This is me.

Category: Reflection

Rec Fem Causes Hip…


EXTENSION!

But that isn’t what this post is about…  Our models for understanding pathology are too primitive to be meaningful.  The background of what I’m thinking:

This article is a perfect example of how remarkably complex human motion really is.  And all I can help taking from it is that after explaining the mechanism to 3 people now, all have fired back with “So, how is that functional?”  Without even giving a minute or two to try to think about a circumstance when something like that might actually be functional.

“This is what I’ve observed.”  “It has to be this way because of the origin and insertion.”


Besides the actual function and clinical relevance discussed in the article, I like to think more about how many other parts of everything I’ve learned act as functional oversimplifications.

These over-simplifications are the basis, for instance, for much of how we model and explain very complex evaluative tools.  I wrote this post a couple weeks ago, and have been thinking about it since then, with a little feedback from a mentor.  At the same time, not too soon after, a friend of mine (@RGWooderson) forwards a blogpost to me called “A Few Tests To Toss”.  It is a great post that actually offered ANSWERS to some of the questions and things I’ve been thinking about.  A recommended read, for sure.

Now my purpose: 

The Low Back.  We try to model the mechanics of it, in all the spine’s complexities.  And evaluate the “motion” people perform by merely touching and observing.  I’m not bashing touching and observing.  I think touch and observation are our greatest tools – just extremely inaccurate, or inconsistent at best.  And seem to fail to achieve proposed/described biomechanical influences. And in the end we are frustrated or confused – as a freaking profession! – about why we can’t cure back pain.  Or why our outcomes for certain sub-populations aren’t better than surgery. 

I’m not satisfied.  Not with the methods of evaluation I was taught in school – like SI movement, low back quadrant testing, and evaluating based on assumptions of biomechanics that don’t hold true.  When I was learning it in school, and disagreed, I felt like I was out of the loop.  Like there was another lecture that I didn’t get to hear. So WTF? Am I an idiot?  Arrogant?  Hopeless? 

Pain I understand – and trying to create a more meaningful picture with provocation testing (see “A Few Tests to Toss”) makes sense to me, especially if it can be linked to treatments that are effective at reducing pain (are they?).  BUT trying to explain the mechanism of pain by assessing 1 – 2 mm of movement through centimeters of soft tissue doesn’t just seem useless, it seems irresponsible.

One answer, as I was hoping to hear (homework: revisit hindsight bias) was outcomes.  We have got to critically analyze our treatments and their outcomes as a GROUP, and hastily discontinue treatments that don’t yeild meaningful results – or as a practice we should be left behind.  Stop trying to explain the mechanism because it is very poorly understood.  Focus on what works, and be certain you are truly quantifying it. 


I started reading Doctors: A Biography of Medicine.  I haven’t finished (thanks, self, for sucking at modalities and cardio/pulm).  There were two main schools of thought regarding medicine.  Both wanted to help patients.  One school of thought was Hippocrates, who, as the father of medicine, and, as I understand it from the book, discusses change in patient condition and patients getting better as the focus of his practice.  The other school of thought in Pergamon focused on pathology, and, ultimately, did not produce a father of medicine.  Galen was more like an uncle of medicine.  Brilliant, to be certain, but wrong frequently about anatomy and physiology.  Understanding of pathology, cell models, etc… was too primitive to be meaningful then, and in many cases today, too primitive to be meaningful now.   I like the clinical prediction rules as a starting point for treatment because, while ignoring the ever elusive question of “why are you in pain?”  it still offers solutions which have documented improvements compared to older methods of treatment. 

Rant over.


Jumping back on the cardiovascular/pulmonary and modalities studying for the NPTE bandwagon.  Thanks for reading. 


-d


Thinking about Thinking

When I started PT school, I knew this is where it would take me.

Bad joke.  Let me explain.

Spent my whole life ignoring things like metacognition, because I preferred more discrete sciences. Love answers. Real answers.  But have, slowly, become enamored with social science and why we think and do the silly things we think and do, and how behaviors and thinking change over time.  Like a playground for my brain!  Errors in thinking… I make a great many errors.

What caught me about this, and why I decided to join the conversation on soma, is a book I’ve been reading about cognitive errors in the assumptions we create constructs of ourselves and the world around us.  The chapters on Hindsight bias and Confirmation bias have taken a lot of my brain power lately.  The book is “You are Not So Smart.”

I suspect that some errors in clinical decision making come from the minds innate need to make sense of the world quickly to move on to the next stimulus.

Clinicians are trained (I just finished school, but hope never to finish training) to rely on “clinical decision making.”  Human make decisions, which are subject to every kind of bias I’ve ever heard of.  Confirmation bias and hindsight bias (narrow spectrum, I know) work together to affirm our mistakes in thinking.  A perfect storm for error!  Hindsight works like this: an event/result/outcome happens.  In reflection, certain events stand out leading up to the incident.  You, being the reflective practitioner you were trained to be, try to construct patterns from randomness.  This is where it falls apart. Hindsight bias is “I knew it all along”.  It’s ignoring how you were wrong previously – taking from coincidence facts and ignoring other data to convince yourself you expected the outcome.   Confirmation bias is “I bought a honda, now all I see is hondas!  I must have bought a great car!”

The worst errors are of oversimplification (for the intent to do good!) of complex models to simpler ones.  This allows them to “see more” and explain more, and rationalize their own clinical decision making. To say “I knew that you would respond to ____” all along.  And a strong bias from then on to find evidence to SUPPORT instead of refute their newly constructed world view.  Confirmation bias is the reason my dad woke up every morning at 5AM to listen to Rush with his morning news before work (politics aside).  People look seek out things that agree with their world view to validate what they are already thinking.  Couple that with a strong hindsight bias and you have the recipe for a guru.  I will explain.  A guru isn’t believable because they are good liars.  They whole heartedly believe that what they are telling you about piezoelectric effect when, in reality, most of what they are saying sounds very plausible because of a very plausible sounding model of electricity.  Or biomechanical models of spine pain. Or justification for ultrasound.  Craniosacral therapy.   I digress.

I am intrigued by the capacity of the brain to justify just about everything.  Including writing this post.

It’s worth noting that I have not even passed my board exam yet.   Turns out I know a lot about neuro, musculoskeletal, and “other systems.”  But less about the foundational sciences of the cardio/pulm system and next to nothing about modalities.  3 of those things are interesting to me.  2 of them bore me to tears.  One of them, as a category of intervention, is mostly crap (so far as my education is concerned, but more independent research on my part should be done). Care to guess which one it is?

Also, I could use a good recommendation for a “review cardio for the NPTE” book, if anyone has anything. Thanks.

-d

Readings and Musings 8/6/12

Who’s driving this thing?!

I get most of my news from twitter and google reader.  I LOVE taking in information from all over and trying to synthesize it into one coherent thought.  I’ve decided to start gathering these readings, tweeters, and resources on a more regular basis and share with you the things I thought were interesting.  Many will have to do with physical therapy.  Some will definitely not!  You’ve been warned.  Without further adieu, my first ever “Readings and Musings.”   Love to hear your thoughts (if I haven’t already).

Appledorn et al. 2012. A Randomized Controlled Trial on the Effectiveness of a Classification-Based System for Subacute and Chronic Low Back Pain  Current treatment based classification schemes do not improve outcomes in patients with subacute or chronic low back pain.

An Essay for Physical Therapists: Lets Move Forward…  An inspiration to move forward, and some issues that are very relevent to physical therapy right now.  There are some great discussion points about manual therapy, and the abuse of modalities.  Comments at the end of the article are worth reading too!

Mannion 2001.  Increase in strength after active therapy in chronic low back pain (CLBP) patients: muscular adaptations and clinical relevance.  Three treatment groups, 1 outcome.  Strength changes through training for chronic low back pain did not appear improve outcomes.

One Word that Defines a Great Brand  Jeff Haden from Inc.com interviews Julia Allison about personal branding.  The interview and picture Julia paints of “personal branding” is organic.  You sell WHO you are, not just what you do.  It’s about representing yourself through your values and connecting with clients.  As physical therapists, we seldom ask a patient “may I help you?”  We ask about their kids, grand kids, their dogs, grades at school, favorite sports teams, or the last book they read.  This article couldn’t be more relevant to PT. 
Natural Cures?  “What medications are you taking?”  “I don’t take any medications.”  We might consider asking about supplements in addition, as I suspect (and I don’t have a lot of evidence for this that isn’t anecdotal, sorry) many patients don’t consider the gingko they are taking to help their memory might also impact their balance (dizziness is a known side effect).  AMA strategies for health literacy.
Build Systems Not Overhead  Rhetorical talk about reducing overhead while improving quality.  Just some food for thought, I guess.
The Right Tools for Negotiating Your Salary – Part One: Your Value.   Part of a 3 part (so far?) blog roll about how to negotiate salaries if you’re a new PT.  Interesting stat of the evening: this year, 12,738 new PT/PTAs will hit the streets looking for jobs. And we alllll want MONEY MONEY MONEY!  
Homework for the week:  Confirmation Bias and Hindsight Bias
People to follow:   @JayS_Tan, @MerylKevans, @Jerry_DurhamPT (unless you’re a Giants fan). 

Meet Mable…

Mable was born on Dec. 27th. She is an English Mastiff. As of the end of July, she’s 7 months old and nearing 70 lbs.  She enjoys long walks, drooling, having her belly scratched, and chewing on anything she can sink her little teeth into.  She is the cause of at least 30% of the anxiety in my life.  Ins’t she cute? 
 Watch closely, you’re going to see that chair again.

How bad could she be? 

She’s just a puppy, right?

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El mejor dia de me vida!

Those of you following me here may or may not know that I’ve graduated!  As of May 6th 2012 you may call me Denver Lancaster, Doctor of Physical Therapy.  Licensure exam scheduled for July 31st.

I thought about taking this time to reflect on 33 months of balls-out academic struggle and tom foolery.  Instead, I think I might just close the book on this one, and show off some fun pictures.

 
There was a party after graduation at Red Rocks!  It didn’t hit me until I was leaving…  I spent more than a full time job’s worth of hours every single week for 33 months with all of my classmates.  Got to know families, significant others.  Made a lot of friends.  Wasn’t thinking, right at that moment, that I will never  be in the same place with all of them again.  Bitter-sweet. :)  Maybe it still hasn’t hit me.  It was a good send off!  Parents got to meet friends, faculty.  I ate myself sick.
Red Rocks is an amazing place.  I will have to make a point of going down there more frequently after I start working and making money.

I’d like to send out a great big generic thank you to everyone who helped me through this – especially family, and good friends (new and old), the counseling center, and modern pharmaceuticals. Thank you.