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.

Physical Therapy: Technology Update

This is my presentation given at Evidence In Motion's Manipalooza 2013 Symposium held in Aurora, CO.

I was traveling at the time but the organizers graciously allowed me to submit my talk as a recorded video. Therefore, you will be experiencing the talk just as the symposium participants did!

#PhysicalTherapy Hashtag Project

#Hashtags are a robust means of tracking or tagging information on Twitter. They help you manage the fire hose-like nature of the constant stream of information on Twitter. Conferences, tweet-chats, and general topics of discussion all benefit from the use of hashtags. Combined Sections Meeting (CSM) of the American Physical Therapy Association, the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT), and the Private Practice Section of the APTA all have hashtags surrounding their conferences. The conference acronym is usually followed by the year. For example, #CSM2013#AAOMPT13 (No AAOMPT conference this year because of IFOMPT Conference), and #PPS2012. Functionally, hashtags  group tweets by keywords. For those not familiar check out Twitter’s help page what are hashtags? or the wikipedia page hashtag.

Personally, I have leveraged hashtags to follow and contribute to discussion surrounding conferences (CSM and AAOMPT for example). I  unfortunately was not able to attend #AAOMPT11 or #IFOMPT12. But I did learn, discuss, and contribute via the conference hashtags. The # creates potential for discussion and collaboration on a topic, course, conference, or issue. Unable to attend a conference or event? Participate virtually! Busy during the time of a tweet chat? No problem, you can search the hashtag later to read, respond, and continue the conversation. Wondering what individuals are saying on a particular topic? Search that hashtag. Storify even lets you create and save conversations or stories based on certain parameters.

Outside the PT Sphere

@HealtSocMed claims #HCSM (Healthcare Communications and Social Media) forumlated in January of 2009 was the first global healthcare tweet chat. Other non physical therapy specific hashtags or tweet chats include #SocialOrtho#SportsSafety, #mHealth, and #MedEd.

Physical Therapy Hashtags

Established physical therapy hashtags include #physicaltherapy, #physicaltherapist, and #physioPT. Kendra Gagnon PT, PhD (@KendraPedPT) who has guest blogged here on PTTT, utilizes hashtags in entry level DPT education. Her students tweeted #WhyIchosePT to communicate their reasons for pursuing the profession of physical therapy. Her class used #PTprof throughout the semester. On her blog, Kendra discusses social media communication as a part of the curriculum in a Professional Interactions course.

In some cases hashtags are utilized both as a tweetchat and to track discussion on a particular topic. #SolvePT is an example with weekly tweet chats on Tuesdays from 9-10PM Eastern Standard Time as well as ongoing discussion related to issues pertinent to the physical therapy profession. @SnippetPhysTher (Selena Horner, PT, GCS) discusses the emergence of the hashtag and the tweet chat. The #SolvePT hashtag continues to be an interesting conversation regarding physical therapy.

Call to Action

I propose a #physicaltherapy hashtag project. As a physical therapy community lets discuss specific hashtags for practice areas, topics, and ideas. I recently began using #AcutePT to tag some tweets containing evidence and rationale for the physical therapist’s vital role in the acute care environment. The Healthcare Hashtag Project has curated content and hashtags relating to health care topics, specific tweet-chats, conferences, and even diseases!

Below are my proposed hashtags for the physical therapy profession in addition to what we currently utilize. What did I miss? Should we change the wording? Let’s get started…

Practice Areas: #AcutePT #CardioPulmPT #GeriatricPT #ManualTherapy #NeuroPT #OrthoPT #PainPT #PedsPT #SportsPT #WomensPT

#PTscience for research, evidence based practice, and critical thinking relating to physical therapy.

#PTAdvoc for physical therapy advocacy and legislative issues.

#bizPT for business and private practice topics.

#PTtech for information relating to technology and the physical therapist.

#DPTEd for topics relating to physical therapy education and educators, including clinical education.

Hashtags for education and student topics could include #PTedu or #PTschool. Rumor has it that #DPTstudent will emerge as a hash tag topic and potential chat spear headed some of the student leaders in social media. You know @MattDeBole is at the center of that! Also check out @LaurenSPT as well.

And last, but certainly not least, #PTHero for inspiration and greatness within our vital profession.



Term & Title Protection for the #PhysicalTherapist & #PhysicalTherapy

APTA Term Protection Ad

The American Physical Therapy Association recently constructed a Term and Title Resource Center regarding the use of the terms physical therapy and physiotherapy as well as the titles physical therapist, physiotherapist, PT, DPT, and MPT.

They have even constructed a 1 page advertisement, that I think is actually rather clever. The APTA announces

The full-page color advertisement will run in future editions of State Legislatures magazine, the monthly publication of the National Conference of State Legislatures which is provided to state legislators, legislative staff, and other state policy makers in all US jurisdictions.

I commend the APTA for their efforts and resources, which are no doubt, an important step. And, there have been some victories. Virginia successfully enacted term protection for physical therapy and title protection for physical therapists.

Unfortunately, physical therapists are currently losing this battle on both the legislative (lack of term protection laws), but just as importantly, the judicial level. In 2010, the Washington State Supreme Court issued an impactful ruling that dealt specifically with physician owned physical therapy services (POPTS). But, the ruling also has significant ramifications for the use of the term physical therapy.  Details about the ruling can be found in an APTA released statement. The Kentucky Supreme Court issued a similar opinion.

The Washington State Supreme Court Opinion states:

Physical therapy is one aspect of the practice of medicine. The practice of medicine is defined by RCW 18.71.011(1) as ‘[o]ffer[ing] or undertak[ing] to diagnose, cure, advise, or prescribe for any human disease, ailment, injury, infirmity, deformity, pain or other condition, physical or mental, real or imaginary, by any means or instrumentality.’ This broad definition readily encompasses all the acts constituting the statutory definition of the practice of physical therapy.

Ouch. But, it gets worse. The Washington State Medical Association exclaimed “Big Win in Supreme Court!!!” following the ruling. They continue:

The decision represents a victory for physicians and medical practices, not only because it is now clear they can employ physical therapists, but because an adverse ruling could have outlawed their employment of other licensed health care professionals (such as nurses).

Double ouch. The ruling as well as the medical community’s reaction clearly illustrate that legislators, the judicial system, and physicians do not view physical therapy as a unique profession nor physical therapists as skilled, collaborative, unique members of the healthcare team. It appears physical therapy continues to be viewed as a prescribed or provided modality with physical therapists as mere technicians or employees under the physician umbrella.

We either need to more aggressive with our formal national, state, and local legislative lobbying and education (including legislators,  patients, colleagues, etc), or we we need to seek and secure allies within the medical and healthcare community, including but not limited to physicians. I vote for both.

What are you doing to #SolvePT? What should we do at the grassroots level?


Term and Title Resources via the American Physical Therapy Association
Term Protection Advertisement/Handout
Physician Owned Physical Therapy Services (POPTS) and Referral for Profit via AAOMPT Student Special Interest Group Blog
APTA Statement on WA Supreme Court Decision
WA Supreme Court Decision and Statement
Virginia Term Protection
Kentucky Court Ruling Information[/list]

Thought of the Week: Be Passionate

Dark Side of the Lens Screenshot

In this stunningly beautiful, award-winning video work from The Astray, the message is about passion. Relax for a few moments and soak this masterpiece in.

I never set out to be anything in particular, only to live creatively, and push the scope of my experience through adventure and passion.

Passion is part of what drives the people who make change. It’s part of what makes someone work deep into the evening to make it right. It’s the people pouring out ideas in the #SolvePT movement. It’s the leadership of the profession, regardless of how effective you think they are.

For a long time I had no passion for this profession or my career. Moving from job to job, I had little fulfillment. With a little luck and a little self-exploration, I was able to discover which aspects of physical therapy resonated with me. Fortunate. My passion is now strong. This job has become my profession. This blog is an expression of that passion. What is your passion?

Live Creatively. With Passion. Expand Your Experience.