Conceptual variation is more damaging, and a bigger issue, than perceivable, apparent practice variation. Because of the multi-faceted nature of the mechanisms of effect in physical therapy treatments, especially for pain, striving for observable decreases in “practice variation” may not actually solve many of the issues within the profession. The real problem is conceptual differences. The stark contrast between explanatory models, and stories told, results in significant variance in explanation and education received by patients. Patients are still routinely told they have “bad” posture, an SI joint that is “out” and weakness causing their painful problems. Such unhelpful and debunked ideas are the unnecessary imaging of our profession.
Words matter. The stories we tell patients, and those we tell ourselves. It appears that in medicine generally, and orthopedics specifically, the language utilized by clinicians affect not only patient’s understanding, but perceptions including pain, disability, function, and quality of life. Beliefs are powerful. So, why do we keep beating around the bush? There is a remarkable range in treatment paradigms, potential mechanisms, and explanations on why things (appear to) “work.”
Now, to be fair, striving for a decrease in practice variation within physical therapy is a worthwhile endeavor. However, I am not convinced current conceptualizations are the appropriate approach. Assessing variation in medical treatments and practice is likely easier than in physical therapy practice. Why? It’s more concrete. Medical treatment relies heavily on the appropriate diagnosis of essential, or substantial diagnoses. Treatment follows, and is mostly dependent on proper diagnosis. Thus, analysis of timely proper diagnosis, matching of treatment and diagnosis, and actual treatment content is more concrete to study. For physical therapy, a different construct is required. The complexities of the clinical encounter and individual nature of the therapeutic process in conjunction with the many potential and identified mechanisms of treatment effect complicate the study of variance. Striving for utilization of the exact same interventions is likely to be a surface level success. It appears like progress. Therapists are dealing with many nominal diagnoses and messy concepts such as unexplained symptoms, function, and behavior change. (note: medical diagnosis is still very complex and full of challenges)
Specificity should be sought after, but not assumed. As more is understood about the effects of interventions it is becoming apparent that techniques, exercises, and interventions themselves are not as specific as originally assumed. If observably clinicians appear to have no practice variation, but utilize different conceptual frameworks and tell the patient in front of them different stories, gross variation is actually still present. Utilization of similar constructs may result in similar “outcomes,” but with significantly different “interventions.” So, what are the common factors?
Regardless of setting, physical therapists should strive for the most accurate deep models of practice, validated and efficient processes in conjunction with an individualized, assessment based, response dependent approach. The best clinical research evidence should be incorporated. This will lead to less practice variation, you just might not be able to see it. Observational variation in interventions may not actually represent difference in concepts. Conversely, two clinicians may perform exactly the same “interventions” with marked disagreements in conceptual framework, reasoning, patient interaction, and patient education. Maybe the method is not the trick? Maybe the process is as important as the product? It’s high time for the accountable practitioner. That means metacognition, critical thinking, and science based practice. Simple…now only if it were easy.
Great blog post, now what can we do to rid ourselves of the MFR, Inominate Rotation, Graston, IASTM; POPTS PTs and all these other alternative physical therapy people that currently hold state licenses? That’s truly the million dollar question.
Nice article Kyle. Practice variation is certainly a tricky issue. It’s kind of like traffic. Everyone is supportive of other people taking public transportation so there is less traffic while they drive. Similarly, everyone thinks that their practice (both physically what they do and their framework) is “correct” and everyone else should adjust their practice to me. We are all the centers of our own little universes I guess. As a profession, we are still struggling with precisely defining a “good” outcome and exactly what the “best” practice looks like in more than just broad terms. As a result, it’s no wonder we struggle with variation in practice.
Well written piece Kyle laying bare some of the biggest underlying issues in the professions self understanding. It may be hyperbolic but I would suspect that unless the profession does seek to resolve this and move to a deeper model of practice it will become increasingly marginalised and irrelevant.
If it doesn’t move on it may deserve what it gets.
ANdy
I appreciate the attention that you have given to conceptual differences. Yes, words do matter. The conceptual framework that we create lays the foundation or creates a significant environment in which healing can progress. As an orthopedic or manual treatment-oriented PT and a Feldenkrais practitioner I discovered that my focus on “kinesthetic awareness” in movement was lost on clients who saw their “problem” as purely mechanical. They were not going to improve under my care unless I did something mechanical to address their perception of their dysfunction. In our clinic we began to develop a “sense” early on for which PT a client would do best with as the client’s story unfolded in their own words.
I support your call to “metacognition, critical thinking, and science based practice.”
Harriet Hall of Science Based Medicine on Why We Need Science
Quantifying Tests, Instead of Good Care
Kyle,
Thanks for sharing these thoughts. You are right about the possibilities of practicie variation (in both technique and concept). These differences (real and perceived) are often where valid and invalid disagreements are made.
This one has me thinking…
The conceptual differences we see are indeed more disturbing to the growth of the profession than technique variability. At first glance, one might think that a PT who is Cert.MDT and FAAOMPT is bipolar. Sure, but not if the underlying treatment philosophies do not collide.
All 4 categories exist (agree with both concept and technique, agree with only technique, agree with only concept, disagree with both concept and technique). The last being the most divisive (I think of caraniosacral therapy here… ).
Solutions? Striving for the deep model will lead you to effective treatments. Treatments follow though processes… so work on thought processes first. One thing that separates us from other “body workers” (or whatever) is that we use science and reduce bias in the search for the truth. Deep models, supported by (granted: ever evolving) research justify our actions. Variation in carrying out the deep models is appropriate to meet the demands of the heterogenious public.
As much as I support different perspectives in care, I do think these variations can go “off the deep end.” It can stray too far off course. I suppose the debate lies in the validity of the connective-ness of our actions to the deep model.
Not to muddy the waters, but all this is on the front end of care. The input, the action. … it does not address outcomes… whew, talk about variability.