Amanuensis (El Dictador)

Suddenly the penny dropped. So in the mindset of getting people to perform exercises that I hadn’t stopped to think. She had tried a variety of exercises without progress. Maybe every patient didn’t need an exercise……. 😱😳😧

Autonomy is identified as a hallmark of physiotherapy and other healthcare professions. The arrival of evidence based practice has brought much data but it’s dangers include dictation of personal care. Our profession becomes like an amanuensis*. 


Do we approach people like an amanuensis? Robotically duplicating our subjective assessment, advice, treatment goals regardless of person. Treating a body as soul-less. Aiming at more exercise, less food/drink, smoking cessation to achieve if not biological perfection at least optimisation. The things that sustain my body are not the same as what brings me life. These are tasks for the amanuensis. No skill needed other than being enthusiastic (a great skill, but not in isolation). Maybe some enjoy absence of responsibility. But these messages do not harness spontaneity or change, in fact likely the opposite!

Can we begin to see the world through the eyes of another? How they see our interactions and input? Exercise for example. I would guess that many health professionals like exercise. I do. Sweat rolling down my body. Lungs gasping for air. Muscles strong but fatigued. But it’s not like this for everyone! Can I see this or do I see myself in everyone?

How might this shape subjective assessment? Well look for more than objective measures. “You smoke x20/day?…… Why is this?….. How does this compare to 3yrs ago?… Why has this (not) changed?”. You will find that people smoke for different reasons enjoyment, stress relief, weight control, habit, addiction, work breaks, boredom. You will know none of this if you only get x20/day.

An excellent blog by Dave Nicholls frames this well. Questioning why if we become purely public health cheerleaders do we need a degree program. Reciters of common sense. As if this encapsulates each individual’s raison d’être. An amanuensis need not think, nor feel, nor care. Just replicate. Not that common sense should be discarded. Indeed it should be consulted more frequently. Surely ‘common sense’ tells us people are unique. Idiosyncratic. Peculiar. Distinct. That care is much more than an interaction or exchange but a process or journey.

Healthcare is being pushed away from this. Neo-liberal political pressure demands productivity and cost cutting. This inherently equals cutting corners on time, space and resource. This initially entices with healthcare professionals being seen as cost effective. The hope of neo-liberalism is becoming lean. Focusing on efficiency, affordability, cutting less profitable, promoting more profitable. This though is only achieved through mountains of paperwork (of arguable relevance). Privatising seems to be leading down a road of less time with people, more time with paperwork (paradoxically considering productivity is the goal). Tellingly there seems little outcome on patient satisfaction and even less on worker satisfaction! What seems good care to a healthcare naïve patient may not be viewed the same by clinician (and vice versa). 

This tends to undervalue care compared to treatment. Care is seen to be non-technical and is de-valued as such. A neo-liberal may come to my clinic and mistake a lack of complexity in treatment to a lack in skill. A lower band/pay grade could do this ‘easy’ work. The same treatment for cheaper. The complexity in healthcare is not always the technicality of treatment but the clinical reasoning. Viewed as a non technical, non profitable and predominantly female the ability to care is not prized in this environment. Witness the trend in reduced care from nurses, physiotherapists, OT alongside increase of healthcare assistants or carers who are often overworked and underpaid. Also note how these low wage positions are predominantly female occupied. Considering being viewed as a non specialist skill that requires no training remarkably few use it. Particularly by those in power who seem to use subservients to do this business for them. 

We need to remember public health messages are designed for populations and not individuals. On reviewing the patients notes I noticed she had a very good level of exercise and actually struggled with rest. She regressed to the mean (whatever that actually means) whilst on holiday with only some advice on relaxation and sitting posture advice. No exercise needed. 

How often do we engage and how often are we the messenger? What culture are we buying into with our approach to healthcare? Do we want to be part of an amanuensis generation? 

Be more human. Be less robot.

Thanks for getting this far.



*In Norway, amanuensis is an academic rank of a lecturer without a doctorate, although this title is going out of use. Førsteamanuensis (Norwegian for “first amanuensis”) is the equivalent of associate professor. This is different to the meaning used in this blog!


Nicholls 2015.

Wikipedia 2015.

5 thoughts on “Amanuensis (El Dictador)”

  1. Hello Neil,

    I couldn’t agree more with this. Lots of issues in there which need addressing by our profession.

    The issues around general public health are relevant to us. The chap who you quote is right in his thinking I believe. We do not need a degree to discuss these with clients and if this is your main angle of treatment then it is not being a physiotherapist really is it? They are relevant though.

    Abstraction of the relevant science and it’s reasoned application is one of our specialist areas. This may, for example, be giving someone five exercises or just giving someone confidence to move in general; or anything else based on a reasoned process. All done in the N=1 environment and treating the person with dignity. Delivering treatment based on science and thought with decency.

    The issue with paperwork is becoming a major issue. Lots of bureaucratic bullshit around. Collecting irrelevant data and trawling through an assessment form where every item has to be filled in. 5Ds, 3Ns, every disease in the book to comment on is mandatory. Objectivising the un-objective. Three minutes two seconds three hundred Nano seconds in standing for the pain to reach 4.67854/10. All for a simple ankle problem. Takes the brain from a physiotherapist if it hasn’t exploded already.

    I can remember being in outpatients as a student. My supervisor said to me ; here is a blank piece of paper. It is yours to do as you see fit.’ Best assessment form ever.

    I have heard stories of good clinicians being berated for not having brilliant IT skills, this being valued in some quarters more than clinical ability and being able to treat people with dignity. If that is where we are heading then we are up the creek.

    So, you play off a lower handicap than me at golf. We play a round and you are obviously more accomplished. However, at the end I am better at marking my card. I am not a fan of golf by the way.

    It is not who is better than who in our profession.
    It is about thinking, trying to constantly improve and doing your best with every patient.

    Thank you for your efforts.

    Kind regards

    Liked by 1 person

    1. Always love your comments! Really helpful. The political landscape has a huge effect on what we have to do, measure, how successful we are viewed. Until care becomes more desirable we are in a tricky spot. The problem is the further up the ladder the less likely you are to use or value ‘care’. It’s more about numbers! Like the golf analogy.


  2. Neil, AMW , very good analysis of the current situation and in your words Neil the ‘neo-libreal’ agenda. To measure,commodify and take things back to lowest common denominator .
    (‘Objectivising the un-objective’) In (n) MSK outpatients I am surprised that there is little realisation in general outpatients that the vast majority of patients are not ‘sports’ rehab cases’ and very few need the blanket rote assessments AMW described. As a gross generalisation, many people I see either never start or have difficulty stopping. The skill is to nudge the person via the interaction towards a little more balance perhaps , overcome mis-placed fears or reach a state of acceptance when things can’t be ‘fixed’ . As an aside I find the older generation much more able to come to terms with this and adapt. Its ironic that the Physiotherapy course has moved to an all graduate profession but more and more it seems the managerialism , notions of pathways for objective disorders (which occur about 5% of the caseload) leaves the reality of the uncertainty of the caseload (undiagnosable pain problems/mixed lifestyle and mild MH issues ) to be ‘treated’ by some unknown psychological based profession . In reality we are this profession but in my opinion (and my experience with students) we are ill prepared to deal with the reality of the caseload . Being more prepared requires people to read , reflect and write blogs like yours so thanks for that !

    Liked by 1 person

    1. What an excellent insightful comment Ian! Worthy of a blog of itself. The politico-economic influence on management and academia is certainly an issue.

      Like you say it requires thought. Something current healthcare doesn’t value or give room for. We are forced to be churners. Rushing from one thing to the next. A change of culture is required.


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