Cross Country 48 - The Unnecessary Profession

[Barrett Dorko]

It’s been a quiet week in Cuyahoga Falls…

To see any sort of academic at my courses is an extremely rare event so when I realized that an OT professor was attending one day this week I was both surprised and pleased. She was a woman a bit older than I with a genial manner and some real experience as a writer so we fell into conversation easily. I have to give her credit for this because I’m just not that easy to talk to, ordinarily.

I can’t quote her precisely but what she said was clear and I doubt I’ll forget it soon, so I’ll present it here as if I had written it down. She said, “These days Occupational Therapy has moved into acute care though years ago we were almost entirely confined to the rehabilitation setting. I’m not saying that this is entirely a bad thing, but I’m certain that what we seem to accomplish with many patients there would have happened anyway. The students see this progress and take credit for it. They come to think that they are doing something vital and necessary and thus they think they are a part of a wonderful profession, but I know better. What they see and then surmise is an illusion.”

I listened carefully and as she spoke I began to appreciate how it was we conversed with such ease; this professor was every bit as cynical as I’ve become about some aspects of her own profession. On top of that, she was actually willing to express this suspicion regarding its worth out loud.

I thanked her for her honesty and told her I might very well use what she’d said as a “hook” for my column about this trip. Unless something else came along that compelled me to do otherwise I knew I would but I can’t predict what the writer in me might chose to notice. He has a mind of his own and long ago I just learned to obey. This remarkably honest statement hasn’t left me, and, if true, its implications are both large and troubling.

There are many places in this world where physical therapy is totally lacking yet people recover from injury and painful problems anyway. I presume that these cultures fill the void with permission to move, some sort of reward for return to productivity and an attitude toward healthful function that has far less to do with appearance than the absurd infomercial-driven world in which we live. In those places personal trainers, “life coaches” and a variety of counseling professions are unnecessary, and might be seen as nothing more than an indulgence for the wealthy. According to the OT this is exactly what has happened to her profession without anyone noticing it. Not entirely, of course.

Since that conversation I’ve been wondering about physical therapy’s movement in the same direction and have come to realize I feel much the same way about a few venues of modern practice.

I’m wondering what others think about how and where we’re unnecessary but either don’t know it or won’t admit it.

Like that OT professor, I assume it will take some courage to address the issue out loud.

Do it anyway.

[Diane]

There are so many layers to this I don't know where to even begin.

An awful lot about the profession(s) need to be deconstructed, many of the places where they intersect with the culture could use a good decluttering, but I'd hate to see the actual professions dismembered and done away with entirely.

Yesterday I spent all day at the provincial branch AG meeting. It was well attended, there was a trade show, three hours of presentations and only three hours of awards/business/discussion about raising fees. (Hot topic.. they want to put the fees up by $40, the first hike in 10 years, for Pete's sake. Duh, what's the issue? But there are quite a lot of stressed out public service PTs who don't think they "get" as much out of the organization for their $ as the 70% who are private. They put up a fight. But they were outnumbered.)

The tables at the tradeshow had paid to be there.. members were invited/ encouraged to walk around and collect initials on a little "passport", which then went into a big jar, out of which your name could be drawn for a whole series of different prizes.

This is recent I think, getting bribed to walk around and look as if you're actually interested in this stuff, enticed by a draw to get initials to qualify for it.. I didn't bite. Nothing could have dragged me around to look at all the gizmos, orthotics, stabilizers, exercise balls, etc. All bright enticing colors. The whole room smelled like polyproplyene.

I went up to the one and only table I was attracted to, featuring models of the body and skeleton, to ask if a long spine/pelvis model hanging on a small stand was bendy. The sales rep said it was not only bendy but it was take apart-able. He didn't lift a finger to show me his wonderful spine in more detail, however, but on a tag I saw its name, "Chiropractic Spine" .. I turned off, then around, and left without trying to fan my own seriously low level of curiosity further.

There was also very spiffy hotel type beverage and juice service and hot lunch, free. Really nice fake leather binders with papers and a pen inside. And some chocolates wrapped in foil. The days when we just got a pen and a cardboard folder and a name tag seem to be gone. The day ended with a cake party and bottles of champagne given away to 10 lucky drawees in honor of PABC's tenth anniversary.

I feel uneasy about how sponsors pay for all our 'partying', and how that lays us wide open to all their memes. I've always been (well, always was) a girl who liked to pay her own way on a date so I didn't feel manipulated into "owing" anyone any favors.

Yet I think the young ones like the gizmos, and maybe need them for a time as they mature into being PTs.. maybe they serve sort of a "training wheel" purpose, help the young grads gather their courage or something... so I suppose there will always be a market for them.

The presentations were good. Neil Pearson (in the CPPSG) did an hour on pain science, drawing heavily from Moseley, but adding local flavor.

The big highlight was a two-hour Whiplash overview, that several committees in PABC have collaborated on over the last year. The project, about to be launched, is a province wide online pooled data base where people can submit their patient outcomes with just a few clicks. The format will let you track your own outcomes, and members will be able to access collective outcomes, while anonymity will be retained.

I'm quite interested in this. Someone (many ones) with sharp research edged minds, and the whole profession at heart, have gone to all the bother of making it easy for any clinician in the province to "do" science, this outcomes level of science. And I appreciate that they did it for free, as volunteers. Heck, I appreciate that they did it at all. It's an innovation in Canada, apparently.

At first it will be info collected on treatment outcomes for only whiplash associated disorders, but later it can be adapted to track outcome data on any chosen "condition". This allows the profession to be cohesive AND for members to maintain autonomous methods.. you don't have to rigidly follow any outside recipe or (especially any) mobilipulative agenda; it doesn't pit one sort of technique against another. Even I, with my (ahem) "suboptimal" care, will be allowed to contribute my results to the pool. My "suboptimal" care might even help make the pool look better than it might otherwise.. The standard is care 3/week for 4-6 weeks for whiplash, with improvements (but not full clearance) on two scales, a disability scale and a pain scale. I think I generally get full or close to full clearance, with way fewer treatments, in about the same time frame. But we'll see.

I've rambled! And I don't think I've contributed any further to the discussion. I'm still in love with the profession and don't want to see it die, or obtain a divorce from it yet. So.. :zip:
Later..

[EricM]

In one of my first posts after attending your class Barrett, I remember cursing your name for having essentially exposed the unnecessariness of most of what I had spent the last few years of my life learning how to 'do.' Of course I wrote this humorously, but for me I knew I had already reached a point where there was no going back. As I think I've told a few of you, I'm leaving the public hospital where I have worked since graduation and am moving into private practice exactly 2 months from now. It is a very sports minded clinic, great reputation in town, appointments will be 20 minutes long and I'm going to have to work hard to make a name for myself. I know this will be all that much more difficult now that I've crawled out of the rabbit hole and quite frankly I'm not sure I will survive. I think my greatest fear is that I will spend the majority of my days performing tasks that I know are unnecessary. Establishing a 'freedom clinic' is an inspiring thought and seems to be the light at the end of my tunnel.
Fortunately, this forum has also helped me understand where and how I can be necessary. Now I've just got to make it work.

Eric

[Jon Newman]

Where to start? Good question Diane.

A profession is only as useful as the meme(s) that gave rise to it. In my opinion, the pervasive meme(s) of PT, as I witness it being practiced, is at risk for contributing to the impoverishment of the human mind and is thus not only unnecessary but will hopefully fail--the meme that is.

On the other hand if the meme that drives PT is to reduce suffering (and all that suffering entails) and is consistent with Principle 1 of our code of ethics then acute care as well as outpatient settings are fine places to find a PT.

This part of the imprecise quote

They come to think that they are doing something vital and necessary and thus they think they are a part of a wonderful profession, but I know better

makes sense to me if the profession is being defined by the "strength, stretch, defeat nature" meme but not from the "reduce suffering" meme.

[Diane]

Jon,
This part of the imprecise quote

They come to think that they are doing something vital and necessary and thus they think they are a part of a wonderful profession, but I know better

makes sense to me if the profession is being defined by the "strength, stretch, defeat nature" meme but not from the "reduce suffering" meme. Yes. Exactly. Thanks for throwing a new frame around that.

[nari]

Eric

Take care in your new job..or you risk ending up a cynic like me. ;)

About four years ago, I saw a bloke who had fractured his olecranon while stocking supermarket shelves, four weeks previously. Normally we worry somewhat about #s in the elbow. However, he didn't. Was totally noncompliant, returned to work the following day after the accident, and when I saw him he had full range, no pain, etc etc. The request from # clinic was 'intensive physio'.
At that point something hit me like a sudden shower of rain. What motivated those medicos to write that? Risk of litigation? Hardly... Why on earth would we need to see him??
What meme is running through the profession that # = physiotherapy?

From then on, I kept thinking about why people need us. To reduce suffering, encourage, educate....yes.
One doesn't need thousands of dollars to do that in CE every year.

And yes, after attending Barrett's course, my "beliefs" were reinforced 500%.
Came to the conclusion that probably more than 50% of what we do is something of a sham; and to boot, exists because of the ego-builder factor.

That OT professor enunciated more than her opinions/feelings about the profession; a number of OTs I've come across over 20 years have quietly expressed a similar view; they saw through the illusion and weren't happy about that fact. Especially in acute care, where they have been for years. One particularly thoughtful OT said: I have no idea why I am here (Intensive Care) and another discipline on top of six others is just ridiculous..

Unfortunately I have never met a PT academic who thought for one moment that PT was not as necessary as others think it is.

Nari

[Jon Newman]

One of the more interesting articles I've read recently is Third Nature: The Co-Evolution of Human Behavior, Culture and Technology by William Johnston. (see citation/abstract at end)

In it he states:

I decompose human nature into three underlying natures. Because they emerged at different times, we may refer to them as first, second and third natures. First nature is material; we are made of atoms. Second nature is biological; we are living organisms. Third nature is, for lack of a better word, ideological; we are creators and carriers of belief systems and their artifacts.

Also this

An improved understanding of human behavior may be vital in today's world because human behavior is implicated in the vast majority of the problems, henceforth referred to as the big problems, that place many forms of life on the planet, including humanity, in jeopardy.

And then goes on to describes a variety of insights and implications but this following stuck with me.

The task in which I am engaged in writing this paper and the thoughts that run through my mind are obviously nothing like what our Paleolithic ancestors experienced. Unlike them, I think mainly third-nature thoughts. Third nature controls and infiltrates my mental experiences both when I am awake and when I am dreaming. The third-nature ideas of progress, achievement, "making something of one's self", and the "American dream", among others, began to infiltrate my mind and shape my behavior decades ago. Because I am immersed within and controlled by the powerful institutional order, I have become a specialist and will receive a paycheck today. The pay we receive for the roles we play in sustaining the institutional order is itself used to sate our culturally-based appetites for other artifacts of third nature and, thus, to further sustain the institutional order. Our paychecks, our professional specializations, our minds and our behaviors exemplify media by which third nature and the big problems self perpetuate.

In other words, it's the culture, stupid. Ok, and how it interacts with first and second natures.

Nonlinear Dynamics Psychol Life Sci. 2005 Jul;9(3):235-80.

Third nature: the co-evolution of human behavior, culture, and technology.

Johnston WA.

Within a dynamical-systems framework, human behavior is seen as emergent from broad evolutionary processes associated with three basic forms of nature. First nature, matter, emerged from the big bang some 12-15 billion years ago; second nature, life, from the first bacteria up to 4 billion years ago; third nature, ideology and cultural artifacts (e.g., institutions and technology), with a shift to self-reflective, symbolic thought and agrarianism in humans some 8-40 thousand years ago. The co-evolution of these three natures has dramatically altered human behavior and its relationship to the whole planet. Third nature has infused human minds with several powerful ideas, or memes, including the idea of progress. These ideas have fueled the evolution of a complex institutional order (e.g., political systems and technology) and myriad attendant global problems (e.g., wars and environmental degradation). The human brain/mind is seen as the primary medium by which third nature governs human behavior and, therefore, self perpetuates.

[gary s]

Barrett,
I think that it's time for "Dance Monkeys, Dance"

[Jon Newman]

Hi Eric,

Good luck and let us know how things go. The essence of your comment

In one of my first posts after attending your class Barrett, I remember cursing your name for having essentially exposed the unnecessariness of most of what I had spent the last few years of my life learning how to 'do.'

was captured by Hugh Macleod of The gaping void (http://www.gapingvoid.com) in the following cartoon.
This monkey is done making "noise" for the night.

[Jason Silvernail]

Well, I see this "unnecessary" thing, but I think my perspective is a little different.

I agree with Jon and add that if we really stick to education, prevention, and reduction of disability, we can't go too far wrong.
I think the closer we get to the consumer (ie private practice, not accepting insurance slavery, er, payment) the better off both the consumer and the PT will be, and the less the culture and it's memes can dominate. Like most of you, I spend a good deal of time every day educating my patients that much of what they have heard, seen on useless imaging scans, and had other providers tell them is....not true or irrelevant.

I also think that given the way our culture is moving - toward more obesity, more sedentary lifestyles, more poor diets, etc, etc we are likely to continue to have customers of all types, and be more needed in fact than we are now. In fact, we can take an active role in slowly changing the culture by engaging and embracing prevention. I think if you take people outside of their culture and compare them to less advanced societies, you'll find most of the trappings of our culture unnecessary. This doesn't mean that those trappings will go away, nor that they're not important for those in the culture now.
This is the great issue, right? If our culture were less advanced, we'd be much less useful. Couldn't agree more.

So, I guess we acknowlege that we should try to make what changes we can of the culture, and in the meantime get by the best we can while doing so. This is not unlike the Vegan thing for me. Many Vegans despair at the cruelty and waste of the modern world, and talk about all the things people have, eat, and do that are unnecessary. Hey, that's great, agreed. But the culture is not going to suddenly go bohemian over the weekend. That said, the only thing to do is to do what we can to influence the world around us and live as best we can. I think many PTs (and many Vegans) are doing a good job of that.

My wife is a personal trainer. This, in more primitive societies, is a quite unnecessary profession. But given the way industrial society is heading, she (and those like her) are more and more necessary, and have their role in trying to steer the culture toward fitness and health.

I guess my point is that while we are unnecessary to some degree, it's only outside the confines of our culture that that's true. Since we're not at risk for having our culture change 180 degrees anytime soon, and while we keep a positive compass to guide us, we'll do pretty well.

J

[Barrett Dorko]

Jason,

As always, a thoughtful post. I think that calling any other culture "less advanced" is probably going to rankle some. Not me, I know what you mean, I think. Cultures where instinctive behavior isn't immediately suppressed to the degree that it is here, where movement toward sustinence takes a little work and where participation is honored over spectation. There's a lot of health in all of that, and movement toward such behaviors would be a good idea. No less than Herman Melville noticed that the "primitive" man recovers from illness much faster than the "civilized" one.

Not that I want to do any of this stuff myself. For me, a culture without TV isn't necessarily primitive, but I wouldn't argue with "barbaric." I suppose vegans have some good ideas as well - I have a wonderful and brilliant niece in that community. But, the return to "simplicity" that is all the rage now strikes me as much too late when I see thousands traveling with a Bluetooth device in their left ear. And I also always smile when I think of the Fran Liebowitz quote regarding her place amongst the creatures of the earth. She said, "My favorite animal...is steak."

Finally there is this, at the risk of questioning your wife's chosen profession: I know we need more fitness - but do we really need personal trainers to get there?

[Jason Silvernail]

Hi Barrett-
Thanks for understanding what I meant by "advanced". I guess I meant more modern, with it's pluses and minuses.

Glad you asked about personal trainers. My wife and I discuss this frequently, that many of the people who come to us don't really NEED us, that they can improve their health, function, and pain quite well without us, if they would simple change their lifestyle or practice movement toward pain relief a little bit. She says all the time, people don't really need me. Do they want me to work out for them? If they just stick to the program, or close to the program that we agreed upon, they wouldn't need to keep coming back...
Of course, if it were that simple, then not only would both of us be unnecessary, but we would be unable to find work! However, it seems that's not the case.

I don't think we NEED personal trainers to get fit anymore than we NEED physical therapists to move and resolve most of the pain that's a consequence of nonpathological problems. However, looking at the evidence, it has become painfully obvious to many of us, especially those with an eye toward statistics, that for whatever reason people are NOT getting fit or free of pain on their own. So, we are left to do what we do - help people as best we can, and do our part to change what part of the culture we can - toward compassion, toward health, toward fitness, and toward a more plant-based diet. :)

J

[Jason Silvernail]

Something else occurred to me ---

We don't really NEED plumbers or contractors or electricians, either, in our houses. Most of us can learn to do that sort of work for ourselves. I should know, I'm finishing nailing down my hardwood floor this coming weekend. However, most of us choose not to learn to do it ourselves, but rather to lean on others with different knowledge, skills, and abilities to help us.

It seems that's no different than trainers or therapists. You could argue that since health and natural movement should be a given in most people, that they should want to seek these abilities for their own health and well-being, that it's different than skills in home maintenance. I guess it's all about what skills and abilities you consider essential. I'm willing to bet my financial planner would be disappointed in my knowledge of the dollar-cost averaging approach to investing that I am participating in. He, no doubt, considers this essential knowledge, and that if people took a little time to manage their own money, he would be unnecessary, too.
Thankfully, there's a market for most of us...
:)

J

[nari]

Perhaps we (collectively) never get to learn how to do things because we are too busy seeing other people who can show us. And when they are wrong, which is often, we work it out for ourselves...or do without.

Which is how the farmer/grazier in the middle of Montana or Ontario or Queensland learns to do everything, and get very fit at the same time. A bonus.
Dependency is endemic in the modern world.

Nari

[Diane]

Jason, I think you're right, we are all mutually interdependent.
Nari, Dependency is endemic in the modern world. Maybe dependency is alienation turned inside out.

I know that my stress levels are much lower since I acquired an accountant and a book-keeper. I know they think I'm pretty inept with pieces of paper, that I have a lot of "learned helplessness" around organizing numbers into columns and spreadsheets, doing a tax return, etc. But I look at them as essential. I'm happy to pay them the big bucks to help me keep my stress level way down and money business on track, because it frees me up to do what I like, and helps me be more calm. Quality of life issue.

Something else that lowers my stress is a guy who comes to my apartment to show me how to do stuff on the computer, and another guy who comes in to fix wiring, plugins, outlets, simple renos, that sort of thing, in my 30 year old condo. I don't mind shelling out $ for things like that. And I would never in a million years try to fix anything under the hood of my car. I even have someone else cutting my hair these days. :)

[Barrett Dorko]

Every Tuesday the Akron paper has a “health” section. Today’s topic is the variable nature of recovery following different surgical procedures, including total knee replacement. The big mystery here is the fact that many people do not recovery at the same rate, even when the surgery is performed bilaterally on the same day. The surgeon speculates that it is variable swelling and scar formation at fault.

Though someone is pictured being “helped in physical therapy” (more than likely by a PTA) this “help” appears to be the standard ROM protocol. Of course, this may be a function of the story’s limitations. But the orthopedist interviewed places the blame for a slower recovery purely on unforeseen painful factors and his remarks reveal no real understanding of pain’s neurologic origins. Without some insight here, how effective will any therapist be? When the connective and contractile tissues are dealt with traditionally they respond as expected but it’s when the patient’s dysfunctional neurology comes to the fore that physical therapy must necessarily alter post-operative approaches. See Oliver, Ian and Me (http://www.somasimple.com/forums/showthread.php?t=2046) for more about this.

Without the special knowledge often discussed here, almost all of it concerning the nervous system, the necessity of a highly trained physical therapist might reasonably be called into question. It seems to me that our usefulness and impact has everything to do with our knowledge, which is no surprise, of course.

Perhaps you’re seeing my point – trouble with recovery is what makes us necessary, but that cannot be foreseen and it’s unlikely that it will ever be understood by an orthopedist.

What does this imply about our relative necessity and the nature of the condition treated?

[Barrett Dorko]

Today I reread the passages in A Leg To Stand On that describe Oliver Sacks’ encounter with the physiotherapist in the London hospital where his post-surgical leg lies somewhere in the bed with him (he doesn’t know where without looking) and he can’t generate a contraction of any sort in the quad. I think pages 59-67 of the hard cover edition should be required reading in every PT program.

Two things stand out; the manner of the therapist and the monumental confusion of the patient. Sacks is especially struck by the therapist’s voice, ending most quotes with “she roared.” In addition to that he describes her as a “field hockey gamesmistress.” I get the picture. Her frustration with the orthopedic community’s disinterest in the issues surrounding recovery is obvious but when Sacks cannot generate any of the movement she wants she is at a complete loss and makes matters worse with her physical and verbal deflation as she leaves the room.

Sacks is left to contemplate the meaning of his failure by himself, and, being one of the most thoughtful and insightful neurologists of the twentieth century, he manages this – spectacularly.

Again, it seems that therapists clearly become necessary when things go badly, especially when there is a major neurologic component. In orthopedics this is far more common than we imagine. Oliver Sacks would agree.

Think about it – all pain is neurogenic.

[Mr. PNI]

Yes Barrett, I strongly agree with your OT professor's generallity. I am an OT who works part-time in acute care. The rub is, that people OT (and PT?) are not trying to adress the underlying health issues/behaviors which landed most of the people in the hospital to begiin with. I try. For example, a pt who has just survived a CABG, or THR, or DBS implantation I routinely ask them, "Well, now that you've survived this surgery, what are you going to do differently when you get home to avoid the need to come back for more? Yes, this is not what that professor or others are teaching there students to know/do. Grads must be good at analyzing gait, doing transfers, one-handed dressing, etc.

I deeply respect that you are raising this question in a public forum.

Mr. PNI