I have previously tried to limit the impact of my personal preferences on my writing. I justified this choice as being useful to reach a larger number of professionals in my field, and ultimately, have a greater influence on clinical practice. Emphatic, assertive statements tend to garner massive support amongst those who already agree with you, but this also leads to quick dismissal from those who fall outside of that group. While this may be true, unspoken points of view also fail to impact beliefs just the same. Backfire effect aside, I am stepping onto a pedestal for a moment to tackle a large pet-peeve of mine that’s been circulating around social media.
In the United States, physical therapists aspire to fulfill a central and irreplaceable role in the musculoskeletal realm. Our profession seeks to “transform society” and “improve the human experience” through our care. An obstacle to occupying this prominent seat at the healthcare table has been our nebulous identity in the eyes of the public. Other medical professions have a clearly demarcated service to provide whereas we struggle to generate a consistent image.
A proposed solution has been to enhance our advocacy efforts and educate the general public regarding the functions of a therapist. Some interpret this approach as a request to set aside our intra-professional differences and create a unified front to address this pressing concern. While well intentioned….this notion is misguided.
It seems intuitive that we need to stop “tearing each other down” and we should instead focus our efforts on promoting our field. However, not only does this sentiment wrongfully imply we are incapable of critiquing practice patterns while simultaneously acting as advocates for our profession, it also undercuts our objective and perpetuates our identity crisis.
Tilting at Windmills: addressing a problem that does not exist
Often, the rationalization to silence public arguments is the theory that patients and physicians see our internal battles on social media and subsequently lose confidence in our ability to treat.
How many medical professionals do you follow outside of your own field? Hopefully, that answer is greater than 0 (because we should all gain additional perspective). If so, it’s most likely either for referral relations or academic interests.
Now alter that question slightly: How many medical professionals do you follow that do not have direct implications on your practice? How closely do you monitor their intra-professional debates regarding best practice?
Anecdotally, I have never had a patient or physician tell me they opted out of seeing or referring to a therapist because they “fight too much online.” Unfortunately, I have had countless individuals claim they avoided contacting a therapist because they “tried PT” and “it did not work.”
While survivorship bias and selective polling make the question impossible to answer in this format- I feel safe in my assumption that previous personal experience has a significantly larger impact on our perception as a field than our online slugfests.
Translation: Calling out unsubstantiated practice patterns online does not lose us many patients; treating with such practice patterns does
And I, by no means, am telling others not to be advocates for our field. This is not a dichotomy. We do not have to make an either/or choice. I am a proponent of conservative care for many conditions and believe our field is in an excellent place to serve an important role in society. I do not have to maintain blind faith in our field as a panacea to hold this belief and I certainly do not believe all therapists possess the same knowledge and abilities to achieve these outcomes.
A Test of Faith
If a loved one (who lives far away) is referred to the local therapy clinic, how confident are you in the care they will receive? Maybe you are more trusting than I am, but my hesitancy in answering that question is why I am usually unable to support encompassing movements like “Get PT 1st.” I do not have unwavering confidence that an individual will receive excellent management and education if they are referred to random-therapist-down-the-street. This is not a knock against any one professional. It is an indictment of the vast variability that exists within our field.
When discussing the shortcomings of various clinical implements, some clinicians act as though their hands are being bound and their scope is being infringed upon. We are professionals who facilitate outcomes. We are not a medium for a collection of modalities. There exist infinite possibilities within what we know to be beneficial to our patients. If you feel limited, the fault lies in imagination and implementation- not scope.
Poor adherence to best-evidence impacts us all. If we do not leverage our current knowledge base to maximize the probability of successful outcomes, there are widespread implications for our profession on a societal level. As I alluded to before, we are often viewed as a homogenous service rather than a cohort of therapists. We are not afforded the benefit of the doubt when desired outcomes are not achieved. The majority of patients will not probe further and seek alternative clinicians. They will simply stop seeking care, concluding that “therapy did not work.” Not only will this lead to potentially fewer referrals for similar case presentations moving forward, but it can also impact our effectiveness for those we do see. Psychological variables (such as the expectation of full recovery) are independent predictors of successful rehabilitation in various conditions. Incorporation of poorly justified or outright invalid treatment options begets unresolved complaints and artificially reduces confidence in our ability to manage musculoskeletal impairments. Therefore, this cascade of events serves to anchor the opinions of the involved patients and physicians to unsuccessful experiences and subsequently reduces their trust in the utility of conservative care.
Excessive Heterogeneity of Care is a Major Problem
To be clear: I am not talking about minor discrepancies in ideologies. I am not referring to the debate around dry needling or manual therapy. I am speaking about ensuring we are addressing the obvious, low-hanging fruit in front of us. Poorly vetted paradigms emerge, in part, because there exists a pervasive sentiment that the accepted standard of care for our field is “behind the times” and unable to effectively address our patient’s presentations. This unchecked exploration is unnecessary. Data suggests that the MAJORITY of treating therapists do not even recognize or engage in practice that aligns with current evidence.
In a 2012 sample evaluating therapist’s knowledge of clinical practice guidelines (CPGs), only 12% were able to identify current management guidelines for low back pain. A more recent look at actual practice behaviors reveals that in the best case scenario, only 55% of those who are fellowship trained and have orthopedic clinical specializations are adherent to all CPGs. Within that same study, only 58% of experienced clinicians without such extensive post-graduate training adhered to exercise guidelines and merely 20% provided education to stay active and pursue an active lifestyle (for additional context, 23% of that same cohort utilized passive modalities such as laser, ultrasound, electrical therapy, and/or bed rest). Variability of practice is great... as long as it is anchored to and includes what has been empirically shown to be beneficial.
But My Experience Says...
Preemptively defending against the inevitable appeal to the “three pillars of evidence,” please know that this is something I have considered at great lengths and believe to be a widely misunderstood concept. As Kenny Venere points out, “Clinical expertise in isolation is unreliable in its ability to infer the benefit or harm of an intervention.”
In addition, the absence of evidence is not the same as evidence of no effect. Many of the practices being questioned have time and time again shown to have minimal-to-no effect when controlling for other explanatory factors (clinical equipoise, patient-therapist relationship, expectations, etc.)
I am absolutely sympathetic to the notion that we may be measuring the wrong variables, we may be using inadequate parameters for treatment within our studies, we may not be capturing the appropriate subgroups, or our study designs may not be adequate to answer the questions being asked. Being overly dismissive may lead to type II errors and let a useful option pass us by. However, we must also acknowledge that most trials are designed to demonstrate positive effects and we are not likely missing something with indisputable benefit. Add this to the small sample sizes frequently used within rehabilitation literature along with the known file drawer effect and it quickly becomes apparent that we should be more concerned with Type I error influencing our practice patterns.
This indicates that when someone’s personal experience clashes with well-conducted research- the burden of proof lies on the individual defending the now questionable practice. Special pleading requires sufficient plausibility for why your circumstances would be expected to differ from the examined group. Most often these arguments are less than robust and many regress into “I’ve seen it work” appeals.
So What is the Solution?
There is no single, definitive answer to address this multifactorial issue. We are still considered by many within our field to be a consumer service industry (see Erik Meira’s article here). There remains a constant struggle to reconcile our evidence base with our desire to make our patients happy. Efforts within education (emphasizing critical thinking and the importance of the scientific process) will likely yield the greatest effects; however, it will not be enough to suppress our innate tendencies as human beings.
What we can do from the ground level is:
1) Stop silencing those who challenge you under the guise of “unity.”
Comments of this nature subvert criticism and prevent (potentially) productive dialogue entirely. Moreover, shifting blame onto the challenger and implying their dispute is an attempt to “bring you down” assumes the contention is with you (the individual making the claim) rather than the premise itself. This misinterpretation adds fuel to the fire of our already muddied self-identity. We should remind ourselves that a challenge to your ideas is not the same as an insult to your character.
2) Do not be afraid to engage in debate.
Science is at its best when it’s a social process. Individual reasoning is inherently lazy and we require multiple perspectives to refine our thoughts and approach the never attainable “Truth.” We should hold each other accountable and ensure we’re capable of appropriately justifying our clinical decisions. Falling into the “it worked for me” trap is unbefitting of a member of the medical team. However...
A word of caution to the internet’s white knights:
That is not to say that all methods of confrontation are equal, or that all situations are capable of producing the desired change in beliefs. Regardless of how terrible you may think a particular intervention or treatment philosophy is, it is almost never warranted to attack the provider directly. Challenge ideas, not individuals. The vast majority of those who enter the field of rehabilitation have the same core value - they want to help others. Most of our decisions are not made with nefarious intent. Quite the opposite, we are compelled to treat because we desperately want to help those in front of us and truly believe in what we are providing. Keep this perspective at the forefront of the conversation and try to limit your emotional responses.
Superficially, this call to action sounds great. In reality, you must know what you’re getting into before you engage in these kinds of discussions. Often, individuals who jump into “attack mode” on various social media platforms are woefully unprepared and do not aid in positive behavioral change efforts. Mob mentalities and tribalistic dichotomies are incompatible with a scientific way of viewing and interacting with the world. Reciting rhetoric from your favorite social media persona is no better than following the practices of a guru. You must understand the data from primary sources, understand the likely contentions others will have, and remain empathetic to their rationalizations. You must also take special care to provide alternative explanations for the apparent success experienced by the clinician. Human beings are generally incapable of accepting uncertainty and will go to great lengths to confabulate a causal narrative to explain their observations. If you methodically attack someone’s belief structure without providing a new paradigm to make sense of their reality: you are setting yourself up for failure. Posts which simply debunk incorrect information may lead individuals to value their prior beliefs more strongly. A 2017 analysis supports this contention by examining a group of Facebook users who routinely engage with “conspiracy-like” information. Individuals who were exposed to and interacted with debunking claims had an increased rate of liking and sharing unsubstantiated posts after being exposed to factual claims.
Although well-meaning, incomplete arguments and unfiltered, holier-than-thou rants do more harm than good. This process sounds like a lot of work….and it is. To quote Brian D. Earp “The amount of energy necessary to refute bullshit is an order of magnitude bigger than to produce it.” If you are not able to fulfill the aforementioned requirements- pause before running to the keyboard next time.
Currently, we are still often viewed as a service (therapy) rather than professionals (therapists). Due to this public perception, we have a burden to bear as a collective. If a patient has a negative experience working with a physician, the blame falls on the individual and they will seek alternative care from another physician. If a patient has a negative experience with a therapist, the blame is placed on the profession, as though “therapy” is incapable of helping them. Therefore, the nonsensical treatments utilized by a local provider not only reduces the likelihood their patients seek conservative management in the future, it also reduces their referring physician’s confidence in conservative care. Limiting the usage of such treatments is imperative to drive the field forward, help more patients, and improve our standing in society. Engaging in meaningful dialogue with colleagues is not going to cost us patients, it does not aim to shut down justifiable opinions, and it will not resemble a verbal assault on a well-meaning clinician. We must hold each other accountable because, as it stands, the opinion of our field is in our hands. We are all contributing authors of this story. We must ensure we do not let others write chapters devoted to ineffective treatments which dissuade patients from our valuable care.
Header image from Sergio Leone's 1966 film The Good, the Bad and the Ugly