One of the inescapable realities of modern life, or should that be post-modern life, is that we have all become skeptical of authority figures that want to tell us that they know the answers, and that we should follow them compliantly, passively and unquestioningly.
There once was a time when people genuinely believed that the church, judges, the police, school teachers, parents, doctors and other authority figures genuinely knew best, but our trust in these authorities has been eroded by scandals, self interest and injurious practices.
And while some of us yearn for a simpler time when the world was black and white, we can’t erase the image of child abuse by Catholic priests, medical malpractice and institutional racism in organisations like the police.
The Internet has helped destabilise the power base of traditional authority figures, and it has done this by taking away their ability to claim privilege over the kinds of knowledge that are deemed to represent the truth. But what we have believed to be true has always shifted, so it was always the ability to be the ‘broker’ of truth that really mattered in society. So when the power of the brokers (the doctors, judges, teachers, etc.) began to dissipate rapidly with the advent of the Internet, it opened up a space for new truths to emerge.
Physiotherapists have become quite obsessive about objective evaluation of their practice and demonstrating that their claims about assessment and treatment efficacy are ’true.’ But it is questionable whether many people outside of the profession really care.
As Miles et al have pointed out in their scathing editorial on evidence-based medicine, there is no evidence that the implementation of EBM has improved the health and wellbeing of a single patient (Miles, 2008). Add to this the fact that our current methods of assessing the efficacy of our practice (i.e. that represented by the hierarchy of evidence), suggests that there isn’t much to physiotherapy that can be trusted. (Look, for instance, at this neat summary of the most influential physiotherapy research studies of the last 15 years here, and count up how many studies brought about change because physiotherapy was shown to be ineffective).
The things that we take to be true may seem on the surface to be black and white, but they rarely are. Even the idea of truth is shifting. Thus any search for absolutes is futile. The idea of a single, all encompassing truth that we can all subscribe to is a fantasy, and today’s (post)modern world only indicates more strongly that we are more eager than ever to see truth as fluid, contextual and personal. This has radical implications for physiotherapy, but it seems physiotherapists are finding it difficult to let go of past truths that meant something in the 20th century, but may be increasingly ossifying today.
Reference
Miles, A., Loughlin, M., & Polychronis, A. (2008). Evidence-based healthcare, clinical knowledge and the rise of personalised medicine. Journal of Evaluation in Clinical Practice, 14(5), 621-49. doi:10.1111/j.1365-2753.2008.01094.x
One of my favourite activities with students is to give them an assignment where I point them to several credible sources on a topic, and ask them to make choices about which source they would use to inform their practice. I have one task in particular that always generates good discussion; I send the students 3 research papers from high impact journals that present fairly strong evidence that manual chest techniques in the ICU actually lead to poorer patient outcomes by whichever measures you want to use (time to discharge, increase in complications, etc.). This is most effective when the students have just finished a theory module on how important physiotherapy is in the ICU (taught by someone else, which is maybe not fair).
Anyway, the students are forced to confront the idea that things like “facts”, “knowledge” and “the truth” are, to a large extent, negotiable and that they can change over time, which they find quite discomforting. They – and most of our qualified colleagues – like to believe that the world is an objective reality and that with enough measurements, they can accurately describe it. It’s challenging when they come up against a set of contradictory facts about the world that are mutually exclusive i.e. physiotherapy is “good” for patients in the ICU vs. physiotherapy is “bad” for patients in the ICU. I’m a firm believer in using a pedagogy of discomfort to disrupt established knowledge frameworks, and thereby creating cognitive space for the encroachment of new ways of thinking about evidence and how we make choices about what we do with patients.
Not everyone likes this approach because it’s “confusing for the students”. But what should we rather do…wait until they graduate and come up against these contradictions in their first month of independent practice? At least in this way we can have an engaging conversation about what constitutes knowledge and evidence, the nature of reality, the challenges of writing up research findings, designing high quality studies, how we make choices about what actions to take, managing the whole person as opposed to preventing bedsores, etc. I think that these conversations are far more useful for students’ professional (and personal) lives, than simply memorising another list of complications that we need to avoid in the ICU.