Physiotherapy Practice Abroad and in Canada: The Cultural Differences

I know as physiotherapists, we love to travel. I’m not sure what it is, but being immersed in other cultures helps us see the world differently.
And if we look at those cultures, they’re always evolving. Just look at how much North American culture has changed over the past forty years.
Moving from another country to practice as a physiotherapist in Canada requires dealing with a lot of culture change. It’s not only the Canadian experience that take some getting used to, but also the physiotherapy work environment. As physiotherapists we work closely with our patients, both physically and relationally.
With that in mind, it’s important to understand the culture you’re practicing in. Not only will this cultural understanding help reduce your anxiety, but it will help you create better connections with patients and give you the assurance that you\’re also meeting your legal obligations.

How Do You Stack Up?

Take this culture quiz to see how well you understand the Canadian physiotherapy practice environment – answer “yes” if you agree with the following statements:

Cultural Quiz for Physiotherapists

It’s ok to only focus on the physical problem that my patient presents with.
In-depth questioning of my patient’s lifestyle, mental health and social supports is inappropriate for me to do as a physiotherapist.
I am unfamiliar with the biopsychosocial model and do not integrate it into my practice.
Once I’ve gotten consent from a patient I don’t need to do it again.
I don’t need to document once I have gained consent.
I don’t need patient consent to discuss their case with a colleague.
Since I’m the expert in the physiotherapist / patient relationship, I don’t need to educate the patient on their other care options.
In Alberta, if a patient discloses that they were injured at work but doesn’t want to claim a Workplace Injury, that is their choice.
Informed consent is the same as implied consent.
Good documentation or charting is important only in scenarios where you are worried about legal action being taken against you.

If you answered “Yes” to more than 4 of these questions, you’ll benefit from reading this article. Learn the key cultural differences and how they will influence your physiotherapy practice.

Let’s Break It Down

In preparation for this article, I spoke with a few internationally educated physiotherapists to get a better idea of the cultural differences they’ve experienced since transitioning to Canadian practice. Here are the big ones:

Patient Centered Care 
Gaining Consent  
Patient Confidentiality  
Patient Education 
Documentation and Charting  
Funding Models 
Team and Multidisciplinary Approach 
Personal Space

Patient Centered Care

What You May be Used To

Physiotherapists working abroad may have become accustomed to a patient coming to physiotherapy for treatment of a specific problem. The physiotherapist would conduct a physical assessment, diagnose the patient\’s injury and provide treatment appropriate for the diagnosis. In their treatment of the patient, the therapist\’s focus would weigh heavily on the patient\’s physical or biological deficits such as weak hip abductors or poor active shoulder ROM.
From here the physiotherapist would devise their treatment plan around these physical domains and discharge the patient once recuperated.

Here in Canada

Canadian physiotherapy education strongly reinforces the need to assess and treat patients within a biopsychosocial model of health¹. In this model, a therapist should consider not only the patient’s physical condition, but the also the psychological and social factors as well. Digging a little deeper during a patient history can help to uncover the potential impact of these other domains. The treatment plan should also focus on providing an integrated plan to help the patient with their recovery. If there significant psycho-social factors, it may be necessary to refer to the appropriate health care provider (e.g. psychologist, dietician, etc).
From my conversations with PTs, I discovered that in other cultures the patient population can be uncomfortable with in-depth questioning regarding their lifestyle, mental health, social supports and coping mechanisms. The large majority of Canadian patients do not find this form of questioning offensive. Discussing these topics with patients in a non-judgmental and caring manner along with the relevance to their physical pain can help connect with patients in a meaningful way.
To help you identify patients who may need additional bio-psychosocial support, I’d like to introduce you to the STarT Back Tool².

Gaining Consent

What You May Be Used To

In my research, I discovered that in some countries there can be an assumption that if a patient is attending physiotherapy, they are implicitly consenting to all treatment. In Canada, this process is governed by a very specific set of guidelines that must be met before consent has been gained from the patient.
Let’s dig a little deeper into the concept of consent. Here are the main elements:

Consent can be expressed or implied in written or verbal form.
Consent must be given voluntarily and be provided by a patient who has legal capacity, meaning they are deemed mentally competent and have the capacity to evaluate the consequences of offering their consent.
They must be older than 18 years and if younger, consent must be gained from both the minor and their parent or guardian.
If there is doubt to whether the patient is struggling to understand the information provided to them due to a language barrier, a language interpreter should be used.

Before a patient is able to provide informed consent, the therapist should talk about the following the patient:

Treatment benefits
Treatment risks
Treatment consequences
Alternative treatment options
Provide clarifying answers to any questions by the patient.

Even though one could assume that consent, once given is always given. This is not the case. Here are some things to consider with maintaining consent with a patient:

A therapist must document this process and specify how and when informed consent was gained.
Informed consent must be regained any time there is a change of treatment plan and it is not transferrable between healthcare practitioners, meaning that if a different therapist oversees treatment, consent must be regained.
Patients have the right to refuse treatment, change their minds or withdraw previously provided consent at anytime.

Following the guidelines for gaining informed consent from a patient is an important step in your physiotherapy practice, as it provides you with an opportunity to encourage patient compliance, maintain patient and therapist safety and protect your liability as a physiotherapist. For more information, visit the Physiotherapy Alberta College + Association website.

Patient Confidentiality

Patient confidentiality is an important consideration when dealing with sensitive patient information. Countries have varying degrees of patient information protection and the practice of patient confidentiality can vary.
In Canada, every patient has the right to confidentiality and it is the duty of all health organizations and practitioners to protect this right. Explicitly outlined in the Health Information Act are a set of rules about the collection, use and disclosure of patient information. The purpose of this Act is to protect patient privacy and to maintain the confidentiality of personal patient information from all but authorized parties.
Aside from legislation, physiotherapists must enforce additional safeguards to protect patient confidentiality in their individual practice. One common situation in which additional care must be taken is when discussing a patient case with a colleague. For many physiotherapists, requesting insight or a second set of eyes from a colleague on a challenging case is common in public and practice care settings. However, there are a few things you must keep in mind when discussing a patient either in person, in writing or online.

Share information on a need-to-know basis. This means only sharing the info your colleague needs to know to understand the context of your discussion.
Do not use specific information or identifiers when discussing a patient or their medical history.
Have your discussion in a private environment to avoid others overhearing.
You may only disclose information regarding a patient to individuals they have explicitly provided their consent for. This means asking a patient if they are comfortable if you ask a colleague to take a second look.

Building trust with a patient is an important step in fostering a therapeutic relationship. As a patient shares personal information, it’s important that they feel confident and comfortable knowing that their information is safeguarded appropriately.

Patient Education

The relatively recent advent of direct access to physiotherapy in Canada has increased the autonomy of physiotherapists in practice. These advancements may not yet have taken place in other jurisdictions where direct guidance by physicians can be the norm. In these situations patients may implicitly trust the physiotherapist given the referral and treatment direction by the physician. Patients may also be more concerned about recovery duration than understanding their condition and self-management.
In Canada, patient education is a central component to patient centred care. As direct access health care providers, physiotherapists are responsible to thoroughly educate patients throughout their treatment program including diagnosis, treatment rationale, treatment options, pain science education and goal setting (to name a few!). It’s a good idea to probe your patients for any questions they may have and answer them to the best of your ability. If you do not have an answer to their question, it’s ok to admit this, but you should be willing to find an answer for them.
Adopting to the Canadian physiotherapy treatment culture of providing in depth education to your patients is a necessary component of treatment in Canada. Patient education plays a vital role in managing patient expectations, addressing patient information gaps and ultimately empowering patients to adopt an active role in their recovery and health.

Documentation

Documentation is another area of potential difference between countries. In Canada, there are specific practice standards for charting that need to be followed.
Here are some important elements of charting in Canada:

Charts must be accurate, legible and complete.
They must comply with confidentiality and privacy legislation.
Acronyms should be minimal to ensure continued understanding between healthcare practitioners.
Each page of a chart must include the following: patient health information, the date the entry was made, the name and signature of the person who wrote the entry and clear patient identification.
Charts must be readily retrievable whether they have been completed on paper or online.
Audits of charts should also be regularly completed by supervisors to make sure physiotherapists are following appropriate guidelines.

A good rule of thumb when charting is that a colleague should be able to easily continue your patient care in case you are absent by reviewing your chart notes. A colleague should be able to easily identify any treatment contraindications, assessment findings and diagnosis, patient goals, treatment progress and the next steps in the treatment plan.
Charts serve as excellent modes of communication between colleagues and other disciplines. They can also help protect you in the case of future litigation.
For more information about charting guidelines in Alberta visit the Physiotherapy Alberta College + Association website.

Funding

Healthcare accessibility and coverage for services really varies throughout the world. In Canada, physiotherapy treatment can be funded by many different agencies. In Alberta, the most common funding sources that patients may access include the Worker’s Compensation Board (WCB), Community Rehabilitation Program (CRP), Motor Vehicle Accident Insurance (MVA), Extended Health Benefits or private payment.
The ability for patients to access these different funding providers can depend on a number of things such as:

physiotherapy clinic contracts,
a patient’s specific extended health benefit program,
a physiotherapist\’s assessment findings and
the region in which the patient is located.

For example, there is no CRP funding accessible in southern Alberta. If in a private clinic, the compensation paid to a physiotherapist can vary by the funding situation.
Dealing with workplace injuries comes with it’s own set of requirements. If a patient acknowledges that their injury was sustained while at work, it is your legal obligation as a physiotherapist to provide treatment under a WCB claim. Sometimes patients may be resistant to this as they do not want to ruffle feathers in the workplace. However, it is imperative that you educate the patient of your legal obligation. Patients also appreciate education as to how claiming WCB may serve their best interest in the case that their injury results in chronic symptoms or functional restrictions.
With all this diversity and variability in funding for services within Canada and each individual province, a physiotherapist may feel a little overwhelmed at first. After a few months of practice, however, the funding models will make more sense. It is important as a physiotherapist to understand your local funding providers and criteria as patients will ask questions and proper guidance and education will be needed.

Team/ Multidisciplinary Approach

Multidisciplinary care has been shown to lead to more favourable outcomes and health care in Canada continues to develop new collaborative care models to further patient outcomes.
Even though the level of collaboration may vary in private and public practice settings, physiotherapists in Canada see themselves as working in a team environment.
In hospitals, physiotherapists will collaborate with a number of different professionals such as nurses, physicians, nurse practitioners, dieticians, occupational therapists, speech language pathologists, audiologists, social workers and recreational therapists.
In private practice, a physiotherapist will carry an independent caseload but work amongst fellow physiotherapists, kinesiologists, physiotherapist assistants and massage therapists.
Building relationships with other physiotherapists and health care providers can really help when challenging patient cases arise and where additional consultation is needed.

Personal Space

Personal space can be one of the more apparent cultural differences that can exist between physiotherapy practice cultures. The acceptable distance for personal space varies depending on the individual, their culture and the situation. In China, the world\’s most densely populated country, the notion of a “personal bubble” is relatively non-existent. According to intercultures.ca, though, Canadians require an average of 14 inches or 36 centimetres of space when lining up in a public area. A report by CBC found similar result, i.e. that the majority of Canadians are most comfortable with 20-40 cm of personal space.
The physical space between you and a patient can change over the course of a treatment program. Initially, ample physical space can occur during history taking. During an examination, certain physical contact may be required to perform the necessary tests. It’s important to be confident in your performance of these tests so as to instill confidence in the patient.
Certain treatments including manual therapy can require close physical contact and it’s important to provide the necessary education to your client before performing the treatment. Another consideration is the sensitivity needed when dealing with the opposite sex. Providing appropriate explanation prior to physical contact is important and appropriate clothing instructions can help minimize any potential discomfort by patients.
While many patients seek physiotherapy treatment with the understanding that physical contact is to be expected, the therapist must ensure they discuss their treatment plan in detail with patients at every encounter. Explain what you will be doing, why you are doing it and the risks and benefits of this treatment. Ensure you receive informed consent before you proceed. This will alleviate any misunderstanding and discomfort for both parties.
For even more information about the non-physiotherapy specific cultural differences that exist in Canada, visit the Global Affairs Canada website.
Well there it is in a nutshell. Cultural differences in Canadian physiotherapy practice. I hope that reading this article has helped you feel more prepared and ready to tackle any challenges you might face!

References:

Sanders, T., Foster, N. E., Bishop, A., Nio Ong, B. (2013). Biopsychosocial care and the physiotherapy encounter. BMC Musculoskeletal Disorders, 14 (65).
Hay, E. M., Dunn, K. M., Hill, J. C., Lewis, M., Mason, E. E., Konstantinou, K., et al. (2008). A randomised clinical trial of subgrouping and targeted treatment for low back pain compared with best current care. The STarT Back Trial Study Protocol. BMC Musculoskeletal Disorders, 9 (58).