Observations made during meetings convened by physiotherapists
Introduction: a change in policy
On 1 January 2006, the Royal Dutch Society for Physical Therapy introduced a fundamentally new policy. As from that date, registered physiotherapists were no longer obliged to become a member of what is known in Dutch as an IOF; in other words, a group of local therapists that meet for discussion on a regular basis. Although participation in an IOF furnishes credits for the professional register, physiotherapists can now decide whether they wish to take part or not. This change has had enormous consequences because at least 6000 physiotherapists have cancelled their IOF membership, so some IOFs have completely disappeared, while others have had to merge. The present number of active IOF members is around the 10.000 mark.
An IOF consists of eight to fifteen physiotherapy colleagues. They discuss matters related to physiotherapy treatment and the organisation of their practice or departments. An IOF meeting usually has a fixed structure: the chairperson declares the meeting open, leads it and closes it; there is someone to take the minutes, and there is also an IOF coach to monitor the group process. The topics dealt with vary from case histories to discussions of the protocols and guidelines that healthcare employees need to follow to ensure quality assurance. Moral dilemmas are also spoken about. The IOF members decide amongst themselves which topics should be dealt with during the year.
The IOF is one of the four components of the quality programme set up by the Royal Dutch Society for Physical Therapy. The other three components are: in-service training and refresher courses, the development and implementation of evidence-based guidelines and the introduction of quality assurance and guarantees.
The stated reduction in the number of IOFs raises a number of questions. If so many physiotherapists have withdrawn with such ease from these meetings, how important are they? This question led to the need for a broad investigative evaluation of the significance of IOFs. This is the central theme of my research and in this article I report how I went about it, making use of a number of specific observations to do so.
An outsider pays a visit
I am not a physiotherapist, so at the start I only had a vague idea of what happened during IOF meetings. To get a better insight, I decided to attend IOF meetings at various places in the Netherlands. This countrywide approach to my investigation would enable me to understand what happens at IOFs: in other words, what is discussed, how topics are dealt with, how conversations proceed, how the available time is used, where the meetings are held, which customs and values play a role, and which topics seem to generate the most discussion.
I prepare for these visits by writing down several general but fundamental questions, although I usually lose sight of them in the course of the evening. Instead I mainly watch and listen, and I write a report immediately after each meeting, always including a precise drawing of the situation. I also mark the positions of the places I have visited on a map of the Netherlands. This can help me to identify any regional differences, although so far there hardly seem to be any worth mentioning. My visits to various parts of the country are showing me that the meetings themselves are interesting but the things that happen before and after help to provide insight into what is actually going on
At the start of one of these IOF meetings, the permanent chairperson opened the meeting by welcoming his colleagues. The minutes of the last meeting were briefly dealt with and then one of the members announced that she had to leave the meeting because she had to take care of matters that were more important than the IOF. Just 15 minutes after the meeting had started, she gathered her things together and withdrew to another part of the building. No one said a thing; you could hear a pin drop. A couple of participants glanced around uneasily while others stared with studied concentration at the pile of papers on the table in front of them. As soon as the door closed, the chairperson proceeded to speak about the topics for that evening.
The meeting looked in detail at an innovative Backpack Computer Treatment Programme. This treatment plan forms part of the 'Getting Better Quickly' programme compiled by physiotherapists and occupational health doctors in the Netherlands. The main aim of this programme is to allow patients with atypical back problems to revalidate at home if possible, by supplying them with clear guidelines and illustrations on the computer. For economic reasons, occupational health doctors always try to get patients back to work as quickly as possible and thus to reduce the amount of sick leave; this benefits both the employer and the economy. Some physiotherapists, however, regard this programme in a completely different light; they feel that automation is undermining their position. They say: "the computer is going to take over my work", or they are afraid the extremely worthwhile contact with people will decrease.
After the meeting had been officially closed, I happened to hear one of the participants telling someone that the lady who had left was the chairperson's partner. This chairperson was also the owner of the practice where the meeting was being held, and his wife was employed there. I heard that he had introduced that innovative computer program in order to earn a great deal of money. In addition, this chairperson has another function, that being IOF coach. I was given to understand that the registration credits played a role here. The IOF coach has to keep track of the number of credits earned, but one wonders if leaving early gives any entitlement to these credits?
Having experienced such an unexpected event, I decided to arrive early at other IOF meetings and also to stay longer at the end. The information I could gather informally seems to be at least as relevant and interesting as that which I hear during the formal meeting. This informal information helps me to place the events in a wider context.
Problems with teamwork
"We have no objection to your visit. One participant believes that it may not be a suitable meeting for you to attend because our group is relatively unstructured and only started up this year. I also feel a bit the same way but, on the other hand, if a meeting or group is not functioning so well, that may also provide you with interesting information." This was the e-mail I received before I went to one particular meeting, so I was very curious as to what I would find there. In fact, the meeting did not go according to plan because it was brought forward by two hours at the very last moment, because the Dutch football team were playing in a qualification round. When I arrived at six o'clock, everyone was sitting at a picnic table outside, enjoying a snack and a drink. At the same time, the agenda points were being discussed. The setting sun gave one of the participants "a feeling of being on holidays". It began to get too cold to sit outside, so the group moved inside and sat around the kitchen table. There was a relaxed atmosphere but the discussion about the annual programme was chaotic. The subject of this programme was 'Professional physiotherapists operating within primary health care' and the participants shared their views about the various forms of cooperation and the legal consequences of each of these forms. Some had not prepared themselves well for this topic, so they did not have all the facts to hand. Others tried to focus on competition, trust and mutual interest. Meanwhile, everyone was drinking punch and talking at once.
Various asides led me to understand that, within the group, there were differences of opinion regarding this subject. It seemed that practice owners say they want to work together but when it comes to the real thing, they are less enthusiastic. I got the impression that everyone was talking around the subject and not discussing any of the important fundamental points or tricky issues.
At another meeting, I met four partners from one firm and five employees at a health centre. Together they formed one IOF. During the meeting they dealt with the Harmonisation of Quality Assessment in the Healthcare Sector. One of the points concerned performance appraisal. The chairperson was obviously not in favour; he stated that performance appraisal sessions were unnecessary, and I did not hear any opposition.
After the meeting, the IOF coach came and had a word with me. She wanted to tell me the following: "the chairperson is one of the partners and so am I. We have fundamentally different opinions about carrying out performance appraisal sessions. He is against them and I am for." She also whispered to me that the chairperson wanted to do everything himself so that some matters were difficult to discuss. As soon as the chairperson came within earshot, the IOF coach changed the subject.
Humans or machines
When the guidelines for treating arthritis of the hip were mentioned, one of the physiotherapists said she preferred working in her own way. She explained that at a certain point in the treatment, she moves away from the guidelines and, relying on her own experience and expertise, continues the treatment on automatic pilot, as it were. She continued: “There are always exceptions to the rule. Difficult cases cannot always be categorised according to protocols or guidelines. What’s more, it costs me far too much time to work according to the detailed protocols. The treatment goes much more quickly if I work according to my own plan.” Nobody had any comments on her remarks, so many interesting questions remained unanswered, such as: How much time is involved in working according to the protocols? When exactly do you follow your own course? Which parts of the guidelines cause problems? In fact, I was expecting a lively discussion on how physiotherapists deal with the clash between the discipline imposed by the protocols and the freedom to use their own discretion. Instead, the discussion just dried up. Other subjects seemed to be more important, like electronic patient files and swimming with dolphins.
Watch in silence or be provocative?
When I attend meetings of professionals, I am the outsider, so I notice things. Such meetings are usually informal, there is a good atmosphere and, not uncommonly, the participants really enjoy being together. However, everyone is talking at once and failing to listen to what their colleagues have to say. I also notice the hidden agendas that strongly influence how some meetings proceed. And I notice that discussions are rather shallow, with important issues being avoided. Usually, I am given the chance to say something during ‘Any Other Business’ at the end of the meeting. They sometimes explicitly ask me what I think of the meeting. In that case, I mostly answer that I found the topic interesting or that I enjoyed listening to their professional and personal accounts. I also say that the atmosphere was pleasant even though I may actually want to convey something quite different.
The observations offer me insight into what is and is not discussed (or at least not openly). If I were to draw initial conclusions, they would be that these meetings are superficial and would probably benefit from more substance. On the other hand, I realise that from my position on the sidelines I can only pick up part of what may be going on under the surface. At this stage of participating and observing, it is probably too early to make my own experiences, opinions and ideas known in order to get a dialogue going. For that reason, I have sought a more neutral way of getting the physiotherapists to talk about IOFs.
Objects that get people talking
Prior to an IOF meeting, the participants receive an email asking them to bring an object with them to the meeting. It should be an object they feel symbolises their IOF. At the start of the meeting, I give a brief explanation of the method I employ. Then the physiotherapists show their object to their colleagues and explain how it relates to the IOF. Their colleagues ask questions and there is always time for discussion. I take photographs of the objects and afterwards, the participants receive a rough, uncensored report of the meeting which they can react to. This is called a member check. The effect of this method of working is that the physiotherapists start to talk to each other in quite a different way from normal. This allows me, the researcher, to get at detailed information.
A red rose, an amethyst, a rope with knots, a hedgehog, a glass, spectacles, a GPS navigation system, a mobile phone, pinecones, a water lily and a bunch of keys: these were some of the objects the physiotherapists brought with them. A wobbly plank represented perfectly how a physiotherapist has to perform a balancing act to survive as a specialist in the continually changing health service. A bag containing sand served as a metaphor for the group that stayed together just as well as grains of sand do. A tuning fork illustrated the necessity of constantly tuning to each other. These objects can be compared and classified. Then you can say that a pack of coffee, biscuits and chocolate Easter eggs and their associated stories belong in the category ‘being sociable’. Some objects related to a category encompassing the physiotherapy profession, varying from a backbone to the Geriatric Guidelines drawn up in the province of Friesland. A third category related to image-forming, for example, how IOF members regard their profession (we empathise really well but get paid really badly), their colleagues (softies or money-grabbers), family practitioners (distant and unapproachable), head office employees (the suits) and health insurance companies (they control everything now). Yet another category gave me insight into the expectations in relation to IOF meetings; in other words, physiotherapists go to these meetings to increase their professional knowledge, to meet colleagues working in the same region or merely to earn credits for the professional register.
As far as the Royal Dutch Society for Physical Therapy is concerned, the continuous process of working on quality is a central theme. However, the society’s members seem to feel that all the guidelines, protocols and quality systems in the daily, intractable routine produce mainly frustration and resistance. Before too long I shall be meeting with the management team of the Royal Dutch Society. They, too, have been asked to bring an object that symbolises the IOF for them. I am curious to know what new images and insights these objects will present.