*this is NOT a political post, despite possible references to political issues. This is a philosophical post. I am also not a philosopher. This is purely my opinion. Level 5 evidence. So take it with a grain of salt.
I recently accepted a job as a full-time undergraduate professor. So, for the last few months I have been preparing lectures while also continuing my day-job as a physical therapist. This has landed me in a really intriguing position–I have been reading A LOT of papers about mechanisms (physiology, biology, etc) while simultaneously treating humans. Medical providers will know what I am talking about…
For the lay people out there, a brief explanation: a lot of treatments in medicine start as bench-science research. You know, people with electron microscopes, pipettes, lab mice, and too many letters after their name to be able to comfortably socialize under normal conditions. Once that has been proven in the lab, it can move out to more real-world testing (e.g. on real humans). What is interesting (and what makes my insinuation in the paragraph above funny) is that oftentimes we can have a really bulletproof understanding of how the atoms and molecules work but then it completely falls apart when applied in real life to real humans. This is explained by the fallacy of composition–where we assume what is true of the parts, will also be true of the whole. And that is the subject of another blog post.
So I’ve learned and re-learned these cool things that are (nearly) cold-hard-facts. And then on Tuesday I go into practice and see it fall apart. Because we humans are more complicated than the sum of our parts.
What happens on Tuesdays is why I thought I would spin a yarn about a few of the common philosophical pitfalls in the attitudes of musculoskeletal practitioners… and maybe a few arguments to help you avoid them.
Philosophical pitfall #1: Fatalism
This is the one I have a directional preference for (bad PT joke!). For those of you that know me personally, you know that I have a big tendency to land here.
As Merriam-Webster defines so succinctly: fatalism is belief that it is all inevitable. Memento Mori. What you are, I was; what I am, you will be. From ashes to ashes, and dust to dust. You get the idea.
And Merriam ain’t wrong. But Webster ain’t right neither! Let me give you an example: bone health.
Bone requires load (weight-bearing activities) to build and maintain mass. In fact, they need HEAVY loads. Often. Just check out this study (LIFT MOR). The physiologic underpinning is Wolff’s law: bone remodels according to the stresses placed on it. And the more stress the better (generally). BUT fatalistically, bone mass peaks at age 20-30 and declines until you take your dirt nap. Certain behaviors can speed loss up, or slow it down. But guess what? It’s inevitable honeybunches.
So this can create a perilous limbo for clinicians. Betty was referred to you after she broke her hip last month. She’s 78. She has been a life-long smoker. Daily drinker. Is post-menopausal, Caucasian woman. She mostly subsists on the tea-and-toast diet. She doesn’t exercise. And NOW, she wants your help. Pfft, good luck Betty! [P.S. for non-clinicians out there, I just listed all the bad lifestyle behaviors for bone health: smoking, drinking, poor nutrition, no exercise. And things outside her control: genetic predisposition, and just had a hip fracture (has about a ~20% of dying in the next 12 months)]. It is pretty easy to throw in the towel with Betty. Tell her to kick back, drink her soda, and rip down those Marlboros because it’s inevitable.
Take heart, my fatalistic friend! You can’t see the forest for the trees. The very scientifically supported, grim prognostic trees... She is READY TO CHANGE. Behavior change is key. And if you know all that mechanistic research about bone loss, you also know that bone will adapt all the way up until you take that final dirt nap. So get Betty under a barbell, get her on some bisphosphonates, get her slugging protein shakes with MILK, and get those bones strong damnit!
Basically, keep your chin up fatalists. Invest in the science. The benchmark science hath saved thee from the pit of fatalistic despair!
Philosophical pitfall #2: Utilitarianism
Ah, our good friend Utility. The level-headed, efficient, analyst type. Actually not so different from Fatalism. Except Utility probably isn’t drunk in the corner, incoherently rambling about ashes at 10am on Tuesday.
In fact, Utility is probably looking at a pivot table on an excel spreadsheet. She has been up since zero-dark-thirty. Short skirt and a long jacket. Touring the facility, and picking up slack (10 points if you know the musical reference).
And even more truly, Utility is stressing you out more than drunk Fatalism. Why? Because analysis paralysis. And at least Fatalism isn’t your fault…you can blame the PT gods. But Utility. Man, you have to begin to decide whether to treat Betty (poor-prognosis) or her twin sister Betsy (the picture of health).
Don’t forget you’re an employee. So is it better to treat Betty, with the crappy insurance that pays precisely 89 cents/visit? Or to treat Betsy, with the top-tier insurance that pays 700 dollars/visit? Your boss has been telling you there might be lay-offs if the clinic can’t see the right mix of payers. But they are both loving, doting grandmothers. But Betty seems REALLY motivated now. Betsy is already crushing it, so what extra help will I be? BUT then what if I don’t treat Betsy and she sees that quack down the road that is peddling red-light therapy and broccoli enemas? But Betty smokes UNFILTERED MARLBOROS while chewing Grizz and doesn’t want to quit. But Betsy can do 40 sit-to-stands, but she does have a genetic predisposition for fractures and bad eyesight. But..but..but…
Insert nervous breakdown. Subsequent existential crisis. And scrolling through employment sites looking for that cush travel gig.
Look, I don’t really have a good answer for this one. Utility makes medical ethics harder than they already were. Having been there (more times than twice) you have to realize something: you can’t help everyone. And it’s not your job to decide who’s journey is more valuable than another’s. You just have to make the best clinical decisions possible that align with evidence (more later) and your moral compass. Leave the rest up to God, or fate, or Buddha, or whatever your particular belief pattern is.
Philosophical pitfall #3: Relativism
Okay, dodged a bullet so far…
Fatalism was getting you down with depressing soliloquies about Death, holding onto the clinic’s model-skeleton’s hand. Weirdo. And Utility got you STRESSED. THE. EFF. OUT. You had to “take a phone call” outside because you couldn’t handle another discussion about ROIs and cost-benefit analyses.
So you have crash-landed comfortably in the realm of Relativism. It’s a sunny field, full of wildflowers, somewhere in the Austrian alps, and Julie Andrews is singing to you… but you have this sneaking suspicion that something isn’t quite right. You don’t know it yet, but this is the most dangerous place you’ve been in your clinical journey so far.
I think relativism is the final resting place for many clinicians. Particularly, the old-school PTs. You’ve met this guy. Owns his own practice. Has since 1978. His degree cost him like 14 dollars. Does the same ther-ex routine with every knee, shoulder, and hip. Uses ultrasound, heat packs, E-stim, and traction units like they have NOT gone out of style. Says ambiguous things like “you can read all the research you want, but EBP is a three-legged stool”.
He’s gone lady, let him go. He’s stuck in a perpetual acid flashback.
He has been lost to the illusion of Relativism. He doesn’t realize that most of those people were going to get better with natural history. That most of his “evidence” was published before you were born and has been summarily discredited by the time you were 10. Plus, clinical experience is better than any article anyway. He doesn’t even consider that taping, e-stimming, and cupping his way to pay-day actually may have negative effects on people. Biomedical-bioschmedical. He just keeps doing it because “it can’t hurt, and it makes them feel good. We are a customer service business first.”
But this guy is a red-herring. This is a pitfall you knew to avoid. You were warned. You chuckle off his bad jokes. You side-step the scraping tool. You resist dropping those forgotten, dusty weights on his foot when you attempt to actually strengthen your patient.
What you didn’t see was the con-ed course that clearly confirmed all your biases. You strategically ignored that one paper that claimed yoga was as effective in treating chronic back pain as manual therapy or exercise, because “it wasn’t an RCT” or “you didn’t have time”. You bought a subscription to a movement screening program because it is clearly “ahead of the evidence”. You cling to beliefs and you don’t know why. You believe that everyone just needs to get stronger, or that being stronger prevents injury, or perfecting the mechanics of the landing will reduce GRF enough that their PFPS will go away…
And that lovely little alpine meadow sucked you in. Perhaps you’ll become the old, blissfully unaware PT. Traipsing around whistling Edelweiss. For your sake, I hope so. Or you may wake up one day and realize that your alpine meadow has now become a scorched wasteland. You didn’t realize that Relativism let your clinical practice begin to creep. You didn’t realize that once you stopped reading research, the ambiguity got easier to deal with. You could explain away most issues with mechanistic arguments and pseudoscience. Confirmation bias set in fully—you only talk to other whackadoodle-certified therapists, you only treat people that keep coming back because you didn’t realize all the drop-offs were from ineffective treatment, that red-light machine only cost $70,000 and it gets AMAZING results…
Okay, okay. Sorry. Got a bit dark and extreme. But I think you get the point. Relativism, the idea that there is truth in every treatment, just doesn’t hold water consistently enough to put out all the fires you started. Red light doesn’t help bone growth like loading does. Placebo like that doesn’t grow bones, sorry folks. A walking program, while good, is not better than jumping to increase bone mineral density. And sarcopenic muscles don’t hypertrophy more with tape.
It’s starting to look like Science will save us from Fatalism, Relativism, and Utility…
Philosophic pitfall #4: Scientific Evidence
Aw yes, the light amongst the darkness. The promised land. The TRUTH: Evidence. That lovely, lovely systematic review with meta-analysis. RCT’s abound. All the studies have low-risk of bias. The conclusions are clear, concise, and adopted by everyone simultaneously across the land. Angel choirs sing…
*Screeching record*
Now before I dive into this, remember: as a student I picked a fight with a con-ed instructor at a free kinesio taping course. And then almost burned the building down on my way out. I like science. I dislike charlatans.
Everyone, especially new-school PT’s, love to hang our hats on glorious science. And rightly so. A few scrolls up I used science to discredit a Fatalistic and a Relativistic argument for barely legal (certainly unethical) treatments. Don’t believe me? Read a few papers. Science is right. And honestly, there are some good papers looking at the cost-benefit analysis of treating various conditions. Spoiler alert: PT isn’t always the choice that provides the most Utility (FROST trial comes to mind).
Science helps fight the 3 big pitfalls I mentioned earlier. So: no more dancing with Death (Fatalism), no more running away from accountants (Utilitarianism), and no more frolicking through mirages of alpine meadows that are actually forest fires (Relativism). How could science be a pitfall itself?
Glad you asked. Diving into all the statistical methods that underlie flawed results would take many, many more scrolls. So let’s suffice to say: there are a lot of areas where error or devious behavior can manufacture misleading results. Let’s not even mention the recent SNAFU over some Alzheimer’s research…
But let’s zoom out a little bit more than that. It all comes back to that first fallacy I mentioned: the Fallacy of Composition. Plain and clear: humans are more than the sum of our parts. We also happen to be messy because we have thoughts and emotions. Science can’t always capture that. More often than not, science doesn’t capture it at all. Just look at placebo research. Or chronic pain research. Or even surgery research.
Taking a sugar pill can be just as effective as a drug that actually changes your physiology. Telling someone to continue to be active is just as good as removing part of your knee. Doing a pleasurable activity (like yoga) is just as effective as an individually tailored, supervised exercise program. Having someone poke holes in your shoulder and then suture you back up is just as effective as actually removing cartilage and tendons and sewing things up internally. CLEARLY, something else is going on that is mediating recovery. CLEARLY expectations, beliefs, emotions, and thoughts are a really vital part of the human experience.
And CLEARLY we have a hard time measuring that with current study designs. Does it mean we can do better? ABSOLUTELY. Does it mean we will ever have all the answers? Probably not.
And probably the truest part: this is the most dangerous pitfall of your entire journey with me today. Why?
The road to hell is paved with good intentions.
Like all good weapons, evidence is a double-edged sword. Evidence can be used to craft narratives of the “good” and the “bad” providers. It can create moral superiority in those that consume more of it. It can be used as a tool to hurt others, confuse patients, and pit providers against providers. It is often cited as the reason people: slip into the comfortable fever dream meadow of Relativism, become jaded and dance with Fatalism, get burnt out by Utility and leave the profession.
Take Home
I can’t tell you the number of times I have contemplated leaving healthcare entirely. So how do we keep finding hope?
Science is a compass. Rely on it to guide your general direction, but don’t forget to look up at the trail once in a while. Otherwise, you’ll be way off the map but still “following evidence”.
Relativism is good sometimes, just don’t compromise on your morals. It lets you be fluid with the messy human in front of you. Because sometimes a patient needs a manipulation and sometimes not, but cannibalizing patients is (almost) always wrong.
Altruism gets you points in the afterlife, but Utility gets you paid in this life. And helps you make the tough decisions–like cutting the cord with some patients that just aren't getting it.
Fatalism helps you cope. You can’t help but laugh after a particularly tough session with someone who is being a butthead. Why? In the words of Theo Katzman, “100 years from now, remember: all new people”. (Oh no, my Fatalism is showing).
Hope my hyperbolic ramblings were helpful, or at the very least entertaining.
-TW
P.S. it’s okay to fall headlong into all of the pitfalls. I did. Just wear a helmet and make sure you have people to help you get back out.
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