Here's another guest post from Jason Eure, who is still a pretty smart dude whose thoughts are worth your time. Follow him on twitter @jmeure
(Preface: The majority of this article was written immediately following the summer olympics of 2016, well before the recent Super Bowl. Needless to say I am saddened by current events)
February 3, 2003: Adam Vinatieri lines up to kick a potential game-winning 48 yard field goal to win the Super Bowl for the New England Patriots. The snap and hold go smoothly, the kick is up and on line… but just as it’s about to sail through the uprights, a St. Louis Rams fan pushes the goalposts back 20 yards and the ball falls short: leaving the Patriots to lose in overtime (or at least I wish this above scenario had happened…I view my happiness as inversely proportional to the number of rings in Tom Brady’s possession).
While we (sadly) can’t influence physical goalposts to this extent, this happens metaphorically during many arguments — evidential standards are arbitrarily altered in order to make a counter-argument inadequate or insufficient. This is an informal fallacy known as (wait for it) ... shifting the goalposts.
To illustrate the concept, I’ll create an example that’s common in my life:
Friend: “Hey Jason, can you come out to dinner on Friday?”
Jason: “Terrible timing, my car is in the shop. Maybe next time?”
Friend: “Can’t you take an Uber? We’ll go close to somewhere you live.”
Jason: “What do you think I’m made of money? (Insert corny joke about student loan debt)”
Friend: “I can swing by and pick you up.”
Jason: “I don’t want to inconvenience you! It’s fine we can go another night.”
Friend: “No inconvenience, I’ll be out that way anyway."
Jason: “I’ve had a bad cold this week, I’ll have to call and let you know how I’m feeling closer to Friday”
What does this conversation tell us? Outside of my friend being overly-persistent and oblivious to social cues, the point is clearly that
I should have come up with a better excuse from the beginning the conversation had a constantly moving target. Every time I made an objection, my friend proposed a viable solution which should have appeased the concern. However, I am compelled to alter the excuse because the underlying issue was never addressed. Quite simply, my core belief was that I did not want to go out to dinner, and digging even deeper, my core values may even be that I do not care for that person’s friendship or even social contacts to a great extent (I’m a borderline recluse). Regardless, the conversation was never about my car, money, inconvenience, or my imaginary illness — and without that understanding, we would be stuck in an unsolvable loop. My friend will never succeed in appeasing my progressive stipulations because I will continue to consciously, or subconsciously, prevent resolution by moving the target.
In the world of rehabilitation, camps are quickly established when a concept like cupping makes national headlines with therapists arguing over either endorsing or rejecting its merits. Often, a spade is simply a spade, and the argument is useful to shed light on a particular subject. Other times, we see an infinite shifting of the goalposts. The objections of car trouble, money, etc. from my previous example are merely replaced with questions regarding quality of external evidence, inclusion/exclusion criteria, appropriate sub-group analysis, and intervention parameters. Ultimately, the disagreement cannot reach a satisfying conclusion until the foundational beliefs and values are addressed.
Our most recent division over therapeutic cupping will probably evoke a sense of dé jà vu to those who frequent social media pages specific to the Physical Therapy profession. When cupping garnered national headlines, the conversations which inevitably followed closely mirrored those being had concerning topics such as manual therapy, therapeutic dry needling, taping, craniosacral therapy, or any other modality with varying levels of evidential support. This is because the current discussion is merely a proxy for the larger conversation often not being had — the differing opinions on how we are able to determine clinical efficacy, the validity of specific mechanisms behind treatment approaches, and/or how we value treatments which may only provide relief through non-specific mechanisms. I attempt to address the former topic in this post, and believe the topic of mechanistic vetting and importance is far beyond the scope of this current article. However, identifying where you stand on those particular topics, and understanding the effect these values have on conversations, is imperative.
When you find yourself trapped in a situation where the target is in perpetual motion, I advise you to delve into the foundational premises. Explicitly state your stance and ask both yourself and the counterparty you disagree with:
What evidence could be provided to change that stance?
If you answer “nothing” — I’d strongly encourage you to re-evaluate your thought process to adopt a Bayesian framework, think probabilistically, accept uncertainty’s role in healthcare, and recognize that there will always be known unknowns and unknown unknowns which render our understanding (and subsequent reasoning) incomplete and inaccurate. By doing so, you allow yourself to acknowledge the unavoidable truth — You may be wrong. Only by admitting this to yourself are you capable of growth. We must put ego aside and concern ourselves with “getting it right” rather than being right. Importantly, this does not mean your values and beliefs are fragile and subject to change when confronted with any retort. Instead, as is consistent with Bayes theorem, you should weigh the quality of evidence provided and judge it against the pre-existing body of knowledge. This process allows our thoughts and opinions to be more nuanced and granulated rather than conforming to a simple dichotomy of right/wrong or yes/no. However, we must tread carefully when our prior probability (or simply “priors” if using Bayesian terminology) is based extensively on experiential knowledge. As practicing clinicians, we are extremely prone to pay selective attention to our successes rather than our failures. We are also more likely to encounter individuals who have higher odds of responding favorably to our given interventions (through a combination of selection bias and survivorship bias as outlined in my previous article). Our poorly calibrated expectation of benefit has been consistently demonstrated and will significantly impact our estimations regarding the totality of evidence in favor of specific interventions. Meaning, we will anchor our beliefs strongly to one camp or another based on an incomplete data set. Therefore, we must account for these common faults and allow for more fluidity in our probabilistic estimates.
If the person you are arguing with says “nothing”, it may be time to walk away from the conversation. This response is typically evidence of an emotional investment and indicates that the ideas/philosophies in question have been incorporated into an individual’s self-identity (as often seen with manual therapy). Any argument will probably have the opposite effect you intended and is best left alone (the notion of changing beliefs is another expansive topic which I hope to write on at a later date). While these conversations can still be of benefit if you are attempting to gain a greater understanding of the opposing stance, or if you hope to mold your view in accordance to the evidence provided, the one-sided discussions quickly become repetitive and redundant. I personally avoid these engagements and save my efforts for those who share the understanding that expressing unwavering certainty is inappropriate in non-physical sciences due to the impossibility of establishing causality in these fields.
The only thing that I’m more certain of than my inevitable attempt to avoid another potential social interaction is
the fact that the Patriots should have lost their last two Super Bowls the future emergence of another controversial topic in the realm of Physical Therapy. Having inter- and intra-professional arguments is vital to expanding our knowledge and improving our practice. Without appropriate communication skills, we are prone to deter growth and remain ignorant to contrasting concepts or ideas. Hopefully you are now better equipped to identify when the goalposts have been moved and can prevent the perpetuation of a futile argument.