• Matthew Low

The Big R’s – Part Deux Reasoning and Responsibility Statements

Recently, Neil and I were invited to be panel members for the second #TheBigRs meeting.  We were both asked to give a 5 minute presentation or statement on one word.  With that word, we needed to make our views clear on our perspectives surrounding it in the context of MSK Physiotherapy practice.  Other panel members shared their perspectives and it was all filmed and can be viewed here and here.  A website has been created that provides more information and a forum for discussion.

This blog shares both Neil and my statements that we gave at the meeting.  Please feel free to comment on what you feel, the direction of future travel should be.

The following is my statement on ‘Reasoning’:

Thank you to Chew’s Health and Connect Health for organising the three R’s events.  I think they should be applauded in their strides to try to bring together a growing movement of Physiotherapists in order to help us travel forwards in a worthwhile direction.

All of us sitting here today are leaders in one sense or another, be that in clinical practice with our patients, or in our organisations in the workplace or in our social environments.  As such, our responsibility and our reasoning are deeply intertwined so I shall try to stay within the realm of reasoning as much as possible.  I will draw from Alex Broadbent’s work, a philosopher of Medicine, to frame this talk. I would like to discuss reasoning in terms of how we view the world, secondly how we reason using our knowledge, thirdly how we reason with our morals and lastly how we reason our professional disagreements.

A place to begin is to look at how we view physiotherapy, its practice and through what lens we see it…and there is no getting away from a perspective of realism.  There will always have to be the fact of the matter.  One area of realism is how we view evidence and use it to make therapeutic decisions.  The hierarchy of evidence-based medicine is a very good comparative hierarchy of internal validity where the methods higher up have better internal validity than the ones below.  This is fine, but in so doing makes the issue of external validity much more challenging especially when making causal inferences.  What is clear is that by using the hierarchy of evidence-based medicine to create a map of therapeutic decision-making is not as straightforward as it seems, and it certainly does not tell you the terrain.  I am not saying that randomised controlled trials should not be done, not at all, they should be and are extremely useful but we should stay critical of all methodological short comings and what they really tell us.  I think that we may have to look at evidence in a more pluristic way, using multiple methods and methodologies to critically analyse the area in question and keep in mind the people that we treat are at the very centre of all our reasoning first and foremost.

The next area is how we reason with respect to knowledge, I believe this should be done in a style and manner of humility.  By that I mean to have the willingness to reconsider one’s belief in the face of disagreement and to recognise that knowledge changes with time.  It also means that we take each other’s differing views seriously.  (This includes my perspective on evidence-based medicine by the way!) This also crosses into the style and manner of our communication that I believe should be inclusive, but not in such an overtly apologetic way that no issues are discussed.  In order to be inclusive, communication styles need to be conducted in the context of the social environment and the people present.  If the size and scale of the social environment is so large, that we are unable to communicate recognising body language and tone, for example in social media, then it makes sense to use a more conservative approach.  I am not talking about policing but I am talking about inclusivity.

Next is how we reason morally.  Because we are all part of one humanity, we therefore derive our moral worth from that humanity.  Therefore, all individuals have equal moral worth and whose views and perspectives should be equally valid and therefore should be listened to, heard and taken genuinely. But equally, held to account if our standards of professionalism slip.

Lastly, reasoning surrounding professional disagreements.  This is possibly the most challenging area, particularly with respect to social media.  Perhaps, attempting to start with cases or areas of discussion where there is agreement in the first instance, and seek to identify, in as specific a way as possible, the values or facts that we might disagree.  This may still not lead to agreement, but it improves the chances, and in so doing, maximizes the areas where we can identify common ground.  This is in stark contrast to using a principled approach, which typically dramatizes our differences and polarises our discussions.

We are all passionate individuals and we are stronger together than we are in smaller groups – let’s see if we can take this rewarding profession forwards by listening to each other, providing space for reflection and by standing on the shoulders of those that have come before us.

Matthew Low, NHS Consultant Physiotherapist

The following is Neil Langridge’s statement on ‘Responsibility’:

Responsibility can mean so many things to so many people and of course this is a personal view and perspective. I feel in this context of discussing our profession we have a number of different ideals to consider; Responsibility is something that can come with a sense of pressure, with social expectation, a sense of maturity and wider view of the world around us whilst considering our culture, society , work and family values and our influence upon these. In considering these values I have narrowed this into our natural conversation in terms of our similarities due to our professional status together and hope this offers some suggestions for discussion. Firstly;

  1. Responsibility to and for the patient – to listen, to be empathetic, to be evidence-based, to be safe in our practice, to empower, support and give confidence to others who have lost theirs through illness, injury, pain and distress. This responsibility in essence is perhaps our driving force when we think about the patient and therapist interaction.

  1. In considering this role we must also give responsibility to the patient. Empowerment is about taking support away at the right time so the patient can be responsible for themselves which inherently is central to the rehabilitation process, and the therapeutic relationship balance that leads to the patient regaining what they lost. To do this we have a shared responsibility as part of placebo, as the process of the patient handing this over to the therapist is therapeutic. The art to this handovers’ success is the context of their barriers to recovery being altered to a positive responsibility, rather than negative one.

  1. We have a responsibility to challenge and change and share. I think here is where I have really seen a major shift in how we as a profession now really are able to internally be critical .Economically as well as therapeutically we must be responsible for how we act and behave, and we must be change efficient and not risk averse. We should continue to be responsible in how we consider best care under the evidence base, it is a professional responsibility to challenge where this is plainly wrong, poorly evidenced or interpreted.

  1. Responsibility to and for the profession is vital –working externally with colleagues, building respectful working relationships with other professions is a key change model but as much as we also have a responsibility to challenge and change, but to also have a responsibility take people with us. We have a responsibility to harness where we can to make the biggest effect, public health is a great example of where we have professional, moral and ethical responsibility to address health and wellness – we must impact here as well as other elements of MSK health. We talk of eradicating certain treatment options, and this is a key responsibility: but lets get the focus appropriately balanced. Let’s take Ultrasound for LBP as an example (should not be used) however – consider the numbers we are taking responsibility for here? The number in the population, the number with MSK pain, the number who then seek GP help, the number referred on (5.6 per weighted 1000), the number in physio with LBP who then receive Ultrasound – we are talking tiny numbers – its important but we surely should be focussing our responsibility to address the public health issues. Addressing non-communicable disease has to be the responsibility of the profession surely that’s more important. Smoking kills 6 million people in the world every year, 1.5 billion adults over 20 are obese and physical inactivity is one of the leading risk factors for global mortality. Fitter people mean a more productive society – let’s think big instead of small.

  1. Lastly, we have a professional responsibility to ourselves and the professional relationships we build, and this is always a tricky one. In the end how we present ourselves professionally in any arena or any format as a physiotherapist comes with it a level of professional responsibility. How people wish to interpret that can come with a flexible approach. People are free to express opinions and offer views but they are responsible for those actions and consequences of them when providing that opinion as part of a wider profession. If you are speaking for yourself, the you are only responsible for yourself, if anyone speaks for “we” as in the profession, then we are responsible in the impact positive or negative the words may have – this is not about towing a line, or not meeting things head-on, far from it, it’s about doing so in a way that creates the biggest positive impact we can – taking someone with you and creating a change (IMO) starts with respect and understanding on both sides and that for me is the hallmark of a responsible professional.

Neil Langridge, NHS Consultant Physiotherapist.

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