Wise choices in physiotherapy: Standardizing practice with a standard view of practice?

This article examines Choosing Wisely (CW) – a campaign to reduce the overuse of healthcare services through the development and spreading of testing and treatment recommendations. Since its launch in 2012 by the American Board of Internal Medicine, CW has become an international and inter-professional campaign. Taking its spread into physiotherapy as our case, we explore how a highly general CW recommendation from the Norwegian Physiotherapist Association – “Avoid starting psychomotor physiotherapy if the patient is unlikely to benefit from it” – resonates with clinical reality; how does CW’s underlying model of decision-making fit with clinical assessments in physiotherapy? Based on a qualitative analysis of three focus group interviews with Norwegian psychomotor physiotherapists, we find a distinct lack of fit, along three related axes. First, whereas treatment in CW is “off the table” unless it is deemed beneficial, physiotherapy starts from a premise of trying to treat and determining “treatment viability”. Second, whereas CW presupposes a process of “diagnosis then treatment”, diagnosis in physiotherapy seems to emerge in the course of trying to treat. Third, whereas CW treats clinical decisions as resulting from professional reasoning, decision-making in physiotherapy is an emergent phenomenon resulting from patient–professional interaction. We discuss the implications of our findings for CW taken as a cross-disciplinary initiative to shape and standardize professional behaviour using clinical practice guidelines. To be helpful, those guidelines must take clinical reasoning – in physiotherapy or whatever profession is in question – as its starting point, and not some standard view of professional practice.