What kind of physio are you: one who follows, or one who thinks?

We rarely stop to think about what it means to be a profession. It feels like it has always been this way. But being a profession is not a permanent status. It has to be earned, again and again. Healthcare is changing fast, economically, socially and technologically, and calls for physiotherapy to reform are growing louder. So it’s worth asking a simple question: what is it that makes us a profession, rather than a set of techniques anyone could follow?

My answer is thinking. And that’s exactly what is at risk.

We’ve all seen it, and if we’re honest, most of us have done it. A patient arrives with a label: “rotator cuff”, “low back pain”, “knee OA”. The same exercises come out of the same drawer. Three sets of ten, a leaflet, review in two weeks. Nobody stopped to ask who this person is, what they want, or why this problem is behaving the way it is.

You could call this practising on autopilot: choosing treatment out of routine rather than reasoning. The problem isn’t guidelines or structured care, which often serve patients well. The problem is therapy without thinking. When routine replaces reasoning, the person in front of us becomes a diagnosis to be processed, rather than someone whose problem we’re trying to understand.

This post grew out of reading David Nicholls’ The End of Physiotherapy. It’s a case for becoming a thinking physio: one who reasons about both the diagnosis and the person, values quality over quantity, and puts evidence before anecdote.

A provocative title, a serious question

The title sounds like a prophecy of doom. It isn’t, quite. Nicholls, an associate professor at Auckland University of Technology, offers a critical history of the profession, read through economic, philosophical, political and sociological lenses.

His central argument is uncomfortable but fair. Some of the ideas that helped physiotherapy grow, and earn its place as a respected profession, may now be the very things holding it back. The book’s stated aim is to help physios think differently, not only about the profession, but about their everyday practice.

It isn’t a quick or easy read, and not everyone will agree with it. The CSP’s own review called it important but noted it tells the story from one, largely Western, perspective. That’s a reasonable criticism. But the question it raises stands: are we a profession that thinks, or one that follows?

The rest of this post is my attempt to answer that, with the help of the wider evidence.

What clinical reasoning actually is

Clinical reasoning is simply the thinking behind our decisions. It’s how we move from “this person has knee pain” to “this is what’s going on, and this is what we’ll do about it”. Everyone does it. The question is whether we do it consciously and well.

It isn’t one single process. Physiotherapy research usually describes several overlapping models: hypothesis testing, pattern recognition, narrative reasoning about the patient’s story, and clinical prediction rules. Experts move between them fluidly. A novice might test hypotheses step by step; an experienced clinician might spot the pattern in seconds, then check it.

The best-known study of how expert physios think is by Edwards and colleagues (2004). They studied six peer-nominated experts across musculoskeletal, neurological and home-based care. What stood out was that experts didn’t just diagnose. They also reasoned about the person: their beliefs, their goals, how to teach them, and what they’d accept. The authors called this movement between different kinds of knowledge “dialectical reasoning”.

Here’s an example. Two patients have the same MRI-confirmed rotator cuff tear. One is a retired carpenter who wants to garden. The other is a young swimmer, anxious and convinced her shoulder is “ruined”. A one-size-fits-all approach would hand them the same programme. Good reasoning sees two very different problems, with different goals, different barriers and different conversations to have.

The person and the diagnosis

A thinking physio holds two things at once: what’s happening in the tissues, and what’s happening for the person. Lose either one, and the reasoning falls apart.

This is the heart of the biopsychosocial model. When George Engel proposed it in 1977, his complaint was that the purely biomedical model left no room for the psychological, social and behavioural sides of illness. Physiotherapy embraced the idea. But embracing a model isn’t the same as using it well.

In practice, the model is often applied in a fragmented way. A 2023 review by Cormack and colleagues argued that it has been biomedicalised, split into separate boxes and used in reductionist ways. We tick “bio”, tick “psycho”, tick “social”, and then deliver the same treatment anyway. That’s still autopilot, just with a longer assessment form.

The opposite error is just as real. Swinging so far towards the psychosocial that we stop taking the body seriously is not better reasoning. A stress fracture, a red flag or a genuine structural problem needs to be recognised. The diagnosis matters. It just isn’t the whole story.

When both are held together, outcomes can improve. In the STarT Back trial, people with back pain were screened for physical and psychosocial risk, then offered care matched to that profile. Compared with usual best practice, this improved disability at 4 and 12 months and saved money. It worked because it helped clinicians respond to the person, not just the label.

Evidence over anecdote, but what does that really mean?

“I’ve seen it work” is the most persuasive sentence in clinical practice, and one of the least reliable. Our experience is shaped by natural recovery, regression to the mean, placebo effects and the patients who never come back. A patient with acute back pain who improves after three sessions may simply have recovered anyway. Anecdote can’t separate these things. Good research can.

So evidence must come first. But here’s where the profession often goes wrong: we treat evidence-based practice as if it means applying a recipe. It doesn’t. The original 1996 definition by Sackett and colleagues described integrating clinical expertise with the best external evidence. They were explicit that it was not “cookbook” medicine. Without clinical expertise, they warned, practice risks becoming “tyrannised by evidence”, because even excellent evidence may not fit the patient in front of you. Patient values were later added as the third pillar.

Two decades on, Greenhalgh and colleagues (2014) argued that evidence-based medicine had drifted from that vision. Among the problems they named, rigid rules and technology-driven prompts were producing care driven by management rather than by patients, and guidelines often fitted poorly to people with several conditions at once. Their call was for “real” evidence-based medicine, built on judgement and the clinician–patient relationship.

That’s the balance worth striking. Evidence over anecdote, always. But evidence is an input to reasoning, not a replacement for it.

Quality over quantity

More sessions, more modalities, more “stuff” can look like better care. Often it isn’t. Low-value care is care that brings little or no benefit, may cause harm, or costs too much for what it offers. And physiotherapy has plenty of it.

A systematic review by Zadro, O’Keeffe and Maher of 48 studies looked at what physios actually choose for low back pain. Only around 35–50% provided high-value care. Between 18% and 44% provided low-value care, such as electrotherapy, and most provided care of unknown value. In surveys cited in another of their papers, a large majority of physios reported using traction or electrotherapy, both considered low-value by guidelines. A similar review found the same problem in cardiorespiratory, neurological and acute hospital care.

Here’s the link to thinking: low-value care is often habit care. The ultrasound, the hot pack, the same ten-session block for everyone. These persist not because anyone reasoned their way to them, but because “that’s what we do”. Reasoning is what lets us ask whether we should.

The counter-argument is real. Patients may expect hands-on treatment, and doing less can feel like not caring. Some services are funded by the session, which quietly rewards volume. But quality isn’t about doing less for its own sake. It’s about doing what matters. For someone with knee osteoarthritis, that might be fewer appointments, built around education, exercise and self-management, rather than a longer course of passive treatment that feels busy but changes little.

Initiatives like Choosing Wisely are trying to make these conversations easier. They’re a useful start, but they only work if clinicians are willing to question their own routines.

So how do we think better?

Clinical reasoning isn’t a talent some people are born with. It’s a skill, and like any skill it improves with deliberate practice. A few habits help:

• Make your thinking visible. Write down your working hypotheses, not just your findings. It’s much easier to spot a weak argument on paper.
• Ask “why this, for this person?” If the honest answer is “because that’s what I always do”, that’s a cue to pause and think again.
• Look for what would prove you wrong. We naturally seek confirmation. Good reasoners actively look for the finding that doesn’t fit.
• Measure, don’t assume. Use validated outcome measures, so “they’re getting better” is something you know, not something you feel.
• Think out loud with colleagues. Case discussions and supervision expose blind spots that experience alone can hide.
• Bring the patient into the reasoning. Their goals, beliefs and preferences are part of the evidence, not a distraction from it.

The end, or a beginning?

Thinking physiotherapy isn’t about rejecting guidelines, or trusting gut feeling over research. It’s about bringing the pieces together. Evidence tells us what tends to work. The diagnosis tells us what’s happening in the body. The person tells us what matters, and what will actually help. Reasoning is what joins them up for this patient, today.

If physiotherapy has an “end”, it won’t be because we ran out of techniques. It will be because we stopped thinking about why we use them. The profession’s future depends less on what we do to patients, and more on how well we think withthem.

If this resonates, I’d strongly encourage you to read The End of Physiotherapy for yourself. It isn’t a quick read, and you won’t agree with every page. But it’s a good book, and it will make you think harder about what we do and why.

If you want to go further, Nicholls followed it with Physiotherapy Otherwise (2022), an open-access book. Where the first book tells the story of how physiotherapy got here, the follow-up brings a century of social theory to bear on the profession. It asks what professions are, what role they play in society, what’s good and bad about them, and what all that means for physiotherapy now, as healthcare heads into what Nicholls sees as a new, post-professional era. It doubles as an accessible introduction to the sociology of the professions.

“In examining the person with disease, we gain wisdom about life.”

— Oliver Sacks

Want to read more?

1. Nicholls DA. The End of Physiotherapy. Routledge; 2017 (paperback 2019).
2. Edwards I, Jones M, Carr J, Braunack-Mayer A, Jensen GM. Clinical reasoning strategies in physical therapy. Phys Ther. 2004;84(4):312–30.
3. Langridge N, et al. The clinical reasoning processes of extended scope physiotherapists assessing patients with low back pain. Man Ther. 2015.
4. Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ. 1996;312:71–2.
5. Greenhalgh T, Howick J, Maskrey N. Evidence based medicine: a movement in crisis? BMJ. 2014;348:g3725. (Open access)
6. Hill JC, Whitehurst DGT, Lewis M, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet. 2011;378:1560–71.
7. Traeger AC, Moynihan RN, Maher CG. Wise choices: making physiotherapy care more valuable. J Physiother.2017;63(2):63–5.
8. Zadro J, Peek AL, Dodd RH, McCaffery K, Maher C. Physiotherapists’ views on the Australian Physiotherapy Association’s Choosing Wisely recommendations: a content analysis. BMJ Open. 2019;9:e031360. (Open access)
9. Zadro JR, O’Keeffe M, Maher CG. Are physiotherapists choosing wisely? A systematic review of physiotherapy treatment choices for low back pain (conference abstract, 2019).
10. Zadro JR, Cheng S, O’Keeffe M, Maher CG. Systematic review of physical therapist treatment choices (high, low and unknown value) for cardiorespiratory, neurological and acute hospital conditions. Phys Ther. 2020.

On the biopsychosocial model

11. Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196(4286):129–36.
12. Cormack B, Stilwell P, Coninx S, Gibson J. The biopsychosocial model is lost in translation: from misrepresentation to an enactive modernization. Physiother Theory Pract. 2023;39(11):2273–88.
13. Nicholls DA. Physiotherapy Otherwise. Tuwhera Open Access Books; 2022.