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Do you need to care to be caring? Sympathy, Empathy, Compassion, and Caring in Healthcare

What I couldn’t say – but wanted to – was the truth: I don’t care.

Seriously. I don’t. I can’t.

Keith P states “I don’t care.” And, I think he’s right. A certain type of detachment from the potential suffering and emotional struggles of patients is vital for a clinician. The ability to assess, analyze, and make proper decisions may be clouded if those treating are overly emotionally involved in the circumstances of those they treat. Further, shouldering the burden of the many unfortunate clinical, emotional, and social situations encountered within healthcare can easily leave one with a sense of hopelessness. It’s quite easy to succumb to pessimism and apathy when the grand scale of suffering, inequality, and just plain bad luck occupy the beds and treatment tables daily. But, is this ideal for patient interaction? What do patients prefer? Establishing and enhancing alliance, rapport, and an environment of care is necessary. An explicit connection with the patient is a precursor to, or maybe even the foundation of, the therapeutic process. Too far to one extreme and the risk is burnout. Too far to the other and the risk is a cold, distant clinician (and still burnout). As in anything, explicitly defining terms and concepts is helpful.

Definitions and Terms

Sympathy, empathy, compassion, and caring are connected concepts, but have differing definitions. And, specifically within healthcare these concepts require more specific exploration. While various, and vague, characterizations of sympathy exist within and outside of healthcare, for the sake of clarity sympathy generally centers around an emotional state of feeling. It can manifest as pity or sorrow for another, a common feeling, or a relationship in which that which affects one mutually affects the other. The simplest definition is entering into or sharing the feelings of another. Empathy, by contrast, is characterized by identification and understanding. But, empathy has been sub-characterized into two, or even three, separate conceptualizations: emotional (or affective), cognitive, and compassionate empathy. To complicate matters, compassion itself is an awareness of suffering of another and a desire to act in order to relieve it. Therefore, compassion is best understood as an action, or potential action. This desire and subsequent action may stem from both rationale and emotional sources.

Healthcare & Empathy: Emotional vs. Cognitive vs. Compassionate

Daneil Goleman briefly outlines and discusses the three (potentially) separate kinds of empathy. Empathy is founded upon understanding and identification which may include projecting ourselves (hypothetically) into another’s situations. And, it can happen emotionally and/or cognitively. Emotional empathy is the ability of a person to feel a similar emotion as another (which confusingly can be accomplished cognitively). Although this appears to mirror sympathy, sympathy is a sharing of emotion, or emotional state, feeling along with another. In contrast, cognitive empathy relates to recognizing, understanding, or even appreciating a person’s feelings. To be fair, the definitions of sympathy and empathy as well as cognitive verses emotional empathy appear to overlap. It seems they are, at times, used interchangeably. Specifically to healthcare, empathy is “a cognitive attribute that involves the ability to understand the patient’s inner experiences and perspective and a capability to communicate this understanding,” Many in healthcare education recognize IQ and didactic skill are only a portion of the ideal clinician equation. The ability to understand and perform within the above constructs relates to emotional intelligence. And, “…empathy, as defined here, must be included in the curriculum. It is a powerful communication tool that enables a clinician to clearly express his or her understanding of another’s suffering while protecting his or her own psychological integrity.”

Do you have to care to be caring in your practice?

A major issue in health care professions generally, but therapy specifically, is mistaking the necessity of cognitive empathy for a requirement to sympathize and feel with patients. Front line clinician burn out is in part due to an understandable inability to sympathize with every patient, and the resulting cold, concrete distance that can result in situations when sympathy is not feasible. Whether clinician fatigue, a need for emotional distance, or carryover from the patient before feeling the emotions, sympathizing, and providing pity to every patient is likely not possible. And, probably not effective. The issue is likely further clouded by a lack of understanding regarding the differences of sympathy and empathy. I don’t ever remember learning about this stuff. But, it’s vital. The concept of objective empathy grossly changed how I approach patient interactions. Patients and practitioners report “compassionate care” is important to successful medical treatment. So, what’s to be done?

The role of the clinical instructor is paramount in helping students to become aware of behaviors that can block empathy. We can no longer simply hope that our students will become mature professionals with compassion and empathy for patients. We must create experiences to develop these attributes, and we must take responsibility for modeling these behaviors and reflecting on them with students, to raise their consciousness about the nature of a mature healing presence.” The art of healing is, in part, made up of a therapeutic use of oneself or a therapeutic presence for patients. This presence is more than knowledge and skill alone; it is also composed of a compassionate understanding of the patient and a communication that the therapist is worthy of the trust that the patient has bestowed. Empathy enhances the therapist’s therapeutic presence and deepens the patient practitioner interactions without fear of losing one’s self in the process. This shared meaning seems to enhance the patient’s process of healing.  Carol Davis, Can Empathy be taugh? PTJ, 1990

To the observer I’m sure it appears I do care, and care deeply. But, in the end Keith, you’re right. I don’t care. And, I don’t need to. Does that mean I never engage with patients on an emotional level? That patient’s circumstances never affect me? That I never feel a connection, or shared emotional states with a patient? Or, a powerful emotional response during the course of treatment? Of course not. It happens. And, that’s OK. But, we don’t need to strive for it. Someone inquired to Keith “I wonder if being detached from our patient makes for a better clinician… Any thoughts?” He responded:

A therapist needs an appropriate amount of attachment for success, but that attachment, I reason, needs to be to a high professional standard of care, not the patient’s outcomes themselves.

You don’t need to sympathize to provide appropriate empathy. You don’t need to care to be caring. You don’t need to feel the emotions of your patients to address the emotions they feel.

When I freed myself from the responsibility for the “outcome” of the clinical encounter, something interesting happened. I freed my patients from blame, also. –Jason Silvernail

It’s important to care, but maybe not in the assumed emotional involved ways. And, I think we should not apologize for claiming not to care. I’m still, I think, a caring clinician. I just don’t make a point of feeling pity for the suffering I encounter. I am passionate, empathetic, and hopefully a thoughtful interactor.

 …an older relative of mine who has cancer is going back and forth to hospitals and rehabilitation centers. I’ve watched him interact with doctors and learned what he thinks of them. He values doctors who take the time to listen to him and develop an understanding of his situation; he benefits from this sort of cognitive empathy. But emotional empathy is more complicated. He gets the most from doctors who don’t feel as he does, who are calm when he is anxious, confident when he is uncertain. And he particularly appreciates certain virtues that have little directly to do with empathy, virtues such as competence, honesty, professionalism, and respect. –Paul Bloom, Against Empathy

We need to be able to treat our patients, all of them, and still function in our own lives. If not, we risk riding the roller coaster of sympathy and pity in clinic at the potential expense of engaging emotionally in our personal lives. It’s a bad outcome all around. Our patients need us to understand, interact, and guide them along the best possible course of recovery. So, whatever we call it, put your pity aside. I’m not sure our patients want it anyway. Be resilient. You don’t need to care to provide compassionate care. Our patients need us to listen, but also to initiate difficult, honest conversations.

Credit: https://practicepath.com/advancedmd-pm-and-ehr-services-and-solutions/

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Physical Therapists in the ICU: ACTION for #ICUrehab #AcutePT

If immobility is pathology, then movement is medicine. But, now that the rationale is present, how is action initiated? Understanding the current literature in regards to mobility and physical therapists in the intensive care unit illustrates the need and the potential for physical therapists. This potential leads to the vision. Yet, rationale and vision do not guarantee action, nor results.

Every patient requires an individualized assessment and interaction to determine the best plan of care, outcomes tracking, and goals. So, does each individual ICU. Evaluation of current practice and culture, barriers to mobility and physical therapy, and a plan to achieve specific goals. Data and outcomes tracking can provide insight into progress.

Research surveying various professions elucidates commonly reported barriers to mobility and physical therapist involvement in the ICU. Yet, many of the identified barriers appear more perception than the reality. Fears based upon “what if?” scenarios. What if the patient falls? What if a line becomes dislodged? What if they decompensate? What’s the worst possible event? Illness severity, safety, and line dislodgment are commonly report. These fears are contrary to the literature on safety and feasibility. Does this indicate these concerns are likely unwarranted?

Barriers: Perception and Reality

Perception is reality. The multi-disciplinary environment of critical care, including the a culture of a specific unit, requires analysis to ensure specific perceptions are identified. Barriers should be overcome with education, discussion, training, and graded exposure. Individual practitioner’s perceptions, fears, and concerns contribute to professional interactions, unit culture, and ultimately patient care. Fear based barriers include illness severity, illness acuity, safety, feasibility, and perceived lack of benefit. Other reported challenges include lack of consults, staffing, knowledge, time, expertise, experience, cost, equipment, and unit culture. All unit specific and individually identified barriers must not only be acknowledge, but adequately addressed. Reported concerns are not to be discounted.

Perceptions

  • Illness Severity
  • Illness Acuity
  • “Too Sick”
  • Unsafe
  • Not Feasible
  • Lack of Need
  • Lack of Benefit

Logistics

  • Time
  • Equipment
  • Lack of Consults
  • Lack of Priority
  • Staffing

Culture, Practice Patterns, & Professional

  • Knowledge of Individuals & Various Professions
  • Experience & Expertise
  • Sedation
  • Current Mobility
  • Current Physical Therapist Presence & Practice

Now, this of of course is not an exhaustive list. A unit may contain unique barriers and perceptions outside of this list. Focused meetings, targeted surveys, and small group discussions can assist in illuminating the beliefs of individuals and the overall culture of a unit. A physical therapist lead quality improvement project to promote early mobility in the intensive care unit utilized a survey of nurses and respiratory therapists to identify current perceptions.

1. Do you think physical therapy should evaluate/screen all intensive care unit/cardiovascular intensive care unit patients?
2. Do you feel comfortable getting patients into neuro chairs without physical therapy?
3. Do you feel comfortable using the mechanical lifts without physical therapy?
4. Do you get patients out of bed/ambulate without physical therapy if they are able?
5. Do you think patients should be getting up on ventilators?
6. What are the barriers to mobilizing patients on ventilators?
7. What are the harmful effects of physical therapy working with patients in the intensive care unit?
8. What can physical therapy do to improve communication with the RNs, MDs, respiratory therapists, patients, families, etc.? Please be specific.
9. What can physical therapy do to improve patient care? Please be specific.

The survey questions revealed many of the barriers listed above. Interestingly, all respondents agreed that every patient in the ICU should be evaluated by a physical therapist.

As much, as soon, as often as we can?

The concept of mobility and rehabilitation during intensive care appears quite important and profound. Therefore, it’s quite obvious that every patient should be out of bed and ambulating at least three times per day. Well, not exactly. Although being in the ICU in the presence of lines, tubes, and life support equipment should not automatically preclude individuals from movement and therapy participation, each patient will present and perform quite differently.

So, what are the specific interventions? How does a physical therapist decide what to do? And, when? What about dosage, intensity, frequency, and duration? Similar to other patient populations (such as individuals with back pain), critical illness is far from homogenous. Even a very specific ICU type contains a range of diagnoses and individuals. Treatment content, duration, intensity, and frequency should likely vary. Further, given the acuity of illness and the medical complexity of patients, close monitoring of many variables is necessary. The specifics of these particular concepts remain complicated and dependent on many variables. At times it appears there are more questions than answers.

Generally, the goal is to decrease sedation, bed rest, and confusion while increasing wakefulness, movement, and engagement. There are nearly infinite options available to accomplish such goals. An approach of “as much, as soon, and as often as possible” simplifies the conceptualization of treatment. But, such an approach is always performed within the specific confines and constraints of the system, staffing, experience, and culture of the current clinical situation.

Response Dependent Progression

An individualized, response dependent approach facilitates proper monitoring from moment to moment and session to session. Decision making requires integration of information from multiple sources to reach an overall assessment that determines progression, pause, or regression. Such a system hopefully decreases the likelihood of grossly “over treating” or “under treating” a specific patient at each specific encounter. The variable nature of medical stability, presentation, and physiologic status of critical ill patients may result in robust, swift changes in vital signs, physiology, and even patient performance. A patient’s specific clinical scenario including diagnoses, physiologic state (labs, medications, vital signs), and current medical goals warrants the a priori construction of individualized safety parameters regarding upper and lower limit values for vital signs.

Response Dependent Progression. Individualized prescription & progression based upon moment to moment assessment.
Response Dependent Progression. Individualized prescription & progression based upon moment to moment assessment.

The research to date suggests that in order to achieve maximum effect physical therapy should be performed in the ICU, while patients are intubated, 5-7 days a week, and in conjunction with or following sedation interruption. Initiate a progressive approach focused on achieving functional milestones such as sitting, standing, marching, transferring out of bed, and ambulating as quickly, but as safely as possible. Exercise testing, prescription, and progression is feasible, effective, and possibly predictive. Although, given the duration of bed is associated with weakness and long term physical impairment suggests functional mobility should likely not be neglected.

Measuring, Assessing, & Planning

An assessment of current and historic practice can include average unit census, average number of physical therapy consults, percent of the unit with consults, and number of patients actually seen per day. Average time from admit to first physical therapy encounter in conjunction with average duration and frequency of treatment provide general insights into current physical therapy practice.

Next, by assessing unit specific data in relation to current practice, predictions for future staffing, equipment, and training can be constructed. Such a model can be further specified based upon targets for the number of patients (or percentage of the unit) to be treated each day, and at what frequency. In addition, the current number (or percentage of) patients who are likely to benefit from, or be appropriate to participate in, physical therapy can illustrate a disconnect between current practice and ideal practice. Identifying a lack of consult standards may shed light on variability in consult numbers, timing, and frequency. Standardized criteria for consults, mobility, or physical therapist involvement provide assistance in decision making. But, each individual patient requires analysis within the framework of guidelines, not decisions mandated by them.

The current demand (consults), physical therapy practice, and provider perceptions are utilized to model need, illustrate the lack of physical therapist involvement, and potentially quantify a current lack of resources to provide appropriate timing, frequency, and duration of therapy. If feasible, informal or formal investigations into factors associated with physical therapy consultation provide further understanding into current practice regarding physical therapy consultation and practice. A disconnect between the research literature and current unit culture, including various professions practice patterns, highlights the need for transdisciplinary practice change and potential quality improvement.

Financial Modeling

Johns Hopkins constructed a financial model allowing prediction of staffing, costs, and potential financial outcomes. By utilizing the number of yearly admits, current ICU & hospital length of stay (for a specific targeted ICU), and direct variable costs of care a very accurate model of staffing, start up costs, and potential cost savings scenarios can be assessed. Varying possible length of stay reduction outcomes allows for a sensitive, yet conservative prediction of cost savings in multiple potential situations. Modeling various outcomes allows for the presentation of worst case, likely, and best case end points. Utilizing actual data from their own quality improvement project and data from the literature they conclude

A financial model, based on actual experience and published data, projects that investment in an ICU early rehabilitation program can generate net financial savings for U.S. hospitals. Even under the most conservative assumptions, the projected net cost of implementing such a program is modest relative to the substantial improvements in patient outcomes demonstrated by ICU early rehabilitation programs.

Measurement and Outcomes Tracking

The potential data and outcomes depend on data availability, program goals, ICU type, patient population as well as any specific research questions. Outcomes can be analyzed at the patient, unit, and hospital level.

Potential construct areas of measurement for ICU mobility, rehabilitation, and physical therapy programs
Potential construct areas of measurement for ICU mobility, rehabilitation, and physical therapy programs

At the patient level there are a variety of impairment, patient report, and patient performance measures, many of which have been specifically investigated for utilization in the intensive care unit.

Impairment based, patient report, and patient performance measures.

Quality Improvement Project Design

Designing and implementing a quality improvement project with a focus on research methodology improves the accuracy of measured results. Such an approach eases discussions with hospital administrators regarding need, costs, and program appraisal. Appropriate planing, background research, and project construction prior to implementation allows for more specific analysis.

Background, Construction, & Education

  • Assess current PT practice, unit culture, clinician perspectives
  • Compare current practice to ideal practice, current program models, and feasible quality projects
  • Construct project goals
  • Model staffing, training, equipment, and program requirements
  • Identify, acknowledge, and address current barriers
  • Identify champions from each discipline: PT, RN, MD, RT
  • Interdisciplinary Meetings & Education: RT, RN, MD, RT
  • Acknowledge, educate, address concerns
  • Join Critical Care Quality Meetings or Committee
  • Identify Lead PT for ICU(s)
  • Assign ICU Unit Based Physical Therapist(s)
  • Identify educational needs of PT and rehab department
  • Identify educational needs of other disciplines
  • Perform education and follow up meetings

Data

  • Identify target data and outcomes tracking
  • Obtain facility specific data for financial modeling
  • Build data tracking sheets & data bases (if needed)
  • Leverage electronic medical record (if able)
  • Train clinicians on documentation and “data entry”
  • “Go live” with documentation and data collection
  • Establish a post documentation training pre-project implementation baseline

Implementation

  • “Go Live”
  • Sustain & Maintain Program via Updates and Meetings
  • Evolve care based on observation, feedback, and data analysis
  • Assess & Analyze Program and Data Collected

The elegance of a quality improvement approach is the potential for an ever evolving feedback loop of assessment, planning, implementation, and analysis. At specified intervals, repeat the process based on current results, identified issues, and current research.

Facility Specific Questions and Issues

1. What if current practice illustrates a lack of consults, infrequent consults, or poor timing of consults (i.e. too late in hospital course)?

Create specific consult criteria. Educate nursing staff and physicians. Provide checklist.

2. What if there is no dedicated physical therapist in ICU?

Quality improvement project focused on unit based physical therapist and increased overall patient mobility.

3. What if patients are too sedated?

Assess RN sedation guidelines and practices. Pair therapy with sedation vacations & awakening trials. Meet with MD’s, RN’s, and RT’s. Work with RN educator to facilitate RN lead project regarding sedation.

4. What if there is a lack of patient mobility outside of therapy sessions?

Nursing staff education. Nurse targeted progressive mobility guideline.

5. How to prioritize if unable to address every consult and patient on caseload in the ICU(s)?

Focus on duration of bed rest, individuals requiring mechanical ventilation, especially those requiring greater than 3 days of mechanical ventilation. Assess last time mobilized and last therapy session.

Quality and Assessment

Obviously, analyzing and interpreting clinically generated data is difficult. Given the complexity of the daily clinical environment and lack of rigor available in a controlled research trial, data can often be inaccurate or even misleading if not understood properly. Utilizing a quality improvement model within the context of critical care is an evolving method for program design and interpretation, but

The results of many quality improvement (QI) projects are gaining wide-spread attention. Policy-makers, hospital leaders and clinicians make important decisions based on the assumption that QI project results are accurate. However, compared with clinical research, QI projects are typically conducted with substantially fewer resources, potentially impacting data quality…Data quality control is essential to ensure the integrity of results from QI projects.

Resources exist for appropriate design, training, data collection, implementation, sustainability, assessment, analysis, interpretation, and translation of quality improvement designs and data.

1. The SQUIRE (Standards for Quality Improvement Reporting Excellence) guidelines for quality improvement reporting: explanation and elaboration
2. Intensive care unit quality improvement: a “how-to” guide for the interdisciplinary team
3. Improving the quality of quality improvement projects
4. Improving data quality control in quality improvement projects
5. How to use an article about quality improvement
6. Rehabilitation quality improvement in an intensive care unit setting: implementation of a quality improvement model
7. ICU early physical rehabilitation programs: financial modeling of cost savings
8. Translating research into clinical practice: the role of quality improvement in providing rehabilitation for people with critical illness
9. Quality Improvement Guide

A variety of complex issues affect potential physical therapy and mobility in the intensive care unit. But, it is possible. Change is a process, not an event. One patient, one provider, one day at a time.

 

 

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Physical Therapists in the ICU: Rationale for #ICUrehab

For 3 weeks I was held in a room, I was tied to the bed if I tried to get away. I couldn’t talk; I couldn’t eat; I was not allowed to sleep;
Groups of people would enter the room and look at me and talk about me and I was sometimes undressed in front a small audience.
I was shot full of drugs.
I was too weak to move.
I could not see my body, but it had been cut nearly in half.
Insects crawled on the walls and ceilings…

Sound like prison or torture? Well, it’s not. The quote is from Nancy Andrews, a survivor of critical illness who developed delirium . And, an articulate spokeswomen regarding ICU sequelae, specifically delirium, from a survivors perspective.

Now, to be fair, I am already bias. I treat primarily in ICU’s (medical, cardiac, and step down units). I also treated in the treatment arm of a randomized control trial of early, intensive physical therapy for individuals requiring mechanical ventilation for greater than 4 days. The treatment group received physical therapy 7 days a week for at least 30-60 minutes. And, I participate in research surrounding ICU physical therapy. Oh, I am also a physical therapist. So, don’t take my word for it…

But, the curse of bed rest needs to end.  In 1966 “The Dallas Bed Rest Study” put five 20 year old males to bed for three weeks. Investigators conducted pre and post testing followed by exercise training and long term follow ups (30 and 40 years). The acute effects of the bed rest and long term outcomes are staggering. Net proportional decline in VO(2 max) over 40 years was comparable to that experienced after 3 weeks of strict bed rest (27% vs. 26%). Additionally, 40% of age related decline in maximal oxygen uptake could be attributed to physical inactivity specifically. Three weeks of bed rest at 20 years of age resulted in a more profound impact on physical work capacity than 30 years of aging.

Unfortunately, each day of bed rest in the ICU may predict a 3 to 11% strength decline up to 2 years later. During a 2 year investigation, the length of bed rest was consistently associated with measures of weakness at all time points. The presence of weakness correlated to decreased physical function and quality of life.

The Legacy of Critical Illness

So, why are we talking about this? It has been well established that individuals who survive critical illness requiring mechanical ventilation specifically acute respiratory distress syndrome exhibit muscle weakness, persistent physical disability, and impaired reports regarding quality of life (via the SF-36) after hospital discharge. After 5 years, with an impressive 86% follow up rate, only 75% returned to work and subjects utilized 4 times the healthcare costs (86% follow up rate).

Sequelae of the ICU

The phenomena of ICU-Acquired Weakness (ICU-AW) and it’s specific subsets critical illness polyneuropathy (CIP) and critical illness myopathy (CIM) have been characterized. Following merely 18 hours of mechanical ventilation structural and functional changes in the diaphragm muscular are present. Those who require prolonged mechanical ventilation are worse off still. Some exhibit global electrophyisologic abnormalities consistent with neuropathy and myopathy in conjunction with weakness 5 years post ICU discharge. Many complain of persistent weakness, disability, and a prolonged recovery period.

Dr. Margaret Herridge, MD, MPH comments:

This is a huge public health catastrophe when we’re saving people’s lives but they’re ending up with severe disability. It’s a very important message for patients, families and primary care physicians because I think patients assume they should be well, so they feel bad that they aren’t.

Sadly, the sequelae of critical illness extend beyond physiologic abnormalities of nerves and muscles, weakness, and physical function. Survivors display significant neuro-cognitive problems. At one year follow up of 821 medical and surgical ICU patients more than 50% displayed memory and attention deficits. The presence of post-traumatic stress and post-traumatic stress syndrome are now well recognized. At 1, 2, and 5 years post ICU discharge reports of depression and anxiety persist in nearly 50% of some studied cohorts. Survivors suffer not merely from physiologic and physical impairments, but significant and quite limiting neuro-cognitive deficits in conjunction with psychological difficulties.

What happened to me in the hospital?   Yes, my life was saved, and I am grateful for that, but life AFTER the ICU was extraordinarily difficult, not only physically but also mentally. -Nancy Andrews

Factors associated with long term physical impairments include duration of bed rest, age, ICU length of stay, and potentially the dosage corticosteroids.  Amount and duration of sedation, development of delirium, and delusional memories are associated with long term neurocognitive impairments.

And, unfortunately it doesn’t end with the patient. Family members and caregivers of ICU patients exhibit mental health difficulties including anxiety, depression, PTSD, and complicated grief following the intensive care experience. Recently, Post Intensive Care Syndrome (PICS) was constructed to assist in recognition and classification of survivors’ as well as family members’ post ICU impairments. The goal, of course, is to improve outcomes following critical illness.

Physical Therapy IN the ICU?

The focus surrounding early mobilization of critically ill, mechanically ventilated patients as well as physical therapists involvement in the ICU continues to grow. Although by no means complete, the research suggests that early mobilization and physical therapy is safe, feasible, and appears beneficial. Findings illustrate potential effects and associations at a physiologic, patient performance, functional, medical outcomes, and health care services level.

The bottom line is having a patient, who for at least a part of the day, can be awake from drug affect, and interact with the environment in a purposeful way is the key foundation to the idea. – John P. Kress, MD

Associations and effects of early mobility programs and/or physical therapist treatment include:

Increased

Decreased

What are WE (physical therapists) doing?

Does clinical practice reflect this strong premise suggesting safety, feasibility, and rationale for physical therapists in the ICU? A survey of physical therapists belonging to the acute care section of the American Physical Therapy Association from 2007 suggests physical therapists are more likely to be routinely involved in the ICU with neurologic and trauma related diagnoses as oppose to medical diagnoses. Follow up survey data from 2012 suggests a lower likelihood of mobility as perceived complexity (either medically or logistically) increases.

Now, given the limitations of survey data, firm conclusions on WHY are not possible. But, it appears that as medical complexity increases, the less likely physical therapists are to be involved. The more “medical” the diagnoses, the less likely physical therapists are to be involved. Is this secondary to perceived risk? Lack of perceived benefit? Lack of knowledge in long term outcomes, safety, and feasibility? The ICU equipment? Staffing?

What is the basis of physical therapist decision making regarding patients in the intensive care unit? Are therapists making treatment decisions based on the presence of machines, the logistics, and the fears of worst case outcomes? In proper risk analysis, it is imperative to also assess the risk of not intervening. The long term sequelae of critical illness illustrate the potential risks of a critical illness and ICU course left to “natural history.”

Road Blocks & Speed Bumps

Regardless of the evidence, rationale, safety, and feasibility barriers do exist. These barriers likely exist within and between individual clinicians, specific professions, various departments, different units, and the entirety of each specific hospital. But, barriers also involve the interactions of these individuals and professions at all levels of the hospital. The staffing, patient prioritization, training, knowledge, and historic practice patterns are all important variables requiring considerations. Many factors and individuals result in the overall, but dynamic culture of a unit and/or hospital. In order to facilitate change, an eventual transformation of ICU culture is required.

What do PATIENTS think?

I was never told by anyone what to expect – ICU Survivor

A current randomized control trial entitled Do it Now (Diagnosis and Treatment of Neuromuscular Weakness) is investigating early, intensive physical therapy (7 days a week, 30-60 minutes) and standard physical therapy (3 days a week, 15-20 minutes) in patients requiring mechanical ventilation for greater than 4 days. Part of the study is a survey investigating patient and proxy perceptions of physical therapy. To date no robust investigations of patient, family, and proxy perceptions of early, intensive physical therapy exist. The literature on long term outcomes in conjunction with individual patient stories illustrate the shattering trauma of the ICU:

It’s been two years and I’m still trying to sort out what was real and what wasn’t. I still think about it several times a week and continue to ask questions of my family. I have a compelling need to know what happened to me… – ICU Survivor

Interestingly, regardless of which arm of the above study, patient’s  and proxy’s reported physical therapy as highly necessary and beneficial. Although difficult and requiring significant exertion, both patient groups were satisfied with the experience. Neither group would have requested less therapy sessions. And, in fact, both groups requested slightly more. Maybe engagement in a therapeutic process can decrease some of the trauma of the ICU experience? In a brief video, Dale Needham, MD of Johns Hopkins routinely observes that patients agree:

Patient’s overwhelming tell us is that they like the early physical medicine and rehabilitation, they like being awake. They certainly like getting out of bed and moving. It shows them that there is hope, it shows them there is a life beyond the intensive care unit. And, a life for them to get back to. It gives them goals for improvement, It shows them that they can get better.

Nancy Andrews comments from a patient’s perspective:

I can share advice based on my experience. Reach out to people. Talk about what you remember. Draw, play games, listen to music, dance, DO PHYSICAL THERAPY, Reconstruct what happened and sort it out. Talk to your doctor. Ask for help.

Summary

1. Immobility is PATHOLOGY
2. Critical Illness  is a neuromuscular, cognitive, psychological INSULT
3. Long Term Functional Outcomes are POOR
4. Mechanisms of physical therapy and mobility are likely multi-factorial
5. Physical Therapist practice in the ICU is evolving, but varied
6. Patients & Family’s understand benefit of physical therapy
7. Patient’s & Family’s desire physical therapy

Dale Needham, MD summarizes the issue

We must stop making excuses about why a patient can’t do rehabilitation today—he has a CT scan or she’s getting dialysis. We need to highly prioritize rehabilitation, which we now see as just as—if not more—important than many other tests and treatments we offer our patients in intensive care.

Change is possible. The rationale is present, it is time for action.

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Data Quality: Garbage In = Garbage Out

Measuring and objectifying observations and phenomena. Numbers. Data. These are the cornerstones of analytics. The presentation and appearance of (apparent) objectivity. Whether in research, health care policy, economics, business, or clinical practice, data is important.

The data doesn’t lie.

But, sometimes the people that interpret it do. Not that they mean to. It’s not done on purpose (except when it is). So, yeah, unfortunately, the numbers can lie. And, they will lie to you if you are not conscientious about assessing them more deeply.

“What gets measured, gets managed.” Peter Drucker

Data Quality

Questions of why this works, or, maybe, more importantly, “does this work as proposed? Does the explanatory model make sense?” are not inherently built into the evidence based approach. Yet, these questions are vital to integrating and understanding outcomes research, while evolving our theoretical models. Such a task mandates metacognition and critical thinking. Failure to critical assess the quality, and potential meaning, of data, will result in improper conclusions.

The evidence hierarchy is sorted by rigor not necessarily relevance –EBP and Deep Models

But, the questions and issues surrounding data quality and interpretation transcend assessing the literature within the context of the evidence based hierarchy. Much like the research literature, the data collected, analyzed, and utilized everyday warrants critical appraisal. It all requires assessment; data encountered inside and outside the clinic, data utilized for decision making and understanding. The concepts of scientific inquiry should be wielded routinely, including assessment of quality, source, and limitations of the numbers. Only then, can proper interpretation and subsequent decision making occur.

Is it accurate?
Is it representative?
Where did the numbers originate?
What do the numbers actually represent?
What conclusions can or can not be concluded from a data set?

The evidence based practice hierarchy is concerned mainly with questions of “what works?” and “what is effective and efficacious?” These are necessary, important, big questions. But, the term “evidence” as utilized by most clinicians and researchers is focused mainly on randomized clinical trials, systematic reviews, and meta analyses of randomized control trials. Outcomes based research. This is a necessary and obvious step forward from purely observational, experienced driven clinical practice and education. Despite the obvious importance of experience (or more accurately deliberate practice) in clinical decision making, analysis based on experience or clinical observation only is prone to errors such as confirmation bias and convenience. Clinical observation alone is limited in it’s ability to ascertain phenomena such as a natural history and regression to the mean. And thus, this issue is related not only to data quality, but proper data interpretation. Understanding data quality assists in assessing “what works”, but also in tackling the complex question of “why does it appear to work?” Both questions are inherent to, and reliant upon, the quality of data.

Numbers, Data, and Objectivity

In attempting to objectively measure the world, has the potential accuracy and quality of data been forgotten? Overlooked even? A number seductively presents the appearance of objectivity and accuracy, but does not guarantee it. Big Data provides an excellent example of data quantity with relatively overlooked quality. Astounding data-sets through avenues such as social media and search engines afford researchers and large companies the opportunity to analyze data-sets that would literally explode your lab top. For example, in 2008-2009, based on web search data Google Flu Trends more accurately and quickly predicted and modeled flu outbreaks than the Centers for Disease Control (CDC). Well, until 2012-2013 when it wasn’t so accurate, over estimating peak trends. In big data are we making a mistake? Tim Harford explores the scientific and statistical problems still present (even when the size of a data set requires it to be stored in a warehouse): 

But a theory-free analysis of mere correlations is inevitably fragile. If you have no idea what is behind a correlation, you have no idea what might cause that correlation to break down. One explanation of the Flu Trends failure is that the news was full of scary stories about flu in December 2012 and that these stories provoked internet searches by people who were healthy. Another possible explanation is that Google’s own search algorithm moved the goalposts when it began automatically suggesting diagnoses when people entered medical symptoms…

Statisticians have spent the past 200 years figuring out what traps lie in wait when we try to understand the world through data. The data are bigger, faster and cheaper these days – but we must not pretend that the traps have all been made safe. They have not…

But big data do not solve the problem that has obsessed statisticians and scientists for centuries: the problem of insight, of inferring what is going on, and figuring out how we might intervene to change a system for the better.

Measurement Matters

Now, just because it can be measured, does not mean it should be measured. Measurement alters behavior. And, the change is not always as envisioned or desired. As soon as a goal is set to alter a metric, incentives apply. This concept transcends clinical care. It applies to business, management, and clinician behavior. Enter the cobra effect.

The cobra effect occurs when an attempted solution to a problem actually makes the problem worse. This is an instance of unintended consequence(s).

So, is the goal to change that specific metric only?  Or, is the actual goal to encourage specific behaviors that appear to directly affect, or are correlated with, that metric. Regardless of the goal, care must be taken in defining success. This requires a clear definition of what is measured and why. Again, deep analysis of data quality and interpretation are necessary to properly interpret results of process changes. Due to the appearance of objectivity in the presentation of numbers, it is easy to make inaccurate or far reaching conclusions. This is especially true when care is not taken to assess all the components of the data:

What does the data actually represent?
Who or what measured it? Who or what entered it?
How was it initially assessed and subsequently interpreted?
What other data needs to be considered or measured?

Now, even with reliable and accurate data input, inaccuracy can occur. The wrong conclusions can be “output” because of the misinterpretation regarding what the data is representing or signifying. Wrong numbers = wrong analysis = wrong conclusion = wrong interpretation = misguided application.

Steer away from subjectivity

The complexity of even the simplest data sets is astounding. Ever present are questions such as: Is the data valid? Does the data represent the assumed construct or principle? What potential bias is involved? Is it reliable between people; between subsequent measurements? Is it actually measuring what we think it’s measuring? Can it answer the questions we are posing? Measured and presented data is rarely as simple as a concrete number.

The attempted objectification and simplification of subjective, individualized, complex phenomena such as happiness, satisfaction, engagement, or pain may be tragically flawed. Commonly, over reaching conclusions are based on assumptions of accurate and/or complete representation. The data presented is merely a measurement, a number produced via the tool chosen.

A tool misused produces data that’s unusable

That tool may, or may not, accurately convey the construct it was initially designed to represent. In the case of patient report questionnaires, the individual filling out the tool will always be biased; influenced by the environment, their expectations of what should be conveyed, influences from others (explicit and implicit), as well as complex incentives depending on their needs, goals, and expectations. Further, most data encountered on daily basis, including clinical outcome measures (whether patient performance or patient report), is not collected in controlled environments with explicit processes. Bias will always affect reporting and recording. Questions of the accuracy, reliability, and validity apply not only to the tool, but also to the person recording the measurement. It quickly becomes complicated. The Modified Oswestry Disability Index never seems so messy when presented as a straight forward percentage.

Compare the stark contrast between how an outcome measure is collected within a research trial vs. everyday clinical practice. In order to minimize both error and affects of bias, outcomes in a trial are collected by a blinded assessor. A standardized set of directions is utilized, with a pre-defined process for administration and measurement. But, even in more controlled, direct data collection environments, what is being measured and what that actually illustrates, is not straight forward. Representation is not always linear. Even in randomized, tightly controlled, double blind studies bias and flaws are present. This does not inherently make the data useless. Leaps of logic need to be recognized.

If data is sloppy enough it is beyond useless. It’s harmful.

Why? Because, unreliable, variable data that is not truly measuring or representing the phenomena one assumes will ultimately lead to inaccurate conclusions. Regardless if the data is positive, negative, or neutral it is misleading.

How? Because, the data itself can not be representative of what we think it is measuring, purely by the the fact that the data itself is unreliable, overly variable, and “sloppy.” Further, if the assumption is made that a measure represents a certain construct, but it actually does not, it has no validity. Without reliability, validity is unobtainable. Without validity, reliability is misleading.

Data Quantity vs. Data Quality

So, should the focus remain on quality or quantity in data? Both. Is more data always better? Well, that depends on the quality. But, what is quality data? Quality is a relative term. Collecting, analyzing, or using data is only part of the equation. Once collected, questioning validity, reliability, representativity, and relevance is necessary. In the cases when data has already been collected and potentially presented, it’s time for some serious skeptical inquiry. Understanding what data actually represents and illustrates assists in proper critical appraisal. Proper critical appraisal allows proper interpretation. Proper interpretation is the foundation for  effective utilization. Less controlled data collection environments do not necessarily produce unusable data, and in fact can be quite useful in the realm of health services and care delivery models. Yet, the conclusions drawn on effects, mechanisms, and efficacy need to be tempered. Focus on understanding exactly what a data set can and can not illustrate given the data collection environment and design and metrics.

Unreliable and invalid data in, wrong conclusions out. Always. Any accurate representation will be by chance alone. But, in these instances, the probability of attaining an accurate representation will often be less than chance. Limits are always present, and can not be avoided, but understanding the limits of the data assists in drawing conclusions that are the least wrong. While the data itself is important, what is done with the data, and why, is almost more important. And, these principles apply whether you are assessing your clinics “outcomes” or tracking disease outbreaks with big data. Focus on improving the quality and accuracy of data collection on the front end. Train those measuring, collecting, and entering data. Improve analysis and inquiry on the back end. In addition to asking “where’s the data?” we should be asking “where did that data come from?” and, “what does it actually illustrate?”

Be skeptical. Garbage in = garbage out.

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Precision in Language

Language is obviously important as words are the basis of explicit communication. As is such, specificity in language and word definitions is vital to interaction. But also, specificity in meaning is required for accurate scientific research. Thus, terms are often operationally defined in studies. It is an attempt to clearly communicate how the researchers are defining, utilizing, and investigating a construct. Hopefully, ensuring appropriate interpretation and application of results while bundling theoretical constructs through explicit definitions.

I’m no expert in linguistics, philosophy, or even language, but I think this is an important professional topic. Now, admittedly, physical therapists deal with complex physiologic systems and phenomena. Some concepts can elude specific definitions physiologically and linguistically. Pain is a perfect example.

The lived pain experience is an emergent, individually experienced phenomena dependent on a myriad of interacting physiologic, psychologic, environmental, social, cultural, and linguistic components. It’s not merely resultant from nociception nor tissue damage or even injury. Yet, the presence of such complex systems and phenomena should not preclude striving for specificity of language. Vagueness does not help us. Investigating form, meaning, and context of language assists in research, education, and patient interaction. Luckily, the International Association for the Study of Pain created a taxonomy, and is attempting to more robustly define terms related to the painful experience. The list includes hyperalgesia, hyperesthesia, noxious stimulus, peripheral sensitization, central sensitization, and neuropathic pain among others. Some terms, such as allodynia (“pain due to a stimulus that normally does not provoke pain”), are considered “clinical terms” and purposefully absent of proposed mechanisms. Other terms, such as nociceptive stimulus (“an actually or potentially tissue-damaging event transduced and encoded by nociceptors”), are mechanistically more specific.

As a more concrete, basic science example, what would result if 100 physical therapists & 100 physicists  were charged to define strength, power, acceleration, stability and balance? How many definitions? How much similarity would they display?

@Jerry_DurhamPT has a hypothesis…

101definitions

101 definitions.

One, exact definition (and likely a formula) from the 100 physicists. And, likely 100 separate, but similar, definitions from 100 physical therapists. These words have explicit definitions and equations within the realm of physics (classical mechanics). As Erik Meira asserts robust, specific definitions are absolutely necessary for science:

I’m not trying to get metaphysical here but we must define our terms in order to be scientific…Poorly defined statements are inherently not scientific. Just because it’s published does not make it science.

Specificity and discipline in language is a necessary first step. It is required for accurate discussion and collaboration within research, clinical practice, and between professionals. This includes other professions (and not just healthcare). But, unfortunately, appropriately defining and subsequently understanding definitions does not account for, nor address, how other healthcare professionals, disciplines, patients, and society perceive certain words. What are their definitions? As an example, lets explore the word “prevention.”

Prevention: the action of stopping something from happening

Within healthcare and physical therapy, true prevention by definition, is kind of a misnomer. But, the health care system, patients, and consumers utilize the term prevention differently. Usually, the concept of “prevention” is actually used to mean “risk reduction.” Thus, the “functional definition” within the context of healthcare and patient interaction is slightly altered. What is actually meant by ACL injury prevention is reducing the likelihood of an ACL tear. Epidemiology provides some insight…

In epidemiology, the absolute risk reduction, risk difference or excess risk is the change in risk of a given activity or treatment in relation to a control activity or treatment. It is the inverse of the number needed to treat. -Wikipedia

In epidemiology, the relative risk reduction is a measure calculated by dividing the absolute risk reduction by the control event rate.

The relative risk reduction can be more useful than the absolute risk reduction in determining an appropriate treatment plan, because it accounts not only for the effectiveness of a proposed treatment, but also for the relative likelihood of an incident (positive or negative) occurring in the absence of treatment. -Wikipedia

Currently, there are no singular interventions to fully prevent the occurrence of most diseases and injuries in normal life situations. In being alive, there is always risk.

So what to do? If other disciplines such as mathematics, physics, or psychology have defined a certain term or construct, I propose it necessary to understand and utilize that definition accurately in professional discourse. The terms above, which originate from classical mechanics, immediately come to mind. We should challenge and operationally alter definitions from other fields only if strong data and logic warrant modification. Further, in research, discussion, and education the most specific, accurate definitions should be sought after. If unknown, questions should arise, discussion should ensue, and operational definitions provided. Science requires precision in language: exact terms. Lastly, the patient and consumer’s definition of certain words needs to be ascertained. Where feasible, more appropriate explanations should be provided to improve public and professional understanding of terminology. Communication is strained, and collaboration limited, if we are essentially “speaking different languages.”

A physical therapist does not need to be an engineer, but understanding the language of mechanics allows for true discussion between fields. It opens the door for increased collaboration.

A physical therapist does not need to be a psychologist, but knowledge of psychological constructs allows for evolved ways of conceptualizing and treating patients. It lends itself to improved research and clinical practice.

A physical therapist does not need to be a linguist, but explicitly defining words is necessary. It helps us understand form, meaning, and context.

collaborate

We need specificity and discipline in our language. Combining our expertise with the language and concepts from other disciplines fosters the ability to more robustly communicate and subsequently collaborate. This allows us to identify the grey, and step into uncertainty. For then we can truly start to explore the chaos, slowly illuminating specificity. Vagueness, after all, is beyond the limits of logic and reason.

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#DPTstudent You don’t need clinical experience…

You need deliberate practice. And, don’t be fooled you still need a lot of it.

The three most dangerous words in medicine are “In my experience.” –Mark Crislip, MD via Science Based Medicine

Especially when you are unaware of it’s caveats and limitations. Per Malcom Gladwell’s Outliers many advocate the 10,000 hour rule regarding the development of expertise. While this is a useful illustration of the sheer volume of practice necessary to develop mastery, it’s likely over simplistic for a concept as complex as expertise in a complicated craft.

Marla Popova comments that

The secret to continued improvement, it turns out, isn’t the amount of time invested but the quality of that time. It sounds simple and obvious enough, and yet so much of both our formal education and the informal ways in which we go about pursuing success in skill-based fields is built around the premise of sheer time investment. Instead, the factor Ericsson and other psychologists have identified as the main predictor of success is deliberate practice — persistent training to which you give your full concentration rather than just your time, often guided by a skilled expert, coach, or mentor. It’s a qualitative difference in how you pay attention, not a quantitative measure of clocking in the hours.

Clinical care, research, and critical thinking are no different. It is not experience, as linear measurement of time, but rather quality practice and volume that matters in developing high level skills. Left to its natural devices our brains and psyches are stubbornly prone to bias and errors in rational thinking. Confirmation bias and improper associations such as post hoc ergo propter hoc (since event Y followed event X, event Y must have been caused by event X) are common and often unrecognized. Thus, practice must be reflective and critical. Practice must be varied and evolve over time.

The skills required (mental, psychomotor, interpersonal, and otherwise) are staggering. It involves knowledge of current research, research methods, critical thinking, connection of concepts, connection  of knowledge, problem solving, listening, examination, hands on techniques, clinical decision making, and patient interaction.

Evidence is more important than experience.
Evidence can not replace experience.
You can’t have evidence based practice without experience.
Experience is meaningless without evidence.

Experience vs. Evidence. I observe these views that appear to be from separate ends of a spectrum, that appear to be contradictory, but in reality are just different concepts. So, does experience matter? Yes, but…experience as conceptualized and measured in years is both insufficient and incomplete. The focus should not be the mere acquisition of experience; but instead on proper, focused practice with the appropriate processes required to develop the necessary skills for mastery. This is not to say volume is meaningless, even focused practice requires repetition and time for effectiveness. Quantity is ultimately meaningless without quality. Quality is meaningless if it can’t be repeated and refined .

Adam Rufa and Joe Brence of Forward Thinking PT examine the concept of “clinical experience.” Their post series, The Experience Wall, assesses perceptions, memories, and interpretation within clinical care. Joe Brence highlights how experience may not result in linear increases in clinical skill and outlines a new definition of clinical experience:

I propose clinical expertise is not simply gained through practice. It is built through assessment of your ability to think, reason and apply scientifically plausible principles into practice. It requires peer-review.  It requires your thoughts and ideas to be challenged. It requires a hint of uncertainty.

 

New grads should be armed with the latest research, and often tout that they are more “evidence based.” Without “experience” they should rely mostly on didactic knowledge, research, and strong science based logic as they lack sufficient “experience” meaningful practice volume. But, clinicians with years and years of experience may claim that this research evidence alone is empty without time in clinic. So, who is right? Well, both of course.

Knowledge of research does not mean you can apply it. True
Having experience does not mean you are providing “evidenced based” interventions. True
Proper knowledge and experience do not ensure best care. True.

Paradoxes exist, and hacking may be helpful to a broader, more accurate assessment of the hows and whys of clinical care. Appropriate “evidence base” and proper “experience” are separate, but interacting components of developing into a high level clinician. Ideally, these are synergistic principles that contribute to each other, instead of mutually exclusive entities that are developed in isolation. Neither “experience” nor “evidence” ensures accurate research interpretation and application. Knowledge of current literature, appraisal of research, application of science, translating understanding into to practice, volume of clinical practice, and level of clinical ability (ranging from communication to therapeutic alliance to clinical decision making) are all differing skills. Of course, this is not an exhaustive list or conceptual framework. But, in essence, developing as a clinician, no matter our professional age, is more than simply evidence or experience.

Residencies and fellowships contain the potential to accelerate development when implemented effectively. The explicit curriculum, reflective practice, and mentorship can result in a more deliberate, critical, and self-reflective form of professional growth and clinical care. But, of course, residencies and fellowships do not guarantee proper mental skill acquisition or development, especially if founded on misguided assumptions or practice theories (but, this is a wholly separate topic); nor are they the only means to foster such growth. I have encountered plenty of physical therapists with bachelors degrees whose critical thinking, clinical decision making, and “evidence” base is quite staggering. And, conversely, I’ve interacted with many residency and fellowship trained physical therapists with doctor of physical therapy degrees whose reasoning and treatment skills were quite suspect. And yet, as Eric Robertson and Lauren Kealy discuss in their post series, The Bane of the New Professional remains significant. New grads are empowered and motivated to engage within the profession, yet some clinics appear to value experience. So, what gives?

Experience is bias.
Evidence is rigid.
Experience lacks rigor and control.
Evidence lacks experience applying to the individual.

There are great janitors and bad rocket scientists. Hacking your education, regardless of your experience, is necessary. These concepts of experience and evidence require critical reappraisal; a reframing that recognizes the necessity of a synergistic relationship. In regards to the myriad of skills encompassed in clinical care, an understanding to the non-linear progression of each. It’s much more than evidence vs experience, evidence or experience, or even evidence and experience. And, it takes practice.

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Metacognition, Critical Thinking, and Science Based Practice #DPTstudent

Metacognition can be considered a synonym for reflection in applied learning theory. However, metacognition is a very complex phenomenon. It refers to the cognitive control and monitoring of all sorts of cognitive processes like perception, action, memory, reasoning or emoting.

A recent #DPTstudent  tweet chat dealt with the concept of metacognition broadly (list of links), but more specifically discussed the need for critical thinking in education and clinical practice. Most agreed on the dire need for critical thinking skills. But, many #DPTstudents felt they had no conceptual construct on how to develop, assess, and continually evolve thinking skills in a formal, structured manner. Many tweeted they had never been exposed to the concept of metacognition nor the specifics of critical thinking. Although, most stated that “critical thinking” and “clinical decision making” were commonly referenced.

What’s more important than improving mental skill sets?

Thinking is the foundation of conscious analysis. Yet, even with a keen focus on assessing and improving our thinking capacities, unconscious processes influence not only how and why we think, but what decisions we make, both in and out of the clinic. We are humans. Humans with bias minds. Brains that, by default, rationalize not think rationally…

Everyone thinks; it is our nature to do so. But much of our thinking, left to itself, is biased, distorted, partial, uninformed or down-right prejudiced. Yet the quality of our life and that of what we produce, make, or build depends precisely on the quality of our thought. Shoddy thinking is costly, both in money and in quality of life. Excellence in thought, however, must be systematically cultivated. – Via CriticalThinking.org

Need a Model

Mary Derrick observed previously in her post that the words critical thinking and clinical decision making are often referenced without much deeper discussion as to what these two concepts entail or how to develop them. Students agree that critical thinking and sound clinical decision making are stressed in their pre-professional education. But, all levels of education appear to grossly lack formalized courses and structured approaches. The words are presented, but rarely systematically defined. The actual skills rarely practiced and subsequently refined. Students thus lack not only exposure and didactic knowledge of metacognition, critical thinking, and decision making, but also lack experience evolving these mental skills.

Critical_Thinking_Wheel_DJacobs
Critical Thinking Wheel via Diane Jacobs @dfjPT 

Need to teach how to think

Alan Besselink argued a scientific inquiry model to patient care is, from his view, “the one approach.”

There is, in fact, one approach that provides a foundation for ALL treatment approaches: sound, science-based clinical reasoning and principles of assessment, combined with some sound logic and critical thinking.

One approach to all patients requires an ability to gather relevant information given the context of the patient scenario. This occurs via the clinician’s ability to ask the appropriate questions utilizing appropriate communication strategies. Sound critical thinking requires the clinician to hold their own reasoning processes to scrutiny in an attempt to minimize confirmation bias if at all possible. It also requires the clinician to have a firm regard for the nature of “normal” and the statistical variations that occur while adapting to the demands of life on planet earth.

Philosophically, I agree. It appears the question “what works?” has been over emphasized at the potential sacrifice of questions such as “how does this work?”  “why do we this?” and “why do we think this?”

Unfortunately, the construct of evidence based practice assumes the user applying the EBP model is well versed in not only research appraisal, but critical thinking. The structure of evidence based practice overly relies on outcomes studies. It lacks a built in process for integration of other sources of knowledge as well as the applicable question of “does this work as theoretical proposed?” The evidence hierarchy is structured and concerned with efficacy and effectiveness only. Many will be quick to point out that from a scientific rigor standpoint the evidence hierarchy is structured as such, because other forms of inquiry (basic physiology, animal models, case reports, case series, cohort studies, etc) can not truly answer questions “what works?” without significant bias. Robust conclusions on causation can not be made via less controlled experiments. And this, of course, is true. In terms of assessing effectiveness and efficacy in isolation, the evidence hierarchy is appropriately structured.

But, the evidence hierarchy does not consider knowledge from other fields nor basic science, and thus by structure explicitly ignores plausibility in both theory and practice. To be fair, plausibility does not necessarily support efficacy nor effectiveness. So, it is  still imperative, and absolutely necessary, to learn the methodology of clinical science. Understanding how the design of investigations affects the questions they can truly answer precedes appropriate assessment and conclusion. Limits to the conclusions that can be drawn are thus explicitly addressed.

Need the Why

Because of the focus on evidence based practice, which inherently (overly?) values randomized control trials and outcomes studies over basic science knowledge and prior plausibility, students continue to learn interventions and techniques while routinely asking “what works?” Questions of “how did I decide what works?” “why do I think this works” and “what else could explain this effect?” also need to be commonly addressed in the classroom, clinic, and research. Such questions require formalized critical thought processes and skills.

These questions are especially applicable to the profession of physical therapy as many of the interventions have questionable, or at least variable, theoretical mechanistic basis in conjunction with broad ranging explanatory models. This is true regardless of effectiveness or efficacy. In fact, it is a separate issue. Physical therapy practice is prone to the observation of effect followed by a theoretical construct (story) that attempts to explain the effect. A focus on outcomes based research perpetuates these theoretical constructs even if the plausibility of the explanatory model is unlikely. In short, while our interventions may work, on the whole we are not quite sure why. @JasonSilvernail‘s post EBP, Deep Models, and Scientific Reasoning is a must read on this topic.

The profession suffers from confirmation bias in regards to the constructs guiding the understanding of intervention effects. In addition, most, if not all, interventions physical therapists utilize will have a variety of non-specific effects. These two issues alone highlight the need for critical thought in order to ensure that our theoretical models, guiding constructs, and clinical processes evolve appropriately. And, further, to facilitate appropriate interpretation of outcomes studies.

It is not “what works?” vs. “why does this work?” Instead, a focus on integrating outcomes studies into the knowledge and research of why and how certain interventions may yield results is needed. This requires broadening our “evidence” lens to include physiology, neuroscience, and psychology as foundational constructs in education and clinical care. Further, research agendas focused on mechanistic based investigations are important to evolving our explanatory models. Education, research, and ultimately clinical care require both approaches. Interpretation, integration, and application of research findings, be they outcomes or mechanistic, necessitates robust cognitive skills. But, do we formally teach these concepts? Do we formally practice the mental skills?

So, now what?

There appears to be an obvious need, and obvious value, to learning how to think. But, that is just the start. The necessity of learning to think about thinking is required to improve the specific skill of critical thinking. The understanding and application of evidence based practice needs more robust analysis. Growth of critical thinking, metacognition, and an evolution of evidenced based to science based practice produces the foundation for strong clinical decision making. The call for evidence based medicine to evolve to science based medicine focuses on ensuring clinicians interpret outcomes studies more completely. It appears to put strong emphasis on increased critical thinking and knowledge integration.

Does Evidence Based Medicine undervalue basic science and over value Randomized Control Trials?

A difference between Sackett’s definition [Evidence Based Practice] and ours [Science Based Medicine] is that by “current best evidence” Sackett means the results of RCTs…A related issue is the definition of “science.” In common use the word has at least three, distinct meanings:

1. The scientific pursuit, including the collective institutions and individuals who “do” science;

2. The scientific method;

3. The body of knowledge that has emerged from that pursuit and method (I’ve called this “established knowledge”; Dr. Gorski has called it “settled science”).

I will argue that when EBM practitioners use the word “science,” they are overwhelmingly referring to a small subset of the second definition: RCTs conceived and interpreted by frequentist statistics. We at SBM use “science” to mean both definitions 2 and 3, as the phrase “cumulative scientific knowledge from all relevant disciplines” should make clear (by jennifer). That is the important distinction between SBM and EBM. “Settled science” refutes many highly implausible medical claims—that’s why they can be judged highly implausible. EBM, as we’ve shown and will show again here, mostly fails to acknowledge this fact.

 

What to do?

1. Learn how humans think by default: Biased
2. Learn the common tricks and shortcuts our minds make and take
3. Understand logical fallacies, cognitive biases, and the mechanics of disagreement
4. Meta-cognate: Think about your own thinking with new knowledge
5. Find a mentor or partner to critique your thought processes: Prove yourself wrong
6. Critique thought processes, lines of reasoning, and arguments formally and informally
7. Debate and discuss using a formalized structure
8. Think, reflect, question, and assess
9. Discuss & Disagree
10. Repeat

Science Based Practice…

1. Foundations in basic science: chemistry, physics, physiology, mathematics
2. Prior plausibility: “grand claims require grand evidence”
3. Research from other relevant disciplines from physics to psychology
4. Mechanics of science: research design and statistics
5. Evidence Based (outcomes) Hierarchy

Questions lead, naturally, to more questions. Inquiry breads more inquiry. Disagreement forms the foundation of debate. And thus, Eric Robertson advocates for embracing ignorance

Ignorance is not an end point. It’s not a static state. Ignorance isn’t permanent. Instead it’s the tool that enables one to learn. Ignorance is the spark that ignites scholarly inquiry.

Ignorance: the secret weapon of the expert.

Growth is rarely comfortable, but it’s necessary. And, that’s a lot to think about….

Resources

A Practical Guide to Critical Thinking
CriticalThinking.org
Logical Fallacies
Critical Thinking Structure
List of Fallacies
List of Cognitive Biases
Science Based Medicine
Clinical Decision Making Research (via Scott Morrison)
Clinical Decision Making Model
Thinking about Thinking: Metacognition Stanford University School of Education
Occam’s Razor
The PT Podcast: Science Series
Understanding Science via Tony Ingram of BBoyScience
I don’t get paid enough to think this hard by @RogerKerry1 (his blog is fantastic)

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Agree to Disagree the Less Wrong Way


No, you’re not entitled to your opinion. Well, so says lecturer in philosophy Patrick Stokes

I’m sure you’ve heard the expression ‘everyone is entitled to their opinion.’ Perhaps you’ve even said it yourself, maybe to head off an argument or bring one to a close. Well, as soon as you walk into this room, it’s no longer true. You are not entitled to your opinion. You are only entitled to what you can argue for.”

A bit harsh? Perhaps, but philosophy teachers owe it to our students to teach them how to construct and defend an argument – and to recognize when a belief has become indefensible.

Usually, agreeing to disagree ends a discussion. But, agreeing to disagree in order to facilitate true debate should actually initiate the discussion. Attack the message, not the messenger. It’s not personal.

And, that’s the point. Rigorously critiquing the message, ideas, and reasoning is not insulting the person. It’s the foundation of the evolution of the scientific process after new data or theories emerge. Heated, passionate debate can (and I would argue should) be followed by laughter and delicious beverages amongst colleagues (and even rivals!). These fiercely disagreeing colleagues can even be friends.

You are safe, but your ideas are not

But, we are dealing with humans. Humans with complex emotions, previous experience, and beliefs. Brains that are prone to cognitive biases and logical fallacies, even when explicitly on the lookout for them. We are a messy, social, complicated, emotional bunch. The online experience evolved to Web 2.0 “the collaborative internet” (now even Web 3.0) resulting in the proliferation of two way communication and information exchange on the web. The user is actively involved in collaboration and user generated content. Interaction with both content and people has become an integral, regular facet of the online experience. Blogs, blog comment sections, Facebook, and micro-blogging platforms such as Twitter are a routine part of our social as well as professional lives.

So, how can we foster real debate and discourse that is focused on the issues? It’s simple (kind of, in theory), but it’s not easy. Philosophically, absolute truth is a hard, if not impossible, concept (wikipedia truth). In discussions regarding both science and clinical care, the aim is not to be right (per se). But, rather, to approach a state of less wrong. Such a concept recognizes the evolving nature of our understanding in light of new evidence and insight. The goal thus becomes a proper analysis of the position or conclusion presented including the evidence (from basic science to outcomes studies) but also the logic, reasoning, and prior plausibility supporting or refuting the stated position. This approach applies to online discussion, article analyses, professional discussion, and education at all levels. The disagreement hierarchy outlines the strength, and relative validity, of a counterargument. It provides a formal guide for framing discussions.

 

Graham's Hierarchy of Disagreement

 

Why is all of this important?

The online disinhibition effect describes how interactions online may actually be more prone to errors in disagreement and discussion. Whether on blogs, Facebook, or Twitter  endless examples of poor debate are present. Ad homineum attacks (you have no experience in this), complaints of tone (you’re so negative), and down right insults (you’re an idiot). Gross illustrations of both logical fallacy and bias (we’ve all got it, except for me of course).

Sometimes, the lower levels of the disagreement hierarchy are actually true. An ad hominem argument highlighting an individuals lack of expertise, knowledge, or experience may be factually accurate. But, while true in and of itself, it does not necessarily invalidate or refute or counter argue the position presented. For example, a cranio-sacral therapist may argue that I have “no experience” performing cranio-sacral therapy. While true, that does not address my position that cranio-sacral therapy’s explanatory model is indefensible, regardless of the perceived or studied effectiveness of the treatment. Thus, even if it works, it does not work as theoretical presented. And, that is vitally important, and often missed construct, when discussing clinical care. Mary Derrick, @Mary_PT2013, previously addressed the use of clinical reasoning and critical thinking from a DPT student’s perspective.

Thinking, Fallacies, and Biases

Unfortunately, an understanding of the mechanics of debate and the basic fallacies of logic is not sufficient. In order to discuss effectively at a high level we also must possess critical thinking skills. We need to understand and recognize logical fallacies and cognitive biases. We need to understand the basic mechanics of science, mathematics, and statistics. We need to understand what certain studies can and can not tell us. We need to understand prior plausibility. We need to think about our thinking (metacognition).

Even more unfortunate is the lack of teaching students how to think. “Schools of thought” and “gurus” continue to dominate our profession as well as public discourse (see Dr. Oz and the muriad of health and fitness fads). Students, practitioners, and even researchers indoctrinated in evidence based practice volley outcomes based RCT’s attempting to illustrate their positions. Professionals argue with each other about tone, experience, and doing “whatever works.” As Jason Silvernail, DPT, DSc observed in his post EBP, Deep Models, and Scientific Reasoning

When I see my colleagues approaching alt-med treatments asking for outcome evidence, I get justifiably nervous – are they just one RCT away from believing in energy medicine? What we should be focusing on is the absolutely indefensible theory here – it’s scientific reasoning that will help us here, not statistics. Let’s never forget that.

Specifically as the profession of physical therapy and more generally in science and public discourse the conversations needs to continue beyond “lets agree to disagree.”

Debate and arguments need to occur

There are beliefs, models, terms, and ideas that permeate our profession, the health care system, and culture that need abandoning. Can you think of any? Understanding the what and why of clinical care and scientific discussion from a Science Based Medicine perspective:

Good science is the best and only way to determine which treatments and products are truly safe and effective. That idea is already formalized in a movement known as evidence-based medicine (EBM). EBM is a vital and positive influence on the practice of medicine, but it has limitations and problems in practice: it often overemphasizes the value of evidence from clinical trials alone, with some unintended consequences, such as taxpayer dollars spent on “more research” of questionable value. The idea of SBM is not to compete with EBM, but a call to enhance it with a broader view: to answer the question “what works?” we must give more importance to our cumulative scientific knowledge from all relevant disciplines.

If only it ended there. What about that uncomfortable feeling? Defensiveness, feeling offended, stomach churning. These feelings and thoughts are a result of your mind, your brain struggling with two conflicting ideas or ideals. Cognitive Dissonance

In psychology, cognitive dissonance is the discomfort experienced when simultaneously holding two or more conflicting cognitions: ideas, beliefs, values or emotional reactions. In a state of dissonance, people may sometimes feel “disequilibrium”: frustration, hunger, dread, guilt, anger, embarrassment, anxiety, etc.

Some studies illustrate that when presented with evidence conflicting their current position or understanding, humans actually become more entrenched in that belief or view point. So, without a focus and understanding on these principles of debate, disagreement, logic, and fallacy discussion poses the potential to be detrimental. The debate disintegrating into personal attacks and emotional based offensive points as each person drifts deeper into their current view point. Each party fighting uncomfortable cognitive dissonance, and actually confirming previously held beliefs. Critical thinking and metacognition are needed. Patrick Stokes again summarizes:

The problem with “I’m entitled to my opinion” is that, all too often, it’s used to shelter beliefs that should have been abandoned. It becomes shorthand for “I can say or think whatever I like” – and by extension, continuing to argue is somehow disrespectful. And this attitude feeds, I suggest, into the false equivalence between experts and non-experts that is an increasingly pernicious feature of our public discourse.

So, please, let’s agree to disagree.

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Comments On: Building Community & Discourse Through Conversation

Often, intense dialogue emerges in the comments section of blog posts. In my opinion, the discussion enriches the original post. Comments add depth to the post, and benefit the reader. Further, it allows a post to remain dynamic over time as knowledge improves or reasoning changes. A guest post on @MikeReinoldBlog entitled Trigger Point Dry Needling for Lateral Epicondylitis resulted in over 220 comments. At one point, Mike even closed comments. Later, in a decision I respect and agree with, he re-opened the comments section. That post is rich in various content, lines of reasoning, and debates on various aspects of science, physical therapy research, pain, and mechanisms of manual therapy. A true resource. On PT Think Tank, our most commented on post  OsteopractorTM Not now, Not ever currently has 201 total comments. In  Comments Off on PT Podcast @ErikMeira states:

Do I not want the feedback? Do I not want to foster discussion? Not at all. The answer is simple: I don’t have the time to manage it. When I have allowed comments in the past I was bombarded with spam posts. This required constant attention to weed out the crap… The other problem is trolls. Most comments are either blind emphatic agreement or blind emphatic disagreement. Then you get into name calling and weird irrelevant attacks. No thanks. I’m not the only one who feels this way. Look here, here, and here for some much more thought out reasons for not allowing comments on blogs.

I agree that moderation can be difficult. Spammers and trolls are a constant, annoying problem. Spam widgets and spam reducing practices exist. See 7 Ways to Reduce Blog Spam for ideas. For those not familiar, @ErikMeira hosts two fantastic podcasts, PT Podcast (@PTPodcast)and PT Inquest. On his site, he published a fantastic 5 part Science Series.

Once a site decides to have comments open the author of a post has a couple of options:

1. Allow the commenting community to discuss
2. Address critiques or questions directly
3. A combination



For moderation, a policy statement can guide decisions to un-approve a comment(s) utilizing set standards as a reference. I uphold that heated discussion and debate eventually lead to progress, are extremely helpful to readers, act as real time peer review, and illustrate when people are being ridiculous. The more people comment, the more obvious their intellect, intent, and true value (or lack of) is displayed. Comments allow for multiple participants and viewpoints to present and discuss issues. Often, connections are made to other concepts not explicitly explored in the initial blog post. For a reader, following the discussion can engage analytical processes, allow them to follow arguments, and challenge ideas. There is value for the author in the for of feedback, questions, and a forum for further clarification. There is value for the commenting to engage with the author and each other in an archived discussion. There is also value to the reader. Personally, I have extracted tremendous intellectual challenge and benefit from reading through a blog post with a engaged comments section.

Although a fear of negative comments is present, allowing individuals to post dissenting views illustrates enriches the post. Even without any moderation the community of commentors can come to the rescue in the case of poor logic, bad reasoning, misinterpreted references, or just plain nastiness.Comments and the ensuing discussion give blogs their true power. In best case scenarios, they are an example of real time, open source peer review and academic-clinical discussion. We can discuss and collaborate around the world. SomaSimple is a prime example of an open forum. Many view SomaSimple negatively, but they have presented a moderators consensus on the Culture of SomaSimple and Information for Guests which includes the Disagreement Hierarchy. One of the resounding themes of the forum is “Here you are safe, by your ideas may not be!”

A prime case example of “comments on” is the contraversial post OsteopractorTM Not now, Not ever. To date, the post has garnered more than 200 comments. The dialogue was not terse and rather intense at times. Overall, I think the comments section benefits those who read and engage PT Think Tank. I attempted to respond to most comments  and critiques. The commenting community dialogued further. Eric Robertson moderated comments that were blatantly attacking individuals or grossly off topic. In total, less than 10 comments total were moderated (deleted or discarded). One comment by a single individual and all the rest by another. So, overall 2 users and less than 5% of all comments required moderation.

Comments? Comments, anyone? Anyone?

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#CSM2013

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#CSM2013 is here! PT Think Tank and it’s contributors are all in attendance. We plan to provide highlights, quick summaries of sessions, and other insights right here on PT Think Tank as well as through the conference hashtag #CSM2013. If you are tweeting do not forget about the other hashtags curated and discussed in the #Physicaltherapy Hash Tag Project 2.0 . Not attending? Follow the hashtags at home and join the conversation.