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International OTs, Nationally

Three foreign-born OTs discuss how occupational therapy in the U.S. differs from abroad

Vol. 25 • Issue 14 • Page 12

Though occupational therapy's roots as a distinct profession are here in the United States, today OT is practiced in developed and developing countries throughout the world.

However, occupational therapy practice can differ from country to country, with some of the most drastic variations existing between the U.S. and other first-world nations.

ADVANCE recently spoke with three occupational therapists who have practiced both in America and abroad: Sara-Jane Crowley, OTR/L, originally from New Zealand, moved to Tennessee in 1992 and is currently working in Florida; Alison Beck, PhD, OTR, of the United Kingdom has been in Texas since 1985; and Izel Obermeyer, OTR/L, came from South Africa to New York in 2000. Each practiced for several years either in her native country or elsewhere abroad before moving to the States.

They shared their thoughts with ADVANCE on the differences and similarities they've experienced in practice.

Health Systems

Socialized health care systems in countries such as the United Kingdom and New Zealand allow all citizens access to care regardless of ability to pay or qualification for specific programs. In the United States, health care is available through private insurers or government services, such as Medicaid and Medicare, to qualified individuals.

The systems dictate different ways of accessing both OT services and therapeutic equipment.

In England, "if a child needed a wheelchair, [the practitioner sends] in the appropriate forms to the National Health Services, and a wheelchair is provided," Beck said. In the U.S., however, if the insurer will not cover the chair, the providers have to ask, "'Okay, what do we do next?' Trying to navigate how to provide resources for the children was very different."

Beck also found that transitions in the U.S. were not as seamless as in England. An American patient transferring out of a hospital to a different facility or into the community may have more difficulty maintaining therapy services. When Beck was practicing in England, OTs did not need a physician referral to treat.

"It took a little while to adjust to the hierarchy [in the U.S.] and the fact that there was both the physician and then the payers of the services who dictated to me what I should provide," she explained. "I was used to a lot more autonomy in England."

More access and independence, however, don't always mean better service. "[In South Africa], there's a big percentage of people below the poverty line," Obermeyer said. "They rely on government health services. But the quality of that is deteriorating. [That's] becoming an issue, and availability is becoming an issue."

Similarly, in the U.K., "You will get a wheelchair if you need it; however, they're not the same level of quality as the wheelchairs we have here," Beck said. "I have a daughter with a disability, and whenever we go back to England, and I take her wheelchair that was provided here [in the U.S.], people always stop us and ask us where we got it, because there's a difference in the aesthetics and the function of the chair."

Additionally, waiting lines for procedures or appointments can be much longer in countries with socialized health systems, Crowley said. "And there is always the risk when you've got these long waiting lists that people die," she added.

"I think each system has its merits. Is each system perfect?" she continued. "No. Health care in this country is what health care is."

Creative Roots

The delivery of occupational therapy services also differs among nations. Therapists in other countries have more strongly maintained their roots in purposeful activities; here, OT has gravitated toward rote exercise to fit into the medical model. As a result, some of the profession's inherent creativity has been obscured.

"In America, I think [the craft and the functional activity] is something the profession gave up. to try and compete," Crowley said. "We lost our roots somehow."

In New Zealand, Crowley worked in an OT department with a weaving loom, pottery kiln, wood workshop with a full-time builder, metal workshop and a full kitchen. "From 7 o'clock in the morning until 4 in the afternoon, that kitchen was always filled with people cooking. Whereas, when I came to the States, yes, we had the kitchen and the remedial bathrooms with the grab bars and equipment, but there was more of an exercise focus to get the goals you wanted," she said.

Obermeyer agreed, adding that the difference is even clearer in poverty-stricken countries. She has worked in Libya, Kenya and Brazil in addition to South Africa.

"We had to use a lot more problem-solving skills and innovation, because we didn't have access to the equipment or the technology that's available in the States," she explained. "In those countries, you had to improvise and make your own [equipment] much more so than you do here."

However, she said, the level of creativity ultimately depends on the therapist, his or her past experience and the situation. "I have seen some very innovative therapy over the years here, and I have seen people who are a little more distant from it."

Beck also said she has seen the focus on the medical model here in the U.S. waning in recent years. OTs are returning to more holistic, creative methods, she said, putting America on par with its international peers.

Size Matters

With an area of 3,619,969 square miles, America dwarfs the U.K. and New Zealand combined. The U.S. also has more therapists and more resources available.

"When I left New Zealand, there were 700 OTs nationally," Crowley said. In comparison, the United States has 144,857 OTs and OTAs, according to AOTA's 2008 State Regulatory Entity Survey.

"I'm hoping that there's a lot more [OTs in New Zealand] now," Crowley continued. When she left, the country had only one OT school and was just developing another. "It's hard to compare New Zealand and the U.S. just because this place is so much bigger-so many more therapists, so many more opportunities for education and learning and practice."

One of the main benefits of being in the United States, for example, is the presence of the leading practitioners in the field, Crowley noted. "People I had read about in books and journals, I now had the opportunity to meet and go to courses where they were the presenters," she said.

Beck believes that the difference in size has allowed the U.S. to take greater first steps in the push for evidence-based practice than the U.K. "Occupational therapy in England has always been a lot more practical," she said. "We are less about the theory and the science behind it. We tend to be more about the interventions than maybe doing a whole lot of discussion about what theories are behind the interventions.

"But again, we're talking about a relatively small country in comparison to the States, and I think OTs in the States have better resources and more of them to develop the body of knowledge. .We probably tend to apply that body of knowledge and adapt it to our cultural needs in England-neither [art nor science] is [a better approach], though. Both are needed."

Universal Truths

Even with so many differences from country to country, some things in occupational therapy remain the same, such as how the general public understands the profession.

"It's funny," Obermeyer joked. "I was in Brazil, presenting at a conference, and I said 'Whatever countries around the world you are from, OTs are very similar. They are overworked and underpaid, and they always tell me that nobody knows what OT does.'"

What else remains the same? The goals and ideals behind occupational therapy.

Regardless of the country, an occupational therapist or occupational therapy assistant still wants to deliver quality care that helps facilitate a patient or client's best quality of life. Today, that means helping garner greater respect for the profession through evidence-based and science-driven research and practice, a worldwide initiative.

"It's a very positive thing where OT is going," Crowley said. "We have to compete on the same playing field as any other health care profession; we can no longer stand there and say, 'Well, we're right just because we're OTs.' We need to be able to prove that what we do on a day-to-day basis as clinicians works, makes a difference for patients and clients. the whole idea of becoming evidence-based and science-driven is happening. It's happening all over the world."

From country to country, "the avenues of getting outcomes for patients or clients in terms of making a difference in our patients' lives are different," she continued, "but we all still practice occupational therapy." n

Sue Coyle is ADVANCE assistant editor.


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