The health workforce is hierarchical and movement across professions is almost always upwards as individuals seek higher reward, recompense and status. Only rarely is there is movement downward. This story tells of a unique occurrence in Israel in the late 20th century where necessity caused qualified medical practitioners to retrain as physiotherapists (Remennick & Shekhar, 2003)
Among some 700,000 Russian Jews who moved to Israel between 1989 and 1995, over 15,000 were medical practitioners; effectively doubling the number of physicians in an already saturated medical market. Some 75 percent of the immigrant doctors applied for the Israeli medical license, causing health authorities and the Medical Association to be gravely concerned about their employment prospects and influence on the Israeli medical profession.
At the same time vacancies existed in the physiotherapy profession. So as part of a unique retraining initiative, the Ministry of Health organised two courses of physiotherapy education for willing Russian immigrant doctors. Acceptance into the courses was based primarily on Hebrew language proficiency. The first course took place in 1991–92, and was 12 months long, including eight months of academic studies and four months of clinical practice. After their final exams, 34 graduates of the 40 students received full credentials as physiotherapists and all of them found jobs soon afterwards. A second course was organised in 1995–96, with the goal of filling multiple vacancies for physiotherapists in geriatric and psychiatric institutions. The selection of the candidates was even stricter (286 MDs applied, 80 were invited for the interview and only 40 got accepted) and the length of training increased to 15 months, including six months of clinical practice. After final exams, 33 graduates were certified as physiotherapists.
Medicine is a lifetime career, and those who have passed through the prolonged ‘ordeal’ of medical training usually remain doctors. Yet, the status of physicians in the Soviet Union of the late 1980s was rather unique. Many lower-rank doctors (mainly in primary care) were bitterly disappointed by their work in the deteriorating medical system suffering of corruption, constant shortage of medicines, diagnostic facilities, and other means of treatment. Heavy workload, low pay, and inability to help many of their patients often caused demoralization, sometimes to the point of leaving medicine for good. If they remained doctors, it was due to the lack of viable occupational alternatives.
Finding themselves as immigrants facing the prospect of entering the local medical market in its lower tiers (eg., GPs in remote clinics, hospital ERs and internal wards, ambulance services – all of it typically part-time and with low wages) was not very attractive for many former doctors. So some opted for the less heroic but more secure career in physiotherapy.
After several years of work as physiotherapists, most adapted well to their new professional role. Many stressed that they were proud of the new knowledge and skills they had acquired that, in the words of one, ‘could put people back on their feet again and make them feel functional, if not completely healthy.’ Most discovered that they could do quite a lot for the patients by means of physiotherapy; help them to regain key bodily functions and return to a normal life after serious illness. As another put it, ‘The possibilities of physiotherapy here are so much broader than back in Russia – due to all the clever appliances, equipment and manual skills they teach you. It is the mainstay of all rehabilitation medicine.’ The following quotes were also typical (the first two from former surgeons, the third one from an internist, all females in their late 30s–early 40s).
I am very glad that now I can help patients using my manual skills, without drugs. Another advantage of being a physiotherapist is that you shape the whole course of treatment from beginning to end, you follow the progress of the patient – it is a very autonomous work, compared to that of junior doctors . . . I am very glad to have made this switch.
I wear the same white coat – just a shorter one than in Russia. I don’t feel that I’ve changed the essence of my work – only the instruments. I used to operate with a scalpel and now I treat by means of electrodes and sound waves . . .
I am as satisfied with my current work as I was being a doctor. I just help the patients in a different way, but the result is the same, or even better. I feel closer to the patient than most doctors do.
There was strong interest among the former doctors of professional upgrading, with most taking additional training courses in different areas and methods of physiotherapy. Many ‘converts’ saw this upward mobility in their new professional role as a kind of compensation for the loss of the medical career. They wanted to achieve the highest possible status within their new niche – both to climb the administrative ladder and to enhance professional skills. ‘If I am a physiotherapist now, I want to be the best physiotherapist possible,’– went the recurrent statement.
Any perceptions of a downturn in their professional career failed to change the self-definition of former physicians. Working within narrowly defined limits, being unable to perform diagnostic procedures, prescribe medication or do any invasive treatments, most still thought of themselves as physicians. Although at times they had to suppress, or at least downplay, their medical credentials in order to live in peace with their new paramedical environment, they saw their patients by doctor’s eyes and still applied their medical knowledge wherever possible.
References
Remennick L and Shekhar G. 2003. You never stop being a doctor: the stories of Russian immigrant physicians who converted to physiotherapy. Health, 7(1), 87-108.
An interesting article.. A bit of a pity that the doctors were being trained in electro therapy, as there is little scientific evidence that it has any value. I realise that this was several decades ago and I hope physiotherapist’s training world wide does not continue to teach this outdated curriculum. Self management and movement therapy ie prescriptive exercise based on sound clinical reasoning is the way forward… Cheers Rob Reed