The verb to hack is a throwback to the days when computer programmers would find creative ways to exploit technology. Present day use of the term has cast it in a more positive light. Recently, an article I read described the hacker ethic as inventive, independent, and inclined to test the limits.
I have drawn some criticism for my recent questions of leaders and the theoretical evidence supporting our field. Those who take to heart well-reasoned questioning see it as a sign of disrespect and irreverence. Others have also felt the specter of disdain when they have questioned the purported mechanisms of manual therapy or the clinical reasoning employed during its use. What seem like fair questions in my mind, given the paucity of support for our attributions of change in our patients, draws the ire of those who believe in these attributions unquestioningly.
Returning to the hacker ethic that encapsulated the methods of early programmers, their irreverence of the system, administrators and society led to the modern structure of the internet and our lives. Napster paved the way for Spotify. An exploitative sorority picture rating website paved the way for a completely novel way to connect and interact–Facebook in case you missed The Social Network.
Before I go any further in this exposition, I want to weave another topic into this post. Social conformity–a phenomenon well known to social scientists but less so outside the field–is the part of our human nature and cognition that enables us to fall into a natural rhythm with those around us (i.e. to conform). Long before the neuroscience-mind connection, mirror neurons, and the brain plasticity rage, a social scientist named Arthur Asch performed a series of brilliant experiments that challenged the notion of just how free our will actually is. Wanting to jump the gun and read more? Take a look at this article he wrote in Scientific American circa 1955 (Asch, 1955).
To summarize his experiments and findings: Asch had subjects sit in a room of confederates (people designed to look like fellow subjects but they were actually experimenters who were part of the manipulation). In this room an experimenter would present a series of lines to the group. The subjects were shown one line, and then presented with three others. After being presented, one-by-one each person in the room went on record stating which of the three lines was most similar in length to the original line. Confederates conspired against the subject by stating that a blatantly wrong line was in fact similar to the line in question. What was actually measured was the number of times the subject exercised his free will or conformed to the wrong answer given by the confederates. Asch found that subjects went from stating the write answer > 99% of the time when by themselves to a startling to 63.2% when conspired against by confederates. Most interesting was when a supporting partner was introduced (a confederate who confidently answered correctly in spite of the majority) the subject’s percentage correct increased to 90.8%.
It is in our human nature and against our better judgment to coalesce in groups. We inherently want to be part of the pack and it is stressful to go against the grain. Our physical therapy education is rife with conceptual theories derived from a concoction of empirical observations that has not stood up to experimental evidence. Physical Therapy is SO much more than we ever learned (or are learning) in school. Our field is not exclusive in dividing itself into cults of beliefs, but the fact that we do should give anyone pause when considering the evidence of a purported theory (Rivett, 1999).
Current graduate education and post graduate education in pain and outpatient orthopedics seem to continue a wonderful legacy of offering a potpourri of various techniques without systematic investigations into why many treatments work anecdotally in the clinic but are uncorroborated with large effect sizes in clinical research (Mannion, Caporaso, Pulkovski, & Sprott, 2012), (Jull, Kenardy, Hendrikz, Cohen, & Sterling, 2013), (Hurwitz, 2011), (Bronfort et al., 2011), (Steiger, Wirth, de Bruin, & Mannion, 2012), (Menke, 2014). Much of the research is carried out with the end of justifying our field–demonstrating outcomes–and is less concerned with the why and the common mechanisms behind many forms of treatment. Casual inference would point a researcher to believe that the invariants that determine successful treatment probably have less to do with our CPT billing codes–coincidentally the most researched part of our profession–but other more general..ahem..nonspecific universal factors.
In order to combat the herd, reclaim your independence and see the world from a more objective standpoint you need to feel empowered–knowing that others are raising questions can be just the bit of dissent needed to get you on your way. In short you need to hack your PT education.
Our future generations are being educated in an era of unparalleled information. This information is becoming cheaper and cheaper all the time. No longer do I have to go to the card catalog to find a book in the library or copy a journal article by hand. We also have vast social networks that connect passionate clinicians from all over the globe that an eager learner can connect with. Neither do we have to wait for information to trickle down from up on high to figure out how to practice; we can go out there and get it. Hacking your education is going to be necessary so as long as your graduate education, your CIs, and your post professional clinical education ignore the inconvenient truth(s) staring them in the face (see the bibliography section).
How do we do this? Well I would like to put that question to the reader. If you’re a student, clinician, clinical instructor, or professor what are your thoughts on how to hack a PT education? Share your ideas here and I will post them to the blog.
Eric Kruger @Kintegrate
Bronfort, G., Maiers, M. J., Evans, R. L., Schulz, C. a, Bracha, Y., Svendsen, K. H., … Transfeldt, E. E. (2011). Supervised exercise, spinal manipulation, and home exercise for chronic low back pain: a randomized clinical trial. The Spine Journal : Official Journal of the North American Spine Society, 11(7), 585–98. doi:10.1016/j.spinee.2011.01.036
Hurwitz, E. L. (2011). Commentary: Exercise and spinal manipulative therapy for chronic low back pain: time to call for a moratorium on future randomized trials? The Spine Journal : Official Journal of the North American Spine Society, 11(7), 599–600. doi:10.1016/j.spinee.2011.04.021
Jull, G., Kenardy, J., Hendrikz, J., Cohen, M., & Sterling, M. (2013). Management of acute whiplash: a randomized controlled trial of multidisciplinary stratified treatments. Pain, 154(9), 1798–806. doi:10.1016/j.pain.2013.05.041
Mannion, a F., Caporaso, F., Pulkovski, N., & Sprott, H. (2012). Spine stabilisation exercises in the treatment of chronic low back pain: a good clinical outcome is not associated with improved abdominal muscle function. European Spine Journal : Official Publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 21(7), 1301–10. doi:10.1007/s00586-012-2155-9
Steiger, F., Wirth, B., de Bruin, E. D., & Mannion, a F. (2012). Is a positive clinical outcome after exercise therapy for chronic non-specific low back pain contingent upon a corresponding improvement in the targeted aspect(s) of performance? A systematic review. European Spine Journal : Official Publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 21(4), 575–98. doi:10.1007/s00586-011-2045-6
Categories: Critical Thinking