So it’s a week or so after ‘The Big R’s 2.0’ and I thought I would take some time to reflect on the event as a whole, as well as some further thoughts on my particular round table discussion.
To start with, I want to say a big thanks to Jack and the Physio Matters podcast team along with Connect for sponsoring. It was a very well organised event and it seemed a distinct move had been made away from shining the light on Connect, to shining the light more overtly the reason we were all there, sharing and developing idea’s! This has to be applauded as I felt it made for a much more productive, useful day.
The layout of the day was also different. The introduction of the expert panels, consisting of some of the best minds in the physio business, was brilliant. A panel of six was created for each of the first 2 ‘Big R’s’ on ‘Reasoning’ and ‘Responsibility’. Each panel member had 5 minutes to give their take on the topic followed by a 30-minute debate between panel members and a Q&A with the delegates after this, with each session totalling 90-mintues.
From my point of view, this led to some extremely productive conversation and reflective thinking. It also made me think of some of the points made by two of the panel members (Neil Langridge and Matt Lowe) in their recent blogs regarding communication. The interprofessional communication I encountered was always respectful whilst retaining the ability to challenge one and other. The panelists points were clear, well made and concise (to everyone’s surprise Jack’s 5 minutes was actually 5 minutes!).
It is here I want to start reflecting on some of the points made from each of these debates starting with ‘Reasoning’. I will apologies in advance for any points I make that I have misinterpreted!
There were a few points I want to pull out from this panel and the initial ones come from Jack Chew who kicked off the first 30 minutes. He drew on a couple of dichotomies that I have certainly found myself in at one point or another in the past along with other clinicians I have worked with. The first being the differences between logical and ideological reasoning. The former being what we should aim for and the latter being something we should avoid. He spoke of not putting the ends before the means and the promotion of critical thinking. In a clinical sense, it can be so easy to fall into an ideological reasoning process and almost assume a diagnosis or treatment plan because a patient at first glance seems to fit the same broad category of a previous patient or patients. We must strive to use a thorough logical reasoning process with every patient and treat every patient as a fresh case. Utilising these critical skills should be at the heart of our reasoning process. The second dichotomy was of that between radical empiricism and radical relativism. Jack articulated well the importance of falling into neither extreme while maintaining elements of both when reasoning the ideal treatment approach. He talked of a radical empiricist model one could justify reading horoscopes to patients if the outcomes were favourable. Whilst appreciating the individual in front of us, with all of their contextual and personal factors, we must also consider what the empirical evidence tell us about the best approaches to certain pathologies.
This lead nicely into two opposing points made by Brad Neal and Matt Lowe who (if anyone has encountered either before will know) sit just either side of the empirical vs relativist argument. Matt was clear that all individuals have moral worth and thus our moral reasoning needs to improve for patient care to be maximised. A quote that stuck out was that physiotherapy was firmly a ‘humanities profession’ in the sense that the humans we deal with on a daily basis must be central to our approach. I do agree with this point and is something I feel needs to improve at an undergraduate level. I do not understand why modules like motivational interviewing are not on every programme. The ability to display true empathy and elicit the right information from the people in front of us, is something I did not develop until after graduating and are things I continue to work on each day! Having a grounding in this at University would have been a real head start! (Apologies to any universities out there who do this, I am aware I am generalising!).
Brad also discussed adding something to all undergraduate programmes and is something I possibly agree with even more. The ability to properly appraise and understand research is something that should be the bedrock of clinical reasoning. To refer back to Jack’s point of empiricism underpinning out ability to reason well, this is not possible without the skills that Brad refers too. Assessing and questioning the external validity of research is something Brad felt is not done enough at present when reasoning. Having the ability to tell the difference between efficacy and the effectiveness of real world implications is essential when interpreting the data. When referring to Randomised control trials he also expressed the need not to just look at if something works but also why. For me this is why mixed methods research is becoming increasingly popular. Gaining the empirical data from the traditional RCT format along with embedded qualitative findings can be highly valuable when investigating the ‘why’.
The great thing about these panel discussions were the different perspectives each took on the topic itself. Moving away from the specifics of individual patient clinical reasoning which was outlined by Matt, Brad, Jack and Matt Wyatt of Connect; John Doyle and Naomi McVey took a strategic, bigger picture view of reasoning.
John spoke of the need to concentrate on the ‘big ticket items’ when it came to practicing what was important when reasoning the best way to develop a service strategy that can deliver the best patient care. He noted that quality can be measured as a combination of safety, effectiveness and experience, and evidence for our effectiveness to clinically reason well is sparse. If we really want to win the attention of commissioners then we need to start here. Along with frequent bursts of ‘measure it’ he noted that we have all been in situations where we have seen ‘bad reasoning get good outcomes and good reasoning get poor outcomes’, we need to know why this is. He left us with (a rather good) mnemonic for a process he uses when planning for strategic change:
I Intentions – What are the intentions of the change
M Messages – What messages are you looking to deliver?
E Evidence – What evidence is there that change is warranted?
A Audience – Who is the change aimed at?
N Negatives – What are the potential negative impacts of any change?
Overall, this was a very useful and productive 90 minutes that gave me a lot to think about moving forward. It has made me think more deeply about the need for strategic, as well as individual clinical reasoning processes. Processes that should always be underpinned with elements of empirical and relativist approaches
Andrew Cuff started off the first of the panel debate and he made a point that really resonated and challenged me. He talked of the responsibility in being transparent and honest, with ourselves, our patients and each other. It seems to me that there are a huge amount of INCREDIBLE physio’s on twitter who talk a really really good game. I do always wonder whether that translates into the clinic (I include myself in this too!) It is something we should constantly challenge ourselves to do; doing and saying what we profess to each other through, whatever medium, when we aren’t being watched!
This was followed by Lesley Holdworth who talked about our responsibility to acknowledge and upskill in wake of the 4th industrial revolution – digital technology. The way the world functions with an ever-growing population of digital natives makes the way in which we approach problems and service delivery fundamentally different. We must embrace this as a profession and have a responsibility to lead innovation in healthcare in that vein; it is a great opportunity we should not miss. I feel fortunate working for IPRS Health who have been at the forefront of this in the last 2 years with the use of app technology, visual triage, webinars and interactive self-help websites. I feel it can be a great benefit to our patients.
Neil Langridge was next up and I was surprised it took this long for one of the panel to make the point that our number one responsibility should be to the patient. ‘To listen and be empathetic’ were some of the comments made by Neil, which I could not agree more with. For me, this is where our responsibility starts as physiotherapists and is the ultimate aim for all physiotherapists. Whether you are a job in clinician, a researcher or involved in implementation of service delivery, all eyes should be pointed at maximising patient care. Neil went on to discuss that we also have a significant role to play in giving back responsibility to the patient. Empowerment, loosely defined by Neil as ‘removing care at the right time,’ is again for me an integral part of our role. We must always be working towards this and an end game. Promoting responsibility over reliance is top of my list!
This idea of empowerment of the patient was built upon by Mark Reid in somewhat of an unusually controversial point for him. Should the individuals within our society take more responsibility for their own health? The NHS takes this responsibility away from the individual, a little too well Mark was hasten to add which may be disincentivising for a person to maintain their own health. At a base level I agree with this statement but also acknowledge (as did Mark) that this is a very complicated issue with many barriers in the way of someone in achieving maximum health from a socioeconomic standpoint. Mark also talked about the responsibility of clinicians to maintain high professional standards with regular CPD. He unfortunately also pointed out that there are minimal incentives to do this at present and clinicians are often rewarded for ‘time served’ rather than clinical excellence. I couldn’t agree more with this statement and I feel it is something that public and private organisations need to address if clinical standards and patient care is to improve. We cannot continue to reward mediocrity.
Simon Smith was up next and he spoke of the responsibility and opportunity we have as a profession to seize the mantel of the leaders in MSK care for patients nationwide. With the first contact practitioner status becoming ever more established it puts us in prime place to do this. We need to shout from the rooftops about our skills, but this also requires us to be able to prove how effective we are. With sporadic data collection amongst public services and inconsistent data collection in the private sector and no central database, how can we prove on a large scale how truly effective we are? Is there a responsibility there for a governing body to co-ordinate data collection of outcomes across different services to allow us to become the leaders that so many of us believe we can be?
Last but no least was Heather Watson discussing our responsibility around work (now we are talking!) She was discussing the work of us as professionals and the work of our patients. Working in occupational health this is a topic I have a huge interest in and Heather has been a leading light for Physio’s in Occupational Health for a long time now! I was fortunate enough to work with Heather on an infographic for her talk prior to the event itself that I will talk about a bit more below.
Being unemployed is really bad for your health! Higher mortality rates, higher medication use and higher hospital admissions all occur in the unemployed. It serves society very well if we take a conscious responsibility to address our patient’s job role and current work status. Engaging people in returning to, or staying in work, has a huge economic benefit for society and a huge health benefit to the individual. Heather’s cycle of responsibility (see picture below) depicts how the employers and the
government have a responsibility to provide healthcare for an individual to return to work, but also that anyone is also free to go straight to a health care provider. Once a patient lands in our care we have a responsibility to engage them in meaningful activities that progress them towards returning to work.
All of the full live streams of the debates are available here for those that weren’t in attendance and want to hear it straight from the source:
I thoroughly enjoyed the panel debates and felt the format allowed for much more open and transparent discussion for all of those in attendance. It gave me a lot to think about moving forward regarding my own practice ad how we could possibly move forward as a profession.
Thanks to all of those on the panels for some great points made. Sorry for the length of the blog but I wanted to do it justice (which I still may have not even achieved!).
I plan on following up in the next week or so with thoughts from our round table discussion on ‘Reforming public messaging’.