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Reconciliation: The 4th R? – Simon Smith

Part two of two… until the next two… from Simon Smith.

It is at this point in my blog I should make a confession. That is, that I am a lover, not a fighter. Past Chinese burns at school, my fighting career reads: fought 1 drawn 1. The bell went and Kevin Moore and myself backed down and went off to Maths. This doesn’t mean I can’t be confrontational, but it’s never my first thought.

I sat at #TheBigRs in Manchester and listened to Neil Langridge give a very reasoned argument for the utility of Manual Therapy. I then heard Adam Meakins give, what I took to be a well formed but very closed opinion. My initial thoughts on this were that this type of position stifles debate and puts up barriers, which I do not see as consistent  with my view on what the Big R’s movement is about. This is not me being anti-Meakins though. I totally get why voices like his are needed in starting debates and raising issues. His reach in deseminating info to clinicians is something most academics can only dream of!!

In this blog I wish to expand on how I feel we move forward as a profession. Moving forward as a BigR’s collective (maybe we could be a massive) is easy. We’re self selecting and are engaged. However I do not want to hear anymore about lazy physios or physios that have given up, voiced in such a way that they are seen to have a malicious intent.

My starting point when thinking about my profession is that I have never met a fellow physio who does not try to do their best for the person in front of them. In understanding how to change overall physio standards I believe we need to understand the journey our profession has been on.

Being a physio cutting his teeth with MSK patients in the late 90’s it was all about learning muscle imbalance, the reason people didn’t get better was because we hadn’t stabilised them. The Aussies came over with their fancy Deep Neck Flexor exercises and my inferiority complex grew as some people still didn’t get better.

This was for me, the  vanguard of EBP, studies showed  that this was important. I could see that there was a fair amount of extrapolation going on, but scientific enquiry never finishes, we could not wait for academia to tell us exactly what to do as I had a 10:30 patient who couldn’t wait. In service training was all ‘Journal Clubs’. We read about the efficacy of certain clinical tests or treatment regimes. Integration into practice was left to us. It was easy to see the evidence we were reading as not in the real world.

“Them academics should try coming and treating the people of Stoke (a little joke for anyone at the conference in Manchester – I’ve never worked in Stoke, but I hear it’s lovely.)” 

What were we saying here? We were saying that our ‘difficult’ patients didn’t fit that paradigm.

Luckily the Biopsychosocial Framework came along. We’re good at the bio, that’s sorted  so if we assess their levels of anxiety and, see that they are fear avoidant, and then see if they’re at work or not, we can understand them better. Suddenly, all the difficult patients went away, hoorah!! Oh…wait!

We have produced decades of physios that see the world through this viewpoint. We have done this. We cannot understand how people act without first understanding the context they made their decisions. Nobody thinks that there was something in the water in Germany in the 1930’s and 40’s that lead to a rise of fascism. Historians debate the rise of National Socialism ad infinitum. Let’s understand why our profession acts as it does.

We did not train free thinking physios throughout the decades, what we did do is have successive convulsions of guruism. Without appropriate context the current push for EBP can seem very similar to Messers McKenzie and Maitland. Hitting them with the EBP stick is just the same as they experienced when they got whacked by Kinetic Control, but at least Muscle Energy Techniques work, because they’re something you can believe in (sarcasm).

People become weary of false prophets. Some seek answers and some go with what they know and run with it. This does not make them lazy, it makes them a product of a failed system.

If you add into this that EPB and the cutting of NHS services is telling our front line physios what it cannot do, we have a current crop that is left with very little in their tool kit. This is not a route forward.

Throughout my career we have been putting too much emphasis on looking for answers to our ‘difficult’ patients in the wrong place. The answers will not come at the end of an RCT. This will tell us what treatments work, but it doesn’t tell us on who.

We should be looking at our patients. Patients tell us what their problems are, we should be listening to them. We should be like Amazon (but pay tax). Whatever the MSK issue, we can help. Not like a butcher, whatever the issue, the answer is meat.

I bring you back to my starting point. I’ve never met a physio who doesn’t want to do their best by the person in front of them. However I have met physios who do not know the harm they do, or have no other way of working. I reckon that if we hit these people with the Patient Experience stick, giving folk like Jolleta Belton a wider platform, and maybe give them some communication skills THEN we wouldn’t have ourselves a false prophet and we would have something to hang our EPB on.

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