapist for the cure (Traeger et al., 2017; Baldwin et al., 2015; Copnell, 2018).

What’s really interesting about the paper by Natalie Armstrong, though, is that it shifts the focus away from the actions of the professionals themselves, and looks instead at the socialconditions that encourage professionals to overdiagnose and overtreat.

Armstrong’s focus is on Susie Scott’s recent work on The sociology of nothing(Scott, 2018), in which Scott argues that there is a real difference between purposefullydoing nothing for someone - in order to help them work out a better way to move, or deal with their symptoms, perhaps - and doing nothing as an act of fear or negligence. 

For Scott, doing nothing can be a very deliberate act. 

Physical therapy has always carried an association with purposeful action, and so to contemplate therapy as an act of ‘passivity’ seems counterintuitive. But this was exactly the theme Filip Maric’s picked up and explored in his 2017 doctoral thesis (Maric, 2017), and was something we wrote about together, in thinking through ways that deliberate acts of passivity might change the way we thought about future physiotherapy (Maric & Nicholls, 2020).

Reading Armstrong’s paper, though, reminded me how often ‘good’ physiotherapy relies on doing nothing.

One of the things that was drummed into me in my early career working in a neonatal ICU, was that a good physiotherapist will often spend 90% of their time thinking about all of the things they shouldn’t do. “Act in haste, repent at leisure” seemed to be our watchwords. The babies we saw were often so metabolically unstable, that just turning them over to improve the air and blood flow to their lungs was potentially life-threatening. More often than not, the only ‘active’ thing we did during a half-hour session was to adjust the wedge under their side. 

We were often left wondering whether the little we did justified our long, expensive training, the prestige we were given, and the pay we earned for our work.

Because of COVID, a lot of physiotherapists around the world are now making decisions like that.

In a recent feature in Vogue Magazine, Jessie Robinson, a 24-year-old physio working in an ICU in London’s Charing Cross Hospital, said that;

“My team is responsible for turning the most severely ill patients from lying on their back to their front or vice versa, which can take up to an hour. The unfortunate reality is that the patients are so unstable, it can result in cardiac or respiratory arrest” (de Rosée, 2021).

I wonder how many of us are now really honing our skills of doing nothing?

But there is also a second, deeper, theme running through Armstrong’s article on overtreatment and overdiagnosis that I think is worth thinking about. It’s about the extent to which we feel we are the agents of our professional destiny. 

All health professions talk about their quest for autonomy, as if it is something that the profession itself fights for and ‘wins’.

The classic narrative goes that a new profession first establishes its identity, either by filling a gap in the market, or carving out a niche for itself. It then attracts sponsors; other more established and powerful professions, that can give it a ‘leg up’: shaping the curriculum, helping with teaching, providing patient referrals, supporting legislation, sitting on governing bodies, and so on. If the profession is lucky enough to survive and prosper, it then tries to distance itself from its sponsors, by demanding the right to govern itself and decide its own professional scope and curriculum. And all the way through this narratvie, we are given the impression of a profession as a coherent entity, initiating change and driving progress.

Armstrong’s paper fits neatly into the vast body of literature that has been written over the last half century showing that this story of profession’s quest for autonomy is a myth (Freidson, 1984; Johnson, 1972; Abbott, 1988; Foucault, 1973; Evetts & Dingwall, 2002; Larson, 1977).

What we now know is that the health professions are much more the resultof social change than the initiators. Rather than the health professions claiming autonomy, the idea of discrete, self-governing profession is really only part of an origin story developed between medicine and some of the other elite professions in the early 20th century, and early ‘functionalist’ sociologists, that the professions allied to medicine picked up on and developed. 

What this literature shows us is that physiotherapy and autonomy are both the result, or the effectof much broader efforts to shape the way people can be health, wealthy and wise in modern society. 

Over the last two years I’ve been beavering away on a follow-up to The End of Physiotherapywhich, I hope, will explain a lot of these issues in much more depth, and argue that the way we have been taught to think about the profession of physiotherapy may have been wrong all along.

The challenge will be whether we actively try to turn physiotherapy around, or step back and let our colleagues work out their own ‘line of flight’.

References

Abbott, A. (1988).The System of Professions: An Essay on the Division of Expert Labor. University of Chicago Press. 

Armstrong, N. (2021). Overdiagnosis and overtreatment: a sociological perspective on tackling a contemporary healthcare issue. Sociol Health Illn, 43(1), 58-64.

Baldwin, J. N., McKay, M. J., Hiller, C. E., Nightingale, E. J., Moloney, N., Vanicek, N., Ferreira, P., Simic, M., Refshauge, K., Burns, J., & 1000, N. P. C. (2015). Defining health and disease: setting the boundaries for physiotherapy. Are we undertreating or overtreating? How can we tell. Br J Sports Med, 49(19), 1225-1226.

Copnell, G. (2018). Should UK based Physiotherapists Choose Wisely. Physiotherapy, 104(4), 395-399.

de Rosée, S. (2021). “We Have No Option But To Carry On, But At What Cost?”: One Physiotherapist Reports From The Covid-19 ICU. Retrieved 2021-02-16.

Evetts, J., & Dingwall, R. (2002). Professional Occupations in the UK and Europe: Legitimation and Governmentality. International Review of Sociology, 12(2), 159-171. 

Foucault, M. (1973).The Birth of the Clinic: An Archaeology of Medical Perception. Tavistock Publications. 

Freidson, E. (1984). The Changing Nature of Professional Control. Annual Review of Sociology, 10, 1-20. 

Johnson, T. (1972). Professions and power. Macmillan. 

Larson, M. S. (1977).The Rise of Professionalism: A Sociological Analysis. University of California Press. 

Maric, F.  (2017). Physiotherapy and fundamental ethics: Questioning self and other in theory and practice [PhD]. Auckland University of Technology.

Maric, F., & Nicholls, D. A. (2020). The fundamental violence of physiotherapy: Emmanuel Levinas’s critique of ontology and its implications for physiotherapy theory and practice. OpenPhysio. 

Scott, S. (2018). A sociology of nothing: Understanding the unmarked. Sociology, 52(1), 3-19. 

Traeger, A. C., Moynihan, R. N., & Maher, C. G. (2017). Wise choices: making physiotherapy care more valuable. J Physiother, 63(2), 63-65.