Progressing the Curve; Practice & Evidence Imbalance
by Tim Fearon PT DPT FAAOMPT
The leading cause of death in the world is falling; the leading cause of falls is balance dysfunction. The logical conclusion is that to avoid premature death it may be prudent to avoid falling. There is a parallel here from individual lives to the collective life of a profession.
The longer one practices with honest metacognition the greater the potential for wisdom. I have observed over time that experts do the basics to near perfection and they do not deviate from this. The developing clinician practices until he/she can do a technique well, an expert practices until they cannot do it wrong.
Yet experts would not advance their expertise if they were content with the evolution of their practice pattern to that of unfailing competence of basic skills. They also become expert at the recognition of failure and responding to the emerging data that tells them that their current direction choice is faulty. The lack of accepting an errant path is what separates them from non-experts. Having followed all of the appropriate steps in the supposed standard of care and finding no success, the expert clinician begins to seek alternative pathways that are determined by the response of the patient at hand.
As manual therapists we should keep in mind that our goal is always to restore normal function to the altered neuro-musculoskeletal components of a patient. There is no limit to the ways that patients create abnormalities and we should have no limit to our creative application of basic principles to allow us to help the unusual or complicated presentation. All the techniques that we have demonstrated efficacy for were at one time created by an innovative practitioner who found a need to diverge from the usual array of techniques which they had been taught.
If we are to continue to grow as a profession, we need accomplished clinicians to pass this element of our profession to the young. They cannot learn this from devoted educators or researchers because these are time demanding, full time professional contributions that simply do not allow the volume of patient interfaces (if any) to push necessity into creativity.
In today’s era of bias toward evidence based practice (EBP) there is a double edge sword that is not commonly spoken of. The desirable aspect of the EBP bias is the push to relatively standardize what a patient around the world should expect to receive when they seek physical treatment for a common problem. This creates a demand on practitioners to meet the prevailing standard which should elevate the practice level of those who were practicing at the lower end of a symbolic bell shaped curve, a drive to the middle. The undesirable aspect of this bias is that it can create a danger of driving the creative potential master clinicians toward the middle by the covert demand implied in the push to standardize.
If the master clinicians among us do not model this practice pattern to the rising young clinicians, fewer of the potential master clinicians of the future will ever be shown the path to developing that mastery. If this suppression of the inherent need to be creative to grow the body of knowledge goes unchallenged we self impose a limit on the natural potential of our profession. One of the founding fathers of clinical reasoning, Geoff Maitland said; “There are no techniques. Technique is the brainchild of ingenuity for the given circumstance.”
It is easy to understand the need to drive those on the negative standard deviation end of the graph in any profession toward the mean. It should be just as obvious that professional growth would be stifled by driving those at the far end of the of the positive standard deviation side of the graph backward toward the mean.
To have an eye on the future of the profession what we should do is encourage those who are innovative in the face of challenge and honest in the assessment of their innovation, to push forward with their creativity. When they find things that consistently demonstrate potential they should then teach those who will follow them. The creative clinicians who are operating at standard deviations above the mean should feel no need to be bound by an algorithm created to elevate those operating at standard deviations below the mean. They should however feel the need to share what they are doing and the thought process that brought them there. The interface between the mentor and the mentees ideally will elevate both parties. In doing so we can move the curve forward toward a higher level of skill and a new, elevated mean. The collaboration can be furthered by sharing the thought process and the evolving techniques with those who would subject it to the scrutiny of research. In this way we truly participate in building a profession for those who follow us and those whom we serve.
Applause is deserved for the drive away from theory toward scientific foundation. However, caution should be urged that we not fall into the trap of being evidence driven but rather evidence informed. Mentoring from those more experienced and wiser than we are should lead us to a freedom to explore the boundaries of what we know, so that we might learn answers to that which we don’t know. This is the task of those truly committed to progressing the profession which they function in and there by move the curve to higher ground.
Karl Barth wrote the following about Wolfgang Amadeus Mozart and it seems an appropriate way to close
From the beginning, he moved freely within the limits of the musical laws of his time, and then later even more freely. But he did not revolt against these laws; he did not break them. He sought to be himself and yet achieved his greatness precisely in being himself while observing the conventions which he imposed upon himself. We must be aware of both these elements together. This is the mystery behind which we must seek his special genius if we are to appreciate the superiority with which he moved within his artistic and human surroundings. To this day he seems to us an eagle soaring above the concert hall.
Let’s stay grounded with what we know but encourage giving flight to more master clinicians. It is in the end what all of our careers are predicated upon. Without clinicians, there is no profession.
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