Critical Thinking

The Point of Paradox

Adam’s recent post and a post by Kyle Ridgeway at PT Think Tank have got me pondering thinking tools.  What is a thinking tool?  For me, this is a conceptual process that one engages to better understand a concept, experience or observation.   The tool I use most often is the paradox.

A paradox is defined as: “a statement or proposition that, despite sound (or apparently sound) reasoning from acceptable premises, leads to a conclusion that seems senseless, logically unacceptable, or self-contradictory.”  To put this in a tad bit simpler terms, if we accept certain statements as true then this leads to conclusions that contradict other (perhaps previous) conclusions.

A more concrete and physical therapy related example would be this:

  1. Some patients have pain.
  2. Some patients’ pain resolves without treatment.
  3. Some patients do not need treatment to resolve pain.

The statement: all patient’s need treatment to resolve pain is the conclusion’s contradiction.

Another example could be:

  1. Some people have structural asymmetries.
  2. Structural asymmetries cause pain.
  3. People that have structural asymmetries have pain.

The statement: Some people have structural asymmetries and do not have pain is a contradiction of the previous conclusion.

In the two previous conclusions (bold) we have logical statements that are contradicted by the statements listed below.  The incompatibility between these two statements is a paradox.

Regardless of the content of a paradox, how can identifying a paradox help you as a clinician, student, teacher or clinical instructor? I have found this quote by the Prince of Paradox, according to him a paradox is, “truth standing on its head to gain attention.”  The paradox for me is the tool I use to focus my attention on a problem that remains unresolved.  The interesting thing is once you start to notice one paradox you start to see them everywhere.  I would even make the assertion that truth is not defined by an absolute value but by a paradox.  Expressed in the form of questions some paradoxes are:

1. Given the fact that people deviate drastically from “normal” running forms,  how do they come to run at similar elite speeds? See this video

2.  If people have the ability to heal from many injuries without aide why do we express pain?

3. How does the nervous system execute fast, coordinated and reactive movements at speeds much faster than our nervous system could hope to coordinate using its full capacity (this is due to limits in nerve conduction velocities in relation to movement and reaction time)?

4.  If there is low likelihood of “tissue remodeling” due to a physical therapy intervention then what can we attribute to changes we see in the clinical setting?

5. Why is their a disconnect between the efficacy of the clinician and that what science shows about the effectiveness of physical therapy interventions?

The beauty of these questions, and a great many others is that there is no definitive answer to any of them.  If someone says that they do know for certain, I would listen quietly and then slowly walk away.  If we did know the answer to these paradoxes our clinical practice guidelines would be much clearer.  This gets to the final points I want to make about paradoxes is that on their flip side they can be immensely profitable to study.  Why?  Because one has to examine both sides of the coin — the argument and its contradiction.  Doing so keeps the mind focused in such a way that continues to spur learning and creativity.

Finally, physical therapy school teaches many things but what it does not teach is deep critical thinking skills.  Perhaps this is changing as it has been some time since I was in school.   Students are taught skills and techniques that follow the path of a syllabus.  When the student reaches a fork in the road, the point of paradox, the teacher can’t slow down, and points of reflection are passed over, it’s on to the next topic.  Fortunate for anyone who has read this far in the post they will find out that Duke University is offering a free course on developing reasoning and thinking skills.  It is called ThinkAgain.  I am currently taking it and find it very well produced and organized.

To tackle the challenges that face our profession we need to identify and keep our eyes focused on the paradoxes that present themselves.  These skills are not inherent to our discipline but with a little effort I think we can master them for the betterment of our patients and ourselves.

Eric Kruger @Kintegrate

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9 replies »

  1. Nice piece, Eric. I believe (& hope) critical thinking skills are being taught more in DPT. I believe the DPT student of today demands it. EBP classes on how to read articles, question findings, challenge assumptions, etc. but difficult if there is no frame of reference (seeing several patients, etc.) I think clinical education and skilled guidance from CI’s is paramount here.

  2. I found this blog very interesting. I agree with the importance of deep critical thinking skills in Physical Therapy and Medicine. I find many DPT students and new graduates often do demonstrate deep critical thinking skills, but I am frustrated with experienced clincians lacking and not interested in exploring deep critical thinking skills.

    If I try to use your example to think deep and critcally:
    1. Evidenced Based Practice is effective and efficient
    2. Patient Centered Practice is effective and efficient
    3. Evidence Based Patient Centered Practice is effective and efficient

    Pardox: Evidence Based Practice is not Patient Centered

    I find there are many contradictions when trying to practice Evidence Based Patient Centered care. I think Patient Centerd Care has grown because Evidence Based Practice has not addressed the patient values component of the definition of evidence based practice. The patient often highly values ineffective treatments.
    Damien

  3. @Mike yes CIs can feel the gap here. However, given the fact that most CIs come from an era the predates even the most current education (where there was probably less critical thinking). I think there are plenty of resources and examples set in other fields that can provide guidance. Asking questions and not having answers is a never ending uncomfortable process. Yet, I think becoming comfortable at least being a little bit uncomfortable (or perhaps just a little less satisfied) in your own beliefs is key as well.

    @Damien you present some interesting examples. I would challenge you to answer the question: what does effective and efficient mean? These must be defined in both domains EBM and patient centered (PC) practice. Just because the adjectives are the same does not mean how they are measured in each domain is the same. It is kind of like comparing centimeters to kilograms. 100 kilograms does not equal 100 centimeters even though they share the value of “100.”

    PC and EBM both have holes in their framework, and their reasoning. They also have strong points. Can you identify these holes and these strong points. One hole of PC is that it does not consider the value of the clinician. Many in private practice have put patient centered care above all else. They have used morally reasoned positioned to justify “whatever makes the patient feel good.” Any manner of persuasion to achieve a mean, without due consideration of a net effect of that mean is a limited position. Consider the position you might be in if you were a surgeon i.e. back surgery where there is not clear classification rules for who back surgery is appropriate. You have a patient that really wants back surgery to fix their back pain that may or may not have organic structural causes. Do you settle your decision on whether to perform the surgery based on their values and or preferences?

    Words and meanings that form the context of our clinical encounters have net effects that reach far beyond simple satisfaction of the expectation of relief. These have to do with the social construction and social modulation of our perception. The challenge to EBM and PC medicine paradigms is to consider public health aspects of pain. When we do consider this we are forced to reckon with effects that occur at a much wider level: the sociocultural level.

    Can we resolve the discrepancies between good individual care and good public care within the clinical encounter? Yes, but in my opinion not if we continue with business as per usual.

    Eric

  4. Eric, I applaud your efforts to think critically. And I’ll graciously overlook the statement that I come from an era “when there was probably less critical thinking” (just kidding with you). The concept of a paradox is slightly different from what you describe however. Your examples:

    1.Some patients have pain.
    2.Some patients’ pain resolves without treatment.
    3.Some patients do not need treatment to resolve pain.

    1.Some people have structural asymmetries.
    2.Structural asymmetries cause pain.
    3.People that have structural asymmetries have pain.

    These are simply arguments and the conclusions aren’t “senseless, logically unacceptable, or self-contradictory” but they are the result of flawed thinking. Let me give you an example:

    1. All roses are flowers.
    2. Some flowers fade quickly.
    3. Therefore some roses fade quickly.

    On the surface this might seem like a sound argument to some people, but it has flawed premises, just like your examples. All roses are flowers, and some flowers fade quickly (such as tulips and daffodils, not roses). But saying that some roses fade quickly would be an incorrect conclusion to make. To look closer at your example:

    1.Some people have structural asymmetries. – absolutely true, this argument is based on valid premises so far.
    2.Structural asymmetries cause pain. – here’s where the argument gets derailed, how do we know this is true? (We don’t!)
    3.People that have structural asymmetries have pain. – if you accept premise number 2 this would be true, but I don’t accept the validity of number 2.

    PT’s I know have made the conclusion that structural asymmetries cause pain. Basically they’ve just flipped this example around:

    1. People that have structural asymmetries have pain.
    2. Structural asymmetries cause pain.

    Your contradictory statements are correct, but all they point to is a flaw in the logic of the argument. I greatly encourage you to question other people’s premises, arguments, and conclusions, though this can be a lonely road. And as a CI, I can tell you that this constant questioning frustrates my students to no end.

    For a true paradox, I’d refer you to Zeno’s paradoxes: http://en.wikipedia.org/wiki/Zeno's_paradoxes. My favorite is the infinitely halving distance. You can halve the distance between points A and B an infinite number of times. If you progressively only move half the distance to point B, you can theoretically move an infinite number of times before you reach point B. Yet try to do this with the wall in front of you and you’ll eventually hit the wall.

    • JB, I come from that same era. However, I see students that are engaging in social media, and reading books that I wished I had thought to read when I was there age. This leads me to conclude that our future generations of students will be much more critical and examine the paradoxes that our generations ignored. I never stated the validity of my underlying examples of the premises I gave, in fact I think there is much to doubt about the validity of these premises. Much of PT education and the dissemination of the knowledge of PT is based on such conclusions without a through examination of the underlying premises. In the light of a contradiction between two conclusions (a paradox) we are forced to examine the premises that underlie each of the conclusions more closely. I believe that is what you are getting at with your point. Which I agree with. Your example of having the distance between two points would be valid in reality if human movement could be as perfectly accurate as the mathematics that describes the paradox. Unfortunately, we cannot move exactly halve the distance each time, we either undershoot or overshoot the distance. There is a certain standard error. Because the movement is always forward i.e. toward the wall. The standard error exceeds the actual distance required to move. So that we error and move more than we should and hence we eventually reach the wall. While math describes life, it is not life. The map is not the territory. Thanks for the very relevant comments. Eric

      • Eric, I absolutely agree that we need to examine the premises of every argument. And you are also correct and make Kenny’s point as well: the example paradox I gave is not valid in reality. As Kenny has cited below: “falsehoods cannot occur”. If you have used a logical thought process and arrive at what you think is untrue, you must question the assumptions.
        But it seems like you are calling any two contradictory conclusions a paradox. In your example: “some patients do not need treatment to resolve pain” versus “all patients need treatment to resolve pain” sounds as outlandish as the conclusions “a water molecule is H2O” versus “a water molecule is not H2O”. I would call neither of these a paradox as one conclusion is clearly incorrect (though contradictory). I think that calling these concepts paradoxes opens the door to denying any and all truths.
        I love the questions you posit but again would not call them paradoxes, and I do think some of them may eventually be answerable. Some of them are closer to being answered than others.
        I would be very interested to know what the instructors of ThinkAgain have to say about contradictory conclusions and paradoxes.

  5. Eric,

    I have really been enjoying your posts here and the discussions that have followed. As a student, they have been invaluable to challenging my thinking and cultivating my ability to reason. Thanks to you and all those who have contributed in the comments.

    I wanted to share a brief excerpt on paradox from Noson Yonofsky’s book “The Outer Limits of Reason”

    “Since falsehoods cannot occur and since our derivation followed valid logic, the only conclusion is that our assumption was not true. In a way, the paradox is a test to see if an assumption is a legitimate addition to reason. If one can use valid reason and the assumption to derive a falsehood, then the assumption is wrong. The paradox shows that we have stepped beyond the boundaries of reason. A paradox in this sense is a pointer to an incorrect view. It points to the fact that the assumption is wrong. Since the assumption is wrong, it cannot be added to reason. This is a limitation of reason.”

    We could all do a better job of learning from our mistakes and our failures. The paradox can be an infinitely interesting and valuable tool for demonstrating the limitations of our reasoning.

    Thanks again,
    Kenny

  6. Yes instead of using Occam’s Broom to sweep up inconvenient assumptions we should be building up our skills and focusing on their unreason.

  7. […] Paradoxes exist, and hacking may be helpful to a broader, more accurate assessment of the hows and whys of clinical care. Appropriate “evidence base” and proper “experience” are separate, but interacting components of developing into a high level clinician. Ideally, these are synergistic principles that contribute to each other, instead of mutually exclusive entities that are developed in isolation. Neither “experience” nor “evidence” ensures accurate research interpretation and application. Knowledge of current literature, appraisal of research, application of science, translating understanding into to practice, volume of clinical practice, and level of clinical ability (ranging from communication to therapeutic alliance to clinical decision making) are all differing skills. Of course, this is not an exhaustive list or conceptual framework. But, in essence, developing as a clinician, no matter our professional age, is more than simply evidence or experience.  […]

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