communication

Managing Complexity In Musculoskeletal Conditions: Reflections From A Physiotherapist

I was fortunate enough to have been invited by Physio First to contribute to their journal ‘In Touch’ and I chose to write about managing complexity with the different types of ‘evidence’ that we deal with in a healthcare setting.

This is an area of interest for me and I still grapple with many areas of clinical practice.  These include balancing the normative and narrative examination, evaluating and weighting the evidence appropriately for the person seeking care in front of me and also reconciling and communicating the reasoning process within a person centred framework.  Clearly, this is work in progress and I hope this reflective piece demonstrates a movement in this direction.

I hope this paper is informative and useful in that it shares some of my deliberations, thoughts and perspectives in clinical care.

Many thanks to Physio First http://www.physiofirst.org.uk/ for giving me the opportunity to share this.

Managing complexity in MSK conditions In Touch Article

Fusion of perspectives

Please feel free to make comments and feedback your thoughts and views below.

 

 

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What can Plato’s Allegory of the Cave tell us about knowledge translation?

The allegory of the cave is a famous passage in the history of philosophy. It is a short excerpt from the beginning of Plato’s book, The Republic (1). There are a number of different interpretations of the allegory, but the one that I would like to present is within the context of education, specifically knowledge translation and the content, style and manner of its delivery. I would like to conclude with relating this to how we, as health care professionals, present knowledge within a professional dialogue.

Plato’s Cave

Imagine a group of prisoners who have been chained since they were children in an underground cave. Their hands, feet, and necks are chained so that they are unable to move. All they can see in front of them, for their entire lives, is the back wall of the cave.

Plato's Cave

Some way off, behind and higher up, a fire is burning, and between the fire and the prisoners above them runs a road, in front of which a curtain wall has been built, like a screen at puppet shows between the operators and their audience, above which they show their puppets”(1)

The-Allegory-of-the-Cave-by-Plato

So, there are people who are passing by the walkway, carrying objects made of stone, behind a curtain-wall, and they make sounds to go along with the objects. These objects are projected onto the back wall of the cave for the prisoners to see. The prisoners talk and discuss these projections and come up with names for them; they are interpreting the view of the world, as it is intelligible to them. It is almost as though the prisoners are watching a puppet show for their entire lives. This is what the prisoners think is real because this is all they have ever experienced; reality for them is an interpretive existence viewing the world as a type of puppet show on the wall of a cave, created by shadows of objects and figures. In a way, this is not dissimilar to our understanding of evidence-based practice, we have a version of truth interpreted through the views of others and we, as clinicians, have to make sense of it and also interpret it ourselves, for others.

Research evidence is still testimony of evidence in that we must trust the rigor, process and presentation of it. We may not have completed and interpreted the research ourselves and therefore careful scrutiny through peer review and individual critical analysis is of utmost importance. The prisoners also co-construct the world between them, sharing a dialogue surrounding the images cast in front of them. As physiotherapists, we also share dialogue surrounding professional practice, or own values and preferences as well as what we think “works” for patients from many different perspectives. Back to the story:

One of the prisoners has help and breaks free from his chains. Then he is forced to turn around and look at the fire. The light of the fire hurts his eyes and makes him immediately want to turn back around and

“retreat to the things which he could see properly, which he would think really clearer than the things being shown him.”(2)

In other words, the prisoner initially finds the light (representing the truth, an alternative truth or reality) very challenging to see and so does not want to pursue it. It would be easier to look away back into the shadows.

However, after his eyes adjust to the firelight, reluctantly and with great difficulty he is forced to progress out of the cave and into the sunlight, which is a painful process. This represents a journey of greater understanding and the challenges that come with it. We have all found the journey of gaining knowledge, interpreting it and applying it a challenge in one way or another in our personal and professional lives. The story continues:

So the prisoner progressed past the realm of the firelight, and now into the realm of sunlight. The first thing he would find easiest to look at is the shadows, and then reflections of men and objects in the water, and then finally the prisoner is able to look at the sun itself which he realises is the source of the reflections. For me, this represents the way in which knowledge can be delivered may be best understood within the context of previous experience including socially acceptable constructs. This allows connections to be made between our prior views of the world and the formation of new information or knowledge that we have perceived and interpreted. When these connections relate to prior experience or conceptualised within familiar paradigms, they become easier to digest, absorb and interpret successfully. Simply being told new information in an abstract way or delivered in a style and manner that is out of keeping of social norms may not be a successful strategy.

Screen Shot 2018-04-08 at 15.24.47

Copied from @michael_rowe twitter feed 28th March 2018

Back to the escapee: When the prisoner finally looks at the sun he sees the world and everything surrounding him and begins to feel sorry for his fellow prisoner’s who are still stuck in the cave. So, he goes back into the cave and tries to tell his fellow prisoners the truth outside. But the prisoners think that he is dangerous because the information that he tells them is so abstract and opposed to what they know. The prisoners choose not to be free because they are comfortable in their own world of ignorance, and they are hostile to people who want to give them an alternative view of the world. My interpretation is that there is a natural tendency to resist certain forms of knowledge, particularly if the subject area has been around for a while. Ignorance is bliss! The prisoner that escaped from the cave questioned all his beliefs as he experienced a change in his view of the world rather than just being told an alternative. Being a passive observer, as the prisoners who wish to stay in the cave, would generally prefer to keep things as they are. This says something to me about the experience of knowledge translation; the impact will depend on a number of variables that effect an individual’s perception.

According to Plato, education is seeing things differently. Therefore, as our conception of truth changes, so will our engagement with education. He believed that we all have the capacity to learn but not everyone has the desire to learn; desire and resistance are important in education because we have to be willing to learn alternative paradigms even though it may be hard to accept at times. Creating the desire to learn through the style and manner of motivational interviewing (3) makes even more sense here, particularly with regards to the ‘righting reflex’. The ‘righting reflex’ is the natural tendency that well-intended people have to fix what seems wrong or incorrect and to set them on to the ‘proper’ course. This often results in telling people what to do in a very directive manner that frequently ends up putting people off or stifling change rather than steering people on an alternative path.

The people who were carrying the objects across the walkway, which projected shadows on the wall, represent the authority of today. Within the physiotherapy profession, they may be our union leaders, educators, researchers, course providers, cultural influencers, social media icons as well as clinical and professional leads; they influence the opinions of people and help determine the beliefs and attitudes of people within our professional society. The person who helped the prisoner out of the cave could be seen as a teacher. Socrates compares his work as a teacher like that of a midwife. A midwife does not give birth for a person, however a midwife has seen a lot of people give birth and coached a lot of people through it, similarly, a teacher does not get an education for the student, but can guide students towards it. Similarly, professional dialogue appears best suited towards guiding people towards alternative “truths” or perspectives. The style and manner of its delivery is clearly important and it appears to have the greatest effect if it is surrounded by within and between each other’s experiences that create connections with other previous understanding. Using a direct style and manner that is out of keeping with professional dialogue is unlikely to facilitate learning or behavioural change, in fact, it is more likely to make people resist it. Much like, if the escaped prisoner returned to the other prisoners brandishing a torch lit by the flame and put it close to them to see an alternative perspective. This would likely cause the imprisoned prisoners flinch and close their eyes from the light, therefore representing stifling learning and behavioural change. An alternative method would be to introduce the light and demonstrate how it changed the shape and position of the shadows while talking them through the process allowing the prisoners to change the perspective through cognitive and perceptive dissonance, therefore representing a challenge in the experience with brand new alternatives presented. Then the attention could be drawn to the firelight and then to the outside and show alternative possibilities.

I hope this blog highlights how we might communicate with each other and helps to reflect on not only what we say, but perhaps more importantly, how we say it! More specifically, the experience of knowledge translation can be transformative if the learner has a direct personal experience. The least effective means of communication of knowledge may be about giving information in a style and manner that is outside of social norms. This is most likely to be polarising, rather than inviting people along with you. A level above this might be information giving that is lacking context or information provided in a style and manner that is hierarchical or top-down. The greatest impact may be that which directly engages with its audience in a way that relates to their previous experiences with the learners making connections themselves during a sense-making process.

References:

  1. Plato: The Republic 514b
  2. Plato: The Republic 515e
  3. Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: helping people change. New York, NY, Guilford Press.

Matthew Low, Consultant Physiotherapist NHS.

 

The Professional Dialogue: A constructive antidote to a combative climate.

 

Guest Post by Dr Neil Langridge, Consultant Physiotherapist NHS.

I recently had the privilege of attending and presenting at a conference overseas, meeting numerous Physiotherapists from multinational backgrounds. They were keen to collaborate, learn, develop and discuss. They were fantastic in their ability to listen, debate, and be critical in a professional way that made knowledge translation and critical review a pleasure rather than a trial. On my return it made me consider the UK Physiotherapy professions’ approach to building on knowledge, and how especially through social media we conduct discussions which inherently are on an international stage. It made me really consider how these are subsequently digested and the impressions our words, and approaches to professional development are viewed.

We work in an ever-evolving profession. Whether you are a new graduate or near retirement, the process of change is continuous. Over time this has happened at different speeds and has been influenced by “movements”, beliefs, individuals, social need, politics,… this list can go on. National development of new models of care has led the profession into different ways of working across many disciplines with a view of supporting patients and colleagues to deliver new and better ways of managing numerous and diverse patient populations.

The responsibility of the profession is to be ready to help, support and hold an offer that allows other professions to realise that offer with us and utilise the skill sets we have. In engaging with other professional groups, national bodies and internationally we as a profession have to ensure the offer is credible and we are seen as credible partners. There are many ways to present as credible colleagues, and one way is how we critically evaluate our practice and subsequently translate that into new ways of working. As part of the panel discussing responsibility at the up-coming 3Rs event I felt it pertinent to consider my views on this subject and I thought I would share one element, which is professional communication with anyone that is interested.

What has really alerted me of late around this in trying to gauge a sense of where we are as a profession, and how we possibly are seen externally and internally is the responses within Social Media inclusive of discussions, blogs and statements. I have always been comfortable in countering arguments, putting myself into situations where I am likely to be confronted by strong opinions and beliefs, and therefore I have always supported anyone’s right to offer an opinion and to stand by it if it is not illegal, immoral or unethical.

What I have come to realise is that some professional discussions seem to be led by emotion when it comes to challenging outdated practice or beliefs. These emotions seem to be led at times by anger, antagonism, and the under-mining of others, overall the context is very confrontational. I believe passionately that we have a responsibility to challenge internally and be critical of what we do and this freedom of speech is critical to the change process.

But, how does freedom of speech interlink with professional dialogue? They are not separate, but should be viewed as a contextual choice dependent on the social situation. This should be tacit without the need for explicit rules and as such should be a natural evolutionas a professional in practice. This is a question that seems to come up regularly, and is generally answered with a retorts such as; you choose to take offence and swearing in professional discussions is positive practice. It seems if you are thought of as being “outdated” then that means others have a right to “call people out” and we should all welcome that because that is the right thing to do for our profession. So let’s consider that in the context of a wider world view. Medical colleagues, national bodies, international groups and professional colleagues, all would wish for best practice, critical thinking and the progression of healthcare for patients, and they would wish to discuss this, learn from each other and share knowledge. How do you think they would wish to do that? Are we offering the right environment, the best external view of our profession and the atmosphere that encourages discussion?

Argument NL blog

I believe we need to seriously consider the inter-relationships of professional dialogue and behavior and the rights to expression. Perhaps it is worth reflecting on the virtual professional learning communities you are involved in? One of these is Twitter, and as such it is worth considering what the value of this is to you as a clinician. These types of professional learning communities have been described as;

“A group of people sharing and interrogating their practice in an on-going reflective, collaborative, inclusive, learning orientated, growth-promoting way”.

I believe that Social media provides this really well, however are the discussions you see or are involved in “growth-promoting and learning orientated”? What I also believe is that as well as having a professional responsibility to critically drive change from within the profession, we also have a responsibility to not be so aggressive in that mission of practice evaluation that it actually stifles behavioral change and in fact implodes on itself because it is led by emotion rather the cognitive empowerment of the profession.

It is easy to create an emotional response, be angry, confrontational, be threatening; making people think requires more than that; it requires clarity, reasoning, giving individuals the freedom themselves to consider their positioning in a non-threatened way and most importantly, their freedom of professional dialogue. Angry responses limits others and so does not encourage change, in my opinion those that angrily, aggressively sound the horn create an uncompromising environment that can only, ultimately limit some of the change behaviors that those that shout are championing for. It seems to me ironic that some of those pushing for change do so in a manner that actually drives the opposite.

work-together NL

Through communication we construct our own social realities and these then shape how we communicate, this can make a circle and this can become a vicious circle, bouncing around the same arguments, with the same outcomes and no effective change occurring. So, let’s consider a change?

Tannen (1998) speaks of “argument culture” expressing concern that confrontational communication can be counter-productive and self-perpetuating. It limits deep engagement and “Stimulates ritualised opposition that reinforces antagonism, this preventing the collective exploration of underlying complexities. These exchanges tend to escalate, polarising participants…in other words, the argument cultures impedes dialogic conversations, and creates the perfect stage for the performance of entrenched monologues”. The diagram I have put together below I hope gives my blog some pictorial interpretation. If you were a patient listening to your clinician who were about to assess you discuss their profession, where in the diagram below would you expect/hope those clinicians to sit?

Screen Shot 2018-04-08 at 20.15.33

In the end using direct opposition tactics to achieve change may work for social movements, but in professional practice, identity and development I would propose that confrontational attitudes, attacking approaches and undermining manners only provide opposition and not a vehicle for change. I am an advocate for change, development, critical review and challenge but not at the expense of our professional courtesy. The professional arguments we have need to be built on credible dialogue, a willingness to explore and debate and provide a context that encourages the communication, not suppresses it. With this in mind I believe it is always worth considering the next interaction, the next discussion, the next blog etc and be analytical and critical in a way that encourages professional dialogue and always considers how our external/international colleagues may view the work of the profession, the future may rest on the words we all write, and emotional responses we control.

1 Stoll et al (2006) Professional Learning Communities: A review of the literature. Journal of Educational Change. 7 (4) 221-15.

2 Tannen D (1998): The argument culture. Changing the way we argue and debate, London: Virago Press.

3 Kerry R (2017) “Physio will eat itself” https://rogerkerry.wordpress.com/2017/04/24/physio-will-eat-itself/

 Dr Neil Langridge, Consultant Physiotherapist NHS.