Knowledge translation

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.

 

 

Advertisements

Knowledge Translation: Is There A Disconnect Between The Interpretation of Clinical Research and Clinical Practice in the 10/10 Connect Health Guidelines?

I too had the pleasure of receiving an invitation to the amusingly titled ‘Big R’s’ and enjoyed excellent company and conversation. Jack Chew and colleagues are to be commended for hosting the event with Connect Health with a proposition to “Reason” with “Responsibility” and the idea of “Reforming” musculoskeletal practice. Connect Health should also be congratulated for putting forwards their values, strategic goals and aspirations in such an open environment.   It is in the spirit of the three ‘R’s that I would like to focus on a common theme throughout the evening that has been touched upon by Neil earlier with respect to knowledge translation.

Connect Health, put forward, as part of their “10/10 MSK Guidelines” (http://www.connecthealth.co.uk/wp-content/uploads/2017/11/Connect-Health-10-out-of-10-Infographic.pdf) for improving efficiency, reducing clinical variation and improving clinical outcomes, a traffic light system that stipulates the appropriate treatment interventions according to each presenting condition. The justification for the traffic light system is emboldened by a speech bubble that reads:

“If you read one article per day, you’d be 20 years behind, so we needed to close this gap and help our clinicians have evidence at (sic) finger tips”.

This suggests that the traffic light system provides a solution to knowledge translation between ‘evidence’ and practice.

Traffic Light Connect Health

I would like to attempt to unpack some of the challenges surrounding knowledge translation and the use of a traffic light system. The traffic light system appears to convey a linear and non-value laden indicator of efficacy. They categorise ‘evidence’ into red (ineffective treatment indicating that clinicians should not do this intervention), amber (uncertain, consider after other treatment interventions) and green (effective, do this treatment) lights. At first glance, this may seem a reasonable, simple and effective method. Let’s take a closer look, first of all, what is knowledge?

Aristotle described three main aspects to the concept of knowledge. They are episteme, techne and phronesis:

  1. Episteme means, “to know” in Greek. It represents knowledge as ‘facts’ and Plato contrasted this with ‘doxa’which meant common belief or opinion. For example, a therapist may need ‘to know’ many areas of human biology in order to understand how exercise can be utilised as an intervention to treat back pain or to prevent cardiovascular disease.
  2. Techne translated from Greek means craftsmanship or skill. It draws from knowledge but is situated in the skill of its delivery. For example, a therapist may be knowledgeable in the theory of motivational interviewing but struggles with the skill of its delivery.   Techne also includes tacit(understood or implied without being stated) knowledge. Tacit knowledge is embodied, sub-conscious and embedded to personal experience and is the type of knowledge that is very difficult to record or write down. For example, emotional intelligence, communication skills, leadership skills and clinical intuition are commonly cited in healthcare research and practice but are very difficult to conceive or teach.
  3. Phronesis means practical wisdom. It relates to the ethical deliberation of values with reference to practice. It is related to praxis in that it refers to an action that embodies a commitment to human well being, the search for truth and respect for others. It requires that a person make a wise and prudent practical judgement about how to act in this situation (Carr and Kemmis, 1986: 190).

These aspects of knowledge described by Aristotle form an individual’s knowledge. Now, referencing back to the traffic light system. Immediately, you can see that the traffic light system delivers one of the aspects of knowledge, namely episteme, but provides little or no reference to techne or phronesis. Its creator(s) must have made this synthesis of ‘evidence’ with some value judgement as to what good evidence is and is not, but it is not clear how this judgement has been made. One assumes that this judgement was based on an evidence-based hierarchy but it does beg the following questions. Who created the judgements? To whom does their purpose serve, the patient, a population, the therapist(s), the organisation or all of them, and in what way? Does it achieve those aims and at what cost? What values are being accounted for (clinical outcome, financial, quality of life of patients, therapist understanding)? What judgements are made in order to delineate an amber intervention as opposed to a green or red intervention? For example, Pharmacology treatment is cited within the low back pain +/- radiculopathy traffic light system as a “green light”. This is despite pharmacological studies evaluating paracetamol being ineffective for spinal pain and osteoarthritis (Machedo et al, 2015) (http://www.bmj.com/content/350/bmj.h1225), NSAID’s not showing clinically important difference against placebo for spinal pain (Machedo et al, 2017) (http://ard.bmj.com/content/76/7/1269) and Pregabalin not being effective for moderate to severe sciatica (Machieeson et al, 2017) (http://www.nejm.org/doi/full/10.1056/NEJMoa1614292?rss=searchAndBrowse#t=article) amongst other examples. Clearly, the context may be of utmost importance here such as the stage of the disorder, presentation, co-morbidities, and presence of barriers to recovery, previous response to treatment amongst a dearth of other relevant information. The question remains, is the underlying context revealed using the traffic light system?

Creating a hierarchy of evidence is in itself is fraught with problems and challenges. Further discussion of these challenges are beyond the scope of this blog and the literature is extensive but I would encourage readers to watch Trish Greenhalgh speaking about ‘Real verses Rubbish EBM’ here (https://www.youtube.com/watch?v=qYvdhA697jI) and work from Roger Kerry (http://www.mskscienceandpractice.com/article/S2468-7812(17)30153-4/fulltext) as well as work from the CauseHealth team (https://causehealthblog.wordpress.com) (https://philpapers.org/archive/ANJD.pdf) (http://ubplj.org/index.php/ejpch/article/viewFile/1129/1129) and also the Alliance for Useful Evidence (http://www.alliance4usefulevidence.org/assets/What-Counts-as-Good-Evidence-WEB.pdf).

Knowledge does not exist in isolation but exists within a social context. An exchange of knowledge occurs through shared cultural understanding, practices and assumptions and not by a mere exchange of factual information. The traffic light system appears to specify an absolute system of context-free judgements on clinical practice regardless of individual and environmental factors. For example, the abandonment of the use of therapeutic ultrasound was posited as a “good place to start” when reforming MSK practice. However, experts in electrotherapy such as Professor Tim Watson are likely to hold exception to such rules as the evidence demonstrates efficacy if sufficient treatment dose, within the context of an appropriate tissue injury and healing stage, has been provided (https://www.youtube.com/watch?v=hpMFI7UPwMo). Interestingly enough, this is the same as many other treatment interventions in Physiotherapy, including, dare I say it, exercise! A more appropriate suggestion might be that therapeutic ultrasound should not be justified in areas of practice where environmental and practical elements prohibit its efficacy, e.g. using therapeutic ultrasound in a sub-acute muscle tear once every two weeks. As a potential consequence of using a broad brush-stroke approach of describing all therapeutic ultrasound as lacking in sufficient evidence, and therefore abandon its use, is very likely to polarise the MSK community rather than bring it together in a reform of practice, particularly bereft of context. (P.S I would like to declare that I do not use therapeutic ultrasound in my practice, as I do not see the appropriate caseload or work in an environment that would constitute its effective delivery).

Perhaps polarising views could be a way to draw people into a debate or discussion and perhaps this could be the right thing to do? But, I can’t help but think that this approach might be rather disengaging and autocratic, using evidence as a proverbial stick to beat you over the head with. It might be seen that organisations could try to ‘kitemark’ what is good evidence and drag the MSK community of practice “up with it”. However, I can not avoid the feeling that a close relationship exists between knowledge and power with evidence being described as “what powerful people say it is” and, that in its pursuit, could lead onto stifling significant change in practice rather than foster and grow it (http://www.ruru.ac.uk/newsevents.html).   Indeed, creating policies without broader considerations could be seen as using rhetoric to achieve the goals of an organisation with an undertone of efficiency making, cost-cutting, money saving and the handcuffing of professional autonomy.

Gabbay and Le May (2011) describe ‘clinical mindlines’ that go far beyond guidelines as “internalised, collectively reinforced and often tacit guidelines that are informed by clinicians’ training, by their own and others clinical experience, by their interactions with their role sets, by their role sets, by their reading, by the way that they have learnt to handle the conflicting demands, by their understanding of local circumstances and systems and by a host of other systems” (Gabay and Le May, 2011 p 44). One could look at the social media explosion surrounding the big R’s event as well as Physiotherapy continued professional development over the last five years and see it in a way that builds clinical mindlines, but perhaps with some unforeseen consequences. Less experienced therapists that seek knowledge through social media may experience a gold mine, full of forward thinking and verbose well-meaning healthcare professionals. What in actual fact, they might receive is ‘doxa’ or common opinion without much critical thinking surrounding such information. All the more reason for open discussion, deliberation and debate!

The vision of providing a system that values reducing clinical variation is both compelling but also concerning. Allowing clinical reflexivity and context-dependent, autonomous decision-making should be rewarded and at the same time ensuring effective clinical reasoned interventions. Is this process one in which is embodied with a traffic light system of intervention that appears to rewards technicians and not skilled practitioners?

Knowledge translation is a complex, dynamic and reflexive process and might best be viewed like this:

Process of transferring knowledge into action

Dr Vicky Ward, Dr Simon Smith, Dr Samantha Carruthers, Dr Susan Hamer, Professor Allan House (2010) Accessed 19/11/2017 18:52 http://medhealth.leeds.ac.uk/info/662/kt_framework/774/project_report_and_publications

This is quite a contrast to the traffic light system and is food for thought in comparison. However, the traffic light system is a start, especially for newly qualified therapists using it as a heuristic for guiding clinical practice. Clearly, this blog asks more questions than it does answer any, but I have tried to put forward some suggestions that might be helpful.

  1. Providing an open and transparent process for judging clinical guidance.
  2. Acknowledge one’s own clinical practice, research assumptions, values, judgements and beliefs as our ‘facts’ are always value-laden.
  3. Provide a framework for understanding and signpost where the gaps of our knowledge are and promote reflective practice.
  4. Be open regarding our aspirations for the future, which may provide opportunities to use evidence in a more informed and reflexive way.
  5. Encourage clinical mindlines by discussion, debate and use the application of multiple sources of ‘evidence’ at the same time as acknowledging the limitations of the methods from which they came.

I would also like to add Roger Kerry’s key messages from his recent paper ‘Expanding our perspectives on research in musculoskeletal science and practice’ in the Musculoskeletal Science and Practice journal as they are very relevant (http://www.mskscienceandpractice.com/article/S2468-7812(17)30153-4/pdf).

  1. Clinical practice should be based on best evidence, and an era of “clinical freedom” should not be returned to.
  2. As scientific research exponentially grows within musculoskeletal medicine, it is timely to re-examine what constitutes the best evidence for clinical decision making and health policy.
  3. Traditional scientific principles on which much existing research is based are dated and limited by real-world complexity, and a crisis period in both research and practice is now evident.
  4. A research vision for the future is focused on knowledge generation which is truly person-centred and embraces real-world complexity, rather than controlling for it.
  5. The research future should incorporate greater alliances between all stakeholders and expand its context and theories.
  6. Clinicians, researchers, and the people we work with to improve their health should continue to reconceptualise the idea of best evidence for clinical decision-making and health policy.

“Love activity, Hate exercise?” Campaign

As the “Love activity, Hate exercise?” campaign from the CSP starts, Stephanie Mansell, Consultant Physiotherapist at the Royal Free Hosptial brings her considered and thoughtful perspectives on this guest blog.

001495_love-hate_1200_x_675px

The “Love activity, Hate exercise?” campaign from the Chartered Society of Physiotherapy (CSP) launches on the 6thJuly. This campaign encompasses and supersedes several previous campaigns including “older people day” and “workout at work day”. The CSP report that significant resource and market research was employed in developing the campaign, with engagement from physical activity experts and members of the public. Data were collected from more than 10 focus groups, via face-to-face, online and phone consultations from across the UK. At its heart, the campaign is a public health initiative, based upon harnessing the collective power of the physiotherapy profession to affect health behaviour change of the population. As a CSP member, I observe how this is in keeping with the CSP’s mission “to transform the health and well-being of individuals and communities by empowering our members and exerting our influence” and vision to“transform lives, maximise independence and empower populations.” 

The “Love activity, Hate exercise?” campaign aims to empower physiotherapists to have conversations with their patients to enable health behaviour change, specifically around physical activity. Certainly, if members engage it would seem it should be feasible to achieve this. And herein lies a potential hurdle to the campaign’s success. There appears to be significant reticence from some clinicians about the “Love activity, Hate exercise?” campaign, especially regarding the strap-line, whilst there is a sense of apathy from others with only 2,000 members signed up. And so I find myself inspired to find a forum to raise some of the points I simply can’t raise in a 140 character limit.

So before we go any further I asked myself: “what’s the difference between exercise and physical activity?” Captain Google revealed a few top definitions:

Exercise:

Activity requiring physical effort, carried out to sustain or improve health and fitness” Oxford Dictionary (https://en.oxforddictionaries.com/definition/exercise)

“Exercise is physical activity that is planned, structured, and repetitive for the purpose of conditioning any part of the body. Exercise is used to improve health, maintain fitness and is important as a means of physical rehabilitation.” Medical Dictionary (https://medical-dictionary.thefreedictionary.com/exercise)

Physical Activity:

“Physical activity is defined as any bodily movement produced by skeletal muscles that requires energy expenditure.” World Health Organisation (http://www.who.int/dietphysicalactivity/pa/en/)

“Any form of physical exerciseCollins Dictionary (https://www.collinsdictionary.com/dictionary/english/physical-activity)

“Physical activity includes everyday activity such as walking and cycling to get from A to B, work-related activity, housework, DIY and gardening. It also includes recreational activities such as working out in a gym, dancing, or playing active games, as well as organised and competitive sport.” NICE (https://www.nice.org.uk/guidance/ph44/chapter/recommendations#Box-1-Physical-activity-definition-and-current-UK-recommendations)

Based on the above definitions one could argue exercise and physical activity are not all that different.

So why the “Love activity, Hate exercise?” strapline?

I’m sure all physiotherapists will have used exercise or physical activity in a treatment plan, after all, that is our bread and butter. I’m sure therefore that you’ll all have seen the shutters go down and patients glaze over at the mention of the word “exercise”. In a recent PhysioTalk Twitter chat clinicians and patients gave a whole host of reasons for this. Every patient will have their own reason for disengaging with this terminology. Personally, I suspect it’s partly because “exercise” has become a medicalised term, but mostly for psychosocial reasons. The “Hate exercise?” aspect of the strapline was born from the focus groups with the aims of engaging members of the public, demonstrating empathy and generating debate and discussion. The strapline certainly seems to be generating debate already.

Physical activity guidelines currently recommend adults should participate in 150mins of moderate, or 75mins of vigorous activity a week, with 2 days of strength training(1). There are also guidelines for children and over 65s. (I love the infographics, by the way, they’re so accessible(2)). Where adults are already achieving these targets, they will only see greater physical fitness gains when they increase their activity levels to 300mins a week(3). The health benefits of physical activity are clear: reduced cardiovascular disease, enhanced mood, reduced chance of diabetes, reduced chances of developing breast and bowel cancer, reduced chance of premature death, lower risk of osteoarthritis, lower risk of hip fractures, lower risk of falls and reduced chance of dementia(3). And these are just the benefits where there is evidence to back these powerful claims. I’m sure you can all name further benefits to physical activity, perhaps some less health-related and more psychosocial. Despite these known benefits, adherence to physical activity level guidelines in UK adults is very poor, with high levels of sedentary behavior and as little as 50% of adults meeting the physical activity guidelines(4). Working as a respiratory physiotherapist I estimate at least 50% of my caseload are people with obesity. What we do know is where people are very sedentary, even small increases in physical activity levels will be beneficial(5)and certainly my cohort of patients are prime examples of such patients. It is in the highly sedentary group of patients in particular, the CSP hope the “Love activity, Hate exercise?” campaign can have the biggest impact.

CMO_infographic

The concept suggested by the CSP of the “power of a conversation” is not new. Very Brief Advice (VBA) has been utilised within smoking cessation public health campaigns for many years. VBA involves very simple clinician training and is easy to implement. It involves an AAA approach:

 

Ask: Are you smoking? Would you like to quit smoking?

Advice: Stopping smoking is the single biggest change you can make to improve your health. The best way to quit is with a combination of medication and support.

ActRefer the patient to smoking cessation services

 

The numbers need to treat for VBA is estimated at 40(6). So as a respiratory physiotherapist I have to employ VBA for smoking cessation 40 times before that results in a successful quit attempt. To give you some context the number needed to treat for cervical cancer screening programmes to prevent a death over 10 years is 1140.  So a number needed to treat of 40 is pretty powerful and increases my job satisfaction knowing the short time I take in the appointment with my patients makes a difference.

Whilst those figures may seem moderately impressive, the impact of similar VBA on physical activity levels are even greater. Public Health England report one in four people would be more physically active on the advice of a healthcare professional(7). Additionally, a systematic review and meta-analysis reported a number needed to treat of 12 for VBA for physical activity(8).

I’ve adapted the NICE(9)recommendations for VBA for physical activity to fit the AAA approach (because it’s easier to remember then!):

 

  • Ask: Identify patients who are physically inactive
  • Advice: Advice patients on the physical activity guidelines and emphasise the health benefits.
    • Tailor advise to patients motivations and goals, current activity levels, circumstances, preferences and barriers to being physically active and health status
  • Act: Provide personalised information about local opportunities.
    • Consider providing written information on goal setting. Document the outcome of the consultation. Follow up at the next opportunity, this could involve reviewing progress towards goals

 

There are 57,000 CSP members. So imagine the impact we could have on the activity levels and subsequent health of the nation if we all engaged in the “Love activity, Hate exercise?” campaign. Whichever area of physiotherapy you are working in the physical activity message is of relevance to you and your patients. If one in four people would increase their physical activity levels as a result of your advice, and numbers needed to treat for VBA for physical activity are 12, then we could very quickly start to see the impact of a more active nation. Think of the benefits a sustained change could have. And then think of the benefit that could have on our highly strained and stretched NHS and health services. And then think of the extra job satisfaction you’ll gain from taking a few minutes of your time with your patient to make use of VBA for physical activity. I’d like you, however, to consider how much more powerful the impact could be if other therapists, AHPs, nursing and healthcare professionals joined in too. Certainly, physiotherapists are experts in “exercise” and so we’re best placed to pave the way for other healthcare professional to join in our wake. I do however make a plea to the CSP to work with other professional bodies to generate a greater impact of this (and other!) campaigns and resources. There are very few physiotherapists working in silo physiotherapy departments these days, with most working in integrated therapy departments or as part of wider MDTs. So to truly reap the benefits of the “Love activity, Hate Exercise?” campaign I would implore you to share the message and the resources with your team members,

We live in a world where the complexity of our patients is ever growing. We’re living in the 4thindustrial revolution and an associated changing social structure. Many of our patients have challenging health behaviours and struggle to engage in their care. In order to instigate health behaviour change we need to move beyond a biomedical approach to treatment and towards a biopsychosocial model of care. In fact, the biopsychosocial model of care is not new, having been proposed by Engel in 1977(10). The biopsychosocial model of care should be particularly appealing to physiotherapists, as it allows and encourages holistic assessment and collaborative treatment plans, whilst ensuring the patient is the focus of attention. You will all be aware from your clinical experience how psychology and society impact on the precipitating health behaviours of our patients, as well as their concordance with treatment plans. It is imperative therefore that physiotherapists arm themselves with techniques to empower patients to make sustained health behaviour changes, or else many of our other treatment techniques will become ineffective or academic.

Motivational Interviewing is a simple technique which uses a guiding approach to establish patients’ strengths and aspirations, evoke their motivation for change and promote autonomous decision making(11). Motivational interviewing is based on the principles that; how we speak to patients is as important as what we say, feeling listened to is an important part of instigating change and that behaviour change is intrinsic and patients won’t make those changes simply because we’ve told them to.  If the patients have found the solutions themselves, then the behavioural change is far more likely to result in long-term and sustained change. There is an evidence base for the impact of motivational interviewing on health behaviour change in a number of different clinical scenarios(12). Implementing motivational interviewing can seem like it might cause a time pressure in a busy clinic. But I would argue that in the long run the time benefits are in its favour. Try following the RULE acronym the next time you start a conversation about physical activity levels with a patient(13):

 

Resist the urge to be didactic in your interaction

Understand it’s the patient’s reasons for change (not yours!) that will elicit behaviour change

Listening is important; the patient will find their own solutions

Empower the patient to realise they have the power to change their behaviour (try not to think of He-man or She-Ra  chanting “I have the power!”)

 

In summary; the CSP’s “Love activity, Hate exercise?” is an evidence-based and worthy campaign. If all CSP members engaged we would potentially make a huge difference. We could make a bigger difference if we engaged other MDT members and healthcare professionals. A biopsychosocial model to care is more effective than a biomedical model one and motivational interviewing can be a useful tool in this approach.

Stephanie Mansell, Consultant Physiotherapist, Royal Free London NHS Foundation Trust, July 2018

 

References

  1. Department of Health and Social Care. UK physical activity guidelines In: Department of Health and Social Care, editor. https://www.gov.uk/government/publications/uk-physical-activity-guidelines2011.
  2. Department of Health and Social Care. https://www.gov.uk/government/publications/start-active-stay-active-infographics-on-physical-activity.Accessed
  3. O’Donovan G, Blazevich AJ, Boreham C, Cooper AR, Crank H, Ekelund U, et al. The ABC of Physical Activity for Health: a consensus statement from the British Association of Sport and Exercise Sciences. Journal of sports sciences. 2010;28(6):573-91.
  4. British Heart Foundation. Physical Inactivity Report 2017. In: British Heart Foundation, editor. https://www.bhf.org.uk/publications/statistics/physical-inactivity-report-20172017.
  5. 2018 Physical Activity Guidelines Advisory Committee. Physical Activity Guidelines Advisory Committee Scientific Report. In: Services DoHaH, editor. Washington, DC: U.S. 2018.
  6. Van Schayck OCP, Williams S, Barchilon V, Baxter N, Jawad M, Katsaounou PA, et al. Treating tobacco dependence: guidance for primary care on life-saving interventions. Position statement of the IPCRG. npj Primary Care Respiratory Medicine. 2017;27(1):38.
  7. Public Health England Guidance: Health matters: getting every adult active every day. In: England PH, editor. https://www.gov.uk/government/publications/health-matters-getting-every-adult-active-every-day/health-matters-getting-every-adult-active-every-day2016.
  8. Orrow G, Kinmonth A-L, Sanderson S, Sutton S. Effectiveness of physical activity promotion based in primary care: systematic review and meta-analysis of randomised controlled trials. BMJ. 2012;344.
  9. National Institute for Health and Care Excellence. Physical activity: brief advice for adults in primary care Public health guideline [PH44]. In: NICE, editor. Manchester2013.
  10. Engel G. The need for a new medical model: a challenge for biomedicine. Science. 1977;196(4286):129-36.
  11. Abraham C, Michie S. A taxonomy of behavior change techniques used in interventions. Health psychology. 2008;27(3):379.
  12. Rubak S, Sandbæk A, Lauritzen T, Christensen B. Motivational interviewing: a systematic review and meta-analysis. Br J Gen Pract. 2005;55(513):305-12.
  13. Hall K, Gibbie T, Lubman DI. Motivational interviewing techniques – facilitating behaviour change in the general practice setting. Aust Fam Physician. 2012;41(9):660-7.

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.