Clinician's Commentary on Cassady et al.

As Cassady and colleagues note in their article,¹ more and more physiotherapists and other health care professionals are volunteering or working internationally in resource-poor settings. Research has begun to explore the types of skills and competencies needed to function well in these global settings for a variety of health professionals.² Cassady and colleagues therefore set out to begin to define the essential competencies needed in these settings from the perspective of physiotherapists.

In the absence of practice guidelines for physiotherapy practice in resource-poor countries, Cassady and colleagues initiated research in this area by conducting a qualitative study using an interpretivist, constructivist paradigm. They carried out in-depth interviews with 17 physiotherapists who had worked or volunteered in resource-poor settings but were also familiar with the Canadian context, using an interview guide based on the Essential Competency Profile for Physiotherapists in Canada (ECP).³

The authors' main findings are that participants saw all seven key roles laid out in the ECP as important in global contexts and recommended expanding two of these roles (Communicator and Manager) with additional sub-competencies. Cassady and colleagues also add three novel roles not covered in the ECP: Global Health Learner, Critical Thinker, and Respectful Guest.¹

In the key role of Communicator, participants felt that a key competency should be added, that of Communication Skills for Differences in Language and Culture. It is easy to understand the value of this competency in a resource-poor country where English may not be the dominant language and the rules governing communication depend on the surrounding culture and context. Although health professionals in different countries share some of the same common professional language and concepts, their interpretation will vary greatly. Given the diverse nature of the Canadian population, it is interesting that this concept was not already included in the ECP. It may be worthwhile to consider amending this competency when the ECP is revised.

Participants noted the importance of creativity and resourcefulness and did not feel that the current Manager competency captured this concept. Again, given the wide disparity of patient resources in the Canadian context, these qualities might be considered essential in all areas of practice.

Cassady and colleagues also identify additional competencies required for working in resource-poor countries that participants did not feel were captured in the ECP.¹ Several authors^2,4 have identified competencies that are essential for global health work. For example, Cole and colleagues have discussed the importance of ongoing education about a wide range of global health issues;² the role of Global Health Learner outlined by Cassady and colleagues emphasizes the importance of critically reflecting on what one has learned. Pinto and Upshur⁴ have outlined the importance of solidarity and humility; although these link with Cassady and colleagues' Respectful Guest role, the image of the Respectful Guest is a powerful one that should be explored further. It would be interesting to explore whether there are any unique competencies for physiotherapists, as this would have implications for curriculum/educational initiatives or future research.

Particularly important is the authors' discussion of reflexivity, which they define as the ability to recognize what it is about each of us as individuals that has informed our thinking, values, and assumptions. I would suggest that all health care professionals require training in enhancing their reflexivity, as this ability is important in all practice contexts, not just in resource-poor countries.

Cassady and colleagues' article should be considered essential reading for physiotherapy students and clinicians considering working or volunteering overseas. It is crucial that health care professionals be competent in the areas the authors outline; if they are not prepared, they risk doing more harm than good or, at the very least, not accomplishing all that they set out to do. Many of their efforts may be wasted through lack of knowledge about the local context, values, and resource constraints.

This article points to many areas for future research. As the authors note, they did not seek the perspectives of colleagues or patients in resource-poor countries, and these viewpoints are essential for a complete picture. It would be valuable to study the competencies necessary to work with diverse populations in Canada and to compare the findings with those of Cassady and colleagues.

This is the first study to examine competencies required by Canadian physiotherapists working in resource-poor countries, and it brings to light previously unreported perspectives. The results not only have important implications for health care students and professionals working in global health settings but also highlight areas for possible additions to the ECP. Educational curricula could be expanded to cover topics such as reflexivity and cultural competence, which are relevant to all health care professionals and not only to those who wish to work globally. Cassady and colleagues will succeed in their stated goal of sparking constructive dialogue on health care work in resource-poor countries.