When Dr. Ferida Khanjani was offered a job at the United Family Healthcare hospital in Beijing, China in 2000, she was pleased to accept. However, when the HR department at the hospital, which is commonly known as BJU, asked her to get an international physical therapy license as part of the job, she declined. Not that she has anything against PT. She thinks it's a fine profession. But she's a chiropractor.
This confusion about the practice of physical therapy may be one reason the profession is growing so slowly in the world's most populous nation. That lack of growth has caught the attention of World Council on Physical Therapy. In a July 2009 press release, WCPT president Marilyn Moffett, who spent two years traveling the world to promote the profession, said, "I'd also like to make sure that we have increasing contact with China and Russia... Neither of those huge countries currently has physical therapy services and education across the board as we know them."
William Liao, a physiotherapist who eventually joined BJU's Integrative Medicine department, agrees. Liao is a native of Taiwan who got his PT training in England and practiced briefly in New Zealand before moving to China. Liao was part of a group of therapists from Hong Kong who participated in a physical therapy rehab project in Tianjin, a port city not far from Beijing, prior to joining the staff at BJU. He says he hasn't seen much in the way of physical therapy outside such rehab clinics in China and isn't familiar with any PT program at any university in the country.
Liao's specialty is trauma, along with post-op and fracture injuries, including hand injuries. However, since joining BJU, he spends most of his time treating musculoskeletal problems. BJU is still a fairly small hospital at 50 beds, so the orthopedic unit is also small. Arthroscopies are the most common orthopedic surgery done, though people who've sustained fractures are also a staple at the hospital. Yet a physical therapy order isn't standard protocol for either. Liao is trying to change that.
"Patients who have had shoulder or knee arthroscopies are usually hospitalized for five to seven days," he says. "I ask the doctor for an order and sometimes can start mobilizing the patient one or two days post-op." Liao is fully aware that similar surgeries are frequently done on an outpatient basis in the U.S. and other countries, but shrugs and says, "You know how it is in China."
"How it is in China" is that people have had free or very low cost healthcare for quite some time, so a lengthy hospital stay hasn't bankrupted them. Philosophically, too, most Chinese have the idea that sick people need plenty of rest and very little activity. So, relatives tend to take care of family members who are ill-even those who are hospitalized-often bringing them food and extra blankets, spending lots of time sitting with them and discouraging the patient from getting up and moving.
The rising costs of healthcare, the development of a Chinese middle class and the introduction of Western ideas, however, is starting to affect these traditional ways of doing things, and BJU is part of that change.
Beijing United Family Healthcare opened in 1997 as a high-end hospital in a city that is modernizing fast. BJU is jointly owned by Chindex, a U.S. company, and the Chinese Academy of Medical Sciences and is the only hospital in Beijing accredited by the Joint Commission International. Staff members at the hospital come from all over the world, with the common denominator being an ability to speak both English and at least one of the major Chinese dialects, Mandarin or Cantonese.
While clientele at BJU has mostly been foreign residents of Beijing and its environs, that's changing, according to Roger Hinson, DC, the head of the Integrative Medicine department. "About 30 percent of our patients are Chinese now," he says.
Having maintained some of the aspects of care familiar to Chinese, such as longer hospital stays, together with the Western-style setting and Western-style surgical offerings, has probably helped to attract those Chinese patients to the services offered at BJU's Integrative Medicine department. And, while still few in number, those Chinese patients are one more step on the road to advancing PT services in China.
Liao recognizes this and is a great ambassador of the profession. "Although things are starting to change, it seems like people only think about surgery or medications - the first half of the disease process," he says. "They think once you have surgery, you're healed. They assume rehab is a natural process following surgery."
Liao says when doctors hear the word "rehab," they think only of patients with neurological diagnoses. "But neuro patients aren't referred here, because our service is fairly high cost." That is, the local population can be treated far less expensively at one of a number of rehab centers found throughout China.
As those who have had spinal cord injuries, strokes or head injuries are not likely to come to BJU, Liao often has to push the doctors at his hospital toward reconsidering their ideas of rehab, even for orthopedic patients. Though he has heard of a few hospitals that have acute care PTs to help mobilize other types of general surgical patients, he thinks it's hit or miss and not yet a trend in China.
Liao says people are starting to show up at his clinic six months or even a year after surgery. Their scars have healed, but their gait pattern is off, or they've lost range of motion. Some even have a permanent disability.
"I have to be the one to push physio," Liao says. He sometimes tells the patients he manages to see in the hospital, "If you really want to get better quickly, you'd better come see me."
Beijing United Family Healthcare is building a new, much larger hospital next door to the current facility. When it opens, Liao hopes to see more orthopedic inpatients. But he's still plenty busy seeing an average of 12 to 14 inpatients and outpatients daily. Liao has two treatment rooms and a small gym in his section of the Integrative Medicine department, plus all the modalities needed to treat people with back and neck problems, who make up about 50 percent of the patients in the Integrative Medicine department.
Besides Liao and the two chiropractors, the Integrative Medicine department at BJU features an acupuncturist, a registered dietitian, a naturopath and an M.D. who's a rehab specialist. United Family Healthcare has two other centers in China, one in Shanghai and the other in Guangzhou. The Shanghai hospital does not have an Integrative Medicine Department, but the one in Guangzhou does. That department also has a physical therapist on staff. Including PTs in this setting may turn out to be a good way to promote physical therapy in China, a country without a historical animosity between medical treatment philosophies.
Still, without the right education and training, no amount of promotion will help the profession develop in China. As far as Liao knows, there are no graduate level physical therapy schools in China right now, though the World Health Organization sponsored physical therapy training in Wuhan in central China as far back as 1991.
Liao says that the few Chinese he's met who call themselves physical therapists are not much more than technicians. He says they not only don't have the skills to properly assess a patient, they also aren't able to make any treatment decisions on their own. "Even to just do an ultrasound, they need a doctor's prescription," he says. Those Chinese PTs who know how to do an ultrasound treatment, he adds, "often don't know why they're doing it, nor do they know when or how to modify their technique."
Those who want to advance their knowledge and learn new skills can find the landscape pretty bleak. Because China lacks a professional physical therapy organization similar to the APTA, it's quite a challenge for therapists on the mainland to meet each other, either for continuing education courses or to discuss ways to promote the profession as a whole.
Liao did meet other PTs when he attended a seminar in Tianjin a few years ago, but otherwise he rarely sees anyone else in the profession. While he was working in Tianjin, he was occasionally asked to give lectures in the use of the modality equipment or to provide insight on other treatments, but he hasn't seen any students since he began working at BJU. The Tianjin job was part of a project put together by a team from Hong Kong. The rehab center where the project was carried out is still there, but the Hong Kong team has departed, so the therapists there no longer have outside support.
For Chinese who want to pursue a career in physical therapy, Liao suggests Singapore, Taiwan or Hong Kong as options. For Chinese who speak English, universities in the West are another possibility.
The WCPT, however, has its eye on homegrown development of the profession. In the spring of 2010, the WCPT unveiled a new set of guidelines that "cover clinical education, faculty qualifications and continuing professional education." These will be among the tools the organization will use to encourage the advancement of PT in China and other nations where there are few therapists or no organized professional group.
Marcia Veach is a licensed physical therapist assistant and has practiced physical therapy in Oregon for more than 25 years. She also holds a BA in journalism from the University of Oregon.