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Walk in Middle, Get Squish Just Like Grape

Is massage therapy a personal service or health-care discipline? There exists a tenuous relationship between the spa and rehab identities in massage within the profession. At our detriment, this is causing confusion as government, insurance funders and other health-care providers struggle to define what massage therapy is, and how and whether it should be funded.


January 18, 2010
By Don Quinn Dillon


Topics

Conversation from The Karate Kid, 1984

Miyagi (played by Pat Morita): [sighs]

“Daniel-san, must talk.” [they both kneel]

“Walk on road, hmm? Walk left side, safe. Walk right side, safe. Walk middle, sooner or later [makes squish gesture] get squish just like grape.”

“Here, karate, same thing. Either you karate do “yes” or karate do “no.” You karate do “guess so,” [makes squish gesture]…just like grape. Understand?”

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Is massage therapy a personal service or health-care discipline? There exists a tenuous relationship between the spa and rehab identities in massage within the profession. At our detriment, this is causing confusion as government, insurance funders and other health-care providers struggle to define what massage therapy is, and how and whether it should be funded.

At its origin, the rehabilitative side of massage therapy split off from physiotherapy and nursing to become its own profession. Massage was also incorporated into the esthetics profession because of its soothing spa applications, hence the broad identity massage now finds itself with. Massage has grown in popularity with athletes, those seeking bodywork for psycho-spiritual growth, office workers, those in palliative care and nursing homes, guests on cruise ships and customers in spas.

Despite the tolerant, all-inclusive nature of massage practitioners to retain these many identities (and work opportunities), I would argue having too broad a scope dramatically affects funding, public perception and credibility.  These dissimilar identities have different – and often opposing – beliefs about regulation, professionalism, lingo, service philosophy and protocols of practice. For example, rehabilitationists advocate for degree-level education and evidence-based practices, which would afford greater access and funding to care. Spa practitioners find excessive regulations onerous and hard to apply to the very different spa business model: think record-keeping, assessment, discounts and package deals. Because of this unresolved tenuous relationship the profession’s identity is stalled like a joint locked between painfully spasmed agonist and antagonist muscles.

HALFWAY ALONG THE PROFESSIONALIZATION TRAJECTORY
A Professionalization Trajectory spans the growth of a profession from unregulated skilled trade to regulated health profession. Donelda Gowan-Moody and Amanda Baskwill describe professionalization trajectory as follows in Report on Policy Issues Concerning the Regulation of Massage Therapy in Canada1;

“Professionalization trajectory – wherein the profession evolves from the status of unregulated trade or service to a recognized and regulated profession with standards of practice. The trajectory begins with the formation of a voluntary association of practitioners who work together to rally toward a common goal of enhancing the status of the profession. As the profession matures, certain elements such as consistent standards of practice, professional ethics and codes of conduct, educational standards prior to practice, a culture of public service and profession-specific language and knowledge base are developed. Eventually the profession reaches the stage where legislators are petitioned for a form of regulation and self governance.”

Massage Therapy has progressed along the trajectory to become regulated in a number of U.S. states2 and currently three Canadian provinces. However. the profession has some way to progress before it receives consideration as a health-care profession internationally.

Although massage therapy is regulated in my home province of Ontario, RMT services are not covered under Medicare.  Further, RMTs are not initiating health practitioners (IHPs) and require an authorizing gatekeeper (physician, physiotherapist, chiropractor or nurse practitioner) to access auto insurance, worker’s compensation and most workplace benefits plans.  Massage therapists are positioned as assistive, paramedical workers rather than primary care providers and require IHPs to unlock access to funding.

Like traversing a high wire, massage therapy as a profession is halfway along the trajectory. If we wish our profession to be recognized as primary health care, we’re told by government,
the insurance industry and other health-care providers we require two things: evidence-based practices and degree-level education – and of course, strong associations and political clout. These two factors improve the credibility and funding afforded such a standing. Without these two requirements we waft between skilled trade and regulated health profession, and are easy pickings for opportunists who would exploit the popularity of massage and the vulnerability of its halfway position along the regulatory path.

PROFESSION UNLOADING
There appears to be a clever scheme afoot by government to unload more duties and responsibilities onto lesser trained, lower salaried positions in health care. Unloading has the effect of creating more middle-level jobs in health care; – these jobs are lower paid than the primary professions that once performed these tasks, despite being assigned increasing responsibility. – The net effect is lowered health-care costs.

Tasks normally in the realm of physicians are now done by nurse practitioners or registered nurses. There is now a physician’s assistant program3 offered at McMaster University in Hamilton, Ont. Nursing assistants (RNA) or personal support workers (PSW) do what nurses formally did, dental hygienists and assistants do what dentists used to do themselves and, recently, physiotherapy’s scope of practice was enhanced in Ontario, indicating a larger role for physiotherapists in health care.4

“…the changes will enable physiotherapists, who have demonstrated the required education and competence, to provide additional health care services such as ordering x-rays, to diagnose conditions that may be identified using a physiotherapy assessment, and to treat wounds and conditions including urinary incontinence or pelvic pain.”

How can unloading affect massage therapy? Physio and occupational therapists now have access to assistants to perform some of the tasks previously only provided by physiotherapists and occupational therapists. Kinesiologists have also become regulated. Because massage remains a popular but not well protected profession, could perhaps the PT/OT assistants add massage therapy to their curricula? The physiotherapist can keep massage services in house rather than referring to the massage therapist down the street, thus increasing their profit margin and control of the treatment plan.

Service Canada classifies Massage Therapy under Other Technical Occupations in Therapy and Assessment5 and lists an average wage range of $18.94. This figure is slightly higher in the United States.6

INFLUENCES OF MASSAGE FRANCHISES AND THE SPA INDUSTRY
Sitting halfway along the professionalization trajectory also leaves the massage therapy profession open to the influences of – and possible exploitation – by – massage franchises and the spa industry, which employ great numbers of massage practitioners. Although some of these influences may be very positive, be aware wages and business practices can be dictated by these powerful players on a profession that does not enjoy the funding and representation of medicine, physiotherapy or nursing.

The spa industry is very lucrative both in Canada7 and the United States8, and attracts many massage therapists with the promise of good wages, workplace benefits and the provision of promotion and administrative services.  Franchises are not ambiguous about the product they bring to market and thus are often more competent than the profession itself in portraying a clear identity to the paying public. Confusion is a killer in the marketplace.

WHAT DOES THE FUTURE HOLD?
So what do massage therapists/practitioners wish to be identified as: primary health-care professionals, paramedical assistive workers, spa esthetic service providers…? Our identity determines funding, public perception, credibility, income potential and business practices of massage therapists. Of course, there are costs and huge investments to be made, depending on how (and if) we wish to position ourselves.

If we continue to be all-inclusive in our scope, I believe we will continue to confuse the public, government, insurance companies and other health-care providers; we will perpetuate a problem that will cause these forces outside our profession to classify and define us, and ultimately direct us. “Walk in the middle, get squish just like grape.”

REFERENCES

  1. Report on Policy Issues Concerning the Regulation of Massage Therapy in Canada. Prepared for the Federation of Massage Therapy Regulatory Authorities of Canada (FOMTRAC). Donelda Gowan-Moody, BA, RMT and Amanda Baskwill, RMT
  2. http://www.massagemag.com/News/massage-news.php?id=7038&catid=250&title=trends-in-us-massage-therapy-regulation
  3. http://fhs.mcmaster.ca/physicianassistant/
  4. http://www.collegept.org/AnnouncementRetrieve.aspx?ID=22212
  5. http://www.workingincanada.gc.ca/report-eng.do?
  6. http://www.workingincanada.gc.ca/report-eng.do?noc=3235&sMode=area&provId=6A&province=35&area=6261&nextButton=Continuer&template=portal
  7. http://www.bls.gov/oes/current/oes319011.htm
  8. http://www.tourism.gov.on.ca/english/research/studies/2006_Canadian_Spa_Sector_Profile_eng%20final.pdf


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