Ray Charles may have been blind, but his hit song “I Don’t Need No Doctor” written back in 1966 makes me think that even he was able to see the snag that MSK practitioners were bound to hit in the 21st century. Of course, I am drawing lines that don’t truly exist. I highly doubt Mr. Charles paid physical therapists or chiropractors much attention. Nonetheless, pull up Youtube and listen to this great throwback hit (you can even play the John Mayer version if you want; it is really good) and see if you find the parallels that I do.
“I don’t need no doctor, ‘cause I know what’s ailing me.”
How often in clinical practice is this the absolute truth? Robin McKenzie, one of the great pioneers in the MSK realm and the innovator behind the McKenzie Method of Mechanical Diagnosis and Therapy, famously said, “my patients taught me all that I knew.” Dr. Craig Liebenson recalls watching Dr. Karel Lewit, the legendary neurologist from Prague, taking patient histories – “He looks into the patient’s eyes, he takes a history like none other that I have ever witnessed. This was before CAT scans or MRIs, when the history was king.” The history was and still is king, because the patient knows what is ailing them. They may not know the exact structure driving their pain, but they know the information that is likely far more clinically relevant in the realm of conservative physical medicine. They know how their affliction is affecting their daily life and their relationships. They know the impact their pain is having on them psychologically. They know all of their prior experiences that are influencing their current experience. They know what their concerns are as they look into an unclear future that they fear may be riddled with pain, disability, surgery, medication, missed work, expenses, etc. They know what is ailing them – all of these psychological and social manifestations that cannot be teased out by a movement screen or orthopedic tests (e.g special tests). These are the things that are brought to light with soft skills- problem-solving, communicating, flexibility, critical thinking and empathy.
“He gave me a medicated lotion, but it didn’t soothe my emotion.”
In this context, the “medicated lotion” could be any number of things: certain manual therapy techniques, special corrective exercises, an e-stim or ultrasound machine, … the list goes on. There is a distinction to be made between the cookbook frameworks taught in weekend seminars and the deep training acquired over years of study. It does not take a very high level of skill or critical-thought to follow a popular cookie-cutter system. As Einstein said, “if you can’t explain it simply, you don’t understand it well enough.” The art of making a complex idea simple demonstrates a higher level of application and critical thinking; an art that becomes lost when we are handed a cookbook to reiterate and follow. This makes me think about how many people in the field of chiropractic and physical therapy are so caught up in the revered title of “doctor.”
Are the majority of us even living up to the title we so desperately cling to?
Some may think they are as they continue to “expand their toolboxes” with different weekend certifications. However to me, being a “doctor” means being an exceptional critical thinker, decision-maker, educator and communicator, possessing soft skills and clinical reasoning necessary to understand such a dynamic system. Why then, do so many of the aforementioned weekend courses offer students and practitioners cookie-cutter style approaches to diagnosis and management? They exist because there is a market for them, and the market exists because students and practitioners would like a linear means of organizing their thoughts to guide their decision making. These brands serve this purpose well. They are a great starting point, but, the mistake is when students and providers get comfortable with one or two and hunker down into a silo. This can limit a provider to a physical-exam-based branching algorithm that does not incorporate the person’s history or Needs Analysis.
What happens when a patient – a complex human being – doesn’t fit that cookie cutter? Worse yet, what if you cannot connect with that person because you have put all your stock into one particular method without taking the time to learn patient-centric skills like motivational interviewing and therapeutic alliance?
Should we just have our patients perform prone press-ups until their triceps explode? It does not make sense to meet a non-linear condition like chronic pain with a linear approach to clinical reasoning.
The pursuit of systems-based approaches is not inherently wrong, it is human nature to seek out a framework to follow when dealing with the uncertainty. The literature would suggest, however, that our time and efforts are better spent elsewhere. A systematic review from Riley et al. asks the critical question, “Are movement-based classification systems more effective than therapeutic exercise or guideline based care in improving outcomes for patients with chronic low back pain?” To answer this question, a search of randomized control trials with moderate to high methodological quality was done, of which six were found containing low to moderate risk of bias. Of those six, no clinically significant difference was found between the movement-based classification systems and therapeutic exercise or guideline-based care. This is not to suggest that such systems are not of value. What this suggests is that considering one can get the same results without them, there are certain skills that are more worthy of one’s time.
“But it didn’t soothe my emotion.”
I need a critical thinker, an empath, a guide, a teacher. A paradigm shift is here. The question is, can we pivot? A learner’s “North Star” should not be any single method. It should be the pragmatic application of the best science. As chiropractic and physiotherapy evolve to handle uncertainty in complex, unpredictable systems, we need to expand the science we examine. For chiropractic in particular, it is time to start looking beyond the adjustment. We say all the time that chiropractic is a profession, not a treatment, suggesting that there is more to us than just spinal manipulation. Yet, it seems many of us only want to share and discuss literature that supports spinal manipulative therapy. The science of manipulation is useful, but scientific journals are ripe with work on all of the soft skills too -learning to recognize and manage yellow flags, practice motivational interviewing, understanding the effects that our words can have on people, barriers to adherence and so on. This can immediately change the way we communicate and frame our clinical decision making. This is not to say that these skills are learned quickly, they are loaded with nuance and require significant commitment, but it is to say that they are just that powerful. The journals and thought-leaders also hold the current best evidence for clinical reasoning and best practices in case management. The only best evidence you will find at any particular method-driven or “system” based course is literature which fits the vested interests of that particular method. As Lewit said, “Don’t be a slave to the methods. The methods should serve the goals.”
It falls on the shoulders of those in the trenches to enhance the process of knowledge translation. In other words, we must communicate better information, which requires us to consume better information. The link between posture and pain, a concept commonly misconstrued by lay-people and well-meaning clinicians alike, was addressed in papers as far back as the 80’s. An epidemiological study from 1985 from Dieck et al. found that as they observed individuals possessing any of these three classic back pain scapegoats; elevation of one shoulder, elevation of one hip, and deviation of the spine from midline of the body, none of them were associated with future onset of low/mid-back or neck pain. This is only one example of many that have accumulated from 35 years ago to today. Despite that, we still have health care professionals today perpetuating the dogmatic notion that we must pursue some “ideal” posture if we ever hope avoid back pain as we age. Again, this is only one example among many. It is no secret that there is a long list of dogmatic beliefs that have survived over the years despite repeatedly failing when put to the test by the scientific community.
Why is this? There are many reasons, but the most compelling reason was once pointed out by Professor Lorimer Moseley. He said “back pain is not a simple problem. There are many forces at play that propagate its widespread mismanagement. The massive elephant in the room— that entire professions depend on the problem remaining unsolved— will be hard to tackle.” A good quote for every clinician to sit on for a while. Does embracing the science mean that many clinicians will have to drastically change the way they treat and communicate in order to meet the standard of care? This is the reality of the situation. Moseley goes on to emphasize the need to improve upon a particular skill that has survived the rigors of scientific scrutiny, “ In the meantime, the glaringly obvious cornerstone of best practice care that somehow keeps flying under the radar is education.” One more unsexy, unexciting but massively important soft-skill. If “doctor” is a title and standard we want to reach and maintain, we must relentlessly pursue the skills that will allow us to live up to it. Ideally, we must transcend it, because society “don’t need no doctor.”
It needs something better.