The Advanced Practice MSK standards: It starts on day one.

As the public consultation on the advanced musculoskeletal standards is launched https://skillsforhealth.org.uk/have-your-say-on-the-musculoskeletal-advanced-practice-and-governance-framework/

I wanted to offer a narrative, primarily directed at students and less experienced practitioners. The reason to do this as one of the authors of the document is to really try to encourage the views from you, as you are the Advanced Practice and Consultant practitioners of tomorrow, and I will be retired and consulting YOU for my various MSK issues. Your views are vital, and just because this looks “advanced” and “special”, the reality is this should, if it is to be useful,  be part of your career aims, goals, values from day one for anyone with an interest in MSK, and not be seen as “special” at all.

So, within the document there are capabilities built around MSK practice and these have been mapped against the multi-professional framework for advanced clinical practice in England https://www.hee.nhs.uk/sites/default/files/documents/multi-professionalframeworkforadvancedclinicalpracticeinengland.pdf . So the MSK framework looks to operationalise the integrated 4 pillars into a bespoke model that reflects your day to day practice. But I thought it might be helpful for you to offer some reflections that are more general in how this frameworks underpins the characteristics of the modern MSK practitioner, and to do this I have highlighted some more general considerations that I hope when you read them may offer some direction of travel and give you the encouragement to get involved in the consultation, as you have advanced practice skills, characteristics and abilities already, perhaps you don’t realise it. This is not about experience, how many weekend courses someone has done or the number of webinars attended. If you can learn from experience and mistakes, and reflect well, you will rapidly build the “skills” as such that you need. This of course starts on day one.

I describe myself as a MSK generalist. I have worked in primary, community and secondary care, I see multi-body parts, I work in diagnostics and offer injections and support patients through rehabilitation from the older person, sedentary, sports and young. So, I don’t have a “specialism”, and in that sense the pointers below are I think the “specialisms” of advanced practice rather than saying I am a spine, shoulder, foot specialist. Therefore, if you have a look at these reflections below, you will probably see you do this yourself in some way, shape or form, and in fact it is you who should be commenting on the frameworks just as much as the “specialists”. The characteristics that make you a great student, newly qualified practitioner are exactly the same as a great Advanced clinician: the difference is the knowing, appreciation and the evidencing of those skills and putting them into practice with the benefit of some clinical experiences –which will inevitably will come, but you should recognise it starts from day one.

Pillars of Practice
  • MSK advanced practice is about rehabilitation.

Rehabilitation of individuals and the population you serve is a vital component not something as I was once told “you just do the final bits don’t you?” – it remains as integral to every interaction we have – it is THE intervention of choice, and comes in multiple formats. The “skills” (think C) of rehabilitation such as Communication, Compassion, Clinical reasoning, Common-sense and Core skills done really well can all be worked on from day one and are advanced when used skilfully. There is nothing fancy about printing a rehabilitation plan, but to bespoke one that is tailored, progressive and goal orientated is advanced, skilful and headline stuff. Throw in the reassurance of Confidence, Competence and Capability and you have an extremely valuable clinician.

  • Advanced practice is not about requesting things.

The advanced practice in this is the reasoning behind these choices, the interpretation of the findings, the communication of those findings and the reassurance you offer with respect to the relevance. It is about the action you take with the results, which requires knowledge but really importantly responsibility for that action. Taking responsibility is a characteristic you already have, just learn to develop it, and so don’t get hung up thinking, requesting an MRI is an advanced skill, it’s not, the accountability for actions is far more reflective of the level. You can develop these from day one.

  • Advanced practice is valuable across the whole system.

In all forms of practice you can influence. Primary to tertiary, community, cross boundary. Knowing how to influence the benefits of MSK practice to a wider population, through not only classically described MSK practice but also public health, emotional well-being and activating physical inactivity are hallmarks of advanced practice. You can do this from day one, it’s a really powerful hallmark of advanced care.

  • Advanced “hands on” skills are not a hallmark of advanced practice.

Good quality handling is needed in any form of practice, respiratory, neurology, frailty, MSK. It can inform, reassure, support. There is no magic to this in MSK, and the advanced MSK clinician needs another C here – Critical thinking. Applying any intervention needs to be evidence based, judicious, person centred and designed to inform, and lead to the realising of the potential. Whether its task, movement, of part of diagnostic reasoning, the Advanced bit of any handling is Communication and Clinical reasoning. Why are you doing something, what does it mean, does it offer evidence based value? These are the advanced skills of handling, not the handling per se. Of course skilful guidance is extremely valuable, watch a clinician gain a frail patient into standing on a ward can leave you thinking “how did they do that?!” –well, the key was not only how they used handling to reassure and guide but listen to HOW they did it, the words they used, the time they utilised with the patient and the understanding of the person before any of it started. These are advanced “skills” from day one which you can use.

  • Advanced practice is not about the title or the badge: leadership key.

Advanced practice uses a range of learning styles, leading styles and harbours great emotional intelligence. The advanced practice clinician wants to get the best out of others, and gets great value in developing others over and above their own needs or reputation. There was a time when for me when “extended scope practitioner” just seemed like a title that took a lot of space on a badge. When I gained these roles the badge was not important, the leadership was the step up and not the “scope” which is not reflective of the role. Now we use the term advanced practitioner rather than ESP, and high quality leadership, was so often missed in the early days of the “extended scope/big badge” development as a lot of time was taken up knowing a lot about orthopaedic surgery and perhaps leadership took a back seat. These leadership principles can begin from day one.

So, I hope you will engage in the consultation. I hope as students and what you might perceive as “less qualified” realise that you are VERY qualified to get involved and your view massively counts. I hope you can see that although we have to have capabilities to support safe practice, much of advanced practice is about behaviours, seeing the wider picture and being broad (not special!).

As one of the authors in the primary care road map and MSK standards I want to state some important acknowledgements. These standards will not be perfect, they will and must change with feedback, the advancement of science and practice and the development of the professions must influence future iterations. A good way to demonstrate your emerging clinical and leadership behaviours is to constructively influence change, so why not get involved in this?

Thanks for reading.

Dr Neil Langridge.

Advanced Practice Standards: What can we learn from what we have missed?

Dr Neil Langridge shares his thoughts on contemporary issues as we approach PhysioUK 2021 in a focussed symposium that he is involved with on Advanced Practice in the UK.

I thought I would write a few lines regarding some reflections I have had concerning the FCP RoadMap (Primary Care Advanced Practice) (Acknowledgements Tim Noblet, Jodie Smith, Amanda Hensman-Crook, Julia Taylor, Matt Low) and the draft Advanced MSK standards across the multi-professions which I have also been involved in.

The prompts for this blog started with a short social media discussion that began with something along the lines of “what is the point of the FCP RoadMap standards? It doesn’t acknowledge experience etc, it’s a waste of time”, and secondly my observations of how a standards document can create battles which at the outset of developing the standards I was naïve about, and subsequently have learnt a lot over that time, and I hope it’s worth sharing.

Advanced practice as we know is developing very quickly. In terms of the MSK Roadmap to FCP and AP in primary care based on agreed standards and the pending advanced MSK standards have moved at a relatively rapid rate. The reason I say “relatively” is because prior to this we essentially had 25 years of slower development in this field. We had new roles, new job descriptions, variable accountability, but as a profession, no national level standards that would be considered agreed and transferable. I gained 22 years ago what was then described as an ESP role with an interview and locally agreed competencies which were signed off locally. There was no bench-marking of this, no central way of “judging” whether this process was robust, effective, fair, but as a profession we did not have anything else, and so in terms of Governance services were duty bound to produce their own. Some excellent work grew from (Syme et al 2013 APPN Resource Manual for Extended Musculoskeletal Physiotherapy Roles) this but it was not always shared, tested, or importantly required and so we all worked in silos with similar name badges, with minimal reference points between us other than implicit levels of practice that held a commonality through the term ESP, and through local needs which were non-transferable or recognised outside the organisation.

Consultant Practice emerged over 20 years ago, very little happened in terms of how to develop these individuals, how to bring them together in a common framework that would allow for the introduction of the title into the health system with the due reference to their skills and expertise, other than.. yep, the job title. How did I get my Consultant post? – through an interview, I believed at that time of my appointment (9 years ago) there was an enormous gap in how we justified these titles without any governance structure or capabilities underpinning them other than what would be locally agreed. I really experienced that when meeting medical colleagues who asked “so how do you get being a Consultant AHP?” I always felt I was scrabbling for a credible answer.

The Multi-professional advanced practice framework broke that process and settled the debate about what is advanced practice and certainly recognising it as a level 7 (masters level practice) and subsequently the Consultant Framework at Level 8 (Doctoral)was a significant line in the sand for Physiotherapy and AHPs to be able to consider aligning to this and getting houses in order to really drive the professions out of these silos into a much more aligned group with transferable standards.

When I initially moved into Primary Care in 2015, as a Vanguard pilot, the first observation I made was this is new and different, it’s not the exactly same as my physiotherapy practice, clearly based on it and influenced by my advanced orthopaedic roles, but importantly it felt different. I thought therefore that this had to be an opportunity to stop complaining about a lack of reference standards and do something about it. We thankfully had the MSK Core Capabilities framework to work with though and there could be no better time to build an agreed reference that would support clinicians, colleagues and services whilst assuring patients by offering a standard to work towards in FCP (Masters level) and advanced practice in primary care. 

We needed to assess in practice the capabilities and competencies of these clinicians at masters’ level against these frameworks and this led to the MSK RoadMap in Primary Care which was built around capability, but also had the remit to bring together career opportunities and portfolio experiences into a common approach.

I knew there were local models already occurring for governance reasons, so we thought why not join them up into a national model? Many services were “operationalising” the Core Capabilities Framework, @Paulawoods5 (Paula Deacon), @simon_ingram13 (Simon Ingram) were good examples of how this was happening.  The plan was to develop something that linked the frameworks already out there, multi-professional, MSK core capabilities and subsequently the advanced MSK standards into document so that clinicians when completing one capability could cross reference that across different pathways. This was felt to be one of the most important components; ensure that advanced MSK and FCP practice capabilities could be mapped and over-lapped where this happened so enabling a framework that could if wanted, cover both pathways. This would reduce work, offer depth and a pathway that clinicians could follow. Of course, FCP and MSK Physiotherapy are aligned in so many ways, and both needed to be on a pathway to advanced and consultant practice if clinicians so desired this.

Support was offered from HEE and with other groups such as the MACP, APPN, SOMM and what is known as the MSK partnership as the building of this occurred. At the same time there was a real drive on standards and governance from MSKR  and I met kindred spirits in these groups and Connect Health @ashjamesphysio (Ash James) who were supportive throughout.

Finally, a primary care standard was agreed, the Advanced MSK standards are now pending and the Consultant Framework will need to have doctoral level MSK capabilities attached to it as we move forward. 

As I reflect on this I also return on the statement “it’s a waste of time”. My view still remains that if so, what is the alternative? I have seen these standards create quite differing reactions from organisations who from what I see and experience had agendas that were not either clear to me, or were in opposition to what we were trying to do. This is where much I my naivety became rapidly apparent. Incorporating standards – my narrow view was, “of course we should all want that, I bet patients would want that, and for career profession, and ultimately patient safety, it’s a must”. Then out of this somewhat blinkered thinking of mine, the drivers/barriers to this began to rear their heads.

Contracts, money, banding, staffing. I assumed that standards come first and then you work the rest around that, however it soon became clear that I may have mis-understood the relationships that occur when agendas are challenged. 

We ran I into the debates on how FCP will de-stabilise services, that we will lose clinicians, that achieving standards will take too long and quotas won’t be reached, which I understood entirely, I didn’t necessarily agree with but I had already written about this problem back some years ago (circa 2001):

 ….but as we move to managing populations and integrating care, the de-stabilisation argument does not in my opinion come from the clinical concept of FCP, but the logistics and operationalisation of the model itself.

This is now where I see the gaps across advanced and FCP practice. There is no value in identifying the gaps and then not offering an alternative and so thinking what next is the key question. The health system we have is cut up into “pockets” but being brought back into “systems” once again that ultimately can provide care at scale across all pathways. 

I feel there is a disconnect between application of standards, professional development of practice and system readiness to accommodate the rapid growth. What I fear is that whilst the profession rapidly works into these new spaces is that firstly patients are not informed with regards what these roles are, they are the advocates the profession should be working under. Secondly the system destabilisation suggestion is not FCP but the method in which it is being allowed to be provided. Individual models that lack integration due to contractual obligations and/or models that don’t promote the integration as a central requirement ultimately are providing contracts for providers at the expense of the pathway, and not really supporting the whole MSK system as much as it could.

This is the time I believe for MSK services to link together, halt being driven into competing contracts, and bring the best of each service (FCP, Interface, Rehab) under good quality leadership, that provides exciting, blended roles. If we have this the barriers I experienced as I saw the Primary Care standards emerge will be managed by joined up, co-produced leadership across a system. If we want to stop the belief that we are de-stabilising MSK services then join them up, economy of scale, re-invest the savings of this model into staffing, recruitment, retentions, and training and build the workforce around the standards and not the other way round.

This then has to be topped off with an agreed career framework for all MSK clinicians working to the same standards, with the same opportunities, whether its sports rehab, therapy, ex instructors, Physiotherapists, if they map to the standards, then they can do the job. Invest across the system and it will offer greater economic development, invest at scale into blended roles, invest in quality and standards, and I believe this ensures it is not waste of timestandards actually are how you stabilise the systemand create a model of growth that patients will benefit from.

So, if we have standards, we now have to create the environment for them to flourish in for the benefit of patient care. It is my belief as advanced practice and FCP emerges that the leadership now is vital, and this must not be at the expense of awarded contracts that do insist on integrating and effecting a wider change rather than just seeing a case load. System management/leadership, blended roles, MSK roles across all professions, integrated population management pathways, contracts that allow for growth and not suppresses it are some ideas that have crossed my mind of late, what do others think?

What I have learnt in my naivety is that without a system change that is symbiotic to the development of standards then patient education, higher education, professional groups will struggle to meet so many differing demands and the full benefits of these changes may struggle to be realised.

Dr Neil Langridge, APPN President, MACP Vice Chair and Education Lead (FMACP, FCSP)

It’s been 24 Years………………………………….!

The last time prior to this crisis I did anything close to being useful on a ward was 24 years ago. 4 weeks ago I was back with a ward team. I wanted to reflect and share some thoughts as it might help a little with the conversations that are already happening around rehabilitation, silos of practice, the future, patient cohorts and Physiotherapy in general.
 
When I turned up to the ward I was assigned to, I have to say I was nervous, thinking ”I am so out of date!” However, good support, a drag out of the memory bank and some common sense and I made a start. Quite quickly, in the days following, the ward was 90% COVID-19 +ve and although this changes your thinking, it didn’t detract from the job in hand.
 
What I quickly began to see were that patients in these scenarios, the frail, fractured hips, complex multi-morbidity and COVID-19 symptoms, needed to be approached with the model of what some may consider basic function: sit and reach, turn in bed, sit to stand and reverse, standing safely, weight transference, walking with and without support. The clinical reasoning really underpinned building these “basic” life functions into a fatigue resistant, safe and successful model but, most importantly, in a bespoke way towards their own social and medical needs. What I quickly realised; the assumed “basics” are complex.
 
Using ADL (activity of daily living) equipment with grounded clinical reasoning behind such choices, understanding the home situation and the context of the patients’ lives were vital in working towards the “basic” goals. Although these “basic” functional tasks are static in someways, the way they are approached from a therapist perspective is complex, due to the fact that they really are so person/life/home/socially centred. The patients’ perception of themselves and their situation leading the narrative around what might be possible is a communication challenge, and one that had to be undertaken sensitively at all times.
I reflected this reasoning experience against my own practice. Firstly, it really emphasised the over complexity that MSK practice may make on a number of presentations that are seen within the general population. The close scrutiny of identifying muscular imbalances, “weakness”, inhibition, “dysfunction” have been challenged of late as not being a valid, reliable observation or even an entity. Although, I am sure there is a debate to be had here, what is not, in my mind, is the validity of a patient not being able to achieve life functions. So, I once again had a really good rebalance of getting to the root need of what might be a successful outcome for a patient before embarking on anything progressive.  Basic loss of function and the mechanisms around that achievement underpin the complexity of reasoning. Multiple causes, medical, social, emotional, biochemical, pathological in multiple domains and relationships lead to the observations we see. As we try to “analyse” this, much of it is beyond what perhaps is possible, but what we can do is look to resolve a persons clear lack of capacity in a simple but broad way using multiple methods as appropriate.

 

This requires looking outside of our normal MSK pathways of practice as well as utilising the grounded skills we learned as new graduates as part of our early rotations and wider experiences. One problem is that using a linear model of practice fails in the multi-morbidity model of population healthcare. As part of my work in First Contact Practice I cited system knowledge as a key element of requirement needed in primary care, and this was not only biological systems but health systems as well, including the knowledge of how the system offers care in the widest sense to serve our patients as effectively as possible.
Screenshot 2020-04-24 at 20.29.20
So, to my second point of reflection and the thorny subject of the Bio-Psychosocial approach and all its interpretations. My experience made me really think about the word social” in the context of MSK and also from the ward/community rehabilitation context. Many times early in my career, I tried to understand MSK patients’ social elements as sports, interests, work, hobbies etc. then as my knowledge and experience developed, I sought to understand the person perspective, values, beliefs based on their lives, interactions, culture, expectations and this proved valuable and much has been cited around these constructs. But in the context of ward to community rehab, I realised that the word “social” also links to the care sector, and this was an area I knew very little, if nothing about.
How the care sector operates and works, the pathways, the potential support available were all new processes that I had not taken into account at really any level other than a low level of understanding from working in primary care. This network is VITAL in the future planning for these patients, and although I was OK (just) on the wards it was in this area I was of little benefit.
Therefore, opening up the word Social in the BPS model for me now needs to include a knowledge base around health AND SOCIAL CARE. I wonder how many of my MSK colleagues can truthfully say they know the local social care network well enough to give good advice but also link into really widening the support systems that patients will need to attain the “basics”. So in this context attaining the Basics is Complex. If anything I am now consciously incompetent in this area which is a move forward from where I was previously.
 
We might be great in MSK at giving a range of progressive knee and shoulder exercises, but contextually, is this the rehab that meets the patient needs or are our heads slightly in the sand here in the current climate? Is exercise on its own really enough? If we are working much of our practice in a digital way, then let’s use this opportunity to offer the widest health and social support we can. I believe that the broad skills of our profession are ideally suited here as our community colleagues can provide huge value and support in determining the development of practice. Let’s really drive down the barriers and get integrated where we can, not just an MSK pathway in a linear way, but broadly across the health and social care sectors.
 
I know that there have been challenges where physiotherapists are accused of lacking exercise prescription skills within certain cohorts of patients. I would now start to argue that if this is so we can improve that very easily, but where we can really have a significant impact is around supporting the needs of the population suffering in this crisis. Perhaps, at this moment, we need to judge that the low level MSK aches and pains that we have seen in the past is just not a priority.
 
My third point therefore is around silos of practice. Not in MSK as such, but in truly integrated care for patients in these situations and in this crisis. Is it time to reconsider how MSK practice in the NHS is really utilised and what skills in the future are going to be important for the populations we serve? My MSK team have been amazing in redeploying (as many others have) across frailty, community services and ward support. The learning after this will be so rich, we must take this opportunity forwards into the future.
There is much learning to be had, but to start that, questions need to be posed. These will inevitably be tough questions around using resources wisely. So, is MSK an independent area of practice when it comes to rehab or should we be better at using our broad skills to approach MSK, frailty, pulmonary rehab, community enablement, social care referrals in one hit? Time to stop moving patients about and perhaps reconsider rehabilitation in its broadest sense possible? Where can really impact the NHS Long Term Plan? We have directors of Nursing and AHPs leading the professional line, we have Medical Directors as well. There is no better time to consider the need for Directors of Rehabilitation that have a focus in community, public health and rehabilitation across all domains?
Screenshot 2020-04-24 at 20.30.30
So, lastly what is expertise going to look like in MSK in the future as a result of what is happening right now? I don’t know, but my experience so far would suggest that we need to serve the population right now and in the immediate future. I am less confident that we need an in-depth knowledge of the rotator cuff, transversus abdominus, or best surgical approaches for traumatic knee injuries. In my opinion, we need expertise in multi-morbidity rehabilitation, with a focus on MSK, but integrated as part of “life function rehabilitation” that sits alongside an improved knowledge of the “social” element of care at its broadest and supportive context.
Defining MSK expertise differently from knowing all about the possible surgical options and high performance level/elite principles as opposed to knowing more about social care options may not look quite so jazzy and expert, but right now it’s a whole lot more useful to the folk that really need our help.
 
Can we ready ourselves for this? It can only make MSK practice more valuable to the population we serve if we do embrace this knowledge and perspective.
 
How we will understand this will be an iterative process, and it will require commissioners to think differently, STPs to work far more rapidly and the profession to see MSK Physiotherapy as integrated and not separate from our ward and community colleagues.
image
It has been humbling to see the work, contributions and support our profession has so far offered, but perhaps there is even more to come.
 
Thanks to all!
Neil Langridge
Consultant MSK Physiotherapist

Reflections on Knowledge and engagement with the Other

I feel very lucky and privileged to be a Physiotherapist. Physiotherapy, a profession that encompasses many dimensions such as clinical, educational, leadership, consultancy and research but most importantly, as a group of responsible people who engage and supports Others.  It is with this in mind, at this most challenging time, that I reflect on my journey with my profession and how I value others.

I was very fortunate to meet Dr Filip Maric amongst a number of inspiring people including Joost van Wijchen, Laura Rathbone, Els Lamers, Ann Gates and Vincent Bastiaans at HAN University as part of an International week.  It was a wonderful visit that both stimulated and challenged me.  During many conversations, I was struck in particular with Filip’s area of interest of fundamental ethics, particularly from the viewpoint of Emmanuel Levinas and I would like to thank Filip for introducing me to this.

The ever-growing fountains of knowledge:

Physiotherapy, as a profession, has grown in its wealth of knowledge with an ever-expanding research base.  An area of interest of mine is how to consider this wealth of knowledge and apply it, in the best way, for the individual person or group of people.  Most of my focus is usually on individuals due to the nature of my job but I recognise that population health is of the utmost importance.  For the purposes of this post, I would like to focus on the care of individuals.

The field of philosophy examines the assumptions, foundations, and implications of science, as well as the manner in which it progressively explains phenomena and predicts occurrences.  I believe now, perhaps more than ever, that science and the humanities are both of equal importance within the context of growing knowledge and technological advancement.  Kerry, Maddocks and Mumford (2008) made a very clear point on this over a decade ago.

How might we understand knowledge and unpack it?

I often refer to Aristotle who describes knowledge as episteme (knowledge as fact), techne (knowledge as craftsmanship) and phronesis (knowledge as wisdom; to do the right thing at the right time, in the right context).  This can be unpacked further but it is clear that knowledge that is viewed in this way is complex and dynamic phenomenon.

If we look at knowledge as facts, it could be seen from the viewpoint of science.  Science attempts to discern objective, concrete and universal knowledge, often through repeatable and measurable ways through the use of our senses.  For science to be taken seriously, it has to rigorously test hypotheses, often through failure, in order to make advancement.  However, the scientific lens may not unearth all of the areas that Aristotle refers to and it may assume that these universal laws are applicable in every context.  This philosophical bias (Andersen, Anjum and Rocca, 2019) may, for good reason, emphasise carefully controlled studies over other methods to minimise contextual or confounding factors in order to establish a truth without bias but in doing this, possibly risk missing the very elements that may be of importance (Kerry, 2017).

Knowledge that is seen as craftsmanship or wisdom, by its very nature, is inherently value laden and embedded within a social context.  As such, knowledge does not exist in its own vacuum and therefore, is not complete without a way in which it is applied in the real social world.  In Physiotherapy practice, it makes sense to me that the ethical position on how we apply this knowledge is of prime importance.  The judicious use of knowledge requires the application of its multiple sources to be grounded within an ethical framework in which it is delivered.  Tonelli (2010) makes the compelling case that clinical research, pathophysiologic rationale and clinical experience are all required to make sound judgement in a casuistic way for the individual case.  This multi-dimensional perspective of understanding knowledge, amongst many reasons, may be why knowledge translation is challenging.  Added to this, the consequences of certain philosophical biases that are incorporated into practice underscore the ethical nature of Physiotherapy practice, thus calling forth the need for a deeper understanding of human beings embedded within their socio-cultural contexts within the complexities of health care.

To summarise, I believe that knowledge is complex, dynamic and context sensitive.  Therefore, a number of viewpoints or lenses are useful in order to make sense and apply this knowledge.  Knowledge from science and the humanities are both important in order to apply it in the real world.  The application of this knowledge, therefore, must be grounded within an ethical framework that is coherent within its setting.  In this case, within Physiotherapy, I argue for a humanistic framework which leads us to a philosophical perspective of Emmanual Levinas and the fundamental ethics surrounding Others.

Levinas and the Other:

Filip Maric and Dave Nicholls wrote a paper ‘The fundamental violence of Physiotherapy: Emmanuel Levinas’s critique of ontology and its implications for Physiotherapy theory and practice’.  The paper briefly introduces the background of Emmanual Levinas of which I will summarise below.

Levinas was born in 1906 in the Jewish community of Russian-occupied Kovno (now Kaunas, Lithuania).  He went on to study philosophy in Strasbourg where he read classical philosophical works from Plato and Other Greek philosophers through to Descartes, but also modern philosophy.  Subsequently, Levinas studied under the famous phenomenologists Edmund Husserl and Martin Heidegger, who were significantly influential in the development of his future method and thought.  The influential tensions that Levinas experienced during the Second World War alongside Heidegger’s affiliation with the Nazi party strengthened his insight towards an alternative fundamental ethical way of being that contrasted with the phenomenological focus on the self.

Much broader, Levinas felt that much of Western philosophy tended to subvert the ethical relation to the other by placing persons within the unifying system of ontology (the nature of being), hence denying persons their right to be themselves or their otherness.  The inherent tendency of a culture based in a philosophy that seeks to overtake a person’s otherness into the same as themselves is one of power, control, oppression and even tyranny.  Levinas makes a phenomenological claim that an ethical relationship, which is founded upon respect for the other’s radical alterity (or difference), exists prior to the ontological relationship, which is based on knowledge and comprehension of the other.

Put in another way, one’s relation to the other is the foundation of human knowing, not the other way around.

When I encounter someone else, I experience a difference between the other and myself. This initial difference is the first moment in ethics, in the acknowledgement of another who obligates me. The foundational nature of the ethical relationship is one that may be neglected in Western philosophy and its branches. The influential work of Heidegger, for example, treats ethics as secondary to ontology (the nature of being) and epistemology (the nature of knowledge).  Levinas suggests that it is the ethical perspective, in the experience of the other, that should be the norm, and that this creates the standard to which other Western philosophical perspectives are seen relative to.

“Indeed, the objectifying thematization inherent to the Western logos as ontology does not do justice to the way in which the Other exists. The only adequate response to the face is my being devoted to the Other. If I reduce the Other to an interesting topic for my observation or reflection, I am blind to the claim that is constitutive of the Other’s coming to the fore.” (Peperzak, 1997, p. 34)

Simply put, the implicit use of objectification that is dominant in Western philosophical reasoning does not do justice to others.  Rather, in Western philosophy, if we attempt to reduce others to our observations or reflections of ones-self then we are at risk of causing potential harm to others.

Emmanuel_Levinas

What implications might this have for Physiotherapy?

Although I have not read around a large amount of Levinas’ work that would place me anywhere near as an expert, the reading that I have done has resonated.  Levinas’ work calls forward the need to embrace diversity, cultural and social differences.  It engenders a mind-set change to hesitate and consider others first and foremost.

In clinical practice this elevates communication and interpersonal skills as a priority because it is through our embodied way of understanding others that we seek to appreciate and comprehend through sense-making, on an equal footing, with others.  We, as clinicians may have knowledge of the body, of physiology, of anatomy or whatever, but first and foremost we are people making sense of each other with the acknowledgement that, in our difference, we are both human beings with different sources of knowledge and experiences.  In all cases, my patients are far wiser than I am, in many ways, but certainly in regard to themselves.  This nurtures a sense of epistemic humility, for example, I could have a huge amount of knowledge and understanding around the latest randomised controlled trials, systematic reviews, narrative review and qualitative papers surrounding a condition like low back pain, but unless I am able to engage and understand others and placing themselves first within the clinical encounter, the sense-making process of each other will be lost.  The inter-subjectivity, or sense making process, using body communication, language and insight to the other uplifts the therapeutic encounter.  A genuine curiousness of the other places them truly at the centre of comprehension that comes before all considerations of being or knowledge of the condition that the other person presents with.   Carl Rogers, the American Psychologist, embodies this perspective in his book, ‘On becoming a person’, wonderfully:

“…I find that the more acceptance and liking I feel toward this individual, the more I will be creating a relationship which he can use.  By acceptance I mean a warm regard for him as a person of unconditional self-worth-of value no matter what his condition, his behaviour, or his feelings.  It means a respect and liking for him as a separate person, a willingness for him to possess his own feelings in his own way.  It means an acceptance of and regard for his attitudes of the moment, no matter how negative or positive, no matter how much they may contradict other attitudes he has held in the past.  This acceptance of each fluctuating aspect of this other person makes it for him a relationship of warmth and safety, and the safety of being led and prized as a person seems a highly important element in a helping relationship.” (Rogers, 1961, p. 85)

Levinas and the face to face encounter

Levinas felt that the human face was of fundamental significance in encountering others.  The face is not considered as a physical or aesthetic object.  Rather, the first, usual unreflective encounter with the face, is as the living presence of another person and, therefore, as something experienced socially and ethically.  The face looks towards others, which both at the same time overwhelms and resists the existential experience of the human encounter. If one refuses the existence of the another’s face, it causes an overflowing experience that calls to the other in a fundamentally moral way.

Levinas insists that science, technology and other theoretical systems of knowledge cannot function independently.  Human existence does not form the basis of knowing in and of itself. Rather, ‘‘…it is the epiphany of the Other’s face and speech rupturing the homogeneity of my universe and breaking its totality’’ (Peperzak, 1997, p. 12).

Modern technology, however, has allowed novel forms of interaction that have permitted clinicians to see others at distance.  During the current Covid-19 crisis, the use of video consultations has transformed the usual clinical encounter.  By seeing the other, in their own environment and communicating as if one where with them has been a revelation.  Those, like myself, now find the telephonic clinical encounter distancing, devoid and stale in comparison.  One can truly see that the healthcare encounter has forever been changed as a result.  The new telehealth system of care will bring both excitement and scepticism resulting in both revolution and disruption. Only time will tell how the future landscape of Physiotherapy care will end up.  Either way, how the profession evolves through considered conversation with others both within and outside of Physiotherapy will determine its own future success.  Educational institutes will have to adapt as well, once again, highlighting the importance of person-centred communication and ethical considerations causing us to hesitate on our own traditional practice and hubris.

The recent months have indeed caused me to seriously reflect on the Physiotherapy profession and perhaps, if you have managed to get this far, I hope this blog has created a space for you to reflect.  Once again, I would like to thank everyone that attended the HAN International learning week that triggered my thoughts.  If there was any time to consider others, I think the time is now. Please, continue to be kind to yourself and more importantly, others.

 

References

Kerry R, Maddocks M & Mumford S (2008) Philosophy of science and physiotherapy: An insight into practice. Physiotherapy Theory and Practice. 24:6, 397-407.

Laplane et al (2019) Why science needs Philosophy. PNAS 116 (10) 3948–3952.

Andersen, Anjum and Rocca (2019) Philosophy of Biology: Philosophical bias is the one bias that science cannot avoid. eLife; 8: e44929.

Kerry, R (2017) Expanding our perspectives on research in musculoskeletal science and practice. Musculoskeletal Science and Practice. 32. 10.1016/j.msksp.2017.10.004.

Tonelli, M.R. (2010), The challenge of evidence in clinical medicine. Journal of Evaluation in Clinical Practice. 16: 384-389.

Maric F and Nichollls D (2019) The fundamental violence of physiotherapy: Emmanuel Levinas’s critique of ontology and its implications for physiotherapy theory and practice. Open Physio Journal.

Peperzak, A (1997) Beyond – The Philosophy of Emmanuel Levinas. Illinois: Northwestern University Press.

Rogers C (1961) On Becoming a Person: A Therapist’s View of Psychotherapy. Boston: Houghton Mifflin.

Motivations and Change: The Coaching Physiotherapist

This blog has emerged from a range of sources and an interest in how physiotherapists can utilise coaching skills into patient care.  It also considers how this can then develop into day to day practice with teams and the wider health-care community.

Debates surrounding the “Hate exercise, Love activity” campaign driven by the CSP, as well as the concept of exercising through pain and around the theoretical proposals of “windows of opportunity” have also made us consider the links between coaching, motivation and the other issues surrounding these discussions.

Motivation-sign-with-a-beautiful-day

This discussion stems from an interest in “self-determination theory” (SDT).  SDT can be traced to humanistic psychology that emphasises an individual’s effort toward self-actualisation, which is the point where the realisation of a persons potential transpires. It is formed via the premise that as long as the basic psychological needs of an individual are met then a natural “growth” will occur.  SDT also relates to how people perceive their locus or control, which is the extent to which an individual views their own behaviour, perceived by internal factors (interests, values and identities), is in relation to external factors such as other people’s demands and regulation through the environment.

self-growth

As clinicians who wish to help our patients, we are in a constant flux with respect to helping an individual move towards self-actualisation.  SDT theory argues that as humans we require three basic psychological needs to be met; autonomy, competence and relatedness  and when these needs are satisfied, then self-regulation creates a sense of well-being and engagement toward their goals.

Self-Determination-Theory-Visual_1

Autonomy can be described as being in control, competence  is the need to be effective and relatedness  is the need to feel valued and connected with others.  It is also suggested that if self-regulation is not achieved then individuals may develop patterns of behaviour that offer short-term benefit but may not realise their long term goals or achievements.  These patterns of behaviour may manifest through feelings of fear, guilt or through the pursuit of an external reward.

self-determination-theory

In physiotherapy we may have to be aware of unwittingly developing these feelings in our patients, such examples may include:


“You must do your exercises to help you, if you don’t, how can you ever expect to get better!”Fear

“It is your responsibility to do these exercises! If you don’t then we cannot help you”Guilt

“If you do these exercises, we can show you have tried, then we can justify asking for a scan, because we have moved through the right process”External Reward


So, how does this relate to many of the discussions around exercise or activity, having a “window of opportunity”, or pushing into pain?

Importantly (Gagne and Deci 2005) & (Spence and Oades 2011) speak of a vital fourth motivation, integrated motivation, where the individual experiences fun and enjoyment from a goal that was extrinsically set.

These concepts, we propose, link to the exercise prescription we offer patients. It suggests that the first three motivations (fear, guilt, external reward) will not lead to the three required; the need for autonomy, competence and relatedness and therefore will not lead to internal motivation.  An integrated approach, i.e. finding what the individual enjoys (internal reward) and make it relatable to their goals, and then motivation led by the individual is far more likely to happen.

Screenshot 2019-08-31 at 22.19.40

So, asking a patient to stand in a room on their own, repeatedly doing a movement over and over again, experiencing pain based upon the premise that it may help, could be conflicted.  The reason that it could be conflicted is that on the one hand, the movements may build power, strength, endurance, flexibility, however on the other, unless it leads to a feeling of control, effectiveness and connecting to others then the chances of the physiological changes observed in studies having any long term benefit is compromised. Of course, if the exercise can be experienced to offer these three needs, irrespective of the pain experienced, and manifest in a sense of reward, then the result is likely to be more successful.  So, the context, meaning and relevance of the exercise must be acknowledged and accepted, and of course it might be a starting point, so we are not suggesting that individual exercise plans are wrong, far from it, rather what we are saying is that they need to meet the psychological needs as well as physiological aims.

Therefore, when developing an exercise programme, the activity and its environment as well as the motivation and choice for the individual will need to be taken into account in order to meet these psychological needs.  This may improve compliance and become an integrated part of life, rather than be regarded as a treatment.  This is far more likely to create a sense of self-actualisation and reach a person’s full potential.

So perhaps, the “hate exercise, love activity” concept is really just a real world self-determination theory model that allows therapists to be wider and more person-centred in their exercise prescription.  The development of social prescribing parallels this and we may see a shift from gyms, and weights to parks, bikes, and rambling (for some of course), as self-actualisation can absolutely come from the gym and heavy exercise, but in the right group and social context.

The term “window of opportunity” is so often linked to hands-on treatment, and is actually in our opinion, a far wider and deeper concept.  It is when changes in behaviours or beliefs lead to the individual having the support to meet their psychological needs.  It is when a humanistic coaching approach opens up the opportunity for change through the clinician-patient relationship.  The window is never opened unless a humanistic coaching process is initiated, and so irrespective of our treatments and their proposed effects, it must be built upon a coached approach to the care episode.

Developing the environment for change requires taking others perspectives into account, acknowledging their feelings, minimising pressure and offering choice that make sense to the patient within their community.  There is no reason why a short term pain relieving intervention offered in the appropriate context should not help this, however, we must remember that, although these treatment offer pain reduction, it is the appropriate psychological responses surrounding this that offer the chance for change. The short term period of pain relief is described as neuro-modulationand it is suggests that one’s self is separate from our physiological being, and of course that is not the case, so perhaps we offer the opportunity for people to modulate themselves, alter the pain experience, and affect beliefs; we therefore, don’t specifically modulate nervous systems!

Good quality physiotherapy offers autonomy, and as such opens a psychological window that offers this opportunity, and as the “window” remains open the growth towards competence can begin.  With the development of competence (this could be confidence in a movement, increased integration of activity, improved engagement in tasks) the key is to then create the social support that offers the individual fun, enjoyment and the opportunity to feel valued (this could be increased social interaction, returning to work, or perhaps joining a club).

So, in summary we propose that some patients refer to activity as part of their normal life and we can see why, conceptually and psychologically, linking recovery to activity and not a pre-determined view of exercise can build upon SDT theory.  When patients are active, then they are of course exercising, but they are not limited by external goals such as repetitions, time and weight, they are influenced by internal integration such as enjoyment, interaction and fun and this perhaps is why the campaign developed this way.

External limited exercise prescription is a vital approach to recovery for numerous patients but perhaps it should be underpinned by SDT theory which may lead to the development of improved personalised exercise plans and improved outcomes.

Many of these concepts can be applied in our working environments and from coaching managers, athletes and staff we can utilise similar concepts across environments.

Neil will be talking about this and more at PhysioUK19 so if you are going, we hope to see you there!

 

Neil Langridge, NHS Consultant Physiotherapist

Matthew Low, NHS Consultant Physiotherapist