84 Hollowing out physiotherapy

But how to begin? Although professionals rarely ever ask whether ‘other institutional or organisational forms than professions could deliver knowledge and expertise faster, better, cheaper, more consistently’ ^[1], I think there could be some real benefits in physiotherapists doing this now. What I am proposing, then, is that we might begin a thought experiment, designed to map all of the aspects of physiotherapy that are already liable to disruption, and using this as the starting point for stripping away the adumbrations we have added to the physical therapies. There’s a fully worked up workshop version of this activity on the next page, but here is the hollowing out idea in principle.

Consider physiotherapy as a large square drawn on a piece of paper. This square represents the entirety of different knowledges, skills, attitudes, concepts, learned approaches and dispositions, beliefs, values, and philosophies, that embody the profession today. Now consider anything that you do that can be written down or explained to someone else in a structured, logical way. Consider anything that could be written out as a series of steps, a therapeutic plan, or as an instructional guide, for instance. Imagine smaller boxes, within the larger square, representing how much space each of these take up, (keeping in mind what you think occupies the space left behind). Now ‘remove’ these smaller squares because these represent the things that will almost certainly be given to someone (or something) much cheaper to train, employ, and update than us in the near future.

Now consider anything that you do in your patient assessments, advice, or treatment programmes, that is routine or can be standardised, that you do repeatedly, or that is labour-intensive, or a physical task that requires little specialised knowledge or skill. Not only the kinds of work that is now increasingly delegated to assistants, but every task you perform that can be seen as habitual, generic, context independent, or conventional. Give each of these their rightful space in the bigger square, and then remove these too. It is highly likely these will be lost as part of healthcare’s long-fuse big bang.

Then look at anything that is common or shared between you and a large group of your colleagues, whether it is an established clinical approach or method of thinking or working. ‘Cut’ these out because AI algorithms will almost certainly take these from us. And now take out all of the work you do to advise and guide because this is already, or will soon be, available to people online.

What remains will no longer resemble a professional identity, and certainly not one that corresponds to our current understanding of physiotherapy. Why then should you try it? Firstly, you should do this because it will help you to find tangible examples of the adumbrations that may soon be lost from physiotherapy, whether we choose to strip these layers away or not. Every profession exists within a ‘highly fluid, interconnected and global’ social context today, and professional territorial claims that were once strong, are increasingly ‘giving way to generalisation, flexibility and the erosion of professional power and privilege’ ^[2][3]. So removing these adumbrations may help to anticipate what the future for the physical therapies may look like.

Secondly, the exercise serves to remind us that the health professions are simply one historically contingent response to a set of questions, and only one of a number of occupational arrangements in the modern division of labour ^[4][5]. There is nothing about the physical therapies that presupposes the existence of disciplines and professionals ^[6]. Indeed, as I suggested earlier, there has been some significant violence done to the intensities at the heart of physical therapy in their capture by physiotherapists, and stripping away this ‘exaggerated fixity’ ^[7]. So stripping away the layers of knowledge, skills and attitudes that generations of physiotherapists have added to the physical therapies might remind that the physical therapies existed long before the physiotherapy profession attempted to colonise them, and will survive well beyond the this current historical moment.

And thirdly, the experiment invites physiotherapists to anticipate the change to come and embrace the possibility that they too might be agents of change. Stripped of its adumbrations, it would be easier to feel the warm glow of physical therapy’s intensities and envisage new physical therapy connections and relations, new assemblages, and new roles; subjectivities that seem impossible within the current ethos: physical therapy as action, touch and reciprocity, shared activity and empathic work, breathing and planetary health, movement pluralism and social justice, touch and mental flourishing, exercise and community resilience. By pruning the physical therapies back, we allow a thousand new shoots to appear.