Ep 269: Don't be quietly competent! With Dr Luc Hébert

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[00:00:55] I remember one of the previous health ministries, I think he was in Alberta, he said to me, you know what's the problem, Luc, with physiotherapists? He said, you are competent, but you are quietly competent. So my advice would be, be loud. Show that you know what you know. It's amazing the added value that physiotherapists can bring to our healthcare system.

[00:01:27] Hello, and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice. I'm Claire Ardern, the Editor-in-Chief of the Journal of Orthopedic and Sports Physical Therapy. It's great to have you listening today. As we get increasingly refined estimates of the extraordinary and growing burden of chronic musculoskeletal pain for populations all around the world,

[00:01:55] the need to innovate in the way that musculoskeletal care is delivered also becomes increasingly clear. Innovation is sometimes used as a buzzword, but today we're exploring interesting and novel approaches to musculoskeletal rehabilitation. Dr. Luc Hebert joins me to share his wealth of experience in musculoskeletal rehabilitation care as a clinician and as a researcher leading clinical trials of different care models.

[00:02:21] Dr. Hebert is a professor at Laval University in Quebec City, Canada, and researcher at the Interdisciplinary Research Centre on Rehabilitation and Social Integration. Dr. Luc Hebert, welcome to JOSPT Insights. Thank you for the invitation. The health system, as we know, it's always changing. And as we all think about different ways that we can be advocating for the important roles that physiotherapists or physical therapists can contribute for the health of all of our communities,

[00:02:50] I wanted to recognise that there are people like you who have been doing interesting roles in the health system, been doing interesting research for quite a while now, and we can learn from people like you. So let's start by talking about different models of providing musculoskeletal care. You've studied lots of these different models. What are the different roles you see for physiotherapists in musculoskeletal rehabilitation today?

[00:03:17] Models of practice and emerging practices in physiotherapy often depend on existing legislation, which varies from country and even within a country, by province, state, or region. And that's the case in Canada. I've been a licensed physiotherapist for over 40 years, and the roles that a physiotherapist can play has evolved significantly. Physiotherapists can act as consultants.

[00:03:46] They can order imaging tests. In two provinces in Canada, they work on the primary care settings, and they can make diagnoses. In Canada, they are in direct access, and there's no need for medical reference or prescription for physiotherapy treatment. In fact, among the seven criteria, essential criteria, for the entry-level practice in physiotherapy in Canada,

[00:04:11] one of these seven criteria is to make a diagnosis and provide a prognosis. So physiotherapists can also work within family medicine groups, and they even help train physicians in the differential diagnosis of neuromusculoskeletal problems. In Quebec, physiotherapists can also work in specialized clinics. And here in Quebec, the Ministry of Health has established MSK clinics

[00:04:39] designed to assess patients on waiting lists for orthopedic surgery. So physiotherapists in these clinics, they work in an interdisciplinary team with other healthcare professionals, which helps determine, for example, whether a patient truly needs surgery or could benefit from an alternative care pathway. And in these clinics, the maximum number of visits for these patients seen by a physiotherapist

[00:05:08] is about five. And in many cases, it is resolved in fewer than five visits. So these patients are then removed from the waiting list because their problem has been resolved. Another example I can give you for physiotherapists in musculoskeletal rehab today is to provide telephone response for neuromusculoskeletal issues.

[00:05:33] It's kind of like a 911 emergency line, but for a physiotherapist. A pilot project currently underway is the establishment of the physiotherapy emergency line called 811. Actually, this line is a free and confidential telephone helpline in Quebec. It's available 24-7 for health advice or psychosocial support.

[00:06:01] So it allows you to quickly reach nurses or social workers for non-urgent issues. So what we are actually testing is to add another option to this line that is a first-line physiotherapy service to provide direct access to a physiotherapist for advice without the need for prior medical referral. So with such a line, the physiotherapist can provide guidance and reassurance,

[00:06:30] assess the urgency of the condition, and if necessary, recommend the most appropriate physical rehabilitation pathway or care trajectory for the patient. You know, it's a very promising profession, and we are more and more perceived as first-line healthcare providers. Lots of interesting, exciting opportunities.

[00:06:57] You mentioned that the legislation really often dictates what happens in the health system, and a good example of that is you're in Quebec, I'm in British Columbia, there's different roles for physiotherapists in different provinces in Canada, and certainly speaking with international colleagues, it's the same. I trained in Australia where we have different roles again. So it's very, there's very different, different health systems are set up in very different ways.

[00:07:23] Now, you've also had lots of experience in military and veterans' health in Canada. What have you noticed has changed over your years of doing research in this area and working as a clinician, what's changed in the roles that physiotherapists play and the way that musculoskeletal healthcare is delivered for these particular military and veterans' populations? How much time do we have, Claire? Well, my contribution to military and veterans' health

[00:07:51] began soon after obtaining my physiotherapy degree, when I completed my basic training as medical associate officer at the Canadian Forces Officer Candidate School in BC, actually, in Chilliwack. I then served with the regular forces for 14 years, and I was appointed to different units within Canada and overseas. And while attached with the first Canadian field hospital detachment, Ottawa,

[00:08:19] I worked an additional 14 years from 2000 to 2014 as the National Physiotherapy Training Director for the Canadian Forces Health Services Group. So in my 40 years of practice as clinician, professor, and researcher, I have seen, especially in the Canadian Armed Forces, the profession of physiotherapist evolved into an independent, I would say mature role, specializing in new and emerging practices.

[00:08:48] For example, physiotherapists within the Canadian Armed Forces have been assigned about 25 years ago, what we call operationally essential. So they've been assigned a role known as operationally essential. This means that when a medical contingent is deployed on missions, whether it is humanitarian or combat, the Canadian Armed Forces must assess whether physiotherapists are necessary.

[00:09:17] So in the early 2000s, Canadian military physiotherapists have been deployed to Bosnia, to Afghanistan thereafter, and in various regions around the globe to provide different types of medical support, something that would never have been conceivable when I joined the Canadian Armed Forces in 1983. And when deployed, physiotherapists can work with patients with severe burns, for example, those with multiple injuries as soon as they are admitted

[00:09:46] to the intensive care unit. And in fact, when I was in the Canadian Armed Forces, I have developed partnerships with the U.S. Armed Forces and our colleagues in the UK so that these armed forces can provide, and they are still providing training to Canadian military physiotherapists under care of patients with severe burns and severe injuries. When I graduated with a degree in physiotherapy,

[00:10:15] there were clinicians on the one side and researchers on the other. Over the years, more and more clinicians have become researchers, physiotherapists, for example, and researchers have become increasingly interested in clinical research so that now many research projects stem from clinical questions, and the results of this research help improve care and develop clinical measurement tools and questionnaires

[00:10:43] that have excellent meteorological qualities in terms of reliability, validity, responsiveness, and low measurement error. And that benefits patients. Luke, tell me about some of the skills you learnt in your physiotherapy training that have translated, or how do those skills translate to the military environment, and what are the differences, I guess, that you've observed in working

[00:11:10] in a civilian role versus in a military role when it comes to being a physiotherapist? In the Canadian Armed Forces, and that's the same thing in other armies, is we're facing very unique scenarios of care, especially when you're deployed. So you need to work really as a team. It's very important to have a very good and excellent cohesion

[00:11:39] between each member of the team so each member of the team knows exactly what the other members can provide in terms of support and health care. Because of the establishment of new clinics, or because of our role in the emergency department, that's the type of work we need to be able to do. You know, to know exactly who is the best person to take the lead

[00:12:08] when someone is facing a rehab issue or problem. And sometimes that's going to be the physio, sometimes it may be our colleague occupational therapist or the physician. You talked about blending the research in the clinic and how you feel like clinicians and researchers have got closer together as opposed to being in their silos. I want to talk a little bit about some of the work you've been involved in. We've seen studies recently looking at different models of care where group-based

[00:12:38] versus individual therapy programs for various types of musculoskeletal problems. Where is the research at now for those types of models of care, at least where you've been involved? What we have shown lately when we compare, for example, in randomized clinical trial, the outcome when we provide care in a group versus one-to-one care, we can see that the outcome

[00:13:07] is exactly the same. But when you look at the cost, providing care to a group of people saves a lot of money. And we do have numbers now to show that. It's not so much that it is one-size-fits-all in terms of exercise. It's a group exercise, but it is personalized for each person. And I think we have seen that for different MSK problems, shoulder,

[00:13:37] knee, especially low back pain, and it does work and it does save money. So this is something that's been put forward in the Canadian Armed Forces about 20 years ago. Now we see that in other civilian clinics. I like that you differentiate the, this is not simply bringing people in where they do the same circuit class. It's bringing people in a group and then the care is really tailored to the individual. That's an important

[00:14:07] distinction, isn't it? It is. And when we look at the musculoskeletal disorders, it's a major public health issue and the economic burden is significant. If I look at Quebec and Canada and it's probably the same elsewhere, the proportion in Canada, just to give you a figure of, the proportion of the population age 70 and older is projected to reach 25% by 2060.

[00:14:37] And people age 65 and older account for approximately 44% of all healthcare spending in Canada. So that's a lot. And these people are often, they often have multiple chronic conditions, including, of course, MSK disorders. We have about 20 to 60% of all adults in developed countries that are estimated to have more

[00:15:07] than one chronic condition. And in fact, healthcare spending is projected to double for each new chronic condition. So the cost associated with global governments, I shouldn't say maybe inaction, but not being sufficiently proactive regarding the management of these conditions. Well, the cost in Canada is about $65 billion. It will be $65 billion

[00:15:37] by 2030. What is interesting is the World Health Organization has even described musculoskeletal disorders as a silent pandemic. So, if you're asking me what are the roles of physiotherapy these days, well, it's to be more and more involved in the management of these cases and to do also more prevention because, again, the economic

[00:16:06] burden is so high. MSK is one of the six most costly health conditions in the country. There's a lot that we can do as physios to contribute to providing population care, and as you say, prevention is really key here. The other aspect you mentioned earlier I want to pick up on is the emergency department setting. And again, you've done a lot of work looking at the different roles PTs, physiotherapists

[00:16:35] can play. What sorts of roles do physiotherapists play in emergency departments, and what sorts of roles do you think we could do? Let's go back to square one. When I first had the idea of doing a randomized clinical trial in the emergency department, people were looking at me, they were telling me, why do you do that, Luke? Because we don't want these patients to be at the emergency department. I said, I totally agree with you, but they have no

[00:17:05] other option. We have a lot of patients that do not have family physician, and when they have a family physician, they don't have access to this physician in a timely manner. so what's left after four o'clock? The emergency department. So in most of our emergency department in Quebec, we have about 25 to 30 percent of these patients

[00:17:34] that do present to the emergency department for a condition that is within the field of physiotherapists. And this is probably very conservative because we are only counting MSK disorders. So what's the role of the physiotherapist in the emergency department? It's not different than when in your clinic. It's to make a diagnosis and to make sure that this is an MSK condition or not and to refer to

[00:18:04] the other professional if that's not within your field of practice. And what is even more important is to make sure that you see the patient at the early stage of the traumatic episode so that it's not chronic yet. Sometimes people think that the cases we will see in the emergency department are more complex, but that's not true. When we did the project in the

[00:18:33] emergency department, it was very important for me to involve right from the beginning the nurses and the emergency physicians. physicians. So we presented them the project, we said, okay, this is what would be the added value of physiotherapy in your context of practice. What do you think? Does that make sense to you? And some of them were quite skeptical when we started the project. We did a focus group

[00:19:03] at the end of the project to present the results, and it was extremely positive from a clinical point of view and from an economical point of view. And there was an open question at the end of the focus group where I was asking all the emergency physicians, say we don't have any economical or human resource constraints, what would be the best offer for you to have in terms of physiotherapy

[00:19:34] covering. And two of them left their hand, they said 24-7. I said, what do you mean? They said, 24-7. I said, okay, you mean you would like to have a physio every day, seven days a week for 24 hours? They said, yeah, why not? Because they did realize that we were having a role and we were really working in a team spirit, and when it was

[00:20:03] not within our field of practice, we were referring to the best professional, most of the time the physician. That was saving them time. They were having more time to concentrate on the highest priorities, highest medical priorities. So it's been very successful and now we do have an offer of physiotherapy services in many of our emergency departments across the province.

[00:20:34] For someone who's listening to us today and thinking about how they might go about moving into some of these newer types of roles for PTs, physiotherapists in the health system, what advice would you have for them in developing their careers? To qualify, I would say for first-line healthcare provider roles, such as in the emergency room, I think you need three characteristics. First and foremost, you must have a solid grasp

[00:21:04] of all the knowledge that enables a physiotherapist to identify yellow flags, red flags. You must possess all the knowledge required to make a differential diagnosis. Is this really a problem within my scope of practice, yes or no? It must be very clear. Then next, you must have all the clinical skills to quickly establish that diagnosis. Performing the right test at the right time,

[00:21:34] for example, is it a calf strain or thromboflibitis? Is it a post-exercise capillary pain or shingles? And above all, and this is the most important thing that I've learned with our project at the emergency department, we need to shift our mindset when providing care in the emergency department, and the same applies in a specialized clinic, we need to switch to a triage

[00:22:03] mode. Certain cross-disciplinary skills are essential. We must communicate effectively and rapidly. We must do it so quickly with both the patient and the care team, and of course with our physician colleagues, and we must demonstrate a great deal of confidence. I remember one of previous health ministry, I think he was in Alberta, he said to me,

[00:22:33] you know what's the problem, Luke, with physiotherapists? I said, sir, no, I don't think I know. He said, you are competent, but you are quietly competent. I said, okay, I know what you mean now. So my advice would be, don't be too, be loud. Show that you know what you know. It's amazing the added value that physiotherapists can bring to our healthcare system. We know that these

[00:23:03] models of care are effective. You've been involved in many of the clinical trials in Canada, there's been trials running in other parts of the world too. So these models of care can work well, whether it's group-based therapy or whether it's having a physio in the emergency department doing triage for non-urgent musculoskeletal conditions. What are the policy settings that have to change to get these roles more widely implemented in health systems? You know that the clinic is

[00:23:33] always preceding the legislation. So the legislation will change to make sure that we allow physiotherapists to be fully autonomous and provide the full spectrum of care they can provide. But I think the first thing that needs to change is to recognize officially in the law not only the capacity but the obligation of physiotherapists to make a diagnosis. That's what we do.

[00:24:03] We do a differential diagnosis and we're probably the best to do that especially with MSK disorders. I know sometimes you need to do a bit of politics and lobbying. It's funny because in Canada we have direct access to a physiotherapist since the early 90s and what do you do when the patient comes to see you or you make a diagnosis. You need to assess that person, make a diagnosis and then manage the case. Yeah and we're

[00:24:33] talking about the advocacy role and we are all as healthcare providers and as registered physiotherapists we have a responsibility to advocate for our profession and that's really what we're talking about. It always helps to have data when you're doing these advocacy things. Luke, you've been very involved in generating some of the important data that we can draw on when we're having these conversations with administrators, with policymakers. So Dr. Luke Ebert, thank you for

[00:25:03] joining me today on JOSPT Insights and talking us through some of the work you've done and some of the data behind it. Thank you so much, Claire. Thanks for listening to this episode of JOSPT Insights. For more discussion of the issues in musculoskeletal rehabilitation that are relevant to your practice, subscribe to JOSPT Insights on Apple Podcasts, Spotify, TuneIn, Stitcher, Google or your favourite

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