The misguided profession

[Dr Damien]

Dear Colleagues

One morning I woke up with a rattling noise coming from my car on my way to work. I didnt want to risk the possibility of getting stuck on the motor way so i went straight to the garage to visit an engineer. I was told the rattling noise was a loose panel underneath the car, i was also told that i had one of the bushells i believe it was called loose in one of the front wheel mechanism. While i was there i decided to have the whole thing checked over, it turned out i needed new brake pads as well.I got a quote for the repairs and realised it was too dear for me to fix right away.So i took the car away missed work for a few days and opted to see another engineer who gave me the same diagnoses. He opted to have me fix the problems in a cost effective manner by doing the most important to the least important over time.

This got me thinking. Why is it that as physiotherapists we do not apply the same principle to patient diagnoses and management? what i mean is if a patient came to see three different physiotherapist , he was likely going to come out with three different diagnoses with three different lines of management. Understandably that a car is different and parts can be changed in a car but really why do we have different methods of addressing the same problem?. One might be quick to add that the main reason is not practicing along the lines of what the evidence suggests therefore the fate of our patients often lie in the expertise of the treating therapist. While this argument holds water, i ask the same question again? why is it that the research evidence continually fail to inform us about how best to treat certain conditions? this is not to suggest that all mechanical car engineers will always arrive at the same diagnoses for a problem especially when the make model etc of the car is crucial. but often enough, the arrive at similar conclusions most of the time at least for the honest ones out there.

I personally dont think research evidence will inform us about anything and i think i would be justified for thinking so. For as long as scientific evidence/research have limitations which however way we try to control we cannot totally, then we will still be left to individual skill and expertise in carrying out our duties. I mean there are guidelines out there for certain conditions but they are only what they are, guidelines based on whatever flawed evidence is out there relative to the time in question.

So i throw myself back when i first qualified to try to find an answer. I realised when we physiotherapists first get ourt degrees we are trained with a general knwledge base which as we develope professionally we begin to divert into specialities. Some might say this is a good thing but sometimes i beg to differ. So we gain these specialities and then get stuck within that speciality and are unable to help some clients that need us in time. Not only that, when we try to develope within our specialities we realise there are a myriad of courses all testifying to manage the same thing with different approaches. So that when a patient comes to therapist who was trained with a mckenzie approach his assessment, diagnoses and line of treatment may ultimately be different from that who was trained with a mulligans approach for instance. Also, we have situations when in a patient is deemed unsuitable for musculoskeletal input simply because he or she has long term neurological problem. That patient gets sent to the community physiotherapist who has had no opportunity to develope his musculoskeletal skills and in the end who suffers...the patient; who clearly still hasnt found the answer to their problem.

For as long as there is a profession called physiotherapy, there will always be new methods of treating patients and further need for more research evidence. from craniosacral therapy, to kinesiotaping, to mulligans, to cyriax to shirley sarhmann, to the pilates, to the bobaths etc, . This is madness i believe. What have we done with the knnowledge that we have gathered so far other than complicate things even more. No wonder there isnt any real evidence out there to inform us, we are spiralling out of control with all this methods which frankly in my own opinion are basically saying the same thing. How do we standardize things?

Many people may not agree with the medical model but it in many ways can be precise and definitive. We as therapists pride ourselves in having the answers to some of the questions the medical model cannot provide yet we cannot agree on what those answers really are. Do we need to go back to the basics and reevaluate how we are being trained as physiotherapists? maybe we need to start collating all this information together and start structuring a model that is standardized ? maybe we need to cut down on speciality and start seeing our patients as a whole rather than individual parts of a system?

I for one would like to see a patient with knee pain for instance undergo the same sets of assessments diagnoses and treatment in clinic A as he or she would have in clinic B. In the area of manual therapy, standardization will be difficult to achieve in all honesty because its so subjective to the skill of the maneoverer however exercise therapy can be standardized. But how can we standardize exercises when shirley sarhmann is saying for neck pain you need to exercise this way and mackenzie is saying no its this way, when the supporters of deep neck flexor activation are saying its this way, and the manual therapists are saying its got to be that way. I cannot even look into frontline and decide how i want to develope myself anymore because there are just too many techniques out there. yes, i can hear people saying this is the reason why these techniques need to undergo scientific scrutiny, my answer is i totally agree but the research evidence is only as good as the method. For as long as the patient who is lying down on my plinth has nothing in common with the sample size of that study its useless to me.

I think its about time we say no more techniques, lets start looking at where all these techniques we have now share a common ground collate them together and form models of assessment, diagnoses and treatment. then test these models research wise

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[physiobob]

And although I do not agree on all points above I think I understand your frustration. The MOST important thing for all students and recent undergraduates to understand is that if a technique or 'exercise' has not yet been subjected to the research then it DOES NOT discount it as a valid, reliable and effective tool. One can only comment on those that have been tested, with specific note to their methods and subject group, as to whether they were effective or not (or more effective than other comparative groups).

I feel the recent graduates and the new students are being brainwashed into the notion that if it is not yet endorsed by an RCT etc that it has no value. I can say for sure that the better and more skilled clinicians techniques that truly help their patients have never been put to an RCT or other clinical trial. We SHOULD NOT base our professional practice on the research of the common or the average. We should strive to learn more, try more and develop more.

Perhaps as you say, we should look a little more at the similarities across things that seem to work and why, but not base that on techniques limited to the research. I feel that although starting with good intentions the profession has lost it's way due to the pressures of government and private medical insurers all trying to save a dollar....... but then that is a new topic of conversation.

[estherderu]

I have to agree with physiobob
Our profession is going the wrong way altogether.
We have always been a practiced based profession and this will hopefully not change.

Of course we need to try to research what we do but some things cannot be researched that easily.
Touch is such a personal thing and reactions will depend on lots of variables.
Touch can make the world of difference as in patient trust of you yes/no.
Every patient is different: be in a different state during parts of the day/week.
When being 'tested' no-one is the same as they are on a day off at the beach.

Who are we fooling?
The patient is not oblivious of what is happening and just wants us to try our very best.
Meaning, use every bit of knowledge and expertise you have, use the knowledge the seniors have ... the practice based evidence, and research if possible and necessary.

Esther

[Dr Damien]

Dear estherderu

Thanks for your opinion, ive always thought i was the only one who feels there should be a change somewhere or perhaps a revisit of what really works.

[estherderu]

Hi dr Damien,

No, there are more of us out there. Most of the ones I know have been in the profession for a long time.

The question is, will the young 'acadamically' trained listen?

I am afraid there is going to be an enormous braindrain (as in practical skills and knowledge) when we all leave.

We will see.

Esther

[physiobob]

Indeed the 'enormous braindrain' is getting very close as people not only retire but leave the profession due to the dismay that it is not what it was when many many of us . Unfortunately the historic 'gurus', whose work we all look up to, would not have much place in the current training and it's approach to treatment. Shame....