Mr. Gary Kowalski, MLA for The Maples

Mr. Kevin Lamoureux, MLA for Inkster

Clerk Assistant (Patricia Chaychuk): Order, please. Will the Standing Committee on Industrial Relations please come to order. We have a vacancy for the position of Chairperson. Are there any nominations.

Mr. Edward Helwer (Gimli): Madam Chair, I would like to nominate Mr. Dyck, the member for Pembina.

Clerk Assistant: I am just Madam Clerk, not the Chair. I am sorry.

Mr. Helwer: Okay, fine.

Clerk Assistant: Mr. Dyck has been nominated. Are there are other nominations? Seeing none, Mr. Dyck is elected the Chair.

Mr. Chairperson: Okay, before we move ahead we need to elect a Vice-Chair. Is there a nomination for a Vice-Chair?

Hon. Jack Reimer (Minister of Urban Affairs): I would like to nominate Mr. Helwer.

Mr. Chairperson: Mr. Helwer has been nominated. Are there any others? Is it by agreement of committee that Mr. Helwer will be the Vice-Chair? [agreed] Thank you, then we shall proceed.

This evening the committee will consider the following bills: Bill 26, The Physiotherapists Act; Bill 36, The Registered Nurses Act; Bill 37, The Licensed Practical Nurses Act; Bill 38, The Registered Psychiatric Nurses Act; and Bill 39, The Medical Amendment Act.

To date we have had a number of persons registered to speak to the bills this evening. I will read the list of the registered presenters aloud. I shall start with No. 1, Mr. Terry Woodard–and this is on Bill 26–No. 2, Dr. Anthony Wright; No. 3, Neil MacHutchon; No. 4, Gloria Gallant; No. 5, Jason Hallock; No. 6, Roland Lavallee; No. 7, Susan Morrow; No. 8, Kelly Robert Milan; No. 9, Madeline Arbez and Dr. Greg Stewart; No. 10, Mark Garrett; No. 11, Marc Arbez; No. 12, Murray MacHutchon; No. 13, Evelyn Lightly; and No. 14, Dr. Ken Brown.

There are two walk-ins. Number 15 would be Ruth Barclay-Gordon; and No. 16, Brenda McKechnie.

Then, moving on to Bill 36, we have one presenter, Sue Neilson; Bill 37, one presenter, Verna Holgate; and Bill 39, Mr. John Laplume and Dr. Ken Brown.

To date, or at least at this time, no one has registered on Bill 38.

If there are any other persons in attendance who would like to speak to one of the bills before the committee this evening and who have not already registered, please see the Chamber staff at the back of the room to register and your names will be added to the list.

In addition, if there are written items to be handed out to the members of the committee, 15 copies are required. If assistance is required to make the photocopies, please contact the Chamber branch staff at the back of the room and the copies will be made for you.

The next item of business that the committee needs to consider is which bill to hear presenters on first. There are two presenters on the list for Bill 26 who are from out of town and one presenter on the list for Bill 37. Did the committee wish to hear from out-of-town presenters first? What is the will of the committee? [agreed] Agreed that we hear the out-of-town presenters first. Thank you. After we have heard from the out-of-town presenters, in which order shall we hear the presenters on the bills?

Mr. Helwer: Mr. Chairman, I believe we should hear all the presenters that we can this evening and then carry it through to clause by clause after that.

Mr. Chairperson: Which order, Mr. Helwer, would you like?

Mr. Helwer: The order that they are listed.

Mr. Chairperson: The order as they are listed, that is the order in which we will hear the presenters. Is that agreed by the committee? [agreed] We will do out-of-town presenters first, and then we will go back and start with Bill 26 and take it in the order in which they appear.

Did the committee wish to use time limits for the consideration of presentations? What is the wish of the committee? No, okay. So we will encourage brevity, short, to the point, if possible.

I would just like to note for the committee that two written submissions regarding Bill 26 have been received, one from Paula Moreira from the Yellowhead Physiotherapy Clinic, and one from Lynda Loucks, a private citizen. Copies have been placed on the table for committee members. Is there agreement to have the written submissions appear in the committee Hansard for this evening's meeting? [agreed]

Mr. Chairperson: We will now proceed with the consideration of the presentations. I will take those with a little star beside them. I will start at No. 4 with Gloria Gallant, please, if you could please come to the podium. Possibly, just for consideration afterward, after we finish the presentations, I will open it up for questions, and I will identify both the presenter just before they answer the question and I will also identify the person asking the question, just for clarity later on. So, just a moment, and then I will ask you to give your presentation. Please proceed, Ms. Gallant.

* (1910)

Ms. Gloria Gallant (Private Citizen): Thank you for this opportunity to address the public committee regarding this proposed new physiotherapy act. I am a physiotherapist living and working in rural Manitoba, and I have been involved in the committee that drafted the legislation that you see before you. The new legislation was required to update several areas to current standards. The main area that required updating was the complaints and investigations procedures.

The advent of physiotherapy occurred in the late 19th Century in the United Kingdom. At that time, physiotherapists used exercise, mobilizations, manipulations, massage and other physical methods to assist their patients on the road to recovery. Physiotherapy spread throughout the world and has grown and flourished. Physiotherapy is currently a four-plus year university course with summer internships and a national competency-based examination required by most provinces prior to entering the profession. Academic standards are high, and graduates are independent and professional thinkers. Physiotherapists are taught a variety of techniques to be used in assisting a patient to obtain and maintain the maximum function possible for that individual. This will often include teaching patients different techniques that they can use to take charge of their own problem and manage it as much as possible. Physiotherapists work within the medical model and have good lines of communication with physicians and other health care providers.

In my practice as a physiotherapist, I have worked in Manitoba, Newfoundland, and England. My education from the University of Manitoba held me in good stead in all those various workplaces. In all of those geographical areas, physiotherapists worked in co-operation with the medical profession without direct supervision or direction. The education received as a physiotherapist includes instruction in various medical conditions and how those conditions vary from the usual conditions encountered in a physiotherapist's clinic. I remember several instances where I assessed an individual for a spinal condition and found that my assessment did not support the physician's request for physiotherapy treatment. The patient was sent back to their physician requesting further investigation.

In at least three cases that stand out in my mind the physician did further investigations and confirmed my suspicion that the problem was not as originally diagnosed but was indeed cancer. I bring these instances up to underline two points. Physiotherapists are educated to assess and treat and to recognize when physiotherapy treatment is not appropriate. Physiotherapists have a good working relationship with medical practitioners. When there is doubt in our minds as to the diagnosis, we can readily obtain the assistance we require.

The current situation in Manitoba is direct access of the public to physiotherapy but requires that physiotherapists communicate and consult with physicians. In practice, this means that a patient will often attend a medical clinic to obtain a physician's letter to bring to physiotherapy. This communication from the physician states something such as: low back pain; please assess and treat. The physicians know that that is all the information required, and if more is needed, we will ask for further investigations. Patients can very easily tell me the same thing: My low back hurts. Could you please check it out and help me out?

The change in the act before you poses no danger to the public. Indeed, the ability to go directly to the physiotherapist will save the public some health care dollars with no increased risk. When the Physiotherapy Association consulted the College of Physicians and Surgeons concerning our proposed new act, no concerns were raised. I personally do not do manipulations in my physiotherapy practice. I use many other techniques such as mobilizations, exercise and lifestyle intervention. If a patient requires manipulations, I send them to a physiotherapist qualified to do that. The professional standards in place for physiotherapists to do manipulations are very high. Manipulation techniques are restricted to those physiotherapists who are specially educated to do them. The physiotherapy college in Alberta is currently developing a new competency standard for manipulations. It will undergo a national validation procedure and will be followed in Manitoba when it is available.

Like most physiotherapists in Manitoba, I carry malpractice insurance that is available through our professional organization. The new act before you would allow the Physiotherapy college to require that all physiotherapists in Manitoba carry malpractice insurance. The majority of physiotherapists carry this insurance already except those therapists who are covered by their employer. The new act would ensure that there is 100 percent compliance. The main reason for redoing our act was to update our complaints and investigations procedure to bring it in line with current thinking. Our present act allows for a finding of professional misconduct but does not allow for findings of lesser problems.

The new act identifies other areas that would require redress in some fashion. It would allow for mediation when it was felt that the issue was one between the complainant and the physiotherapist, allow for counselling or require courses to rectify an identified problem area. It would also allow for censure of a physiotherapist, impose conditions on a physiotherapist's entitlement to practise physiotherapy as well as to suspend or cancel a member's registration and therefore their right to practise physiotherapy.

In Manitoba, the current Physiotherapist's Act was proclaimed in 1981 with a prior act in 1974. The following are the major changes in the new proposed act and the benefit to Manitobans. The first one is a name change from association to college, which provides a stronger position for public protection. Physiotherapists and physical therapists would be protected titles which is less confusion for the public. There would be more public representatives on council and committees which allows for more public accountability. There would be direct access to physiotherapy, which is a simplified process for the public and less costly to health care.

The function of the college would be clearly stated to serve and protect the public interest, not the interest of the profession. There would be a simplified two-stage complaints process, more accessible and more accountable to the public. The complaints process will have more option. The public interest would be better served in correcting problems through mediation, censure, monitoring practice requiring a member to take courses, et cetera. The regulations provide for establishing a continuing competency program, which again is public protection. The regulations provide for a requirement that members carry professional liability insurance, which is again public protection.

The council may appoint practice auditors to review the operation of a physiotherapy practice. This is public protection both proactive and reactive. The new act would allow compliance with the AIT which allows for portability across Canada and therefore more availability of physiotherapists. It allows for simplified categories of registration which is less confusing to the public, and it allows for an annual report required to the Department of Health, which is more accountability to both the government and to the public.

The Physiotherapists Act before you is good legislation for all Manitobans. It corrects problems in our current act, strengthens the public accountability and protection of the public aspects of the act and brings Manitoba in line with the majority of other Canadian provinces. Patient safety is foremost for all of us, and this new act allows us the mechanisms to ensure that safety is indeed always the main issue.

Mr. Chairperson: We wish to thank you for your presentation. There are several questions upcoming. I will ask the minister to pose his first.

Hon. Eric Stefanson (Minister of Health): Thank you very much, Mr. Chairman, and thank you, Ms. Gallant, for your presentation. I only have two questions, because you have addressed a couple of the issues that have been of some concern. You touched on the issue of liability insurance, and it is my understanding today that any physiotherapists who are in private practice as a basis of good business carry liability insurance. But I know that through the preparation of the regulations, the College of Physiotherapists will be consulting, will be reporting back to us, and we as a government will have to pass those regulations.

I take it from your comments that it would be your inclination and that you would be supportive that malpractice insurance be mandatory for individuals who are going to be practising a private practice.

Ms. Gallant: Actually, I would support it being mandatory for all physiotherapists, even those working inside a hospital setting, just because there is always the option of the hospital covering you and then suing you in return. So my opinion would be that it should be mandatory for everyone.

Mr. Stefanson: The other issue is then the issue of manipulations that you speak to in some detail in your presentation, and once again that the College of Physiotherapists will be reviewing that issue under the regulations, making recommendations basically relative to the whole issue of the requirements to do manipulations, particularly as it relates to spinal manipulation. So again, I just ask for your comments on that process and your views.

Ms. Gallant: I would assume that the process would be that we would write regulations setting up standards for manipulations, and because the College of Physiotherapists in Alberta are right now looking at competency standards for manipulations that will be undergoing national validation, those competency standards are probably what we would use. Our professional association has already standards in place, but because our particular profession is divided into a professional and a licensing association, it is not the licensing association standards; it is professional standards. All physiotherapists follow those standards anyway, but the new national competency standards would be what I would hope we will adopt.

* (1920)

Mr. Dave Chomiak (Kildonan): Thank you for the presentation. Curiously, both the issues that I was going to address have been approached and then broached by the minister. I just do want to clarify the issue of malpractice, because that issue has come up.

In your presentation you indicated the fact that right now most physiotherapists, if not all physiotherapists, are covered by liability insurance. I presume that one of the issues that will arise will be, well, now that there are direct referrals and perhaps there may be a greater need for this, and I will assume from the minister's comments and your comments, as well, the regulations which are not mandatory which say may require members, I assume that the association will be recommending–and since you drafted legislation–they get mandatory. Is that correct? I would also assume that the government will be proceeding on that basis. Is that a correct assumption?

Ms. Gallant: That is a correct assumption. I do not think it is written as mandatory in the regulation section of the act, but if you require malpractice insurance by all members, regulations are enforceable.

Mr. Chomiak: I will also be looking to the minister in terms of a confirmation later on when we go clause by clause through that particular section. Of course, the other issue is the issue of manipulations. You had indicated in your practice that if there was an occasion, you do not specifically handle manipulations yourself, but you do direct them toward someone who is a specialist or has more experience in that area. Is that the general pattern that is followed? Can you give me information on that, generally?

Ms. Gallant: Yes, I would think so. I work in rural Manitoba, so my setting is slightly different than most of the people that work in Winnipeg. But, when there is somebody who needs a manipulation, I encourage them to go further afield, which is usually Winnipeg, in order to get that specialty area. There are chiropractors in the area, and I have sent people to chiropractors as well. But I encourage them to go to a specialist in the area.

Mr. Gary Kowalski (The Maples): As the other speakers have said, we have received a lot of letters as MLAs from a number of physiotherapists and also from chiropractors. The two issues that the chiropractors brought forward was the issue of malpractice insurance in manipulation and you have covered that. I was just about to ask you the question about your relationship with doctors. You explained that doctors have been referring matters, and sometimes you have referred them back to the doctors. I was going to ask you what is the working relationship with chiropractors and physiotherapists. You have said that there have been occasions when manipulation was required and that you would refer people to chiropractors where I was led to believe that they were a competing service. Are they complementary services, physiotherapists and chiropractors, or are they competing services?

Ms. Gallant: Well, you can look at it both ways. In my opinion, the best treatment for the patient is what all of us are supposed to be looking toward. I do not work in a private practice setting so my pocketbook does not dictate my referrals. So in the instance where somebody needs a manipulation, I will send them to whoever I feel is the most qualified, and I have on occasion sent them to a chiropractor. The majority of the times, I will send them to a physiotherapist because I know a physiotherapist's training much better than I know a chiropractor's training. But, living in rural Manitoba, that means a long drive for most people, and if that drive is not acceptable to them, then I have suggested that they go to a chiropractor.

Mr. Kevin Lamoureux (Inkster): Just for clarification, you indicate that you do not do manipulations. Is that because of your choice? Right now you would have the training any physio can do manipulations, but you choose not to do it. Is that a fair assessment?

Ms. Gallant: No, I have the background training to do manipulations, but I have not taken the courses that are required to do manipulations in all areas. There are a couple that I could do, but I do not work full time as a physiotherapist, and I feel that you need to be practising on a regular basis in order to continue doing a procedure like that, so I have chosen not to do those procedures that I am trained for because I do not feel comfortable doing them.

Mr. Chairperson: If there are no further questions, thank you very much for your presentation. We will move on to our next out-of-town presenter; that is No. 6, Roland Lavallee, please. Okay, if you could please start with your presentation as soon as you are ready. I do not want to rush you. Mr. Lavallee, thank you, proceed.

Mr. Roland Lavallee (Private Citizen): Good evening, honourable ladies and gentlemen, colleagues, members of the public, as well as, members and representatives of the Manitoba Chiropractors' Association. I wish to thank you for the opportunity to address the committee here on Bill 26, The Physiotherapists Act. I do so as a private citizen but also as a physiotherapist with a unique perspective, I think, on some of the major issues being discussed by the one group opposing aspects of this legislation. It might be useful for the committee to understand my perspectives, how they were formed.

I graduated from the University of Manitoba in 1983. Since that time I have been active on a number of different committees. Some of note, I have been chairperson of the Manitoba Sports Physiotherapy Division of the Canadian Physiotherapy Association; chairperson of the Private Practice Physiotherapists of Manitoba. Currently I am chair of the discipline committee for the Association of Physiotherapists of Manitoba, and I have had that responsibility for the last five years or so. I have had my own practice since 1986, and I have worked under the banner of Windsor Park Physiotherapy.

I have, as many of my colleagues here, extensive postgraduate clinical training. My specialty is in orthopedics. At this time in Manitoba, there are five physiotherapists with my clinical designation of a Part B. Part B practitioner is that practitioner who has studied and been tested for orthopedic specialization, as well as, peripheral and vertebral manipulation

There is another section of specialist. They have a Part A, and they have been tested in peripheral manipulation and many of the aspects of our orthopedic specialities. So there are five of us here in Manitoba that have that Part B designation. We are termed Fellows of the Canadian Academy of Manipulative Therapy. We are responsible for assisting Manitoba physiotherapists who have an interest in gaining clinical knowledge and experience in orthopedics and peripheral manipulation. I teach orthopedic courses, and some of those courses include peripheral manipulation and I refer to peripheral as wrists, ankles, knees, et cetera. I am working towards becoming an examiner for the Canadian orthopedic examination system of the Canadian Physiotherapy Association.

I understand there are two major issues being discussed and opposed, I might say, by the Manitoba Chiropractic Association. The two main issues are this, and they have been alluded to already, that is the continuation to include manipulation in the physiotherapists' scope of practice, as well as the provision to allow the public to gain direct access to physiotherapy services.

Regarding the first item, I hope you all realize that manipulation has been in a physiotherapy act since the '50s, so this is not a new aspect of treatment. My specialized orthopedic training places me, I think, in a situation where I am the practitioner as well as a teacher in this aspect. I want you to understand the Canadian orthopedic and manipulative training system is highly regarded in Canada. Canadian physiotherapy associations form part of the International Federation of Manipulative Therapists, that is the IFOMT. Our system of clinical training for orthopedic physiotherapists is copied throughout the world, and what I mean by the world, I am talking about the Netherlands, Australia, England, the United States. Canadian physiotherapists have reason to be proud about our world reputation in the practice of manipulation and orthopedic training, in the training of that and in the practice and research of manipulation. Indeed, I am proud to be part of that education system also.

* (1930)

Quite simply, ladies and gentlemen, physiotherapists have been practising safe manipulation in Manitoba and in Canada for years. There is no evidence to suggest that Manitoba physiotherapists are unsafe practitioners of manipulation. That reflects on my work and the efforts of my colleagues in Manitoba and Canada. As chair of the discipline committee of the association, I would hear any investigated cases on malpractice of manipulation. In my tenure, there has not been any. In the past there have not been any complaints made by groups or the public regarding manipulation and physiotherapists. That is a matter of public record. I think this reflects on the expertise, the training and the clinical judgments of physiotherapists to choose manipulation or to not use manipulation. It illustrates a very high standard of practice that you should all be made aware of when you are considering the merits of Bill 26.

Our system of education is different than that of chiropractors. The philosophy of orthopedic and manipulation offers, in my opinion, Manitobans a choice. Our system of training works in providing effective–but the issue here is it also has been proven to be safe. Manipulation across the world is practised by many professions, if you did not know, physiotherapists, chiropractors, certified athletic therapists; some physicians have been trained, physiatrists, who are physical medicine specialists, osteopaths. No single group in the world has exclusivity on the training or the practice of manipulation, and, in my opinion, nor should they. Please make sure that Manitobans continue to have a choice. Our standards in manipulation have a solid basis and they are safe. The evidence speaks for itself.

The second issue I want to discuss here is the issue of direct access. When I was preparing my presentation I thought I would give it a title. I was trying to think of something flashy. So the first thing that came to mind was First Contact: The Landing of Bill 26. Now if any of you in the committee here are sci-fi enthusiasts, you know that term "first contact." I am a sci-fi person; I love that sort of first-contact concept. However, when I sort of thought about it, I realized that that is not the right title, that is wrong. Ladies and gentlemen, physiotherapists landed a long, long time ago. We have been a key member of the health care team long before I graduated. Direct access, in my opinion, is a rite of passage for our profession. In fact, I stand here before you today defending a policy that I essentially have had since graduation. Let me explain that.

This is an example of a patient who comes in with Blue Cross. Contrary to what some groups may think, patients choose my services without a direct patient's referral. That is, they come, they make an appointment with me, I assess their problem, I decide a course of treatment. Current legislation requires that I treat that patient in communication with a physician. I do that by either a telephone call or a short note. Insurance plans, like, I said, Blue Cross, do not require a physician's referral to pay for my services.

Ms. Gallant said, and I will emphasize again, the public has had the chance to obtain direct access by a physiotherapist since 1981. Bill 26 is not a large leap of faith for you to take. In fact, I think it is a small refinement of a system that already works in Manitoba. I hope you will be hearing presentations from the faculty at the University of Manitoba. They will provide you with the details of the pathology and differential medical conditions training that physiotherapists get. The public, as well as groups, have never made a formal complaint to the association in regard to our duty of care when patients were assessed and given a physiotherapeutic diagnosis. We are firmly entrenched in the team approach.

The College of Physicians and Surgeons is fully supportive of the proposed legislation. I feel they have got good reason to be confident in our skills to assess musculoskeletal conditions and refer other conditions on to medical doctors for further evaluation when necessary. We work closely with medical practitioners, and therefore we have quick and easy access to relevant information that is required to provide safe, efficient, and effective physiotherapy care.

I want to clarify something because the point has been brought up earlier, that is, the issue of malpractice insurance. I have practised since 1983. I have had malpractice insurance since then. I have owned a clinic since 1986. Nobody would work in my clinic without malpractice insurance, and I am totally confident that would be the case in all of the private clinics in the province, that it already exists. No one would be there to support us in the event that we would have taken a malpractice suit.

We all recognize the escalating costs in medical care. I am sure you are familiar with the burden of the long waiting lists and the busy medical practices. They are all understood by you. You need not be an economist to realize that direct access to physiotherapy services can provide an effective means of alleviating some of those burdens. There are many instances–sprained ankles, athletic injuries, back strains–when a physician's time is saved when his or her patient visits the physiotherapist first and a treatment plan is set out. That initial physician appointment can often be a rubber stamp. Yes, you have a sprained ankle, go see the physiotherapist. Well, it is not Blue Cross that paid for that physician's visit; it is the Manitoba medical system that did. There is an automatic saving there for Manitobans when it is literally speaking a rubber stamp.

Many doctors would agree that this situation often occurs in their practice. The College of Physicians is not concerned with the ramifications of Bill 26 when it comes to direct access. No opposition has been forwarded except by the MCA, and, with all due respect I am not familiar with the evidence, and I underline the word "evidence," that would justify their concerns.

My final point illustrates how early consultation to a physiotherapist is paramount in providing good rehab care. I refer you to the last page of my presentation that has a coloured form here. This is an excerpt from a larger study, and I have a 54-page document. I wanted to save a tree and not provide 15 copies of that, but this is an excerpt of that analysis.

I form part of a network of physiotherapy clinics across Canada. We have taken aspects of our physiotherapy files, and we have looked at 25 factors. Some of them include: how long did it take to see a physiotherapist? Is someone taking medication for their primary diagnosis? Is there a rehab consultant involved? Twenty-five factors. We wanted to do that because we wanted to extract information right at the beginning of patients' care so that we could recognize who is at risk for chronic, perhaps long-term rehab, and if we can recognize those people, we would maybe be able to pull in other disciplines–psychologists, occupational therapists, whatever–to try to assist in their care. So this excerpt, I will just illustrate quickly, this is from 3,000 physiotherapy files. That bank that we have now in Canada is over 10,000 files, so the information is coming and will be more and more reliable as time goes on. The large arrow on my presentation is highlighting the main factor that existed in patients who had chronic problems.

I do this as a way to provide you with some proof how direct access could help Manitobans. Lag time of referral is the term that I want to use here, the time it took for someone to see a physiotherapist. If it took greater than four weeks, the person was in treatment longer, and success, that is, return to work, took longer to get them back to work. So the earlier the better is the point I want to make about that. Get them into physio earlier. Direct access will help that. Get them active, in my terminology.

The final illustration that I will want to say is how physiotherapists have worked well here in the system in Manitoba. This here is the final document I have presented to you, the one that has the blue highlight on it. This document is the Standards of Excellence Program that was jointly developed between the private practice group in Manitoba and Manitoba Public Insurance Corporation through the guidance of Ernie Toews, Don Gaudry, Dr. Neil Creighton [phonetic] who formed the MPIC contingent of this. We developed a joint program on how patients injured in motor vehicle accidents could be educated, made active early to reduce the chances of chronicity.

This is a unique document, ladies and gentlemen–this does not exist anywhere else in Canada–where a motor vehicle insurance company and a professional group came together with ideas to help the public to reduce any chances of chronicity.

I want to read just the very top thing here: MPIC acknowledges the positive contribution made by the private practice physiotherapists of Manitoba in the creation and implementation of the Standards of Excellence Program.

Physiotherapists are ready for Bill 26. I feel strongly that you will better serve the public in Manitoba if you allow its quick passage. Thank you.

* (1940)

Mr. Chairperson: Thank you very much for your presentation. We will open it up for questions. The honourable minister first.

Mr. Stefanson: Thank you, Mr. Lavallee, for a very thorough presentation. I will not ask you again to reiterate comments on malpractice or manipulation, recognizing we have about 16 presenters, but you did speak at some length about the issue of public access, and again I appreciate and agree with your comments. My understanding is not unlike many other health care professionals, that your code of ethics, the Association of Physiotherapists requires physiotherapists to request consultation with or refer to colleagues or other members of the health care team when such is necessary in the interest of optimum patient care. Could you offer any further comments on that?

Mr. Lavallee: I have been doing that throughout my time as a physiotherapist. Any time a patient would have seen me, if they came without a referral I would have always communicated to that practitioner that I have seen their patient, what is their problem, do you have any concerns, if you do, please contact me back.

There are a number of instances where patients have come with an incorrect diagnosis, and we just sort of phone call discussed it back. We are here for the patient and having patients as quickly treated and as quickly understanding their problem the better, and that has just been the normal course. I do not see Bill 26 changing any of that. If anything, as I mentioned before, it will refine it.

Mr. Chomiak: Thank you for the presentation. Because there are a lot of presenters I do not want to go over a lot of territory, so I am going to ask you a question that perhaps–I wanted to have a little bit better understanding of the designations under Part A, Part B, et cetera. I do not know if I should pose that question to you or perhaps–I note that there is going to be a presenter from the University of Manitoba who might better be able to. Either way, can you give me a layperson's sort of a breakdown of those designations, please?

Mr. Lavallee: The orthopedic training that exists in Canada today follows the Canadian Physiotherapy Association's specialization document. That is a sort of a step procedure. Currently graduates from the University of Manitoba, and this is where faculty might answer the question better, are graduated with the first level of course termed the E1V1. "E" stands for extremity; "V" stands for vertebral. So if someone does an E1V1, they graduate; they are interested in orthopedics, they carry on. They take an E2V2. Then they take an E3V3. After they have taken a V3 and they have this desire to challenge the examination system in Canada, that examination system happens through three steps: a written presentation, an exam, as well as a practical examination. That practical and written examination happens once in Canada every year. So people prepare to do this exam. They have gone through their first levels. They take their examination. They earn a Part A. A Part A allows them, that the association recognize that they are skilled and have been tested in peripheral manipulation, specialized orthopedic assessment, and they are able to teach some of the lower level courses, the E1s, the E2s, the V2s.

The next step: you take a V4. The V4 is the manipulation course. After you have taken the V4, most people take another V4 from another practitioner in Canada because there are very specialized people in Canada that teach these courses. Once you have taken your V4, you can challenge the Part B exam. Once you have challenged the exam, successfully completed, the association would consider you capable of peripheral and vertebral manipulation as well as teaching the higher level of courses. That is the system. That is how you get your A and B.

Mr. Chomiak: Mr. Chairperson, I presume that there might be an argument about the issue of manipulation and the level of training under these designations. Can you comment on that?

Mr. Lavallee: My first comment might be some of the comments I have made. The proof is in the pudding. There has never been any action against a physiotherapist in Manitoba. Our system in Canada works.

I made a comment about so many professions do it differently. There are osteopaths. There are even osteopaths who practise in Manitoba. It exists in Quebec. It exists in the States. Osteopaths manipulate. Is it the same training as mine? No.

So I guess I make the comment, the training certainly can be debated, and I would not want to compare my training to that of a chiropractor. I am not a chiropractor. I am a physiotherapist. Our philosophy is embedded in our educational system. Quite simply, it is safe. That is, I think, the issue that might be the concern. I do not know of any evidence to the contrary.

* (1950)

Mr. Lamoureux: Yes, I did have a couple of questions for Mr. Lavallee. When today little Johnny or Jane is walking through a field, steps in a hole, sprains their ankle, you indicate that if Johnny walks over or is carried over to your clinic, there is an obligation for you to consult a physician in order to treat little Johnny.

I am interested in terms of a percentage basis, and I can appreciate you are going to have to guesstimate possibly, of the numbers of cases that there would be no real requirement for these individuals, whomever they might be, to have to go and see a physician prior to physio.

Mr. Lavallee: My first comment would really stem to the dollars and cents issue. It depends on the insurance company. Currently, Blue Cross is the insurer in Manitoba that will pay for the service. Great-West Life requires a physician's referral, so that Johnny, depending on mother or father's insurance plan, quite simply would have to go to see that physician and get that rubber stamp to see me.

Now you are talking about percentages. Blue Cross forms the largest component of what comes to see me in my clinic. Clearly, 80 percent of private insurance users of my services are Blue Cross, which would then sort of fit that the largest majority of those patients certainly can come in with that patient's referral. So it first of all depends on money for that patient coming in. If Johnny's parents could afford my services without an insurance, fine, they could come in, but that is a small percentage. Blue Cross forms the largest good 80 percent. If I see three or four new patients a day, 80 percent of them are Blue Cross and, for sure, daily, someone comes to see me without a referral. So figure the amount of days that that might be, and how many times that happens.

Mr. Lamoureux: Johnny hurts himself. He goes to the hospital. A registered nurse at the emergency or whatever sees Johnny. He has a really bad sprain in his arm. In order to see the physio at the hospital, Johnny would have to be referred from the doctor.

There are two things here. One is the cost factor. The other is the potential problems that are incurred as a result of Johnny maybe not seeing a physio as early as he could have had he not had to go through a medical doctor. So what sort of a cost factor is there by having to go to the doctor first? Are we talking a nominal fee? Are you talking a substantial fee? When you call the doctor's office and say: well, look, I have this patient; Blue Cross obligates me to talk to you–[interjection]

You know, there is going to be a fee to MHO. What sort of a fee are we talking about for that doctor to say, yes, you can treat that?

Mr. Lavallee: No fee. The physician does not bill to see my note or to hear a phone call from me. I suppose that is perhaps, I will say, from the government's side, the beauty of direct access is my services are paid through third-party payers. Private practice is not supported by Manitoba Health Services Commission. If a patient is seen in the hospital, then fees are incurred. The fee issue is, when they see me without a doctor's referral, there is no cost to the system. It is all borne by a third party, Blue Cross, Great-West Life, whatever.

If they are seen in the hospital, that is a different issue. I do not know the current fee of what MHSC has to pay the hospital to see a physiotherapist. I do not know that fee.

Mr. Lamoureux: I just want to be clear on the point. If Johnny wants to see you and Blue Cross says: well, you can only see Johnny if you have a doctor's referral–

Mr. Lavallee: Blue Cross never does that.

Mr. Lamoureux: Okay, are there any organizations that would require that sort of service?

Mr. Lavallee: Yes, Great-West Life, for instance. If Johnny's insurance company is Great-West Life, Great-West Life in their stipulation says you need to see a physician first for us to pay the services. So then the cost to MHS, to the health services, does occur. I would say maybe from the perspective of Manitobans, I would like to see the day that Great-West Life does not make it a requirement of their insurance policy. It currently exists for Blue Cross, who is the largest insurer in Manitoba; it does not for others. This is just another step in that direction. I anticipate corporations like Manitoba Public Insurance Corporation, once Bill 26, or hopefully if Bill 26 is enacted, that the use of a physician in those kinds of simple strains and sprains in a motor vehicle accident, we will not require that physician visit to start the system.

Mr. Chairperson: Thank you. Are there further questions? If not, thank you very much for your presentation.

We will move on. As was previously indicated under Bill 37, Verna Holgate has indicated that she is not from out of town. So we will proceed and stay with Bill 26 and move up to No. 1 now, Mr. Terry Woodard, please. Do you have any copies for distribution?

Mr. Terry Woodard (Private Citizen): No, I do not.

Mr. Chairperson: Okay, please proceed, Mr. Woodard.

Mr. Woodard: Mr. Chair, fellow committee members. Further to what many of my colleagues up previous to myself have said, I would like to thank you for the opportunity to speak to Bill 26, The Physiotherapists Act. It is certainly, as has been touched on many times so far, a bill that is very important to myself individually and also to our profession.

My name is Terry Woodard, and I have been practising physiotherapy in Manitoba since I graduated from the U of M in 1992. Currently, I work at the Victoria Hospital.

I guess the first thing I would like to do is congratulate the government on bringing forward this legislation to the committee stage; and secondly, commend you on the consultative process that occurred prior to bringing it forward. I would also like to take the opportunity to thank both the official opposition and the third party for the attention that they have paid to this legislation up to this stage. My remarks on the bill will be quite brief.

Simply put, Bill 26, The Physiotherapists Act, is very important to Manitobans, and it is important for a variety of reasons. I would like to touch on two, and fortunately, the people speaking before me have taken it into a greater depth than I will even touch on. Number one, it will allow Manitobans direct access to physiotherapy, and I guess the way I would look at it, with the continued focus on our patients' best interests as a health care provider. We will continue to work co-operatively and in collaboration with many of the other health care practitioners, whether that be physicians, nurses, dieticians, chiropractors, whoever we feel is in the best interest of our patient to see is who we are going to continue to work collaboratively with.

* (2000)

I guess, No. 2, as has been touched on by Ms. Gallant in a lot of detail, was with regard to the public accountability and the discipline process certainly being firmed up and tightened up to ensure a lot smoother and fairer process if that need arise. During the development of the act, there was extensive consultation with many different organizations and with government. There was strong support for the act and also for the principles that it was based on. The College of Physicians and Surgeons, the Manitoba Association of Registered Nurses were two such groups who offered support for the act. I think I had chosen those two groups of the many who have offered support because they are two of the groups that we work strongest with and certainly two of the groups that we spend a tremendous amount of our time liaisoning and consulting with, with regard to how we can best serve our patients and meet their needs.

As a result of the consultative process, many suggestions and comments were brought forward, and they were studied and they were acted on. The result is the act that you see before you. In my opinion and many others, as a result of this, this act is in the best interest of Manitobans with regard to health care delivery. Issues such as professional liability can now be acted on as a result of Bill 26. We have certainly gone into a lot of detail about that already. The bill now gives the College of Physiotherapists, if the bill is to be enacted, the right to require members to carry the insurance. So again, one of the many concerns that was brought forward by a particular group I think we have certainly touched them and dealt with many times over.

I guess from a personal perspective, I am able to comment on the tremendous impact that myself and many of my colleagues have on Manitobans in terms of dealing with their health care needs. Helping a person overcome a disability, trauma or an injury, many times it is difficult to explain what that can mean to not only the patient or the client but also to the person who is providing those services. The ability to work as closely as we do with patients certainly means a tremendous amount to us, and again one of the areas that the act can certainly help us deal with.

As a key member of a collaborative health care team, the betterment of our patients, their health, their well-being and their future is a reward for us. I think the term "team" is something we need to touch on because that is how we approach it. Earlier in my presentation, as well as many of my other colleagues, we talked about what "team" means. We are not out in the health care field practising independently. We are working collaboratively with other agencies and with other disciplines. Sure each of the team members may bring a different frame of reference to the table, but the goal is to provide quality health care, quality safe health care.

For the continued delivery of excellence and physiotherapy care, I would urge you all to strongly support Bill 26. I would like to thank the Chairman and the committee for the time.

Mr. Chairperson: Thank you very much, Mr. Woodard. Are there questions?

Mr. Kowalski: Ms. Gallant, when she made her presentation, and I believe the previous presentations are in private practice and you work in the hospital setting, she talked about malpractice insurance not only for those in private practice but for those working in hospitals and clinics. The rationalization there was that even if the hospital carried liability insurance, the hospital could cover the patient but then they would sue the physiotherapist. Her assertion that would make all physiotherapists obtain malpractice insurance, would you agree that that would be something that would be accepted by all physiotherapists? Number 2, who would pay for that malpractice insurance? The individual therapist, the employer, who would pay for it?

Mr. Woodard: I think you bring up some very valid points. Right now the way that it works, as Mr. Lavallee had mentioned, my understanding is that in terms of private practice, all or essentially all of the members would carry liability insurance. Working in a hospital, at this point in time, the hospital covers my liability insurance. The comment that perhaps there would be the potential that the hospital may sue the physio, it was important for me to hear those kinds of remarks from Ms. Gallant, because it is certainly something that I would support in terms of all the members of the physiotherapy community having their own private insurance, whether they work in a private practice or in a hospital. So it was certainly a new point for me to consider, but I think I would have to strongly agree with her.

Mr. Kowalski: Do you have any idea how much malpractice insurance would cost for an individual therapist, any idea what the costs are of that?

Mr. Woodard: With regard to obtaining malpractice insurance, the majority of the physiotherapists in Manitoba would obtain their insurance from the Canadian Physiotherapy Association. I believe it is about $100 or $125 a year for the insurance. I could not tell you what level that would cover up to, but, again, it is sort of the standard amount that most physios would obtain.

Mr. Chairperson: Are there further questions? If not, I wish to thank you for your presentation. Thank you very much.

We will move on to our next presenter, Dr. Anthony Wright, please. Dr. Wright. Do you have copies for distribution? We will just wait until your copies have been distributed. Okay, please proceed, Dr. Wright.

Dr. Anthony Wright (Physiotheraphy, University of Manitoba): Thank you for the opportunity to speak to you this evening. Just to introduce myself, I am Dr. Tony Wright. I am here this evening as head of the physiotherapy program at the University of Manitoba. To give you some of my background, I hold an honours degree in physiotherapy. I also hold a masters degree in manipulative physiotherapy, and I completed my Ph.D. studies conducting research, investigating an experimental model of joint pain. I have also been very active over the last decade or so in conducting research in the field of musculoskeletal pain and also in relation to manual therapy and looking at the phenomena of manipulation induced analgesia, in other words, the pain relief that occurs after manipulative treatments. I publish extensively in that area, and I am also a member of the editorial board for the journal Manual Therapy.

Now I am just relating these points just to indicate to you that I do have some background in relation to the areas and topics that are currently under discussion. Let me begin by saying that I feel there has been a good deal of general satisfaction with Bill 26. Its initial drafting spanned a significant period of time with substantial consultation both within the physiotherapy profession and with other professions and stakeholder groups. On the whole, there has been a good deal of satisfaction with the legislation as it is being drafted and currently stands. At a late stage in the consultation process, the chiropractic profession, through the Manitoba Chiropractors' Association, made a submission to government in which they raised a number of objections to the new legislation.

These last-minute objections represent the only significant negative comments that have been raised. I would like to take the opportunity to deal with a number of those points of objection and to show you how they have been addressed. The initial objections can essentially be summarized as follows: there was some objection to protection of the title physical therapist; there was objection to the public having direct access to physiotherapy services; there were concerns about the level of professional liability insurance held by physiotherapists; there was objection to the fact that physiotherapists practise manipulation; and, there was a belief from the chiropractic profession that in some way they should act as gatekeepers for all those who would practise manipulation techniques.

* (2010)

Many of the previous speakers have addressed a number of these issues. I want to take the time to deal with each of these issues in turn and to show you how they have been or are being addressed beginning with protection of title. Following initial consultation with the Manitoba Chiropractors' Association at a meeting called by Mr. Carson, it was made clear that protection of the title physical therapists does not prevent other professional groups, including medicinal and chiropractic, from using physical or physiological therapies. This appears to have satisfied MCA, and, in subsequent correspondence, there has been no further objection to this particular aspect of the bill.

Direct access to physiotherapists is essentially a fact of life for all Manitobans under the current act. Currently, members of the community can visit a physiotherapy clinic and obtain treatment. Under the existing legislation, the physiotherapist is expected to consult with the patient's physician, but they do not necessarily require an initial referral from that physician. They do not necessarily end up being examined or fully examined by the physician. The present legislation simply recognizes and streamlines what is, in essence, a de facto situation.

Concern raised by the chiropractic association was that physiotherapists do not have the necessary examination and diagnostic skills to act as primary-contact practitioners. In subsequent correspondence, I have outlined the training received by physiotherapy students, and it provided assurances that physiotherapists are very well trained in this area. The physiotherapy profession has for very many years realized and recognized that physiotherapists practise as de facto first-contact practitioners, and in many jurisdictions around the world this role is fully recognized in legislation. As responsible educators for physiotherapists who may subsequently practise both in Manitoba and in any other part of Canada or elsewhere in the world, we realize that our graduates will be fulfilling this role and for many years we have educated them accordingly.

Now I would just like to relate to you something that I read and picked up on a website for the American Chiropractic Association, and it is quite interesting in terms of describing the role and expertise of chiropractors and is of very great relevance, I think, to the role and expertise of physiotherapists. In answer to the question what is a doctor of chiropractic, it says chiropractors are first-contact physicians who possess the diagnostic skills to differentiate health conditions that are amenable to their management from those conditions that require referral or co-management. Chiropractors provide conservative management of neuromuscular skeletal disorders and related functional clinical conditions, including but not limited to back pain, neck pain and headaches.

If I were asked to provide a description of the role of physiotherapists practising in the muscular, skeletal or orthopedic field, it would be that physiotherapists are primary-care practitioners who possess the diagnostic skills to differentiate health conditions that are amenable to their management from those conditions that require referral or co-management. Physiotherapists provide conservative management of neuromuscular skeletal disorders and related conditions, including but not limited to back pain, neck pain and headache. As you can see, there is really no significant difference. Of course, the strong overlap is one of the major factors underlying the chiropractors' objections.

If you are involved in presenting one of two competing products, it is imperative that you create difference between those products in order for the consumer to wish to partake of the service that you are providing. Much of the chiropractic correspondence has laboured on the topic of differential diagnosis. It is very clear to me that neither profession, physiotherapy nor chiropractic has access to the laboratory and imaging facilities necessary to be able to undertake a full differential diagnosis in complex cases.

What they possess is the training and screening skills to determine that a patient might have a spinal tumour, for example, and that they should undergo further investigation. They are not equipped to determine if that tumour, for example, is a latent benign lesion or a high-grade malignant lesion. Such differentiation is obviously important to the specific management of that patient's condition. The skills for full differential diagnosis in those areas rests with the medical profession. The skills that the physiotherapist possesses are the ability to recognize those conditions and problems in presentations that fall within their normal scope of practice and to recognize those patients with unusual or complex or presentations that cast some doubt about the potential diagnosis and to make referral to the necessary services for further investigation to be carried out. There is no evidence that physiotherapists in Manitoba have been failing in this role, and I am sure that the medical profession would have raised objection if there were any concern about the ability of physiotherapists to fulfill this primary-contact role.

It is interesting to note that, while in correspondence from the Canadian Chiropractic Association there was a recommendation that physiotherapists should not be granted primary-contact status until they meet minimal base standards. I note that in the most recent correspondence from the president of the Manitoba Chiropractors' Association such a recommendation has not been included. I am therefore assuming that chiropractors have accepted the assurances and information that has been provided and that they are now withdrawing or withholding their objection to physiotherapists acting as primary-contact practitioners. The failure to recognize that physiotherapists can and do fulfill this role essentially flies in the face of reality.

On the issue of professional liability insurance, the MCA seems to lack a full understanding of the legislation and the current situation. Currently, most physiotherapists in private practice hold professional liability insurance, as you have been previously advised. Most therapists working in the public system are covered by insurance held by the institution.

The new legislation has been drafted to specifically give the college the power to create regulations requiring all physiotherapists to obtain and maintain professional liability insurance. It is my understanding that such regulations will be developed and that they will have to be approved before the act is applied. Clearly, APM has recognized this issue, and it has ensured that it is addressed through the new legislation.

Essentially, from my point of view, the question of professional liability insurance is essentially a nonissue. It is very clear that the new legislation provides for it and that once the legislation is in place and the regulations are prepared, that will become a reality.

The main points of continued debate revolve around the use of manipulation by physiotherapists. To some extent, this is not surprising. Currently, chiropractors in Manitoba receive government reimbursement for spinal manipulation. Physiotherapists in private practice, on the other hand, who provide spinal manipulation or peripheral manipulation services do not receive such reimbursement. The physiotherapy profession has made representations to government seeking equitable funding for their services and pointed out that Manitobans who receive manipulative treatment from physiotherapists are to some extent disadvantaged. What better way to secure your financial monopoly in this area than to use legislative means to prevent other professional groups from providing this service?

In relation to the use of manipulation and the safe application of manipulation by physiotherapists, the first point to make is that manipulation is not a new treatment for physiotherapists. In some correspondence and in some parts of the chiropractic literature, there is a strong inference that physiotherapists have only recently begun to use manipulation. I would like to explicitly state that this is incorrect. Physiotherapy predates chiropractic as an organized profession. The physiotherapy profession emerged in England in the 19th Century. Chiropractic, on the other hand, began in North America.

* (2020)

At an early stage, the Chartered Society of Physiotherapy accepted manipulators into its ranks, particularly in the north of England, and manipulation has been a component of physiotherapy practice essentially since then. While it is not the case that all physiotherapists practice manipulation, the one point to realize there is that physiotherapy is a very broadly based profession. People practise in a number of different areas, including, for example, in the pediatric field, in the cardiorespiratory field, in the neurological field, the management of stroke and the management of patients with amputations, as well as practising in this musculoskeletal orthopedic field. There have always, however, been some physiotherapists who utilize manipulation.

In the late 1950s and 1960s, there was an international awareness of the need to provide high-quality education in manipulative therapy for physiotherapists and also for physiotherapists to conduct research on this topic. This led to the formation of the International Federation of Orthopedic Manipulative Therapists. This is the organization that regulates physiotherapy education and manipulation around the world. Canadian physiotherapists have been very prominent in IFOMT, including the fact that we are privileged to have had a Canadian, Mr. Bob Sydenham, as past-president of IFOMT. The essential point is that physiotherapy education in manipulation exists under an international regulation and accreditation process.

In Canada, training in manipulative physiotherapy is essentially a two-tier process. At the undergraduate level, physiotherapists receive extensive training in musculoskeletal examination, clinical reasoning, the application of a number of joint mobilization techniques, as well as a restricted number of high-velocity manipulations. A system then exists which has been fully expanded for those physiotherapists who specialize in the musculoskeletal field to undertake further postgraduate training in this area. Those physiotherapists who follow courses leading to the Diploma of Advanced Orthopaedic Manual and Manipulative Physiotherapy undertake further training, including instruction, in a greater range of manipulation techniques. Any suggestion that physiotherapists practising manipulation are inadequately training in this area is incorrect. There is a very well-established, thoroughly reviewed and regularly updated process of training.

Let us just consider the topic of safety since many of the objections raised by the chiropractic profession have essentially worked around the concept of safety concerns. The first point to make about manipulation is that it is essentially a very safe treatment. Compared to many drug treatments or surgical interventions, for example, the risks are very low. For example, in all of the published trials of the use of manipulation, evaluating outcomes from manipulation, there have been no reported adverse effects within any of those trials. One major difficulty, however, is that an adequate scientific literature does not exist to really define what the proportional risk is for various adverse events that might occur with manipulative treatment. While manipulation in general is a very low risk procedure, we cannot ignore the fact that manipulation of the upper neck in particular does carry with it a small risk of very serious complications, including stroke and death. Sadly, the main at-risk group for these adverse reactions are relatively young, previously fit and healthy individuals. It, therefore, behooves all professionals using manipulation to exercise due care when manipulating particularly the upper neck or upper cervical spine.

The physiotherapy profession provided leadership in addressing this safety issue in the late 1980s when it introduced mandatory vertebral artery testing for all patients in whom a physiotherapist is contemplating an upper cervical manipulation, so that we are aware of the risks and steps are taken to try to minimize those risks. Unfortunately, the bottom line is that with the best will in the world and with all of the best procedures being followed, there is still a small random risk attached to these procedures.

Now there is one particular aspect or piece of information that has been presented in both the brief that was forwarded to the government and in subsequent correspondence about the issue of differential risk for different professional groups. I would like to deal with this in some detail, because I have as a scientist great concerns about the way in which some of that information has been presented to you.

The brief presents one piece of information or one piece of data from a study in the United States and suggests that chiropractors carry out 94 percent of all spinal manipulation in the U.S. They then take data from another study of the world literature reviewing reported cases of adverse outcomes following manipulation and suggest that by combining those figures from both studies that there is a case suggesting increased risk for nonchiropractic manipulators. Now this is a gross aberration. Essentially, for example, they have not presented any figures for the percentage use of manipulation for all professional groups worldwide. We have heard before that both physicians, physiatrists, osteopaths, chiropractors and physiotherapists use manipulation worldwide. In many, many other countries, the number of chiropractors and the percentage of manipulation being carried out by that profession would be much less. So to compare a figure from the United States to figures obtained from the world literature is a gross misrepresentation.

Also, if you consider this figure of 94 percent, it refers not to the number of spinal manipulations carried out. It refers to the number of insurance claims for manipulative therapy. Closer analysis of the data shows that under this claim heading were included claims for physical medicine visits, office visits and X-rays. In relation to first visits, only 39 percent of claims were actually for spinal manipulation, and of follow-up visits, 66 percent of claims were for spinal manipulation. So the figures do not add up even to justify the suggestion that in the United States, chiropractors carry out 94 percent of spinal manipulation.

The bottom line on this issue is that we essentially do not know what the relative utilization rates for manipulation are for different professional groups. We have no good information or data on the rates of adverse events for different professional groups. Quite simply, the research that might support such assertions has not been done.

Also, in some items of correspondence, various members of the chiropractic profession have tried to promote the concept that technical proficiency guarantees safety. In other words, the technical skill of manipulation guarantees safety. I would like to make a couple of important points which demonstrate that technical proficiency alone is no guarantee of safety in this area. The first is that addressing major safety issues in manipulative therapy is largely a cognitive skill rather than a motor skill or a technical skill. You need to be thinking rather than doing while you decide whether it is appropriate to carry out a manipulation on a particular individual or not.

* (2030)

All of our students are provided with extensive lists of contraindications to the use of manipulation, points from the examination or assessment of a patient that would specifically exclude the use of manipulation for that patient. This is a skill that we expect students to acquire at an early stage in their training even before they become technically proficient in the use of manipulation techniques. In other words, even at the early stage of training, learning and acquiring manipulative techniques, we want to ensure that people are safe to the extent that they are thinking about the particular presentation of a patient and determining whether or not this person falls within a group or a category or has some other disorder that might preclude the use of manipulation. This is there from the early stages.

The other point I would make is that the most serious adverse events that occur with manipulation are largely random events. In other words, the fact that you have a lot of experience, the fact that you have a great deal of technical skill, the fact that you have the cognitive and reasoning skills that are necessary does not guarantee that no adverse event will occur for a patient in your care. The risk is small, and there is a random element to that risk. We take all the steps that we can to provide people with the technical training and the reasoning that is necessary, but we are aware, and we make our students aware, that nevertheless there is a risk. There are no guarantees.

In a number of letters the chiropractic profession has recommended that they should have some sort of undefined role in determining the competency of physiotherapists to manipulate. Why is the physiotherapy profession resistant to this suggestion? The reasons are simple. Firstly, we are a responsible profession with a long history of using these techniques. We have demonstrated our responsible approach by developing internationally validated training programs. We have many highly skilled practitioners within our own ranks who are more than capable of setting and evaluating standards in this area. The physiotherapy profession in Canada is providing leadership in this area by developing written documentation defining the competencies required to practise manipulation. As an independent profession, we are more than capable of regulating our own affairs. Granting a gatekeeper status to some other profession over our skills and practices would be a very dangerous precedent. It is essentially like saying that dentists should evaluate the competency of medical practitioners to examine the oral cavity. It essentially flies in the face of the normal independence of professional groups.

Now I am coming to the finish of my presentation. Let me pose a question. Why are the chiropractors really objecting to this legislation? If their primary concern was with the safety of Manitobans, we might expect to have heard about more specific safety problems here in Manitoba. We might have expected to have heard about specific incidents or problems. Why is it that the arguments that we read in their brief are well-worn statements that have been promulgated in a number of other jurisdictions, in the United States, elsewhere in Canada, and in other places in the world? Why is it that last year or in the last year or so physiotherapists in Michigan, Tennessee, New York, Virginia in the United States, and in Alberta here in Canada have had to mount successful defences of their right to provide manipulation as a treatment? Is there some sort of national or international process at work here? Could it be that the objections have more to do with protection of market share by the chiropractic profession?

Let me read to you some brief extracts from a document prepared by the chiropractic profession to provide them with potential plausible scenarios for the future of their profession in a rapidly changing health care marketplace. It provides a realistic evaluation of where the competition lies. The document states that, on the one hand, there will be no major competition from medical doctors. They essentially write off competition in that direction. On the other hand, there is likely to be new competition from osteopaths, with British and French osteopaths bringing their traditional emphasis on manipulation and holistic care back to North America and into other world regions. Additionally, North American osteopathic skills will refocus on their manipulative roots as the oversupply of physicians provides a more competitive marketplace in general. There will be significant competition from the physical therapy profession. In Scandinavia, Australia and New Zealand and increasingly elsewhere, a significant number of PTs are doing formal postgraduate courses in manipulation.

Elsewhere in the document they go on to state that the loss of market share–and just mark that term market share–will be larger than it might have been, principally in the U.S., Canada and Australia because of the difficulties in developing a clear identity and role for chiropractors as providers of expert manual care of the neuromusculoskeletal system. The chiropractic profession is clearly concerned about defining its role and protecting its marketplace. What better way to achieve both objectives than to impose legislative restrictions on those other professions that provide such care.

I will conclude by saying that the Legislative Assembly here in Manitoba should take no part in creating artificial legislative distinctions between professions who provide basic aspects of care to Manitobans, to all Manitobans. Bill 26, as it is currently formulated, is a very satisfactory piece of regulation. It requires no amendments. Thank you, gentlemen.

Mr. Chairperson: Thank you for your presentation. There are a few questions. I will ask the honourable minister first and then Mr. Chomiak.

Mr. Stefanson: Thank you, Dr. Wright, for also a very comprehensive presentation. As well you have been copying me on some of your correspondence to the department, I think at least two letters dealing with many of the issues. In fact in one of them you pointed out that the University of Manitoba has been providing teaching physiotherapy since I believe 1960. You went on to talk about, with this legislation, that we are really following what you described, I think, as a very well-trodden path in recognizing the role of physiotherapists as primary contact health care providers. Would you care to just take a moment to elaborate on your knowledge in that area in terms of what has happened elsewhere, either in Canada or even internationally?

Mr. Wright: Elsewhere in Canada, within other provinces, physiotherapists are primary contact practitioners. That, as I said, knowing that a significant number of our graduates will go to practise in other provinces, we provide training to meet that standard. It is my understanding that primary contact legislatively has been in place in some areas of the world since the early 1970s. So, essentially, as a legislative procedure, this particular act follows a path of legislation that began about 1974.

Mr. Chomiak: Thank you for the presentation. I just have one question. You note that physiotherapy profession provides leadership in addressing the safety issue in the 1980s when it introduced mandatory vertebral artery testing for all patients in whom the physiotherapist is contemplating an upper cervical manipulation. Could you just elaborate on that for me?

* (2040)

Mr. Wright: That was a process that was essentially established by the Australian Physiotherapy Association in approximately 1987-88 when that association developed a protocol for vertebral artery testing in patients in whom physiotherapists were contemplating manipulation so that there is a structured process both in the subjective aspect of the examination to look for symptoms that might be indicative of vertebral artery insufficiency and then to conduct testing procedures to determine whether movements of the upper cervical spine produce symptoms that might be indicative of vertebral artery insufficiency and then to sustain the patient in the position in which the manipulation will be carried out for a period of time in order to determine whether any symptoms occur.

Now subsequent to the IFOMT meeting in Cambridge in 1988, many other groups, physiotherapy groupings, throughout the world brought this into their professional protocols. Now I need to say that that particular procedure does not guarantee safety, but it does indicate that we take that aspect of safety very seriously, that we evaluate the patients fully, and if there is an element of doubt in the physiotherapist's mind, they are then obliged to carry out other procedures rather than manipulation.

That is something, as I have said, for the last decade or so that has been an aspect of practice.

Mr. Lamoureux: I wonder if you can indicate how many, to your knowledge, provinces in Canada actually have direct access today.

Mr. Wright: I would have to say that I am a relatively–well, I am not even a new Canadian as yet, I am a relatively new person to this country, and I cannot give you specifics on that. I am sure that some of my colleagues, particularly Brenda McKechnie from the Association of Physiotherapists of Manitoba, will be able to give you specifics. My understanding is that at least four provinces have that. I could stand corrected.

Mr. Lamoureux: I guess, finally, a two-part question. One is, in the States, and we recognize the reporting tools that were used to getting the 94 percent in terms of manipulation, but having said that, can you give us any idea in terms of what percentage guesstimate that physios would do here in the province of Manitoba for manipulation?

Mr. Wright: It essentially would be an guesstimate because the research has really not been done. That is my main point on this, that the research studies, the international studies, that would be required to determine who is providing this service, how often or how frequently they are this service has simply not been done. Any figure is a guesstimate.

Mr. Lamoureux: 10 percent? 80 percent?

Mr. Wright: I have no idea. I would not hazard a guess.

Mr. Chairperson: Thank you very much for your presentation, Dr. Wright. Then we will move on to our next presenter, please. Mr. Kowalski, on a point of order?

Mr. Kowalski: Not a point of order, just a procedure, whatever. For people who are not here, are they going to be moving down to the bottom of the list and be called a second time if they are not present or they do not answer, or will they be dropped if they are not here?

Mr. Chairperson: What is the will of the committee? We need to determine that. It would be my understanding that they would be called twice, then would drop to the bottom of the list. Is there agreement by the committee to proceed in that fashion? [agreed]

Mr. Kowalski: The reason I ask that question is I believe a number of the private citizens who are listed as presenters here are physiotherapists. I believe that a lot of them will present the same information. Depending on the presentations from the Manitoba Chiropractors' Association and the College of Physicians and Surgeons, they might not find it necessary to present. It might expedite the matters if we called on presenters No. 9 and 14 before we go through the others. I am just talking to some of the people in the audience. A number of them are physiotherapists. It would be repeating the same presentation. Depending on what comes from those two, it might expedite matters tonight.

Mr. Chairperson: I thank you for that information. What is the will of the committee?

Hon. James McCrae (Minister of Education and Training): I have very quickly canvassed the audience myself and, you know, the honourable member for The Maples just may have a point here, that we might want to perhaps, if there is a way to do that yourself, Mr. Chairman, go ahead, but I think that he has a good idea here.

Mr. Chairperson: What is the will of the committee? [agreed] Okay. Then with the will of the committee, we will move on then to No. 9. I would like to call on Madeleine Arbec and Dr. Greg Stewart, the Manitoba Chiropractors' Association. I assume, is it Dr. Greg Stewart? Okay. Do you have a presentation for us? Thank you. Then we will wait until we have received those and then I will ask you to proceed once we have received them. Please proceed, Dr. Stewart.

Dr. Greg Stewart (Manitoba Chiropractors' Association): You will be happy to know I am the only chiropractor presenting this evening. I am speaking on behalf of the association in this matter.

My name is Dr. Greg Stewart. I am governor to the Canadian Chiropractic Association. I was appointed by the Manitoba Chiropractors' Association. I am a past president of the Manitoba Chiropractors' Association and member at large. Reference was made earlier about being a team member and used to working with other people and other professions. I am proud to say that I am the chiropractor for the Canadian track and field team. That is something I am very used to, working as a team effort with physiotherapists, athletic therapists, massage therapists, and physicians. I also believe my record in my community speaks favourably for my use of the various professions when I feel necessary for my patients' well-being.

Firstly, I will not address research, because I do not have the references that we provided earlier. As well, I have no way of qualifying or making comment on the passages that were read by other individuals this evening. So I apologize. If any of the information is necessary to clarify our position you may have received some correspondence on, please let us know.

I would like to begin by thanking the members for the opportunity to make this presentation on behalf of the Manitoba Chiropractors' Association, which I will refer to as the MCA, regarding Bill 26. I would like to begin by commending the Association of Physiotherapists of Manitoba for a beneficial and thorough consultation process, as well as the Department of Health for their assistance.

The MCA and the chiropractic profession is acutely sensitive to the issue of turf protection by various health professionals, as the chiropractic profession has often been subject to various monopolies and misrepresentations since our inception. I especially take somewhat offence to terms such as utilizing legislation to pursue monopolies and turf. It is because of our profession's experience with these issues that the chiropractic profession respects the regulatory legislative process and the right of the self-governing professions to regulate themselves.

As articulated throughout our correspondence, the MCA's presentation this evening is not intended to block legislation, nor is it intended to slight our colleagues in physiotherapy. We come to you this evening to bring what our profession believes to be legitimate concerns regarding public safety. The opinions presented to you this evening are based on consultation with our national association, the Canadian Chiropractic Association, our provincial associations, as well as the Canadian Memorial Chiropractic College feedback.

Our objective this evening is to share with you constructive amendments to the legislation which will allow the process to continue and be completed within its desired time frames, increase the public safety and protection in the act regarding spinal manipulation, build a collaborative effort for areas and activities commonly performed by doctors of chiropractic and physiotherapists.

Our presentation this evening will focus on two issues that resolve around our collective concerns as health care providers, the safety of the Manitoba public we serve. The first issue, and it has been addressed earlier and I apologize for any redundancy, is regarding public liability and malpractice insurance.

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In 1985, a worldwide insurance crisis occurred as a result of the disaster in Bhopal, India, at the Union Carbide plant. Consequently, reinsurance was no longer available for professions who did not have their own protective agencies. Insurance carriers notified the doctors of chiropractic and their licensing bodies that their incident coverage was not attainable at a level required to ensure adequate public protection due to the world-wide shortage of insurance. Because of this, the CCA created the Canadian Chiropractic Protective Association which would protect the chiropractic profession and the public from prevailing mood fluctuations of the insurance industry. This model for the chiropractic coverage was designed after the Canadian Medical Association plan.

Currently, chiropractic patients are protected by a plan which insures doctors of chiropractic to a total of $4 million a year per practitioner, $2 million per incident. The coverage is mandatory for all Canadian chiropractors. During our meetings with the physiotherapists, it was disclosed by the physiotherapists of Manitoba's representatives that malpractice insurance is optional for physiotherapists in Manitoba. Why is this an issue? Harrison's Principles of Internal Medicine, 12th Edition, states "Every medical procedure whether diagnostic or therapeutic has the potential for harm," regardless of the competency level of the practitioner.

Historically, physiotherapists were under medical referral and were protected under the auspices of the medical practitioner. However, the reality is that private practice physiotherapists must now assume the burden, as well as the benefits, of being primary contact health care providers and provide the proper public liability insurance for the protection of the public and themselves. Every other self-regulatory mainstream health care profession has mandatory malpractice insurance. This leads us to the following recommendation.

While we are pleased to hear that mandatory malpractice insurance would be within the regulatory process, it is imperative that the practitioners who are assessing patients independently maintain adequate malpractice insurance to protect the patients and themselves. Secondly, the MCA has been assured that this matter will be dealt with through the regulatory process which is under the discretion of the physiotherapy association.

The current regulatory section of the act states that the therapists may–and you brought this out earlier, leaving this issue to the discretion of the association. For this reason, the MCA recommends the following: that current legislation incorporate a provision which states a mandatory requirement for all private practice physiotherapists to maintain proper public liability insurance. The amount of insurance coverage could be fixed by the regulation, for example, $1 million or other such higher amount as fixed by the regulations from time to time. If the legislation does not address public liability, then a commitment should be made by the physiotherapy association to ensure that it will become mandatory and it will co-operate with the appropriate government body to fulfill its commitment.

The second issue was regarding spinal manipulation. Chiropractic training was an evolutionary process that was developed to ensure safety, efficacy and proper application of chiropractic procedures. The primary form of treatment by chiropractors, as you are well aware, is spinal manipulation. The MCA believes that spinal manipulation is a specialty which requires training and daily use of the techniques. The MCA's concern is that there is insufficient protection built into the current legislation for the protection of the public. It was stated earlier that we might not be aware of how many people are treated with manipulation in this province, but we know how many people are treated by chiropractic in this province. We know how many procedures were undertaken, as a doctor is only reimbursed for the actual spinal adjustment, and we know that there were in excess of 130,000 different Manitobans treated last year with spinal manipulation by chiropractors.

Canadian doctors of chiropractic treat approximately 120,000 Canadians on a daily basis, spinal manipulation being the primary tool. As a doctor of chiropractic, I will perform an average of a thousand different spinal manipulations every week. The association believes that in light of the inherent material risks involved that the public has a right to expect that anyone who is legitimately allowed to conduct spinal manipulation will have met a uniform set of standards and competencies.

A recent inquest into the unfortunate death of a chiropractic patient brought forth a set of recommendations regarding spinal manipulation. The doctor of chiropractic involved was exculpated of any responsibility. The incident, which was a first in the profession in more than a hundred years of practice, was extensively reviewed and resulted in a set of recommendations from the coroner of Saskatchewan, and these are enclosed in your handout. These recommendations were distributed to all provincial Ministries of Health and are applicable to anyone conducting spinal manipulation.

Recommendation five of the report states: increased communication and collaboration among all specialities in health care to maximize benefits and minimize risks inherent to cervical spinal manipulation treatments. It is because of the inherent risks involved with spinal manipulation that all Canadian doctors of chiropractic had adopted the following well before the incident. Firstly, there were written, informed consent forms, and there is one in your package. These outlined the risks and rights of patients to be informed of the risks prior to treatment. In other words, when a patient comes into my office, with the other information they fill out, they also sign an informed consent form talking about the various risks they may be subject to and their rights about whether to extract information and of course talk about their right with all procedures, that being to refuse care if they are unsure of the risks and they are not risks that they are willing to undertake given their condition. These are signed and witnessed in our offices prior to any spinal manipulation being undertaken. Also, there is mandatory malpractice insurance coverage to protect the practitioner and the public.

Special risks require special training, and for a physiotherapist to conduct spinal manipulation, the MCA believes that they should have to meet the same or comparable standards to the stringent standards applied by the Canadian chiropractic profession. For example, in the case of acupuncture, the MCA members are to provide evidence that the acupuncture training has been received through an accredited Canadian Council of Chiropractic Education institution, as well demonstrate that they are in good standing with the Chinese Medicine & Acupuncture Association of Canada. They must also show proof of proper malpractice insurance before they are permitted to practise acupuncture.

The policy was established as the board of directors of the MCA did not purport to establish a regulatory force upon an area outside of their expertise. They did, however, want to ensure public safety all ongoing with the procedures that are taking place within chiropractic offices. This took place while I was president myself, and we felt we were stuck with a situation we did not feel that we were the experts in that field, and therefore we actually transferred some of the regulatory processes and competency standards to another organization which we felt would have a level of standing that we felt would ensure public safety when they were in our offices receiving acupuncture.

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The issue the MCA has with the current legislation, as it relates to spinal manipulation, is that the physiotherapists are permitting their members to perform a procedure for which they do not have the same or comparable training and expertise as doctors of chiropractic. There seems to be a reluctance on their part to recognize that spinal manipulation is a highly specialized technique for which doctors of chiropractic have the most experience. Chiropracty is primarily devoted to spinal manipulation, and the profession brings a wealth of experience as primary-contact practitioners. It is our understanding that a select few of the physiotherapists in Manitoba have undertaken the advanced training sessions in spinal manipulation in order to achieve this satisfactory level.

The profession brings these issues forward in the spirit of co-operation for public safety in this very delicate area. The legislation, as it is currently worded, and that is wording regarding manipulation, does not address the potential ambiguity and as a consequence does not safeguard the public against the inherent risk of spinal manipulation.

Therefore, it leads us to the following recommendations. The MCA recommends the current legislation be amended with the following proviso: (1) The addition of a subsection 2, paragraph 3 (a) proviso: no physiotherapist shall perform any spinal manipulation unless the physiotherapist satisfies all criteria established and is certified as a specialist in spinal manipulation in accordance with all applicable standards and regulations.

The MCA would suggest–this is not part of the amendment, by the way–that the consultation process could be undertaken in the following manner: the Minister of Health would appoint a committee consisting of representatives from the Department of Health, the physiotherapists of Manitoba and the Manitoba Chiropractors' Association charged with the responsibility of establishing agreed-upon standards and competencies. The association is aware of the current work being undertaken in Alberta and believes that Manitoba could consider Alberta's framework within its solution.

Reference was made earlier to the competency standards being established in Alberta but it was not stated that the Canadian Chiropractic Association and the Alberta College of Chiropractors were consulted and are part of the team in order to establish these competency levels. So this is not new ground. I will personally be part of the process in Alberta looking at the competency standards.

It was never our intention, and I have to reiterate this, that we do not believe that manipulation or spinal manipulation for that matter is exclusive to chiropractic. That kind of approach I could not even stand here and speak to you about today because it would be so obviously self-serving that I would be very embarrassed to make such a claim. It comes down to procedures based on skill level and hopefully the intellect and the physical capabilities of the person performing the procedure regardless of his academic background. Anyone in this room, whether physiotherapist or chiropractor can be trained properly and I think to a satisfactory level to perform these procedures given the fact they have to go over a certain bar. So I have to reiterate that is not why we are here today.

In conclusion, the MC believes that the new legislation will allow a new level of co-operation between the chiropractors and physiotherapists previously unattainable with the current legislation. As you remember, the current legislation talks about consultation with medical practitioners. We have had very little direct contact with physiotherapists because of the restrictive manner of the previous legislation. For example, I could send a patient directly to an athletic therapist but for a physiotherapist they would have to get permission from the medical doctor to treat my patient. As you can imagine, that circumnavigation does not do the patient any benefit.

It is not our intention also to be gatekeepers for physiotherapy. As stated earlier, they are self regulatory. We would like to be part of a process. We do not wish to be included within their regulations. The MC brings these recommendations in the spirit of joint co-operation and with public safety as its primary concern.

There exists a new level of responsibility inherent with the legitimate status of primary contact health care provider and the physiotherapist must meet the standards not unlike all other mainstream health care providers. Current national research shows that the trend towards alternative health care is rapidly growing with more than 55 percent of people seeking alternative health care in the last five years. Though the physiotherapists have conducted spinal manipulations under their legislation, the fact is the number of patients who will seek spinal manipulation will be considerably more than previously due to the wealth of research showing the benefits. Therefore the number of physiotherapists conducting spinal manipulation will increase considerably more, and so will the risk.

Although the regulatory section of the act may address the issue of malpractice, this decision is left to the discretion of the physiotherapist while all other mainstream health care providers are required to have malpractice insurance for the safety of all involved. Its final manipulation is a specialized technique to physiotherapists not unlike acupuncture. The health care practitioner has an inherent responsibility to ensure that a consistent and uniform standard is applied for the safety of the patient.

The MCA hopes that the committee will consider these two amendments, or variations of them, aimed at protecting everyone involved. We thank you for your time and would be pleased to address any of your questions.

Mr. Chairperson: Thank you very much for your presentation, Dr. Stewart. I will ask the honourable minister to start with questions.

Mr. Stefanson: Thank you very much, Dr. Stewart, for your presentation this evening and for your contributions towards this issue over the last several weeks. I really want to deal with your few recommendations very briefly. Your first one on page 3 of your submission you deal with the issue of malpractice liability insurance, and further in your brief, I believe it is the bottom of page 6, you refer to the other mainstream health care providers being required to provide the insurance. My understanding of that is, in most of those cases, if we look at our Medical Act or our Midwifery Act or our nurses acts, all of those have been done through regulations. You have heard the comments here this evening from a number of individuals associated with physiotherapy relative to the opportunity to address this issue through regulations, not unlike these other professional organizations. At the very bottom of page 3 you basically say that. You say if the legislation does not address it specifically, then you are looking for an indication or commitments that it will be implemented and so on.

There is some merit in doing it through regulations in terms of having discussions about amounts, having discussions about the impact if you are in private practice or if you are employed by an additional employer, so I guess I would ask you, in light of what you have heard here this evening, based on at least four presentations, are you more comfortable that that issue can and will be addressed through the regulation-setting process?

Mr. Stewart: Very much so. I was happy to hear much of the comments made today, especially the personal comments where their own feeling was that it should be mandatory. I think that matters to me more than anything else does, because I am sure they are very reflective of members of their association or they would not be here speaking today, and I am sure that there would not be a huge vocal opposition if it was made mandatory.

Mr. Stefanson: Thank you very much for that comment. The other one is your other recommendations which are basically on the bottom of page 5, top of page 6. I guess my question is very similar there as well. You are well aware, I believe, that under Bill 26, the College of Physiotherapists can again make regulations requiring completion of postgraduate training and in high-risk manipulations as a prerequisite to the use of such techniques. I believe at least one previous speaker, Ms. Gallant I believe, touched on that issue again in some detail and ask you a similar question. Are you more comforted and confident that again this issue can be addressed through the regulation process?

Mr. Stewart: I really do believe it can be part of the regulations; however, there may have to be a qualifier under the word "manipulation" in the legislation, that we separate manipulation. I have no doubts that people who graduate from physiotherapy can adjust elbows, wrists, ankles, et cetera, but I am just trying to make a distinction between manipulation and spinal manipulation and that specific reference to spinal manipulation be made within the act, like I said earlier, in making reference to the regulations which would outline the competencies. Obviously, when it is in the regulations, the various competencies could be modified over time to a satisfactory level.

Mr. Chomiak: Thank you for your presentation. It is curious to me. There was a time when ministers and I would not generally agree on questions and responses, but I am finding today that we are concurring, and the minister has asked several of the questions that I had intended to ask. But are you at all persuaded or convinced in terms of the information that was provided by Dr. Wright concerning the protocol as it relates to what I understand to be cervical spinal manipulations which, from what I understand, is the issue at risk? Is the fact that there is a protocol in place and has been in place for a decade that provides for testing and an assessment procedure, does that not provide you comfort with respect to your proposed amendment?

Mr. Stewart: A reference was made earlier about no test gives a guarantee, and Dr. Wright is accurate in that situation. In the Saskatchewan incident, for example, I understand that those screening procedures were applied in that instance, so obviously it minimizes risk but absolutely does not remove it entirely. I believe that everyone has an obligation to perform procedures that are recognized by the courts in these areas and instances to be the expected course of examination prior to delivery of these procedures, so therefore they are rather universal. As far as having a regulation to be provided, we do not have. It is part of our education process, and the informed consent part talks about the procedures that will be undertaken.

Now the request from the coroner, like I said earlier, they talked about further research–and you have a copy of it–talking about further research into screening procedures for the various risk procedures. I think reference was made to not having access to some equipment. I mean, personally in my office I have diagnostic imaging, X-ray equipment at my disposal when I feel it is necessary right there and then. We also have access to a CT scanner in Winnipeg, which we can have access to immediately.

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So we feel that the encumbrances we have regarding diagnostic procedures are the ones that are forced upon us. We are trained in laboratory diagnosis, urinalysis, venipuncture, et cetera. It is just the current legislation as it lists in our act in Manitoba which precludes us from utilizing these other screening tests, these other screening procedures.

Mr. Chomiak: Did I understand it correctly that you had included the five recommendations from the coroner's report in our presentation, Dr. Stewart, because I do not have those.

Mr. Stewart: I am sorry, we have it here with us. We can get copies made if you wish.

Mr. Chomiak: The issue of informed consent, of course, is a requirement regardless of legislation. It is a legal requirement for all professions regardless of whether or not it takes a written form, as I understand it, but you are saying it is a matter of course for chiropractors to provide for mandatory written informed consent.

Mr. Stewart: It is dictated by our insurance carrier that it is mandatory.

Mr. Lamoureux: Mr. Chairperson, like the member for Kildonan (Mr. Chomiak), the minister did take a couple of the questions away in terms of what it is we are wanting to pose, one of the benefits of leading off, I guess.

In looking at physiotherapy as a profession, it was encouraging in listening to your recommendations. I think in most part the concerns that you raised with the committee were, in fact, addressed in previous presenters. A good example of that is the liability insurance where you state a million dollars, for example, as a minimum or higher. From what I understand, at least in the private sector, it is considerably higher than that. So it just kind of reinforces the profession in its ability to be able to do the things that are necessary in order to demonstrate public safety, if I could put it in that fashion.

In spinal manipulation, I posed a question to the speaker prior to you in terms of percentage. You have some numbers in terms of what it is that you would do. Can you give the committee any idea in terms of overall spinal manipulation what chiropractors would be doing percentage-wise in the province of Manitoba?

Mr. Stewart: In the province, like I said earlier, we treat 15 percent of the population, approximately, per year, and over a five-year time frame, we are treating approximately 40 percent of the population. We have very accurate statistics regarding our procedures, and every one of those visits involved spinal manipulation. The ones that did not involve spinal manipulation are not in the numbers from the Department of Health.

So we had about 126,000 patient visits regarding spinal manipulation which were billable to the Department of Health. We had another 15,000 or so visits via MPIC, and I believe it was in the neighbourhood of 5,000 to 7,000 different patients regarding WCB.

Mr. Lamoureux: Would you have any idea in terms of, and, again, it could be a guesstimate, the possible numbers that the physiotherapy profession would do?

Mr. Stewart: No, I do not. I just know by, again I am speculating, feedback from patients and the contact I have with various well-established organizations in this province, that they found it incumbent upon themselves to bring a chiropractor into the facility in order to provide, and it is the most widely recognized physiotherapy institution that brought a chiropractor on staff, as there was increased demand and the fact that chiropractic is well identified, for lack of a better word, with the procedures.

Mr. Lamoureux: Finally, Mr. Chairperson, you indicate in the report that you believe the legislation will bring to a new level more positive rapport. If I put myself in the shoes of being a physio, it reads: no physiotherapist shall perform any spinal manipulation unless the physiotherapist satisfies all criteria established and is certified as a specialist in spinal manipulation in accordance with all applicable standards and regulations.

Given the presentations that you have heard this evening, is it not safe for committee members to believe that that particular profession does have the abilities from within to protect the public's best interests, given their history in doing spinal manipulation?

Mr. Stewart: The way the act is currently written, and I asked this question very pointedly during our deliberations, was whether physiotherapists may adjust or manipulate–we use the word "adjust" in our profession–a spine upon graduation, and the answer was they would not. That is not my question, I said. I said may they. Are there any repercussions? Is there anything written that precludes them from performing these procedures other than their own self-identity as far as being able to do the procedure safely? The answer was, yes, they may, based on the way it is worded in the act.

Personally, if we are leaving it up to everyone to make judgment calls on what they may or may not do and what they feel they can and cannot do, we would have a very, very quick little examination process and regulatory process because everyone would be doing only what they really can do and would not ever do things they cannot do.

I think that legislation cannot be drafted in a way that there is that sort of latitude in judgment, and the responsibility in health care legislation, in particular, is such that it is defined when it is possible to be defined. I think in this situation that they have acknowledged the fact that they have continuing education; they have recognized experts in the field; they have postgraduate courses to reach a level of competency which I believe I could be satisfied with and most people in this room could be.

In chiropractic, we do not have postgraduate training to attain different levels of manipulation. The postgraduate training that occurs takes place in utilizing different approaches, ongoing continuing education and reinforcement of techniques and broadening the procedures that can be developed, but, overall, when a chiropractor graduates from chiropractic college, he is capable of manipulating basically every articulation of the body as a requirement for graduation. So, therefore, the steps that are in place in their own field I think reflect the need for the ongoing education in order to perform spinal manipulations safely and, not only that, effectively.

We are a little bit hypersensitive about these things, because when things go wrong it is called chiropractic procedures; when things go right, they are called manipulation procedures. So we are so highly identified with spinal manipulation that in various articles and literature through the years, it is tagged on as a chiropractic type of procedure. This has been causing misrepresentation in the literature regarding stroke incidents, et cetera.

Mr. Chairperson: Thank you very much for your presentation, Dr. Stewart. We will move next on our list then, as indicated before, to Dr. Ken Brown, please, College of Physicians and Surgeons. Dr. Brown, do you have copies?

Dr. Ken Brown (College of Physicians and Surgeons): I do not have a presentation that is written, if I could just make a few comments.

Mr. Chairperson: Certainly, go ahead, please, Dr. Brown.

Mr. Brown: The college has been involved in health regulation for 128 years. I have not been there that long, but it is getting that way, 25 years this year. So I have seen a lot of health regulation. I have seen a lot of physiotherapists. I think it is quite apparent to us and has been apparent for many years that the physiotherapists are capable of independent practice. We opened discussions with the physiotherapists approximately six years ago, and I would stress that it was the college that initiated the conversation in order to encourage the move toward legislative reform.

There seemed to be some difficulty in achieving the reform, largely because, I think, of the political process about which you would know more than I, and, as a result, we advised our department, our minister, a few years ago that we would like the indulgence of the government if we were to accommodate the physiotherapists by interpreting the language as liberally as possible, so that we could recognize a reality which is that our patients have been having independent access to physiotherapists for several years.

It is quite true that the physiotherapists work with physicians, but that is because it is a common body of knowledge and because there is a very clear recognition of the risks that are associated with many of the procedures.

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So they have developed the self-discipline which makes it possible for them to discriminate between those situations with which they are safe to proceed and those with which they are not. In our experience, we have had a good communication with the association. We have never have had reason to be concerned about the quality of the investigation should it be brought to their attention.

So, in short, we would regard them and we do regard them as well-educated. They have sound training in many specialties. We believe that changes are appropriate, and I think the most important thing that possibly I could speak to is that they follow very good regulatory processes. I think in this respect the processes that they have demonstrated they can function with should see reality in their legislative change.

Mr. Vice-Chairperson: Thank you, Dr. Brown. Are there any questions for Dr. Brown?

Mr. Lamoureux: Doctor, I am curious, from your perspective in terms of the spinal manipulation, do you have any limitations or qualifications that you would put with that particular procedure, with physios personally?

Mr. Brown: We have a lot of experience with manual therapy of manipulation with respect to the medical profession itself, and none of these processes are things that all physicians would attempt to undertake. So I would have to start with that sort of background.

The physiotherapists would be more akin probably to the branch of medicine called physical medicine. In that branch of medicine, you will find manipulation used quite frequently. The physiotherapists have, understandably, developed particular skills with respect to manipulation. I think it is commendable that they have shown, through their research, that you do have to develop tests in order to screen your patients to ensure that it is appropriate to proceed with manipulation.

Mr. Lamoureux: I guess, finally, you would not then have any personal problem with their being able to regulate that aspect of their own profession?

Mr. Brown: I do not think the issue is whether or not every single physiotherapist is prepared to manipulate or not to manipulate. The issue is can the profession itself control its members in a way to guarantee safety to the public, and it is in this respect that we have confidence in the physiotherapists.

Mr. Chairperson: Thank you very much for your presentation, Dr. Brown. We will move back to No. 3, Neil MacHutchon, please. Neil MacHutchon. Okay, then we will move on to our next presenter, Jason Hallock, please. Defer, okay. Move on to Susan Morrow, please. Ms. Morrow, please proceed with your presentation.

Ms. Susan Morrow (Canadian Physiotherapy Association): Thank you, and I will be very brief. I just come to you this evening as a member of the board of directors of the Canadian Physiotherapy Association for the past five years, and I bring to you a position paper that was developed in 1997. I was given the task of chairing a national committee for the Physiotherapy Association to look specifically at manipulation and its practice in our profession, and I believe this might be important for you to have this information from a national association perspective.

The national Physiotherapy Association is a voluntary association for physiotherapists in Canada. It currently represents over 9,000 physiotherapists across the country, and its mandate is in the areas of ensuring excellence in the education of physiotherapists, in the clinical practice of physiotherapists and in the body of research relating to physiotherapy education and practice. This position paper on manipulation was undertaken over about a 14-month period where we looked at current case law in the United States, in Canada, in Europe, Australia, New Zealand and Britain. We looked at the education of physiotherapists, and the position paper speaks for itself.

The position of the Canadian Physiotherapy Association is that manipulation is one of the shared aspects of scopes of practice which is current in the health care system today, that many professions share aspects of scopes of practice. The position of the Canadian Physiotherapy Association is that this is the best system, and manipulation, spinal or peripheral, falls into this category. Thank you.

Mr. Chairperson: Thank you very much for your presentation. Are there questions of Ms. Morrow? If not, thank you. Then we will move on to our next presenter, Kelly Robert Milan. Do you have copies of your presentation for handouts?

Mr. Kelly Robert Milan (Private Citizen): Yes.

Mr. Chairperson: Thank you. Please proceed, Mr. Milan.

Mr. Milan: Good evening, again, I will be brief as many of these topics have been thoroughly covered. I come to you this evening as a private practice physiotherapist in Winnipeg and also a private clinic owner as well. I graduated in physiotherapy in 1991 here at the University of Manitoba. I have a few points I think I might be able to add to some of these issues just from sort of a physiotherapist's ground-level perspective.

My first point that I want to make is that we have had a lot of discussion tonight about direct access but basically we do have a direct access system right now. The proposed legislation is simply a refining of that and perhaps a streamlining, so it is a matter of degree. Right now we have what is defined as direct access, but this will be refined somewhat.

Physiotherapists can currently assess a patient, but we must communicate with the patient's physician regarding a treatment program. This will not change with the proposed legislation. It is unethical and unprofessional not to communicate with any of the members of the health care team. Physiotherapists have always had a close working relationship with doctors and other health care providers, and this will certainly not change in the future.

The proposed legislation will allow easier access to physiotherapist services, particularly in rural areas as well, and it will contribute to reducing duplicate visits to other health care practitioners as well. So there are some benefits to the health care system in Manitoba.

I would like to touch on the example that was brought up earlier about little Johnny with the sprained ankle coming into the private clinic. For example, if I were to see this patient right off the street, yes, I would take a full history and fully assess the patient, but in all likelihood and I am almost sure, even without seeing the patient, I would be directly communicating with the physician for their evaluation as well. But there are cases where, for example, a patient with back pain that we have seen three or four times during the same year, it may not always be necessary to have the physician involved right away. So there are some advantages to the way this new legislation will work and streamline things.

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Physiotherapists–my next point–have an excellent safety track rec