Physical manipulation is a medicinal practice practiced by osteopaths and chiropractics; in recent years, some physiotherapy training courses have incorporated aspects of manipulation. There is a high degree of sectarianism between these three groups. In North America, osteopaths are also medical doctors, although elsewhere the osteopathic profession is viewed as an alterative or complementary medical profession. As osteopathy and chiropractic present themselves as alternatives to physiotherapy, at least some of the inter-professional rivalry may be attributed to competition for patients.