This post is the second part on my series: Observations in Practice (part 1 here).
On his blog, NOIJam, Dr. David Butler introduces a great discussion on grade V manipulation and wants to know who is doing it, is anyone researching outcomes, “And are there others like me who have moved to more educational/mobilising strategies – but in the back of their minds they don’t want to give it up completely and so they keep “cracking” as an option?” A great discussion has started in the comments section and I highly recommend you check it out.
While Dr. Butlers post leads to the debate of the use of manipulation, I would like to begin a discussion on a similar but broader topic…“The Clinical Toolbox” vs. “Clinical Reasoning“.
Over the past several years, I have interacted with, and observed, the practice of many Physical Therapists and students. I have been fortunate to take some great CEU courses and interact with some very bright minds in the field. Like many, I have enjoyed learning new “techniques”, but in the end, I have to wonder, is it about the “technique” or “the interaction?” What drives my outcomes?
I have written in the past about uncertainty, placebo, and expectations, and as we learn more about the therapeutic alliance between clinician and patient, how important is the infamous toolbox, really? In an age where literature has challenged the relationship between patho-anatomical abnormalities and patients symptoms, do we need to know 10 different ways to manipulate the spine? Is my patient not getting better because I only learned 9 ways? Is my practice not eclectic enough? Maybe it’s because the state of PA has yet to embrace dry needling?
Through my own observations and reflection, I suspect that the toolbox is only as deep as one’s ability to clinically reason. Great clinician’s are those who have an understanding of the human condition. They are those who are able to achieve outcomes with minimal amount of force, tools and rules. They are those who embrace the individual nature of a condition and can justify (cognitively and meta-cognitively) each of the interventions they employ. They are lateral thinkers who do not blame the individual or the tissue; they instead learn how to interact with it.
So all of this said, what would you prefer: To have an uncanny ability to clinically reason OR have every tool in the toolbox?