Upon graduation the next step in the physiotherapists journey has been either to directly study for a masters course or to seek employment. Participants reported that there were issues about the availability of employment in some areas, attributed to the increased number of physiotherapy colleges turning out large numbers of graduates, many of whom could not find physiotherapy work. The educators asserted that the public sector had not increased the number of physiotherapists that it employed in the last twenty years, but that potential employers now included Non-Governmental Organisations and an increasing number of private hospitals in the cities.
"The scenario over there [India] was very much saturated. The
physiotherapists all around, everywhere physiotherapists. There are more physiotherapists than the patients."
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The participants reported that physiotherapy practice in India was unregulated and there was no physiotherapy autonomy. Like the educational institutions there was purportedly a lot of variability in the clinical settings and the way in which physiotherapists practised within a department. The scenario commonly described by the clinicians and focus groups was that physiotherapists could only treat patients by following protocols, defined sets of exercises or an electrical modality would be "given" dependent upon the patient diagnosis. The doctor determined the diagnosis. They also identified that they saw 20 to 25 patients a day and so rarely had the time to take the history, evaluate in detail, think about treatment and then actually 'give' the treatment. Some clinicians (FG3 and Minda) described it as mechanical work without thinking; Lalit (an overseas returnee now working in elite sport) was more philosophical in his perspective
" ... the facilities have to be for the masses and not for the classes, and it has to be more about quantity than quality (...) so most of the institutes in
India are here to treat the masses."
Lalit (overseas returnee)
The participants described two distinct work place scenes where the ways of working, scope of practice and levels of authorised decision making were different. The hierarchical culture within the department and the relationship with the medical fraternity determined which work culture was prevalent in any one department. These contrasting clinical environments are explored further.
Most of the clinician participants described a scenario where they found it difficult to implement practice that they had learnt in their training. The practice was based upon doctors referrals that were prescriptive and frequently demonstrated a lack of understanding of physiotherapists' skills. FG2 participants attributed this to diploma qualified senior staff who, due to a lack of knowledge, adhered to conventional treatments. Some FG3 participants
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described departments where hierarchical structures meant that the head of department did not encourage dialogue, and there was an expectation that the more junior physiotherapists would not question or offer their own opinion; they should follow the protocol in the same way as the more senior staff would.
" ...there is a very major senior - junior thing in India (...) what your head of department is doing, so you just continue with that."
Bipasha, FG3 (masters in UK)
Participants in FG3 and Minda (overseas returnee) also talked about more progressive cultures where the heads were more proactive and advised on the use of McKenzie and other modalities, and encouraged staff to attend workshops. The physiotherapists described that they had been able to build a reputation by demonstrating their knowledge through dialogue with the doctors, suggesting alternative forms of treatment that were more beneficial for the patient. However, these conversations would only occur if they had the support of the head of department. The educators identified that once the doctors had seen the results a couple of times, they considered you differently and when they refered the next case they just said 'pain management' and left the physiotherapist free to decide the modality. These clinical environments had evolved to an informal semi-autonomous way of working. The considerable improvement in communications and interactions with medics, was identified by the educators as being due to an improved physiotherapy knowledge base and the expanding scope of physiotherapy.
"Because it is because of the knowledge of the physiotherapist is increasing now. (...) the interaction between the physio and the physician
has improved a lot."
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However, there were also reports (Adeeb, Rani) of significant "conflict with the
doctors", as a result of Indian physiotherapists prefixing their name with the title
doctor; this is explored further in the 'respect' subcategory in the next chapter.
From a philosophical perspective, Foucault asserts that medical dominance, bio-power, exists as a 'necessary evil' and might be the best for the health of society (Gastaldo 1997), therefore other health professionals should compromise their professional standing and relinquish authority to medical practitioners and the ideology of medicine. Whitehead and Davis (2001) consider that the medical profession has been guilty of maintaining its strong societal position at the expense of other individuals and groups, and that health care has, and continues to be, organised around medical dominance. In the west there has been a gradual shift of this power away from doctors to a more equal basis with the introduction of evidence based practice and the empowerment of patients (Watts 2009). In this study the participant interviews suggested that a change in agency had not occurred in India. Therefore, it may be suggested that the control by medical doctors is disabling the effectiveness of physiotherapy practice, hindering the development of the profession and consequently is impacting upon the effectiveness of rehabilitation in India.
One discourse that was not evident in the research interviews of this study, was that of the patient and the position of their empowerment; patients had been talked about but very much as recipients of treatment and not in an empowered context. This may have reflected that the interview focus was on the individual physiotherapist and their motivations and aspirations, and Indian physiotherapy. Alternatively, it may have reflected the ongoing nature of the dominant cultural practices based upon a biomedical model, where the subjugated power relationships within a healthcare encounter ensure compartmentalised roles
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between the patient and the clinician (Pease 2002, Eisenberg 2012), as well as between the physiotherapist and the medical doctor.
On a more positive note, the returning clinicians (Minda and Lalit) reported that they felt the overall perception of physiotherapy in the major cities had changed, as other healthcare professionals realised the scope of the areas of practice and of what physiotherapy services could offer. The public awareness and perceptions of physiotherapy were considered to have increased and it had become recognised as a viable alternative to surgery and other medical modalities. Lalit articulated a virtuous cycle of development that accounted for the increased recognition and standards
"The standards of physiotherapy have increased because the students are better informed and they want to learn more, they do extra courses, they
do workshops, they keep updating, attend CMEs [continuing medical education]. On the other hand the community as a whole, has started appreciating the value of physios; so it goes hand in, hand in hand because the community expects more, the students work harder and because students work harder, the community gets better treatment and
the whole thing rises."
Lalit (overseas returnee)