Unearthing the History and Future Prospects of Physical Therapy: A Deep Dive with David Nicholls

all of the work that I do, it's all around trying to understand, maybe diagnose, physical therapy, physiotherapy as a profession, almost archaeologically digging around all of the evidence that's there to try and understand what's happening or how we got here and, most importantly, where it might be leading. We're going to talk about the stuff that I'm just writing around what's wrong with osteopathy, but also I'm just in the midst of I've just submitted an article to physical therapy which is a response to Peter Stillwell and Connix's letter, which was a response to an editorial that I wrote which was talking about how inactivism might be a problem, and not just inactivism but a lot of the psychological and physical therapies, biopsychosocial model, a lot of the trends that are coming into, particularly in your area, sort of modern pain science, modern pain thinking, and one of the things that I put at the start that article was that for me I'm not so interested in whether inactivism works or not or cognitive functional therapy works or not, so that's not my interest. My interest is in what that doing is doing, what the emergence of something like inactivism or the biopsychosocial model tells us about where physical therapy is moving and almost in a sense of you diagnose where the patient comes in with these symptoms and then the week or so later they come back and the symptoms have shifted. You're trying to work out, okay. So what mechanisms are working here that mean that symptom now appears when it wasn't there last week? So I would see these changes not so much in and of themselves but really as diagnostic of something happening in physical therapy and to then to try and reverse, engineer that and start with where physio is. Look at these then, these emergent technologies, these emergent ideas, and try to work out from that why we're, why we're reacting the way they are. So I see things like inactivism and bad behaviorism, cognitive theory, biopsychosocial model, the drive towards holism all of those as symptoms of some kind of shift. And I'm interested in what the profession, why the profession is shifting that way. And to give you a good example, one of the things that's emerged in the literature a lot in recent times is a sort of turn towards the patient's voice, wanting the patient's voice to be stronger than it has been past. So my question is really well, and it's a classic kind of theory, critical theory question why this? Why now, given that the patient's voice has not only been, has always been there? And if you talk to a physio from the 1950s or 60s, they would say even back then patient's voice mattered. But also the idea that the patients have a voice has been a constant being of sociological criticism for the last 80 years, and we have philosophies of the patient's voice that go back prior to the birth of modern medicine. Why only now have we decided that the patient's voice is a valuable thing? Because all that stuff was always there, but we never actually said, we never claimed it. And so the act of claiming it and saying now, all of a sudden, that patient's voice is a valid, valuable resource in that you're suitable for a more holistic form of physical therapy, is interesting.

Do you think that comes out of the? This maybe you could call maybe you could call it a failed pursuit. This whole body as a machine gets into the whole Cartesian dualistic thoughts of the mind and body being two completely different things, and that's, I guess, my view of it is. It seems like that biomedical, positivists, empiricist type of way to try to drill down to the essence of what can help somebody overcome a pain situation that it seems we've run up against a wall where that we've. How do you capture the emotions and life experiences and adverse childhood events and different things like that? It's hard. Again, we have maybe some screening tools and things that can do their best to quantify it, but I just guess. Well, I wonder what your thoughts are as far as. Do you think that's just a natural kind of progression when we've run its course? As far as health helpful, that biomedical way of trying to linearly look at health and pain what do you think?

I mean we talked about this before, but to me that idea of the role of the body as a machine in physical therapist history is absolutely different. It's what the book the end of physiotherapy was all about trying to trace the reasons why the body is machine mattered so much. Because it just seemed to be so prevalent, and it still is very prevalent. If you look at most physical therapy college curricula, they're still rammed full of anatomy and biomechanics and kinesiology and physiology and pathology. There's no doubt that the quotes core subjects, as physical therapy, according to the educators, is still those kind of biological sciences, and when you make that decor of the curriculum, then everything else builds on top of that. So I think that we can't get away from the fact that this idea of the treating the body as machine was absolutely core and crucial to the establishment of physical therapy as a profession. But equally, I think for some time now and I put the transition point is around the early 1970s, with that, with actually the oil crisis that affected most developed countries because of the inability to pay for public services, the growth of the welfare state suddenly collapsed with the oil crisis in the 1970s, which meant that most governments had to stop thinking about large-scale government interventions in house and find ways to give people access to health care but to shift the narrative so that they took more personal responsibility rather than the state funding health care as it was At that point. Then the market opens up for competition. And when you have a market for competition, then physiotherapists, physical therapists, can no longer just rely on their historic affinity with medicine and the state to guarantee service, and with the growth of private practice and the need away from the public sector, you get a whole generation of physical therapists who don't want to be tied to some kind of state-based welfare, bureaucratic health care but want to be freer to practice in the way they want to. But of course that puts them in competition with osteopaths and car practice and exercise physiologists and nutritionists and occupational therapists medicine so many other people. And of course, why that then generates over time is the sense that you've got to be more than just a good technician. You've got to be. You can't just treat a body as a machine. Now you and I both know that the really good clinicians have always been people. They've always left college and realized that they work in the big wide world and you can't get away with just treating a person like they're an adductor. Longus it just. You won't survive long in practice if you really do genuinely treat people like that. But the problem is they have to learn how to become people and find a way to be physical therapists and that kind of practitioner, despite their training and their socialization and curriculum. Rather because of it, and for a lot of them I think it's felt in the past like a bit of a betrayal. If they want to become very humanistic in their practice or very interrelational in their practice, if they want to break free from the kind of narrow constraints of a 25-minute treatment and assessment period and then all the billing arrangements that went with it, and do something that was more kind of ursinal, it would be difficult but of course the market dictates and they had to change, they had to move, they had to find a way to speak about a bigger form of physical therapy it was always latent, it was always there but never officially acknowledged and find language for it. What it's done is it's opened up a real can of worms, and I think this is where things right now are fascinating. Because if we take a really practical example of in the pain sphere In the olden days, when we just treated the body as machine, it was very easy to know where pain was. It was in the tissues, and all we had to do was just debate which tissues was in the disc, was it in the facet joints, was it in here or there? And you could have experts who rise to the top just on the basis of their claim that it's all here or it's all here. Very easy, if you introduce genuinely introduce the idea that the tissues are not the issues to use one of the kind of cliches that goes around now then where's pain gone? Because it is not in the tissues anymore. And I don't include people who argue for pain being a neuroscientific or having a neurological source, because to me that's just. That's another tissue that still resides. The pursuit is still to try and find the biological tissue that derives, that is, the source of pain. But if you're certainly a true phenomenologist, as the inactivists claim, then there are schools of phenomenology that say that, whilst the body might be real, there's just no way of you knowing, because all of your experience of everything in the world comes from your senses, and so, even if there is an objective reality, you could never know it. And so in that sense you have to think of where pain might be then. If there's no necessarily biological reality to it, where's it got? And if you're saying it's not in the body but it's in some kind of psychic space or it's in the space between people, it's socially constructed in interrelations or something, then you've got to change the whole physical therapy curriculum because there's no point teaching all that anatomy and biomechanics and physiology and stuff if pain is there. Now, as yet, nobody suggested that. People are just suggesting we can just add a bit of personal lived experience onto basically the old biological body. But it will be interesting when this conversation, when the ontology and the philosophy behind some of these new emergent ideas comes through to say, okay, where are things like pain and breathlessness gone now? If they're not in the spine, it's not in the disc and your philosophy is based on the idea of a phenomenological or intentional kind of reality, then we need a new curriculum and we need a new scope of practice and we need a whole new idea of what physical therapy is. So I'm interested in the emergence of these kind of ideas, not because whether they work or not, just because I think physical therapists are now starting to entertain the idea that a form of physical therapy could exist that doesn't see health and illness residing in the body, and that would be very interesting.

Yeah, it's a fascinating thoughts to have and I think these are things that I, as professions, often so many of the just day to day physios don't even consider, some of the things that are implicitly functioning or some of the philosophies and things like that I'm curious like, because this kind of gets into this whole biopsychosocial physical therapy and I've written about that and I have some thoughts on that, and you had even mentioned the dangers of the biopsychosocial model because you have some interesting concerns about that. I'm wondering where you see those concerns and as far as the this has been, a big push obviously is if it's not the bio, we just got to bring in the psychosocial, If it isn't human, it isn't a machine, it's a psychosocial. But then we try to neatly put it in its nice, this bucket and the psychological, the social bucket. Yet again, it's this kind of nebulous thing that we can't maybe put in these nice, neat, tidy categories. But I'm just curious where you see the biopsychosocial model. Maybe where has it as it's emerged in your concerns, as it's being applied?

It does seem to be a term, an idea that's captured the imagination of a lot of physical therapists, which again, I think is a mark of the fact that people are open to the idea of a bigger idea of physical therapy, which is quite exciting. I think the problem that I have with the biopsychosocial model generally is actually a problem with the idea of wholism. My problem is that the biopsychosocial model has to be inclusive. It has to include concepts and philosophies that encompass a very wide range of philosophical beliefs, or else we need to know what's outside those three. Those are Dabben diagrams. If there's stuff outside those circles, in the wide space of the page that you've just drawn the three circles on, then we need to know that. The assumption that I get from most the way that the biopsychosocial model is being taught about is that no, we are happy, that captures everything. If that's the case, then in each of those domains you've got a very wide range of beliefs and ideas. Let me give you an example the biological domain. I think we understand very clearly, very well. We've resided in that space for a long time. What we seem to be doing is drifting now towards maybe the more psychic psychological space, if you're imagining them as circles, then imagine this psychology circle. In that psychology circle you're really talking about things that don't reside in the body but reside in the person's mind, their psyche, their spirit. In there you've got to include anything that is about an individual's lived experience, anything about their understanding of being in the world. This is where the phenomenology comes in as well as the psychology. There are branches of psychology which are very close to their biopsychological. Really, I think a lot of the behaviorism and cognitive theory in psychology is much more towards the biological end. Most of the work that's done there is RCT's, experimental clinical trials type stuff. It's very quantitative in the way that work's done. But down towards the other end you've got some really deep existential, phenomenological stuff where you're talking about people whose the only understanding of reality that you can say exists for this philosophy are those that are in the conscious mind of the person to which their subjective experience is king. In that part of that domain there is no tolerance for the biological. There's no kind of the biological underpins this. And then I just come to subjective consciousness of the world. The subjective is your entry point into the world. It denies the existence of the biological. It says, no reality of the world is not in the brain, it's not in the tissues, it's in the person's psyche, it's in their intentionality, and if you look at the work of people like Heidegger and Husserl and Molo Ponti, all these phenomenological existentialist Jean-Paul Sartre, simone de Beauvoir all these people have been writing for 100 years about what that understanding of thought and being in the world is about. A lot of the qualitative research that's appeared in Hells over the last 40 years has drawn on that as inspiration. The point, though, being here that there are aspects of that psychological circle that are incompatible with the biological, and, in fact, if you look at it, it's drawn in the diagram there's a zone that is purely biological and there's a zone that is purely psychological, and there's an overlap. So, implicit in the biopsychosocial model, if you draw it that way and I understand it can be represented in different ways is an acknowledgement that the psychic, the psychological, is a discrete area unto itself, and that means the understanding of the reality of health and illness is discrete and different. Now, one of my bugbears, major bugbears, is the coupling of psycho and social. I'm a sociologist by training as well as a physio, so I prickle a bit when people put those two together. Because just as the psychological space is unique in what it offers our understanding of health, it's unique by comparison with the biological, so is the social. The social is the space where you're talking about socially constructed meaning, meanings that are constructed between groups, between entities. The idea, say, of physical therapy is a profession. There's no biological reality like a pen to physical therapy. It doesn't exist just purely in the minds of individual people, it's something that is collectively constructed. Now in that social space you've got people who would argue that reality of the world is not constructed in the brain, it doesn't exist in the brain, it doesn't exist in the minds of individual people, it only exists in the collective space. And so a lot of that social world is where you get the focus on things like gender and race and class and structural issues that affect a person's health and illness, before they have any agency in the world, but before they have any choice. So again, this is a fundamentally and radically different view of the reality of illness to the psychological and to the biological. So here we get to. The major problem with the biopsychosocial model is that it only really makes sense as a two-dimensional drawing of circles on a piece of paper and you can only really talk about being biopsychosocial as a practitioner if you're only going to operate at the most superficial basic level of just talking niceties about. Oh, there's a bit of biology going on here, there's a bit of being nice to people and there's, of course, they live in the world, their environment informs their mental state. That's about as far as you can go. But as you go deeper into these domains and you say where is my practice situated, I think it's entirely possible that you could have a form of physical therapy that is deeply embedded in existential, hermeneutic, phenomenological practice. In fact we've seen this with a lot of the Norwegians who work in that space, the Norwegian psychomotor group. They are working on this idea of a Merleau-Pontier phenomenological form of physical therapy. I think it's entirely possible to operate in that space and be true to that underlying philosophy. And I think that would be amazing if we could have physical therapists who said my practice acknowledges that the biology is not the basis of disease, that I'm going to claim that the nature of the illness, the nature of disease that presents to me, is an individual psychic experience and that's what my practice is going to look like. So I'm going to have to throw out those short appointment times and all the objective assessments of knees and things, because to me that doesn't capture the reality of illness. I'm going to have to organize my practice in a different way. So it's more relational, it's more about building connection with people. It's more about their stories and their lived experience. It gives them time to explore that. It maybe is a recurring experience of development rather than bank treatment. Equally, you could have somebody who says no, that doesn't feel like the reality to me. The reality to me is that I need to be working in my community. I need to be in service of a community goal. I need to be thinking about social determinants of health. I need to use my power to maybe improve public access to walkways and safe spaces for women to exercise and I need to think about stigmatization and those kind of things and those pressures that prevent people from being active and being healthy. You could situate your practice in a social space. So I wouldn't say that for me, a more positive future for physical therapy is not in some kind of wholeness bowl that's trying to do everything you can but in the end saying nothing. I think the answer is not wholeness, I think it's pluralism. I think the answer is that you and I ought to be able to operate in distinctly different ontological spaces but still remain within physical therapy and then seeing this kind of splintering and this rhizomatic kind of expansion of physical therapy into all these interesting new places and domains, without feeling like we all have to be clustered into a small image of a, we're all being holistic, I think, to me. I think this is a temporary phase that we're going through as we're trying to explore an expanded idea of physical therapy. But I then think the biopsychosocial model effectively functions like a kind of capture. It collapses everything down into one single meaning of everything, rather than allowing that fracturing and that blossoming of a thousand possible ideas of what physical therapy is. What I was saying about pluralism seeming to me to be one of the main weights forwards. I would see it absolutely viable that you could have a physical therapist who is totally committed to the body as a machine, really believed that's where pain lied or lay, or where breathlessness lay or function lay, and committed to it, and established their physical therapy basis on that. I think there would be. I don't see a reason why not. I've grown up interviewing and talking with Brian Mulligan and Stan Parris and Rob McKenzie and all those great musculoskeletal physio who would absolutely subscribe to the idea that a person's back pain is in their back and we need to fix their back. Now, as a practice for 50 years doing that stuff and that made enormous capricious out of it, I'm not going to be the person who says to them that you're completely wrong. I think physical therapy is plenty big enough to accommodate those people who are straight hard of biomechanists. I think it's big enough to include anybody who's an existential phenomenologist. I think it's somebody. I think it could accommodate somebody who's a hardcore Marxist, feminist. I think it can accommodate all of those things because the physical therapies reside in many different places. What I have a problem with is somebody saying they're a bit of a feminist Marxist who believes that pain resides within the biomechanics of the body and also quite likes a bit of existentialism. That's a problem. I think what we need is people practicing in those domains but doing it properly, searching out the deep ontological reality of those things. But I have no problem if that's going to be a biomechanist. The second thing is like the barriers to this. I think the biggest barrier that we face as a profession is the fact that I think we're trying to protect the profession too much. I think if you ask some colleagues and I asked some colleagues at a training session this weekend actually the same question if it was in the interests of physical therapy, if sorry, if it was in the interests of the public to shut down physical therapies as a profession, to collapse it down tomorrow, would you do it? Now sometimes I ask that question and people have to think about their answer for a minute, as if it wasn't obvious. The point is, if it's in the patient's interests, of course you would do it, because your goal is to try and help people get better or feel well. Now, if that meant closing down physical therapy, it shouldn't be a question. But some people think either I've trained in this profession, I love physical therapy, I want to do my best for it, I want it to survive whatever, or if there wasn't physical therapy, I wouldn't have a job, and then I've got to put food on the table. Both of those are not the reason. They're not the reason to hold on to the physical therapies. The reason to hold on to the physical therapies is because they were, because they do something in the world that's powerful. This means moving aside from a profession which wants to contain the physical therapies and restrict them and keep them quite small and manageable. Then I think we have a duty to move past that. I think we have to resist that. I think we have to have a quiet rebellion in the profession because, as I said earlier, I don't doubt that the physical therapies are going to be there for a long time, long past surgery, I think, which looks to me like it's going to be very robotic quite soon. But there's a lot of things in healthcare that can be done by robots and machines. I'm not sure that there's a lot of things in the physical therapies that can be. So I think, delb, I think it'll be there for a long time. And if I was thinking about my daughter going to somebody because she had some pain and she wanted careful handling, would I just get her to go to a person down the street who got a certificate on the wall, who trained last weekend. No, I don't want somebody I trust to use their skill and judgment in their hands in a skilled, caring, thoughtful way. I don't think you have to be trained as a physio to do that. So I think those things are going to still exist. I just think they're going to be in a different form. And I think what we're going to have to do is think about, not the superficial reasons why you employ or why you employ physical therapies. I think those of us who have been in the profession for some time now and I wouldn't say this is the urgent project, because that's a cliche and people always talk about that, but a very important project right now to me feels like we need to get to the essence of what the physical therapists are. We need to strip away all those superficial things and get to the root of what the physical therapies are. There's an exercise towards the very end of physiotherapy otherwise, which has a chapter on post-professionalism, and it's called a hollowing out exercise and it's a bit like that kind of analogy of a mound of sand on the beach. How many grains of sand can you take away and it still remains a mound. This hollowing out exercise is a bit like that. If you think of physical therapy as a box and you think of all of the things in that box, for instance, that can be reproduced easily or taught easily or explained in a sheet of書. Those things are going to go to people who are a lot less expensive to train and employ than we are. They are going to go. Routinization of work, robotization, ai is all going to take that stuff. So cut that stuff out now. Think about all the stuff in your curriculum or all your scope of practice, or all the things you do every day in work that could be easily transcribed onto an instruction sheet. Cut them out. Give them to somebody who's cheaper. What's left then in that sort of jagged-edged box that remains is the essence of physical therapy, and that's where our growth will occur from. I don't think we're even close to understanding what it is that drives the physical therapies. I've been doing some work, and this is the stuff that people will see on the paradox aside, which I think will probably be amusing to a lot of my colleagues, but it's an attempt to really push the boundaries of thinking around physical therapy. I wrote an article recently which is about how do you touch an impossible thing, and it starts off with a question about what is therapeutic touch. Is it, for instance, when you consciously do something to a patient in a therapeutic way? It can't be just that, because there's many times when I would do something inadvertently therapeutic, not knowing that I'd done it. I don't know necessarily that my conscious decision this is going to be therapeutic means the same thing to that person. So it can't just be a conscious act, isn't it something necessary? That's just a human thing. But if a dog rests its chin on your knee and looks dolefully up at your eyes, that can be very therapeutic. Having a pet can be therapeutic. So it can't be just a conscious thing, it can't be just a human thing. So if this expands this idea of therapeutic touch to a much bigger field, what does that, does it include? So at the start of this article I asked the question if a leaf falls from a tree in the fall and lands on the ground and decays and feeds the soil, is that a form of therapeutic touch? Because what's the difference between that and the leaf offering something through its touch to the soil? It doesn't touch this lampshade on my desk, it touches that bit of soil. So there must be in some way some relationship between those things that are therapeutic. And it feeds the soil with its nutrients. And when I was working as a respiratory physio, we would often use manual hyperinflation with a person in a particular position to try and reinflate a segment of the lung that had collapsed. So I'd be using the force of the air to try and drive open the lung tissue. I would think of that as a therapeutic act. So is there any difference between that and the air molecules flowing under an aeroplane wing that keeps the plane up in the air? Is that a therapeutic act? And if it's not, why not? If it is, then we need to completely rethink the whole idea that we have about therapeutic touch. We're trying to do a similar thing now with movement. We're trying to do a similar thing now with the idea of therapeutic time, all those fundamental basics that we've always claimed. And, of course, one of the directions that we're going in is the idea of a post-humored physical therapy. That physical therapy isn't just something that I do to you as a person to person. In a sense, it's never been that, because we've always had fracturing belts and electro-therapy machines and treatment beds. Lots of non-human stuff has been part of our treatment, so it can't be just the stuff that a human does to a human. So what are the therapeutic agents? What's working? How does it work? What's this idea of now? The possibility of this ex-ended world of physical therapy. Even 20 years ago people couldn't have imagined it's such an incredibly fertile time in the history of our profession, because for so long our professions put a box around what you can think and do and now it feels like that's become a very porous, leaky box and it's allowed people like me to go off in these kind of weird tangents, which don't seem so weird to me actually when I think about it. Why did we always say therapeutic touch began and ended there and why not here? All of this stuff is feeding into these kind of debates and conversations around the articles and bookchats and things that are being written.

You bring up some great points of where physical therapy is the capacity to go and where, if we can maybe lose some of the rigidity of and we've already spoke to the body's machine, thought processes and different things like that. What do you see as the biggest barrier to that? Some of the writings I was reading on your and we'll link David's blog, paradoxa it's on Substack, highly recommended. It'll make you think and it'll teach us a lot of good topics around physio and some of our professional struggles and just from our history to where we are today and possibly where our future is. As we've already talked about this whole thoughts of post-professionals maybe we can move into that a little bit as well, because I think you bring up some good points. When I was and again I definitely don't have the depth of understanding a lot of the philosophical underpinnings of the writings and things, but some of these things were professional, just even the thought of being a professional, how that emerged. You had even written on some of the writings I had read earlier today about how we didn't really have physiotherapists or this profession didn't emerge out of just the need for rehabilitating folks after war, because it didn't exist in Napoleonic times. It didn't exist in these other times. Yet here we are. Physiotherapists emerged out of this. We've questioned some of its emergence and different things. I know I'm getting into some different topic areas there, but where do you see some of the challenges? Or profession Post-professionalism?

is an idea that is only just now emerging in healthcare but has been in the literature for over 50 years now, since the early 1970s. Even back then you had sociologists who recognized that the professional period of time in human history was coming to an end. Now, actually, when you think about it, that professional period has been quite short. If you go back 100 years, there weren't that many professions in existence. Go back 200 years and there wouldn't be any. You'd have medicine, you'd have theology, maybe law, but medicine itself wasn't really an established profession. It didn't really come into any kind of regulated form until the 1850s. But up until about 1910, the most of the medicine that was done was what was called heroic medicine, because nobody had done any placebo-controlled trials. Most everything that might well have worked in medicine was unprovable. Or it was heroic because what the doctors did was they prescribed things they knew to be potent. Often things like arsenic and mercury and heroin and things like that were prescribed because they were so powerful it gave the impression that the medicine was stronger than the disease. So this is what was called heroic medicine. But medicine had become a genteel, quite established upper-class profession in the 19th century long before you could prove its efficacy. In fact, even in the 19th century, right up until the late 1800s, medicine is the figure of fun in a lot of social commentary, as people are described as quacks and snake or salesmen and charlatans and these kind of things. It didn't really have much respectability. And if you think about careers for women, really in 1850, the opportunities for women in a professional role were very few and far between. And yet you had an enormous class of middle class of men and women who were extremely well educated. And most of the literature points to the fact that the idea of setting up the professions was largely an attempt to establish some legitimacy for a middle class, a middle class that had become increasingly affluent with the industrial revolution, educated and wanted some vehicle to help out society but also to gain some prestige and respectability, the kind of respectability that previously only existed in the very elites of the kind of upper classes, medicine and law and those kind of things, to borrow some of that respectability. So you made the point earlier on, one of the arguments in physical therapy in the States is that it came into being because of World War I. But that argument doesn't really hold up because there's been plenty of wars before and we didn't have physical therapy then. So why this war? And similarly, some people have said they'd blossomed really during the infantile paralysis, the polio epidemics in their 10s, 20s, 30s, but again, up until 1940 infectious diseases were the main killer in the developed world. So it can't be just because a new infection comes along. There must be something else. As the reason why the point about post-professionalism is those to say, first of all, understand that the professions as a class are relatively recent and that most of the things that have caused us suffering and illness and most of the health need in human history has never been met by a professional class. It's only really in the last 100 years that we've had that and that professional class has been important and powerful, but increasingly, since the Second World War, been seen as problematic. And one of the main tenets of the arguments around post-professionalism is what's called the unbundling of goodness and expertise, so the claims of the professions, particularly in healthcare, that they are a good, in other words morally good, ethically good, they do the right thing, and then the expert. So if we take the goodness, for instance, one of the main arguments there is that these people in health professions are morally good people. Unfortunately, over the last, during the entire time of health history, health professional history, we've had countless examples of medical mispractice, of abuse of power, of ethical abuses. Britain's biggest mass murderer is a doctor, a GP, harold Shipman, who killed 300 of his patients by giving them morphine just before they, just after they'd signed over their last will and testament to it. The Tuskegee syphilis trial, the opioid crisis in the States it's just like a catalogue of stories in which people have lost faith in the beneficence and the non-malificence of the medical professions. And where they go? We go because we're so tied to them. So the goodness question has become increasingly problematic. One of the fundamental arguments from the professions themselves was that they were altruistic and they were public-sperienced. It was one of it's one of the arguments always as to why somebody becomes a nurse, say it's because you just want to do good in the world, you just want to help people and because you want to have that it's claimed as a calling. Almost you couldn't help yourself but go into a caring professional role. It's been one of the reasons why people have argued that these people shouldn't be paid very well because it's something that they want to do as a passion, almost like a monastic calling. That's in the fact that it's an intake nursing case, for instance. It's a profession that's dominated by women, and one of the most cynical views of the nursing profession is that because it's a primarily caring role and in a patriarchal kind of notion of healthcare, that kind of work is women's work and it's natural to women to want to be caring because that's what women do. Then they shouldn't be rewarded in the same way as a doctor who is objective and detached and value free and comes into a work with a kind of scientific rationality, and they're the people who should be elite. All of these kind of criticisms have been leveled against health professions for many years now. That stuff doesn't feature in our training. That stuff we don't hear about that stuff. We don't get that in our curricula, and neither do we get the questions about expertise, about the fact that the health professions have always been the center of expert knowledge. Now, not just since COVID, but even before then, with the development of the internet, we've seen a massive democratization of health knowledge. So pretty much anything in a physical therapy curriculum now you can find on YouTube. I was looking the other day and I found a YouTube video of somebody showing us a grade five cervical spine manipulations on a horse. Now, I've never done one before. I've certainly never tried to manipulate it at horses neck before, but the fact you can find that on YouTube is testament to the fact that we don't hold the knowledge of our profession like we used to in dusty medical libraries which are inaccessible unless you'd gone through a formal medical training or you're in that you had access to those libraries. It's all out there. So this unbundling of goodness and expertise is a commentary on one of the fundamental claims as to why we need the health professionals because they're morally good. They're not so now, and they're exposure, not that either. That in itself, though, is only one of the three main drivers of post-professional change. The second one is the economic drift into neoliberalism and late capitalism, and the reason why this is so important is because, for the early history of most of our developed economies in the States in Northwestern Europe, economic growth was led by industrialization and industrial revolution, which meant that you could produce massive amounts of surplus from raw materials, but those raw materials there was limited space you could draw those raw materials from at home to in a country like the UK. But if you also look at the colonial empires of the Netherlands and Spain and Portugal and countries like that in the 15th, 16th, 17th centuries. They had to go elsewhere. So in a sense, those colonial projects of stealing other people's land and put enslaving other people into forms of egregious cheap labor was an attempt to try and keep the economy, the domestic economy, going, and it certainly did. The enormous wealth that those countries accumulated at the expense of other places, like my country, new Zealand, was just, is just an ongoing legacy of abuse. But by the 1950s, the immediate post-war period, it was realized that those countries' abilities to keep exploiting other people's land and people was no longer appropriate, was and the land just wasn't there anymore. With the exception of places like Alaska or the moon, there aren't that many places left where you can just strip mind to find resources to keep your economy going. Most developed economies have been moribund for about 20 or 30 years. Gdp has been collapsing, has been falling and gradually depleting. Productivity is declining. We're in a late capitalist stage where it seems difficult to find where the markets are going to be for growth and unlimited growth and expansion, until about a decade ago when for some reason, mostly brought about by legislative change, economists started to realize that there was a marketplace for massive expansion, perhaps bigger than anything that anybody had ever realized before, and that was healthcare, and particularly the body. And if you could open up the body to a thousand new experts and a thousand new possibilities, you had a market that was potentially unlimited. Because we're all interested in our bodies, we're all interested in being healthy and well, and if you could raise that discourse around. You're going to have to keep fit, you're going to have to eat the right foods, you're going to have to have good relationships, you're going to have to be productive at work, you're going to have to connect the idea of optimal health, the never achievable but always pursued dream of perfect, optimal health. If you can instill that in people's minds and you can open up the body to a marketplace for experts, then you can have what we have now, which is thousands, millions of people who will advise you on the latest exercise we've achieved, or the right thing to eat, or the right thing to drink, or the right kind of relationship to have. There's just the plethora of these people is incredible. You can't have that expansion if all of those domains are held in the hands of a few elite professions. So, at the same time as opening the body up to this new market for expansion, you have to contain the power of professions like medicine and all their discourses and all their ideas. You have to dampen down their influence on society. You have to reduce their power legislative, financially. So there's an example in physio, otherwise that I give which is about nutritionists. There are 400 registered nutritionists in New Zealand for a population of 5 million people. So the numbers are terrible. The numbers of nutritionists you can get at a population is tiny and, of course, because they are the orthodox registered specialists, they are given economic and legal privilege, but there's so few of them that their work is mostly constrained to intensive care units and really high acuity patients. At the same time, in New Zealand, just like everywhere around the world, food culture has gone off. Everybody buys Jamie Oliver books, they're on YouTube channels, they're looking on Google to try and get reviews of restaurants, they're interested in the latest way to cook sourdough bread, they're baking cookies in the kitchen. They've got the food culture has just exploded in New Zealand. They're Netflix channels and goodness knows what else. So you've got this little rump of very kind of elite nutritionists trying to hold on to nutrition as the things that they do, whilst in the rest of the kind of culture of New Zealand is around the world, food culture has just expanded in a thousand different ways and they're not holding on. And that's the kind of image that we are increasingly facing in healthcare, particularly in areas like physical therapy, which, a bit like nutrition, is just a fundamental aspect of everybody's life and we're like the little nutritionists trying to hold onto it and claiming it's our own to justify our privileged status with the state and the economic and legal support that we get for it. But it's coming to an end and that's the point about post-professionalism that we're in the tail end. I heard a great analogy about it the other day. It's like physical therapy is like a profession that's swimming 100 lengths in the pool and we're, as length 93 and starting to look pretty tired. I'm interested in what happens at length 100, what happens after that, because to me the physical therapies are vital, absolutely crucial in people's lives. But I'm not wedded to the idea that we can only do physical therapy through a physical therapy profession. I don't mind if in seven laps time the profession decides to just go on a breather. I think the physical therapist will still be there. I think the skills that you and I learned and other people are learning will never go out of fashion, regardless of digitization and AI. I think people will always want touch. I think they'll always want movement analysis. I think they'll always want these things that we can do, but I'm interested in how they get.

Yeah, and reading your digital disruption latest series of that, it was fascinating as far as the experiential economy and things that you can automate, like you mentioned, like touch and some of the things that we can offer. But it's interesting to see you bring up great points the social media world we live in, with a lot of YouTube, university people call it as far as they're going for a lot of their information and things and it isn't to the doctor's office or things. I think it's going to be fascinating to see where, especially as physiotherapists are concerned, where we fit into that you do see a lot of physiotherapists adopting the digital world we try to do. I have a YouTube channel. We try to spread the. We'll be playing this on the YouTube channel. But are there any concerns you have as far as, like, our lack of adaption or anything? Or do you see, I guess what are your? I know you've obviously had your book, the End of Physiotherapy, and there's different reasons behind that topic, but I'm just curious any concerns you have for our profession? We've talked a little bit about some of our still stuck in the body's machine thought processes, yet Are we have a culture and a lot of socially and culturally created narratives of that kind of practice. Profession has amazing job bringing that into the lexicon of millions of people where when there's something slipped out of alignment and that's going to be the root and that's still pervades. I still hear that narrative coming to my clinic regularly when people, when I ask them, they give me their thoughts on why they think they're having pain. That's not an uncommon one and maybe now that we've talked about this you had mentioned because and this is going to circle the topic we had spoke about talking about earlier, but the and you're writing in the process. I think you either have a publisher, it's in process of a response to the what's wrong with?

osteopathy. Olly Thompson, who is well known to probably a lot of people on the podcast, wrote an article with Andrew McMillan talking about what's wrong with osteopathy and it's caused a firestorm profession Because he proposed to sort of move towards a biopsychosocial, more existential, more critical view of osteopathy and a lot of people have said there's nothing wrong with osteopathy, or we should, it's going the wrong direction or we've always done this. It's caused an enormous flow of interest and it feels a little bit like the kind of debates we were having in the early days of the critical physio network 10 years ago. So I thought I would throw some fuel on the fire really, and my argument to them was if you think that Olly and Andrew's article was radical, you ain't seen nothing yet. Because if you see what's coming down the pipeline for osteopathy, like for us, it could be really threatening to people or it could be the best thing that ever happened to our physical therapies and the possibility that you and I could explore our own unique forms of physical therapy feels to me to be incredibly seductive.

And almost could be liberating for some of you either. Oh absolutely. Very traditional models that stifled exploration and that type of thing. David one, I appreciate that we have folks like yourself who are pushing these thoughts and thinking this deeply on topics to help push our profession forward, because I do think we need folks like you to help us navigate some of these waters. Because I agree, after reading a lot of your work on your paradoxes site and I will link that in the show notes definitely has me thinking, which is again probably a good sign that you're doing some great work over there, because it's definitely very stimulating stuff that you write and you write it very well. So I really appreciate your work. Thank you so much for your time and again, thank you for all your work.

Thank you for having me, Mark. It's always a lovely time chatting with you and I look forward to the next time.