Evolución de las pautas de tratamiento

One consequence of the establishment of sports medicine as a recognised medical speciality has been the development of formally recognised sport and exercise medicine qualifications which serves as a marker of a "new type" of expert, the sports medicine clinician. In relation to doctors, many of those who have been promoted to prominent positions have attained such qualifications. The majority of doctors interviewed suggested that an emphasis on sport-specific medical qualifications had served to improve standards of medical practice, provided a better foundation for the career development of doctors already working in this area and would encourage those hoping to access the area in the future. Doctors viewed these qualifications as an

increasingly important means of securing a career in sport and exercise medicine, as sports medicine organisations (e.g. EIS), national governing bodies, other doctors, other health-care providers (e.g. physiotherapists) and athletes prioritised these in making medical appointments. One doctor reflected on the change in the following way:

I think at the end of the day there is some baseline standards in terms of qualifications and there is an expectation now within most sports that the job descriptions are more and more frequently written by a medical practitioner. I mean it used to be written by whoever, you know, the person who had been running the trips. But now, most would write "needs a higher education in sports medicine". Those are the sorts of demands that they are starting to ask for now.

Not only were sports medicine qualifications seen to be important in the eyes of employers, doctors also reflected on the importance of athletes being aware of the expertise a doctor had so that they could be sure that they received treatment from an appropriate source. One doctor stated:

What I think is no longer acceptable is to have people who have a self- declared interest in sport and exercise medicine who have no added qualification because it shows that they have not undertaken any additional education and I think it is confusing for patients and athletes. Athletes should know "am I seeing someone with a sub-specialty interest or am I seeing a specialist"?

Similarly, another doctor simply stated "my athletes don’t see anybody who doesn’t have one [sports medicine qualification] full stop". Those doctors who possessed sports medicine qualifications emphasised the extent to which this distinguished them from other doctors practising in sport, and thus formal qualifications became fundamental to their identity as sports medicine doctors. In this regard, one doctor

doctor said that doing higher qualifications had "created their [own] network and their own set of standards". In this regard, formal qualifications appeared to give sports medicine doctors a sense of legitimacy within the sports community.

In addition to sports medicine qualifications for doctors, the introduction of formal, written qualifications in sports physiotherapy was discussed by a number of interviewees. In a similar way to the sports medicine diploma or MSc, physiotherapists intending to seek employment in sports medicine, as well as those already involved in this area, were encouraged to complete postgraduate qualifications. Like doctors, physiotherapists recognised that the introduction of formal qualifications created a more structured profession with a clearer career pathway for those hoping to pursue employment in this area. They also described how such qualifications may encourage current sports physiotherapists to continue their learning. In sports physiotherapy, it was obtaining an MSc that was given the most credence. One physiotherapist stated that "certain key roles in sport pretty much demand it [the MSc] now" and another stated that postgraduate qualifications were "becoming more and more important for you to progress". When discussing these recent organisational changes in sports physiotherapy another physiotherapist noted:

Physiotherapy, as a whole, is very much being pushed in that direction. Anybody can say "I can do this, I can do that" but if you have got it written on a piece of paper then you can show that you have it as a qualification.

Not only did interviewees see the possession of a sports physiotherapy MSc as desirable, they also discussed several other formalities they were required to pursue in order to successfully progress within the profession. Of these formalities, it was the CSP’s (Chartered Society of Physiotherapists) Continuing Professional Development (CPD) portfolio scheme developed in 2001 that was most often discussed by

interviewees. Changes in state registration requirements through the health professions council now involve a mandatory and audited record of CPD. In addition, the increase in funding for support services in sport at the elite level has led to an increasing number of physiotherapists able to pursue a career in sport and the Association of Chartered Physiotherapists in Sports Medicine (ACPSM) suggest that this "has led to more courses providing a variety of levels of qualifications in sports related healthcare, with more individuals competing for employment in this limited workplace" (www.acpsm.org). Thus, in a bid to establish their status as desirable sports medicine practitioners and in an attempt to distinguish between different providers of physiotherapy care, ACPSM registered physiotherapists are encouraged to provide increasing evidence for their clinical and professional skills. For example, one physiotherapist stated:

They have got to filter a lot of people out. So what they are doing is they have produced a set of guidelines with what they call a bronze, silver or gold level clinician and they are asking people to fulfil certain criteria to get those levels.

It was these more practical elements of learning that were considered by the majority of physiotherapists as crucial to their professional progression and for improving their physiotherapy skills. Given physiotherapists’ more "hands on" work (both literally and metaphorically), practical as opposed to written qualifications were considered to be central for physiotherapists’ career progression and this added an additional dimension to physiotherapists’ career portfolios in comparison to their doctor counterparts.

Whilst obtaining a written qualification such as an MSc was largely considered by physiotherapists as a further prerequisite for obtaining a job in elite sport, interviewees were less unequivocal about their desirability. On the whole, those who

most vehemently resisted this development were physiotherapists who had already practised for a number of years. For example, one physiotherapist reflected on the added pressure for physiotherapists in certain roles (in this example, managerial roles) to have this qualification:

I would never have chosen to do it. I think there was a bit of pressure put on me in that if I was going to be suggesting physiotherapists really needed an MSc then really I should have an MSc.

Another physiotherapist described a similar situation:

The only reason I am doing it is because I have to do it. I’m not doing it because I want to do it. I love my profession and I want to keep doing what I am doing but I can’t do that unless I do these stepping stones. It annoys me that I have already got the experience and I have done x, y and z ... I don’t see why a piece of paper is going to make me a better physiotherapist.

Despite physiotherapists’ endeavours to create a more formalised and professionalised structure in sports physiotherapy, a number of interviewees discussed the unintended consequences of such changes. For example, part of their resistance to the introduction of written qualifications was reflected in a number of interviews where physiotherapists described the tensions between younger, MSc qualified physiotherapists and older, experienced, but non MSc qualified physiotherapists. In contrast to data from doctors where younger, specialist qualified practitioners were given greater status in sports medicine, it was the younger, specialist qualified physiotherapists who were described by a number of interviewees as problematic within the profession as they were regarded by many as having a restricted scope of practice. One physiotherapist described this problem thus:

Physiotherapists are specialising far too early in sports. A lot of very nice, young physiotherapists who have got more qualifications, you know, they

have got the masters but they have not got that background experience which I think is actually quite dangerous.

For many, there was a concern that physiotherapists who had obtained an MSc had achieved this qualification to the detriment of establishing basic, background physiotherapy skills which many older, less specialised physiotherapists argued could only be obtained by working in the NHS or perhaps via extensive voluntary experience in sport. One physiotherapist suggested that "a good sports physiotherapist has to be a good physiotherapist first and foremost and then specialise in the sports area". Another physiotherapist described the issue of specialisation in the following way:

Yes you need the qualifications and yes you definitely need the ongoing education, but you also need those very basic background skills of communication and those kinds of things. I think that is where I am nervous about it [the profession] falling down because I see physiotherapists now, young physiotherapists who sadly can’t get jobs and they go straight into private practice treating sports injuries.

Perhaps surprisingly, those who had already obtained an MSc and those currently working towards one also shared these views, which is in contrast to those doctors who placed a higher value on higher education qualifications. Whilst formal, written qualifications in sports medicine were seen by the majority of doctors as crucial to the practise of sports medicine and vital to their status as sports medicine practitioners, physiotherapists in the current study believed that the MSc was not particularly useful to their clinical practice and did not feel that it gave them any greater prestige in the sports physiotherapy community. Reflecting on the increasing importance which employers placed on an MSc, one young physiotherapist currently completing the MSc felt that the greater emphasis awarded to this qualification had negative

consequences. In a disbelieving tone, s/he said: "I have known people who have had maybe two or three years experience in sport and they get overlooked by someone who has six months experience and an MSc". Another young physiotherapist said "people just get it [the MSc] to get the paperwork really and when they come out with it it’s not clinically useful". Another physiotherapist working towards this qualification highlighted one potential consequence that striving for more academic qualifications could have on the physiotherapy profession:

I feel that the profession is developing too much on the academic and written side and we will lose our skills if we are not careful. We will get people who are robots and who don’t know how to think outside of the box.

It would appear that attempts to incorporate formal qualifications into sports physiotherapy have not been as successful as they have for sports medicine doctors given the generally negative attitude towards formal qualifications such as the MSc. Despite being received by the majority of physiotherapists less favourably, a number of physiotherapists discussed possible reasons why academic qualifications had become more important in sports physiotherapy. For the most part, this was an attempt to imitate the achievements of their doctor counterparts in establishing sports medicine as a speciality. Whilst sports physiotherapy has not yet been awarded speciality status, sports physiotherapists were keen to adopt some of the more formal features of a speciality profession (such as written qualifications). However, attempts to emulate doctors had unintentionally created negativity amongst many practising sports physiotherapists. For one physiotherapist, this was because leading physiotherapists had been too lenient in their approach. That is to say, rather than making academic qualifications a formal requirement, these physiotherapists had simply suggested that physiotherapists would be "better placed" in sport if they had

obtained the MSc. This interviewee suggested that this was incorrect and dangerous. When asked to explain further, the interviewee replied:

[The focus on the MSc] was probably born out of wanting to make things open and honest because it always was perceived to be a closed shop. It was always perceived that if you were in the right gang and knew the right people you would get the right opportunities. To be honest, to a certain extent that is still the case today. You can try and make it as open and honest as you want but if you are the person who is taking away a team to the Olympic games you want to take people that you know you can work with. So, you are going to take people that you know. You’re not going to take somebody you don’t know because that’s a risk because you have no idea how they are going to react in a situation where you are in charge. Nothing can change that. No amount of us wanting to put up a fantastic pathway and a career development and no amount of being as open and honest is ever going to change that because, ultimately, you are going to take people you can work with. I would defy anybody to say they would do it any differently if they were in charge. I’m not saying don’t have a pathway but just be open and honest about the fact that you can’t always be open and honest.

It would appear that, despite movements toward a more formally organised and structured sports physiotherapy profession, some emphasis on traditional and less formal means of employment and evaluation remains in this area of practice. Whilst doctors are comfortable to market themselves to athletes as sports medicine "specialists" by virtue of their formal qualifications and see such qualifications as the basis of their credibility in the sports medicine community, physiotherapists are reliant on demonstrating their expertise via hands-on work with athletes and by establishing good working relationships with their clients and colleagues for further recommendation. In this regard, data indicate that the introduction of formal qualifications such as the MSc, are, in some ways, incompatible with the traditional practicing methods of sports physiotherapists’ work. However, encouraging sports

physiotherapists to obtain more academic qualifications is a reflection of their position in a profession "allied to medicine" and thus, their interdependence with sports medicine doctors and other governing bodies involved in the development of the speciality in order to gain validation. Physiotherapists felt constrained to follow in doctors’ footsteps in order to meet the criteria of the sports medicine speciality even though this was not considered to be a unilaterally positive development. The different ways that doctors and physiotherapists have reacted to the introduction of formal qualifications demonstrate that attempts to develop a "professional project" (Larson, 1977) can be disordered in particular contexts. Furthermore, it highlights the differential traditions of education in the two professions with physiotherapy having been conventionally associated with "applied" and "supervised" work in contrast to the more educational, theoretically informed and autonomous work of doctors (Larkin, 1983). As a result, it is likely that sports medicine doctors are more able and willing than physiotherapists to draw up the educational criteria for their own and physiotherapists’ work. Data indicate that the character and boundaries of sports physiotherapists’ knowledge and work have been affected by what is permitted by the larger monopoly of sports medicine rather than by what is desired by physiotherapists (Larkin, 1983). In this regard, sports physiotherapists have adopted non-traditional "educational" qualifications as opposed to "vocational" because of the scrutiny of more powerful interest groups.