Why you need to hack your PT education

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
Asch, S. (1955). Opinions and Social Pressure Exactly, 193(5), 31–35.
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
Menke, J. M. (2014). Do Manual Therapies Help Low Back Pain?: A Comparative Effectiveness Meta-Analysis. Spine. doi:10.1097/BRS.0000000000000230
Rivett, D. a. (1999). Editorial – Manual therapy cults. Manual Therapy, 4(3), 125–126. doi:10.1054/math.1999.0195
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

All Comments

  • Clinician here,
    Started as an aid doing the usual US, massage and E-stim.
    PT school, ‘ortho’ stuff didn’t make much sense (SIJ’s, facet dysfunctions, whatever), didn’t really fit into ‘neuro’ or ‘cardiopulmonary’ and figured I was screwed.
    PT clinical rotations, enjoyed the interaction, learned more science behind what we were doing, did a lot of manual therapy, but still some stuff didn’t make sense (why are you still having pain!?).
    Led me down the rabbit hole of pain neuroscience and I have been invigorated ever since, and question myself, you, her, him, everyone’s premise with relation to what best science can tell us (somasimple.com was very helpful in this regard).
    My thoughts on hacking the education are to open your mind fully, read the latest science (all these blogs and forums are very helpful in this regard), listen to other clinical experiences (the good, the bad and the ugly) and ignore the friggin protocol crap. Find your own frame of reference, challenge it, add to it, subtract from it, build on it. Read Bruce Lee quotes. Always keep the human patient in front of you in mind. Assess, treat, re-assess. No shame, no blame. Flow like water.
    Thanks for playing.

    Nicholas Marki, P.T. March 25, 2014 10:31 pm Reply
  • Hi Eric,
    Great post, I’ve definitely tried to ‘hack’ my physio education a few ways. Firstly Twitter provides a platform to talk to clinicians all over the world – I pulled all their knowledge and advice together to create a Reading List for myself and other student physios ( http://wp.me/P48Z0D-1t ). This hopefully set me off on the right track from the start.
    I also try to read a whole range of blogs (such as this one) which highlight what research and topics are currently relevant and often provide a great insight into how to appraise literature and apply it clinically.
    I would say I definitely benefited from doing a Sport & Exercise degree first which really encourage critical appraisal of literature and evidence and I have carried this forward into my physio training.
    Rory Twogood
    UK Physio Student

    rorytwogood March 26, 2014 8:39 am Reply
  • I think the first step in “hacking your PT education” is to not be afraid to questions things, actually question everything you’ve learned, become a skeptic. When I graduated PT school some things just did not make sense to me, but I rolled with it because it’s PT school, it must be accurate info. The patient’s 40 deg ROM improvement in one visit must be due to the mobilizations I performed to loosen up really, really dense tissue…right? What else could it be? Now I’m not bashing PT education, they taught me some great stuff, however looking back retrospectively PT Education seems to be missing the mark on a lot of subjects, mainly educating about pain. When I finished residency I had even more questions, and continue to question everything as I matriculate through fellowship with NxtGen Institute. I now question everything, which leads to more unknowingness, and more frustrations, however that’s ok.
    A second step is to be a non conformist, go where other PT’s aren’t, try new things. Many PT’s conform to the same treatment philosophies that have been around for years, ones we’re finding aren’t as accurate or spot on as we thought. Don’t be afraid to go upstream, try something different no matter the resistance (employers, coworkers, etc.) if research shows it will help. Chances are the resistance is due to not knowing or not understanding, use this as an opportunity to educate others. Unless it’s due to lazyness, then you’re just screwed.
    Last but not least, I agree with utilizing social media. There is so much good info out there via twitter, blogs (this blog, somasimple), and continuing ed opportunities (NxtGenInstitue.com). Just get out there and grab it, and utilize it in the clinic.
    That’s where I’d start

    Mark Powers March 27, 2014 12:13 pm Reply
  • Great post Eric and follow up commenters! My husband and I have been practicing for over 3 decades, and I have always believed in thinking “beyond the box”! Actually what box? There are always a multitude of different treatment techniques, approaches, etc. that we, as therapists, can try. As one comment said: We are professionals and not technicians. We should treat the patient as a whole human being, not a Left CVA or a R knee ACL recon. I will always love and respect this profession of ours, and this new gen of PTs has the entire globe at our cell phone fingertips. I just received an email from Turkey. We must take advantage of our global knowledge, use what treatment tools will benefit our patients the most, with what we are most skilled at, and complimenting our own professional mindset.
    And I believe we should emphasize Prevention in all of healthcare. Also, Stand like Mountain, Flow like Water (as other commenter stated).
    From Linda MenekenPT
    A hacker from day one in this great career and life in general

    Linda Meneken March 31, 2014 7:28 pm Reply
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  • First off, great post!
    2 things I do as a student.
    1. Bother the heck out of my professors to give me the why and if they can’t call them on it and challenge them to think about it.
    2. I spend my time on things that will benefit me as a clinician not on things that will give me the best grades. I wrote a post on this http://www.followmetodpt.com/philosophy-of-education/

    zduhammy November 22, 2014 11:24 am Reply
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