What is rationalization?
As society progresses forward, its many aspects adapt to the everchanging circumstances of the world and environment. This phenomenon can be observed in regard to infrastructure, technology, the economy, and the job market. Professions evolve to become increasingly rationalized, a process defined by American sociologist George Ritzer as replacing traditional and emotional thought with reason and efficiency. Ritzer maintained that rationalization occurs over a set of four dimensions: efficiency, control, calculability, and predictability, all of which work together in unison to facilitate a world that can be characterized by increased standardization and technological prevalence. How has the process of rationalization affected the field of physiotherapy?
The Early Days of Physiotherapy
The first documented account of what is contemporarily known as physical therapy was in the year 460 BCE, introduced by Hippocrates, Father of Medicine and one of the most extraordinary physicians of all time, as the idea of manual manipulation for pain relief. Some of the earliest forms of physical therapy were massage and hydrotherapy, a precursor to aquatic therapy, and were implemented by Hippocrates as well as another Ancient Greek physician known as Hector. Historical texts from regions all over the Eastern Hemisphere, namely Persia, China, and Egypt all contain records of health methods that describe the benefits of exercise, movement, and massage for ailments. These techniques were enveloped into the sub-field of medicine modernly known as physiotherapy. From India, we see the practices of yoga and Ayurveda as precursors of modern-day physiotherapy practices.
Modernization
Few recorded advancements were made in the field for centuries afterward until about the 1800s. It was during this time period in Europe that we began to see further institutionalization of the profession. In Sweden, a health educator name Per Henrik Ling opened a medical-gymnastics institute, establishing the Swedish word for physiotherapy which was also transferred to other Scandanavian countries.In 1887, physiotherapists were given official registration by Sweden’s National Board of Health and Welfare, and soon after, other countries in Europe followed suit.
One of these other European counties was Great Britain. In the late 1800s, the British Medical Association (BMA) investigated the background and methodology of various proclaimed massage practitioners based throughout London and discovered that the industry was heavily comprised of prostitution; workers lacking education and vocational skills forged qualifications and worked under the guise of massagists when in reality they were sex workers. In 1894, four nurses, Lucy Marianne Robinson, Rosalind Paget, Elizabeth Anne Manley, and Margaret Dora Palmer, formed the Society of Trained Masseuses in order to protect their profession in response to press stories that warn the English public of suspicious women offering massages as a euphemism for other services. This society later became the Chartered Society of Physiotherapists.
Advancements that result from the World Wars and the polio outbreak
A common theme that emerged in the first half of the 20th Century is the institutionalization of the profession in order to protect those who practiced it. There was a lot of doubt in regard to the nature of the profession of massagists, especially female massagists, because they didn't have a lot of credibility, and proving legitimacy was truly challenging. However, with both the World Wars, the polio outbreak, and all of the other events that transpired during the earlier twentieth century, physical therapy services became more in demand, and hospitals and medical boards became more incentivized to accredit the individuals who practiced physiotherapy. Thus we were able to witness the formation of the Division of Physical Reconstruction at the Walter Reed Army Hospital which later yielded the establishment of the American Physical Therapeutic Association. This was also how PT services transitioned into becoming more outpatient-oriented.
There were many advancements to physiotherapy in the late 20th Century that involved organization and legislation
- After WWII, the America Physical Therapy Association (APTA) leadership began to advocate for tiger regulation and a greater quantity of individual state mandates to further protect and professionalize the field.
- APTA took the initiative to develop an objective test that would evaluate individual competency.
- The result, in 1954, was a seven-hour multiple-choice examination with 310 questions spread over the basic sciences, clinical sciences, and theory and procedures
- By the 1960s, the membership of the American Physical Therapy Association had grown to about 15,000 with 52 schools for PT instruction all across the country (APTA)
- The first national physical therapy month in October was celebrated in 1992.
Looking across the four dimensions in modern times
Efficiency
A strong theme within the field of healthcare in the early 1990s was the undertreatment of pain, so physiotherapy was geared toward pain relief. OxyContin was prescribed as a universal pain reliever, and if the pain persisted, the dosage was simply increased. This decreased the strain on physiotherapists that came with the difficulties of treating the challenging and time-consuming cases: chronic but non-malignant pain. The drug was long-lasting with only a 1% addiction rate. “Physiotherapists were expected to treat more patients in a shorter amount of time—a goal for which the slow, attentive evaluation and therapy patients in pain require are not amenable” (Hughes et al.).
Calculability
Insurance companies have placed increasing pressure on physiotherapists and the collective agencies for which they work to numerically track patient outcomes to prove their overall worth. These insurance companies rely on quantitative figures to boast, but this notion interferes with the administration of physiotherapy, subsequently impacting the patient experience in a negative manner. There is a way to implement calculability into the field in a more favorable way: Net Promoter Score is a survey of sorts taken by patients toward the conclusion of treatment measuring their likelihood to recommend services to others, incentivizing physiotherapists to achieve the highest level of patient satisfaction.
Predictability
Insurance companies have placed increasing pressure on physiotherapists and the collective agencies for which they work to numerically track patient outcomes to prove their overall worth. These insurance companies rely on quantitative figures to boast, but this notion interferes with the administration of physiotherapy, subsequently impacting the patient experience in a negative manner. There is a way to implement calculability into the field in a more favorable way: Net Promoter Score is a survey of sorts taken by patients toward the conclusion of treatment measuring their likelihood to recommend services to others, incentivizing physiotherapists to achieve the highest level of patient satisfaction.
Control
One way in which control is being exerted in the vein of rationalization within the field of physiotherapy is the development of evidence-based practice (EBP). Evidence-based physiotherapy is defined as “the integration of best research evidence with clinical expertise and patient values” and has become an increasingly prevalent theme of rehabilitation over the last couple of decades. “EBP is a field in which physiotherapists can collect relevant information, use a variety of research methods to produce scientific evidence on topics related to patient evaluation and interventions in physiotherapy, and assess the quality of the scientific evidence already available”. By establishing universal standards, physiotherapists now have access to a baseline model to which they can refer when working with patients who are experiencing a variety of needs, ensuring that they provide the highest quality of care in an organized and ethical manner.
Irrationanlities
The universalization of physiotherapy practice has many benefits, but it should be implemented with caution. The human body is incredibly complex, and each individual's unique medical needs vary from one another. Without taking this phenomenon into consideration, the only benefit of rationalizing physiotherapy becomes decreased liability and a better corporate appearance. EBPs and CPRs make PT treatment more generalized and systematic, and this process has the ability to foster the implication that there is a "right" and a "wrong" way to treat patients. This rigid and binary system of thinking could have dangerous ramifications in fields that are as complex as medicine and healthcare, where the thing that is at stake is human life and wellbeing. Therefore, it is imperative that the concept of the institutionalization of this field is approached carefully and treated with an abundance of caution in a way that makes increasing patient health-related quality of life the greatest priority.
Concluding Notes
The field of physiotherapy has undergone extensive rationalization as we can see with the formation of all of those societies, the creation of degree and certification programs, and the popularization of EBPs and CPRs, but even then, some things remain constant, which is why I was able to heal a back sprain through Indian stretching and a heat pack. It may be impossible to label the concept of rationalization as wholly “good” or “bad” but one thing is certain: physiotherapy in a hundred years, a thousand years, may not look anything like what it does today, but the underlying principles and the overall goal will always remain the same.
References
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