Thoughts Down Under!

For the last three weeks, I’ve been travelling, teaching and talking to lots of healthcare professionals in Australia about shoulders, pain, and the healthcare system. So whilst I’m sat on a plane for 24 hours on my way home I thought I would reflect on some of the conversations I had down under.

The first thing to say is as much as I love Australia and think it’s an amazing country with great people, fabulous coastlines, vibrant cities, diverse cultures, great food and belting beer, why is it so far away from everything else. It feels like I’ve been sat on this plane, wedged into my seat, breathing other peoples recycled farts forever and there’s still another 6 hours to go!!!

But besides the long arsed journey, I’ve really enjoyed my time in the land of the kangaroo and digeridoo meeting lots of great people. I would like to thank everyone again who came along to the courses for your time, feedback, and participation (except for the two ladies on one course who looked like a couple of bulldogs licking piss off a thistle all weekend). I would also like to thank all those who helped organise and/or hosted me on this trip as well.

PT’s v EP’s

So the first thing I want to discuss that I found interesting on this trip was the tensions I saw between some of the physios and exercise physiologists or EP’s. In case you don’t know what an EP is they are a new-ish profession in Australia that provides exercise and rehab interventions to patients with cardiovascular, metabolic, neurological and some MSK issues. 

During my trip, I heard quite a bit of tit-for-tat backstabbing from both physios and EP’s with the physios slagging off some EP’s for treading on their toes and seeing patients they should be seeing, and the EP’s ragging on the physios for doing and saying stupid things to some of their clients. 

I found this disappointing but not that unsurprising as historically there has always been rivalry and backstabbing between all allied health professions. I often hear physios, osteos, chiros, and some others claiming that their profession is better, more effective, more evidenced-based than another one.

Now I’m not one for sitting on the fence or hiding my biases but when it comes to saying what I think the best profession is, I don’t think there is one. I see just as much good, bad, and ugly practice in all of the professions pretty equally… except for maybe the chiropractic profession which does seem to have its unfair share of wackos and quacks.

Anyway, back on topic, I am unaware of any EP’s working in our healthcare system in the UK and I am undecided if we should have them or not. Don’t get me wrong I think what EP’s do in Australia is great, really important, extremely worthwhile, and very much needed. However, my thinking is shouldn’t what EP’s do also be what physios do? 

Personally I think Aussie physios have slipped up and missed a golden opportunity to prove their worth and help the health of their population by trying to do what EP’s now do. Instead, I think too many physios have wasted their and their patients time, energy, and resources by fucking about and fannying around with their silly passive treatments like manual therapy and machines that go buzz or bing.

I’ve talked before here how I believe the MSK physio profession in the UK is far too reactive to the conditions it sees and how it should be trying to be more proactive on prevention and the promotion of exercise and activity in those at high risk of poor health. I think if UK physios are not very careful then we may see our healthcare systems soon look to EP’s to step into the role that physios should have been doing for decades.

Over or under treating ?

Another regular discussion I had with some physios down under was about how many of them felt frustrated and uncertain in how to find the balance between booking patients in for follow up sessions or trying to get them to self-manage. Many told me they try to get patients to take ownership and have an active role in their own recovery, which is great, but this often means they don’t come back for follow-ups and so they either get their managers chastising them for low retention rates or find it hard to earn a reasonable income.

Well if it’s any consolation this is a dilemma I still have even after 15+ years as an MSK physio, and I think it’s one that all honest and ethical healthcare professionals the world over have. I think the biggest issue we all have is trying to decide when does OVER or UNDER treatment of a patient start?

I think many physios should take a close look at the patients they currently see the most compared to those they see the least, because I think many will see that they OVER treat patients with problems and conditions that have very favourable natural histories, and high chances of successful outcomes. But I also think many physios UNDER treat patients with complex conditions and difficult problems and backgrounds who have low chances of successful outcomes.

This is what I call the physio over/under treatment paradox!

Many physios like to over-treat the quick and easy things that mostly get better on their own, things like ankle or muscle sprains, even non-specific low back pain in patients with low psychosocial risk factors. Yet many physios often abandon, give up, or wash their hands of the harder more complex patients with conditions and problems that aren’t quick or easy to manage, things like the diabetic frozen shoulder or the widespread persistent pain patient from a lower socioeconomic background.

If physios were more focused on doing more to help those that need our help and support the most, and less worried and concerned about seeing to those who don’t really need our help then things would be better for everyone both patients and physios.

One of the simplest ways I find helps to navigate this over/under treating paradox is to just ask the patient what they expect and think they need from you. Ask your patients if they want a one-off session for some advice and guidance, or regular check-ups to keep them focused and progressing. Or do they even want more frequent sessions to do their rehab under supervision to help motivate, encourage, and ensure it gets done?

One of the most common phrases I used on this trip was “if you’re going to over-treat a patient for their pain or disability you better be over-treating them with exercise”. Or a much simpler way I found of saying it was ‘rehab the fuck out of your patients’

I think many physios don’t like to get their patients in regularly for rehab sessions, because they are ill-equipped to do it, both in resources and training. But I also think many physios don’t like to ‘just’ do rehab or exercise with patients because they believe its beneath them.

Many physios think that if they are not seeing a patient in their consulting rooms using their silly little machines or their super-duper magic hands then they are not doing their job. This is just utter nonsense and more physios need to get down off their high horses and get into gyms more with their patients and help them move and get active.


So there we go just a couple of thoughts from my time down under. I do understand that for any healthcare professional with a straight moral compass it can be really challenging to find a comfortable balance between earning an income to live a comfortable life without feeling like a shyster screwing the system or patients out of their money.

And this isn’t helped by the fact that most healthcare systems are set up to financially reward the giving of treatment rather than the results of treatment, and unfortunately, the promotion of self-management, quick results, and effective early discharge is currently a pretty shitty business model.

So until this changes please continue to over treat your patients with exercise and rehab the fuck out of them for a win/win situation!

As always thanks for reading





  1. “shouldn’t what EP’s do also be what physios do?”
    Yes and No. From a musculoskeletal perspective, my understanding is that in Australia a gap emerged where physios for whatever reason were treating from a very manual therapy and biomechanical framework, which allowed EPs to slip in.

    On the other hand, EPs work in a very broad field, providing exercise for metabolic, cardio, respiratory, cancer etc. These areas don’t strike me as something physios would be strongly trained in.

  2. I think over and under treating needs to be discussed a lot more. Really liked these points. We should not complicate the simple cases and give up too early on the complex patients.

    Do you think EPs have spent too much time on things like cycle ergometry (VO2 max, etc)? Curious about your thoughts on where EPs should focus their efforts more?

  3. I think a lot of this over treating/under treating dilemma has to do with how physiotherapists (And other healthcare providers) are typically compensated (although I can only comment on this for Ontario, Canada). A lot of healthcare services are under a fee for service model which financially rewards volume of visits over quality of care and outcomes. Add in that most private sector PT’s here are compensated based on commission and what you get is short term thinking and goal setting. I think this is a big driving factor in therapist burnout and physiotherapists leaving the profession.

    If there is a way to get more healthcare providers (including PT’s) on a reasonable fixed salary then I think therapists will be less inclined to pack their schedule with unnecessary visits and their schedule will naturally fill up with a mix of patients with both simple and complex presentations.

Comments are closed.

Related news