I am someone who rarely feels compelled to offer my unsolicited advice in a public forum. Therefore, it may seem strange that I am writing for the second time on the issue of intra-professional communication. Despite my desire to remain an impartial observer of the world surrounding me, an unnerving theme persists and motivates my interjection. In many ways, we fail to engage in constructive dialogues regarding professional topics.
Argumentation is imperative for both personal and professional development and criticism is an opportunity for refinement. Without others to reveal our intellectual faults and shortcomings, we are likely to remain stagnant. Individually, we are prone to settle for an inferior version of ourselves. Collectively, we are insulating ideologies, slowing the forward progression of knowledge, and hindering the formation of more comprehensive clinical questions for study.
I am not suggesting that this process is easy. Even when constructive appraisal is direct and removed from any personal affiliations, it is difficult to avoid an emotional response. This is human nature. Argumentation becomes even more trying when the language used lacks the necessary precision. This ambiguity leads to misinterpretations, effectively blocking beneficial conversations from occurring. Thus, it is essential to outline common assumptions within arguments and specifically state what is being said and what is not being said (or implied) to prevent missed opportunities for growth.
Communication is the vehicle for the exchange of knowledge or ideas and it is considered ‘effective’ when the information shared is understood without the intended meaning being distorted or altered. While this productive interaction is seemingly simple, we often fall short of this goal. To understand why this may be occurring, a more disciplined view of communication is required.
The ability to accurately convey messages and influence others’ beliefs and attitudes has tangible benefits. As such, communication abilities and persuasive skills have been valued since our species has been in existence. Many theories have emerged regarding the nature of communication; each with distinct emphasis and conceptualizations of the process. Entire courses are dedicated to this topic, and exploring the intricacies of each model of thought is unnecessary for this post. What is important is the underlying structure of all inter-personal communications: the interaction between the sender and the receiver of information.
My first article primarily tackled the content of professional discussions or the transmissions provided between two participants. This post aims to shed light on the ramifications of interpretation and response on successful communication.
A successful verbal exchange requires that a message is interpreted correctly and actionable feedback is provided specific to that message. A potentially positive interaction can get derailed quickly due to misperceptions of a critique and/or inappropriate responses. Emotionally-charged topics such as patient care are particularly vulnerable. Individuals often conflate beliefs and values with self-identity and self-efficacy. This misunderstanding frequently leads to escalation, defensive reactions, and unproductive feedback which does not move the conversation forward in any meaningful way.
To combat this ineffective communication pattern, I want to explicitly identify common misperceptions that occur within professional disagreements to help us all stay on target.
When debating the merits of an intervention, If I present data which shows “X” “Y” or “Z” has no clinical efficacy and does not add value to your care: I am NOT saying:
1. You are not a good clinician, you have not achieved successful outcomes, and you are not intelligent
Your competency as a therapist is not isolated to any single intervention or ideology. Your outcomes over the years are something to be celebrated and are a reflection of your intellect and interpersonal skills. That does not mean everything you have employed has directly influenced that process and is an essential component which cannot be removed. There are many reasons why ineffective treatments can be perceived as helpful when they are not.
People are poor historians drawing from limited data. Physical therapists are no exception. These faults do not make you dumb, they mean you are human. To quote Richard Feynman: “you must not fool yourself, and you are the easiest person to fool.” We must recognize the limitations of our thinking, understand that the scientific method is specifically designed to help reduce these biases, and be willing to accept that what we see is not always the complete story. A challenge to your ideas is not the same as an insult to your character. Do not assume personal implications. Instead try to re-frame the critique as an opportunity to enhance the precision of your interventions.
2. Your mentor was wrong and their contributions to the field should be forgotten.
Our beliefs and subsequent actions are always inextricably linked to the context of our environment. The early pioneers of the field of physical therapy developed therapeutic paradigms to the best of their abilities using the given understanding at that time. Without this groundwork, the profession as we know it would not exist. However, the integration of science-based medicine has pushed the available knowledge regarding physiological and psychological principles far beyond what was initially used to develop said paradigms.
I am not claiming to be smarter than the revered icons of the field. I am simply fortunate to live in a time where the collective body of knowledge has allowed me to be less wrong. We are capable of remembering and respecting those who came before us without anchoring ourselves to their initial proposals. It would be indefensible to ignore emerging evidence regarding mechanobiology, pain neuroscience, and the non-specific influences of therapeutic alliance, clinical equipoise, and placebo within our practice.
(If your mentor is still practicing, see point number 1)
3. This is the only way to practice. If you do not follow “X” protocol, you are wrong.
Often, when providing external evidence to support or refute the merits of an intervention, there is a knee-jerk reaction by clinicians to assume they are being shoe-horned into a cookbook approach of medicine. When conducting intervention studies, the parameters of the intervention need to be standardized to reduce potential confounding variables associated with the observed outcomes. These same parameters are often adopted in follow-up studies as a means of continuity to limit noise in the data. This is commonly misinterpreted by practicing clinicians as saying you must perform this specific exercise, in this specific manner, at this prescribed dosage, or you are not “evidence-based.” Such a narrow view of what constitutes “evidence” is unnecessary and unproductive.
There is, and never will be, a “one-size-fits-all” approach to care. External evidence is not granular enough to provide all the answers on a individual basis. It is merely the foundation for which we should draw from when forming a treatment strategy (As I’ve discussed previously, or as Erik Meira has recently expanded upon here). We are not at risk of becoming too evidence-based because we are always tasked with contextualizing the individual human within population data.
Therefore, do not feel threatened by such a critique. “Optimal” treatment will always be individualized. Treating the same condition, while pulling from the same evidence base, can yield drastically different programs and still be considered well within the range of justifiable.
Important to note: while I am not implying these notions when I offer criticism, it does not mean that others are not. I would argue that under most circumstances this attack is unwarranted and unlikely to be constructive.
When Common Sense is Not Common
At first glance, these distinctions appear blatantly obvious. Anyone reading this article will probably find this post self-serving while scrolling through. Everyone believes they embody the perfect combination of art and science required to thrive in a clinical environment... everyone believes they are capable of objectively evaluating arguments for their merits... and everyone most certainly believes they are the ones who have been on the wrong end of the unproductive conversations alluded to above.
This is simply not true.
All humans are susceptible to a number of subconscious, implicit biases which shape our actions and predict our behaviors better than our conscious values. The knowledge we actively pursue, and the years we spend practicing, are not easily forgotten. We allocate greater value to our owned beliefs and can readily become personally and emotionally attached to our ideologies. This tendency leaves us irrationally resistant to changing our beliefs. Compounding this inadequacy, we are prone to revert back to our tribalistic nature on polarizing issues. The desire to conform to a collective mentality narrows our perspective, prevents us from entertaining unfamiliar points of view, and predisposes us to misinterpret philosophical opposition.
No human being is perfect and no idea or approach is infallible. We do not improve if we are always “right.” Criticism and argumentation is a powerful asset which allows us to grow as individuals and as a society. It is easy to misconstrue critiques as personal attacks and shield ourselves from the intended message. We must separate our identities from our beliefs and prevent ourselves from inferring meaning which does not exist. In this way, we can refine our practice and provide more efficient, valued care for those in need.
Header image is the album cover for Universal Themes by Sun Kil Moon on Caldo Verde Records. Listen to 'Birds of Flin' here