The biggest problem facing the physical therapies

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As humans, we have a desire to create a self-identity that we are proud of and to be someone who we can face in the mirror every day. As physical therapists, in whatever way that may be, we spend a lot of time learning and developing our skills before it becomes a massive part of our lives. Our profession, and love for it, naturally leads to us taking this on as our identity – it becomes a part of us, just like our family and friends, just like all the other passions we hold so dear to our hearts. Now, if I were to tell you your parents were evil and were having an adverse impact on our community you'd more than likely defend them (hopefully!). You do this not only because you love your parents but because I would be telling you the opposite of what you believe and primarily attacking a part of your identity, and this would be personal. Now I want you to pretend that your father is Kim Jong-un. I'm going to tell you that you have fond memories of your childhood, you remember playing catch together in the fields, he'd take you to the circus and to watch horse racing on the weekends. He'd tell you jokes and read you stories at night, he'd hug you when you were down and supported you through the hardest days of your life. In your mind, he is your hero – your view of the world is that he is a great man and he could do no wrong. But now I'm going to tell you the same thing as before. Your Dad is evil, he is potentially the most threatening person in this world as it is today. You would still reject this thought, although it may be a more accurate representation of the world, it challenges your identity.

As physical therapists, we are very much the same. Our traditional training has a history, often 4 or more years of education where numerous ideas are drilled into us. Most of us have had placements where these ideas are reinforced, along with the way we have mentors and teachers that inspire us, that have so much confidence we would dare not question their teachings. Through all this we are welcomed into a circle – from an outside observer it might be seen as a cult – but we have a firm belonging to our profession. I mean, there is so much crossover between the different physical therapies, whether that be exercise physiology, physiotherapy, osteopathy, etc., but how often have you witnessed a person from one profession advocating their profession over another? All the bloody time. But when another profession encroaches on your territory or tells one of your client's something different to your opinion it's only natural to feel like you are personally being attacked. It’s these experiences that mould us and become so much a part of us that we resist change. When our identity is questioned, and our beliefs are challenged it becomes personal, and we instinctively reject it as it is outside our current schema. 


This challenging of our beliefs often has the opposite effect than its intention and instead of persuading our ideas it leads us to further reinforce our current beliefs. This is called the backfire effect. As the example of being told your father is evil, these challenging ideas may help create a more accurate representation of the real world, but we naturally want to reject it. Instead of being willing to try to continually increase the accuracy of our perception of the world we reject and protect our beliefs, and furthermore try and reinforce them where possible. This is possibly one of the greatest problems with physical therapies and health professions in general. This is problematic as it stunts our ability to provide progressive health care, to develop best practice and to help more of our clients and patients.

I want you to think back to your studying days. Can you think of anything that didn’t quite sit right with you in your learning’s? Something, that perhaps wasn't logical or that it seemed based more on an assumption than evidence? Do you remember questioning it? I'm going to say that there's a good chance you didn't. Mainly because of some of the points we mentioned before. But also because we have a trust for our education and our teachers as there’s a certain confidence we put into them. We are confident they have done their research, and if they are spending the time teaching it, then it must be right. Right?

There’s an amazing writer named David Thorne who write’s satirical pieces for his online blog. Most of his blogs are email threads of interactions he has had with others and are a very entertaining read. Check them out  - it’s worth it. One such thread is one that he has with a disgruntled co-worker regarding time sheets, and the reason I bring this up is because of one email response where he tells a story to counter his colleagues’ obsession with the importance of time sheets. The following is an excerpt of the story;

“I once read about five monkeys that were placed in a room with a banana at the top of a set of stairs. As one monkey attempted to climb the stairs, all of the monkeys were sprayed with jets of cold water. A second monkey made an attempt and again the monkeys were sprayed. No more monkeys attempted to climb the stairs. One of the monkeys was then removed from the room and replaced with a new monkey. New monkey saw the banana and started to climb the stairs but to its surprise, it was attacked by the other monkeys. Another of the original monkeys was replaced and the newcomer was also attacked when he attempted to climb the stairs. The previous newcomer took part in the punishment with enthusiasm. Replacing a third original monkey with a new one, it headed for the stairs and was attacked as well. Half of the monkeys that attacked him had no idea why. After replacing the fourth and fifth original monkeys, none had ever been sprayed with cold water but all stayed the fuck away from the stairs.”

Just because something is done a certain way, it's always been that way, or because someone you respect does it that way, doesn't mean it should be done, that way. Healthy criticism and constant reflection on our own practice is important. 

How do we keep an open mind and avoid being a statistic of the backfire effect? It’s a great question. You can find some good reading and research that looks at how you can argue with someone in ways that may decrease the backfire effect that they have, but this is the flip side of the coin – how do you actually reduce this effect for you. 

1. The first point is to look at detaching your identity from your profession. Am I Brendan the Exercise Physiologist with (insert beliefs around human movement)? Or am I Brendan. Brendan that works as an Exercise Physiologist and has a keen interest in (insert ideas about human movement). This may seem like semantics, but changing the way in which we identify with our profession may be the first step.

2. Try to remember that learning new facts only improves the accuracy of your view of the world. Replacing an old idea or fact with a new one only moves you further forward – no penguins will die because you adjust your point of view.

3. Envisage how a new idea or fact may change how you practice, it is fine to challenge back, but if you make that challenge a tool to clarify if it is something worth taking on board, then it is a far healthier challenge than one that is designed to reject a point of view. 

4. Actively seek out opinions from the other camp, look for the supporting research.

5. Seek debate with others, play devils advocate, and question even the people who have the same view as you. You may find the rationale behind their clinical reasoning not to be as consistent with yours as you first assumed.


6. Respect that other professionals have also had significant clinical outcomes with different approaches, if we view everyone as someone we can learn and develop from we will move forward. It doesn’t mean you have to agree with them, but don’t just question them, also question your own beliefs. 

7. Don't be offended by someone else's point of view about your profession and views - they aren't attacking you. Toughen up.

8. Educators need to be aware, and also have a responsibility to encourage questioning and critical thinking from students. 

The more you are prepared to accept that your health professions beliefs are not you and that maybe some of your ideas are a load of shit (calm down, I'm not saying they are), the faster we can all move forward.

Let's promote cognitive agility in our professions, and then, theoretically with time we may see some societal change in the way we practice and communicate. I’d love to know if any readers have any other techniques they use to try and combat our natural confirmation bias. Feel free to comment. Until next time!