June 10, 2008

Can physiotherapists be put on a par with doctors?

Intensifying a turf war between physiotherapists and medical doctors, a parliamentary standing committee is exploring the possibility of upgrading physiotherapy from a paramedical discipline to an independent system of medicine.

If physiotherapists' claim to have the competence to provide diagnosis and prognosis for medical problems is accepted by Parliament, physiotherapy will attain the status of an independent system of medicine. Doctors fear that the disruption of the existing hierarchy of healthcare may compromise the interests of patients.

One of the common causes for low backache, for instance, is the spread of cancer to the spine. Says S L Yadav, associate professor at the AIIMS department of physical medicine and rehabilitation: "Since he is not equipped to detect cancer, the physiotherapist may routinely administer traction or a heat modality, which could aggravate the problem and cause paralysis."

Ali Irani, president of the Indian Association of Physiotherapists (IAP), refutes the suggestion that greater autonomy to physiotherapists would undermine the health care system.

"Given our own expertise, we are as capable as general physicians in noticing the pathology of a patient and referring him to an oncologist for cancer treatment," says Irani, who was the Indian cricket team's physiotherapist for 10 years from 1987.

"It is just that doctors are unable to come to terms with the fact that our science has developed to an extent where we too could refer patients to them and they can't demand cuts from us any longer."

Irani adds that since IAP is not asking for any power to prescribe medicines or to perform surgery, "nobody can accuse us of encroaching into their domain".

What has caused alarm in the health ministry is a note prepared by the director general of health services, R K Srivastava, on February 12 after representing the health ministry at a closed-door hearing of the standing committee dealing with the Paramedical and Physiotherapy Central Council Bill.

The note, a copy of which is with TOI, begins by expressing surprise at the fact that the questions put to Srivastava were "focused only" on the proposed central council for physiotherapy, although it is just one of the three councils envisaged in the bill, which had been introduced in Parliament in December 2007.

The "salient points" of the discussion before the standing committee headed by Samajwadi Party’s Amar Singh included, according to director general of health services, R K Srivastava's note, a review of the very "definition" of the profession in order to pave the way for "equivalence to the medical doctor" and "recognition of physiotherapy as a system of medicine".

In his note, written within a day of the standing committee's hearing, Srivastava told other "concerned officers" of the health ministry that before the minutes of the meeting were sent by the Parliament secretariat, they should keep their responses ready so that the issues could be "disposed of quickly".

Health ministry officials are exercised over the issues raised by the standing committee as they see the hand of the physiotherapist lobby, which has been at work since the early 1990s to counter the proposal of setting up an omnibus council to regulate over a dozen different allied health professionals including radiographers, medical lab technicians and operation theatre technicians.

But thanks to the pressure mounted by IAP, the bill that was eventually drafted had accommodated their demand for separating them from other paramedical personnel. The proposed omnibus regulator was accordingly renamed as the Paramedical and Physiotherapy Central Council Bill with a provision to constitute sub-councils for various disciplines.

In September 2004, the cabinet of the UPA government cleared the bill in that form. But the bill was diluted further when it was introduced in Parliament after a lapse of more than three years. Instead of an omnibus body, the 2007 bill provided for three separate councils, including one for physiotherapists and occupational therapists.

Equally significant, the 2007 bill also gave up the idea of allowing medical specialities to have a say in the regulation of their paramedical disciplines.

Despite the concessions extracted in 2004 and 2007, IAP discloses in its latest website update that it is trying to get more changes in the bill by being "in contact with all top politicians and parliamentarians".

Drawing support from a couple of state legislations, IAP's most ambitious demand is that the standing committee should recommend a radical change in the definition of physiotherapy. This is because the bill defines it as a "medically directed therapy", thereby implying that physiotherapists will continue to work under the supervision of doctors such as orthopaedicians, physiatrists and neurologists.

In a bid to gain more autonomy, IAP proposed that their subject should instead be defined as a "physiotherapeutic system of medicine" involving "treatment modalities which have a diagnostic, prognostic, preventive and rehabilitative dimension".


Dr Rajshekher said...

This is an issue which keeps cropping up, and now the physiotherapists' national body has taken a very bold step. Everybody loves to be called a doctor, even politicians! Whenever a PhD proudly tells me that he is a doctor, I address him as doctor, and that sort of humbles him ("oh, I am not a medical doctor" and so on). All my physiotherapy colleagues ask their patients to address them as "doctors" and all my patients refer to them as "that doctor" and so on...not that I mind that so much...anyone wearing a coat and giving advise can be called a doctor (the term has lost much of its sheen, anyway)..what rankles me is that all manner of people (including so-called "RMPs" in villages, who are in reality 'URMPs') exist to dupe people. Gastro physicians will let their pts feel they have operated on them (and not the gastro surgeons) neurosurgeons will let the pt feel they r qualified to treat medical conditions, general physicians will try to play down the role of superspecialists (in the smaller towns, they train the pts to be cautious of those 'big city practitioners' who r 'out there to fleece money from u', so that it becomes an uphill task convincing them that a particular test is really required)...and so on an on...its an endless litany...when things r like that, I feel it is of no great concern that physiotherapists want to call themselves doctors..let them join the bandwagon...it will make part of their behavior legal, and their status official..we should worry about trying to legislate or implement existing laws in a way that ensures ethical behavior by everyone involved in medical practise. That is an entirely different T20 game, one worth starting a separate blog about!

Anonymous said...

How can Physiotherapists diagnose diseases independently? Are they competent enough to do that? In a lot of cases Physiotherapy itself is contraindicated. How can the Physiotherapists manage such cases without a Doctors supervision?The quality of the Physiotherapy education itself is a big controversy
as most of the colleges are grossly understaffed.

Dr sathya PT(MPT) said...

In the developed countries like US, UK, Australia, Canada, NZ Physiotherapist enjoy autonomy & are first contact practitioners and exercise professional judgment and they need not require prior referral from a medical doctor. Such countries have upgraded the existing Physiotherapy course/structure to DPT - Doctor of Physiotherapy. Adding to that they need not use the title "Dr" as the patients/clients very well recognize them as a health care professional.
Also if MCI and Indian system of medicine has adopted its early rules, regulations, acts, scope of practice from the UK laid in early to mid 20th century, then they must also look on to the fact that "Dr" is a title that is exclusively used by medical professionals holding a MD degree (doctor of medicine) & a subsequent higher degree (eg DM). Health care professionals having a Phd, dentist (after revolting in late 90's) & few others use the title "Dr" in the UK. Surgeons including orthopaedicians having MS (master of surgery) degree do not use the title "Dr" as it doesn't confers to a "doctor degree". Even MCh holders are no exception.
Does this mean that we follow UK & not allow our Indian surgeons to use the much dignified title "Dr"?

Many of us must be aware of the medical school system in US & the very loop holes existing there; an Indian MBBS holder after getting his/her credentials evaluated & clearing USMLE is awarded a MD title there; this means the Indian MBBS degree confers to a MD degree in the US ! The Indian BPT/MPT degree holders too after getting themselves evaluated & clearing the NPTE are eligible for DPT/t-DPT(doctor of physical therapy) in the US !

Unknown said...

Physiotherapists know better than Physicians or Specialists about the indications/contraindications of its various applications. So without having a deep knowledge about any subject one need not comment.

What would an Orthopaedician do if he/she gets a joint replaced/Bone fracture? Or for that matter, how does a neurologist/neurosurgeon get rehabilitated after an episode of stroke/ head injury?

The list is endless.

The bottomline is - From the womb to the tomb Physiotherapy has its presence.




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