Abduction

[Barrett Dorko]

There have been over 70 views of the Postural Restoration (http://www.somasimple.com/forums/showthread.php?t=2444) thread without another comment so it’s probably time to move on.

When conclusive evidence for a specific, relevant and accurate essential diagnosis is hard to find we cannot simply follow the typical inductive or deductive processes of reasoning we are used to, but rather must include the logical inferences of abduction detailed in Discovery and Abduction (http://www.barrettdorko.com/articles/discovery_and_abduction.htm) on my site. I would like to see whether others have something to add to this.

I have some thoughts but I’ll wait.

[bernard]

Barrett,

The is a dead link in your file => http://www.faseb.org/opa/pylori/pylori.html which may be replaced by this one http://opa.faseb.org/pdf/pylori.pdf. I made a pdf version of your essay with a working one. And I dowloaded the pdf about Helicobacter.

[nari]

I did some more Ix on de/in/abduction; lots of papers comparing the three in google.
Based on Peirce's (sic) work, Dr Chong Ho Yu writes:

Neither deduction or induction can help us to unveil the internal structure of meaning.

Which I take to imply understanding.

Deduction..cannot lead to new knowledge (on its own)*
Induction.. is inconclusive in infinite time
Abduction is not symbolic logic but critical thinking.

*my parenthesis

What I hope to do is play around with examples of the three as they relate to physiotherapy practice and research. More later...

Cannot type the link as it has squiggles.

nari

[Barrett Dorko]

Thank you Bernard. And Nari, some wonderfully succinct comments there.

From my essay:

Abductive reasoning follows the following pattern:

Some phenomena P is observed.

P would be explicable if H were true.

Hence there is reason to think that H is true.

In other words, the scientist confronts puzzles that arise naturally during the course of their work, thinking about them in light of their intimate knowledge of the system and then they make a creative leap of the imagination to say, “This would all make sense if H were true.”

Using the formula above, if "P" is spreading pain, spontaneous pain, tingling and numbness, alteration with position and use and autonomic disturbances, well "H" can't be posture or asymmetry or weakness or any sort of localized injury - it has to be something else.

To me, the consequences of an abnormal neurodynamic are so commonly present in cases of persistant discomfort that every day I am further convinced that it is by far the most likely essential diagnosis appropriate for my patients.

Is there another condition that would fulfill "P"? Isn't abduction the best way to reach this conclusion?

[BB]

Hi Barrett,
I love the last 2 lines of that essay!

I had a conversation yesterday with a co-worker who, after attending a workshop this weekend by a well known orthopaedic manual therapy certifying group out here, told me that her instructor "sure didn't have nice things to say about your nerve stuff."

She explained that he thought these things were explained by a list of various other tissue involvement. I made the argument "why doesn't everyone with abnormal posture have pain then?" and started to talk a bit about the nature of the nervous system. At this point she broke in and said, "they just are big into science, and will always have trouble with the artistic side of PT."

I think this is part of the reason why so many PTs have trouble or issue with pain physiology and the role of the nervous system outside of being another tissue. It is not mechanical and does require some abductive reasoning. I wonder if they would call anything that isn't in/deductive as "artsy?"

Cory

[nari]

Cory

I find that an amazing statement; it implies they are not into science, but what looks good or feels good. I thought the USA was big on EBP...but perhaps, scared off with abductive reasoning because it seems to be outside EBP, are stuck with in/deduction.

Did you get the feeling that you were not being listened to?

Nari

[Barrett Dorko]

Cory,

Please warn your co-worker not to attend my course. I'll probably end up making her cry.

It is also common for people to complain that I lack any appreciation for science as they understand it, that I'm too "intuitive." Next thing you know they're going to complain about my hair.

It's hard for the manual sorts to understand that problems that are truly neurologic can mimic orthopedic ones. This changes many things, not the least of which is the manual approach required.

Tell your colleague to watch a few episodes of House on Fox TV. He uses abduction all the time. His manner is even worse than mine - something I've always found comforting.

[nari]

Cory

I realised, after a second reading, that I misunderstood what your colleague was saying - it was rather that the manual/orthopaedic guys were into science and the neuronuts were 'artsy' - sorry about that.

Good grief.

So the brain is artsy, while fascia, ligament bone and muscle are "real" science. Real because these structures can be prodded and poked at, imaged, and given a life of their own without any input from the brain.
Deduction and induction analysis..

Yikes. It is worse than I thought....

Nari

[Diane]

Way, way worse that you ever dreamed Nari.

[nari]

I have been playing around with ab/de/induction in reference to common clinical conditions that we all see at some time or the other, to try and sort out the clinical reasoning process. There are other folk here online that can do this sort of thing better, I know, but these snippets came to mind:

What are the processes of logic for these:

The use of McKenzie's principles for severe LBP with peripheral pain and paraesthesia:

Pain increases with restricted flexion, no pain with restricted extension. Repeated extension leads to slow resolution over some weeks. The NP has 'returned' to where it is supposed to be. Thus, the method works. Induction, generating empirical laws.

McConnell's routine for PFS:

Physical observation that the patella tracks anormally (sic). VMO is a bit shrunken. Taping provides a change in tracking path, and VMO is strengthened by global and local exercise. Pain reduces - therefore it is the Q angle and a weak VMO that caused the problems, including the hip and foot. ???

Impingement in shoulder:

Zillions of tests to pinpoint a single cause. (Usually a bony one, or a tear in RC or both) Clinically, improvement can occur with complex exercises. Therefore specific strength restoration solved the dysfunction. ???

None of these simplified examples suggests abduction.
All of the above can be managed in terms of an abnormal neurodynamic approach, not exclusively via SC, without acknowledgement of other tissues in the first instance. General exercises and improving fitness certainly can follow after pain is managed first.

Comments?

Nari

[BB]

I've had several discussions with this co-worker. There are, as always, other factors at play here. The biggest of which is a fear of change.

Nari, I think you are right. If they can't see it, touch it, scan it then it must be bogus, or touchy feely/artsy. I think a lot of PTs will classify what they see mechanically and then label the rest as psychosocial and therefore not in our realm. An easy excuse to not have to reason abductively?

Cory

[Randy Dixon]

I was going to comment on this last night, but sometimes I sound like a broken record on this subject. People are different. There are those who have an aptitude, and hence a preference for inductive reasoning, and those who have an aptitude for deductive reasoning. While a deducer can use inductive reasoning they use a deductive process to understand it. The can't understand abductive reasoning at all, because it is contrary to deductive reasoning. To them, abductive reasoning means "guessing".

I discussed this before in terms of personality type, in/abductive reasoning is an open ended process, deductive is close ended. We can only really be comfortable with one of these, even if we are able to use both. The people who choose to inhabit forums such as this one, who find theory and philosophy, allegory and analogy, in short; open endedness, useful and interesting will be open to ideas expressed here. It's no coincidence that the neurological viewpoint is more evident to these types, since deductive reasoning doesn't get you far enough on this road.

I've also noticed that many viewpoints are essentially seeing and saying the same thing, and communicating them in ways that seem to contradict each other. That is how I see many of the debates on these forums.

The truth is often found in a fine line down the middle, but often an issue that appears to be dichotomous is actually more like an unfinished circle, with the extremes at either end almost looped around to touch each other, but instead of trying to look for the similarity in the small gap that separates them they look over the vast distance that makes up the rest of the almost finished circle.

Or maybe it is more like a Mobius strip, with points that appear to be on different sides of the strip, but if one connects all the points, one realizes there is no "opposite" side.

[Barrett Dorko]

Randy,

I appreciate your thoughts here and agree with some, especially when you say that "people are different." No doubt.

But our differences, including the way we see things, doesn't change the fact that some investigate everything that comes along using Occam's Razor and a keen appreciation for biologic plausibility - to say nothing of physical law - and others find something they're comfortable with and lie down there. I'm a committed skeptic and thus obligated to investigate carefully anything another offers. Believe me, it's a lot of work.

Induction, deduction, manipulation, strengthening regimens, postural instruction, traction devices, TENS, most modalities of heat or cold application along with many other traditional methods of thinking and practice have one thing in common - an ignorance of recent neurobiologic discovery. I say this because I've spoken individually to hundreds of therapists who think and practice this way and, at most, their familiarity with the subject is that they've heard David Butler's name. I'm not making this up.

When therapists know next to nothing about neurobiology as it exists today they simply aren't going to take the time to look for an answer there.

Abductive reasoning doesn't require an entirely new way of seeing things and we use it regularly. An example: Don't see the morning paper? Well, if the paperboy is sick that would explain it. But other explanations can come to mind that would make sense of this and each should be considered until the solution is discovered. If we think our first guess is always right, well, we won't look in the bushes.

And that's the key to understanding this: in/deductive reasoning tends to create a reason for what is seen and then attempts to make our observations fit that premise. Abduction asks questions - "If a certain thing is present, what might further testing reveal? What are the appropriate questions to ask?"

Ultimately, in/deduction follows a form that adheres to some condition we've imagined to be present. In short we create it. Abuduction discovers the condition through further and less-biased means.

[Barrett Dorko]

After that last post I walked Buckeye for a while and I thought of this:

What a therapist admires in a certain kind of care or if they have a personality variant that lends itself readily to a certain interpersonal approach, this cannot dictate what sort of problem a patient actually possesses.

I've met many former or wannabe athletes who practice as if everybody in pain simply hadn't "worked-out" enough to overcome it. Others are cheerleaders who act as if strong verbal encouragement and personal perkyness (just made up that word) would be enough to teach others how to get better. Still others are frustrated (and personally needy) psych counselors - and we know what sort of trouble that leads to.

If we are scientists first and foremost we need to understand that we can't create or describe the universe in the way we would prefer it to be but only, to the best of our knowledge, the way it actually is. Then we have to figure out a way of living in it without imposing our personal "belief" system upon others who aren't interested in it. To do otherwise is evangelizing. That's religion's job, I guess.

Not uncommonly a student will firmly say to me "I believe in good posture." I remain calm, but I always think, "Here we go again."

If alienation follows it has nothing to do with my demeanor, it has to do with my introduction of abductive reasoning. I know that's irritating to many. To others the subject simply is too intricate to handle and too destructive to the in/deductive conclusions they've drawn.

I'm convinced that's why the MFR and PRI therapists bailed out or retreated to ad hominem attacks. If I'm wrong, they need to explain how and why.

[Diane]

Could abductive thinking be regarded as the more science-based version of lateral thinking? (Cows are animals but not all animals are cows..)

[Barrett Dorko]

Diane,

I'd prefer to stick with what the author of the original article in The Skeptical Inquirer says. Abductive reasoning leads to discovery, and, if we examine carefully the great scientific discoveries in years past we can see it has always been used.

[BB]

I really like your response Randy. People are definately different and have different mechanisms and personalities which affect their way of seeing and exploring the world around them. (I've had Kiersey's Please understand me 2 on my shelf for a while, because I really want to know more about this. Any useful references or resources you could send my way?)

I also like your response, Barrett. Just because people are different doesn't make a theory wrong. It doesn't make neuroscience irrelevant.

If we are scientists first and foremost we need to understand that we can't create or describe the universe in the way we would prefer it to be but only, to the best of our knowledge, the way it actually is.

Maybe what we need to be able to do is be prepared and able to explain the way things are from multiple perspectives.

Maybe Nari's post above, for examples of different reasoning, could be explored to practice ways we could explain what neuroscience has to say from different angles. In ways that a person who tends to think dominantly in/deductively would be able to swallow.

Cory

[nari]

People do things differently for sure. That is part of human nature, and it is also why we have a broad code of conduct for clinical practice. The stringent rule is: Do no harm. However, it is prudent to also do good, in the most efficient and logical way, because we owe that to our patients. Doing good means not telling them wild and woolly stories about energy fields,tissue memories, pain originating in muscles and rationale which does not fit with current knowledge.

But we can still be thinking laterally, or abductively.

For instance; those of you who do ULNTTs as a test and treatment, it was probably demonstrated and taught with the therapist standing, probably behind the patient's shoulder. I do it differently, because I need to see the patient's face, and he/she does not need to have a standing person towering over them (a threat to the CNS). I sit on a moving stool, facing them, and rest their upper arm on my knee. I'm at their level, and can easily support a heavy limb with no effort on my part.
Someone said: But that is not how Joe Bloggs (the teacher) said to do it.
I said: no, this is how I do it. It is my preference.
I'm not changing the basic neuro understanding base, but the way the technique is carried out. There is great scope to do this, and it makes a difference to the patient/therapist interface or whatever the trendy term is these days....

Nari

[Randy Dixon]

Cory,

I think MBTI is interesting, some people get too wrapped up in it, but I've found it useful for understanding myself. The most useful thing I found in it was "so that's why I've always felt out of place" and "so that's why people think that way", because frankly, people are usually a mystery to me.

My guess, and my theory, is that you are most likely an IN**, probably INFP. I think most of the people on this forum are IN**'s, I know Nari is an oddball INTP like me, and I strongly suspect Barrett is an INTJ. So take the test in the book, and see if the description resonates with you. Let me know the results.

If you are an IN there are forums created for your type so you can talk things over with people of the same type. If you are another type, the chances are fairly small that someone created an online forum.

[nari]

I was pretty cynical about the whole MBPI thing, until I had to answer one in a course, and was surprised at its accuracy. Seven of us did a comparison together to see if it interpreted anything individual or just gave horoscopes out - but there was a pattern of accuracy.

Randy, I know I am weird, but an....oddball?? ;)
I remember that conversation from a while back. But if it is anything to go by, I would expect most of us regulars here are INs, as you do.

Nari

[BB]

Hi Randy,
Well, you are correct. I'm an INFP which is the "Healer" category. I was actually very close on outcome (9 to 11) between F/T and P/J. The healer description definately hit closer to home though. That's enough of a prod to get me reading this book, finally. I'll post on another thread as questions arise.

As far as this thread goes though, does your ability to potentially recognize someone's personality type (category) enable you to come to any conclusions about their explanatory style? If so, could we conceivably bring a topic that requires abductive reasoning to a person that uses in/deductive reasoning in ways that fit their model, without sacrificing content?

Cory

[Barrett Dorko]

Cory,

I appreciate your thinking. Perhaps an actual educator could address the issue. Of course, getting an academic to participate here has proven impossible so far.

I struggle to get others to even consider the neurobiologic aspects of manual care, not because they deny the existence or worth of the literature surrounding them, but because (it seems) they occupy some alternate culture, perhaps even an alternate universe. There they seem satisfied with the plethora of theory that precedes a large variety of methods without critical examination. Even worse, they honestly believe that theory, or even hard thinking, isn't an important part of everyday practice. They are driven by protocol, overwhelmed with record keeping and constantly mindful of productivity.

In short, they've become robotic, and even in/deductive reasoning has lost its place in their practice.

[nari]

Cory,

That would be a useful exercise to at least attempt, on another thread. I actually set out to look at conditions which would be usually dealt with via de/inductive thinking, and apply abduction, but got myself into all sorts of conundrums.
Give it a go!

Barrett,
I learned on RE that the push for productivity and alignment with protocols seem to overtake most PTs, and this is a concern for the health of the profession in some ways. Even if the 'others', whom you refer to, had the time and interest in replacing complicated thought with complex thought..would they do so? Introducing the complexities of neuroscience would seem to add tons to their already overloaded universe, with its separate components of mesodermal structures.
Do you see any solution to the protocol-driven and documentation conglomerate? If there isn't one, abductive thinking may never occur....

nari

[Barrett Dorko]

Nari,

Presently, I see no way out. Tomorrow morning I fly to Orlando to attend the National APTA meeting. Maybe a solution will present itself in one of the bars where most of my lectures will be conducted. Maybe a bartender will have an idea.

I've noticed that if I begin by saying "This profession is all but dead" that a lot of people stop listening at that point so I'm working on an alternative opening. I'll let you know how it goes.

[Jon Newman]

How about, "Do you suppose the best way to reduce unwarranted practice variation is start by reducing the number of theories that give birth to such disparate practices in the first place?"

Now what can I get 'ya? We have Guinness on tap.

Brilliant!

[Barrett Dorko]

Jon,

Great, great question. I'm going to commit it to memory.

Maybe I could follow it with, "Or are you one of those who thinks that theory should follow technique rather than precede it?"

You don't think anyone will take a swing at me, do you?

[Randy Dixon]

Barrett,

Not if you are buying.

I agree with you, the primary problem seems to be that most therapists, like most people, aren't really concerned with critical thinking. They want to be told how to practice, if pt. has A then therapist does X, they then concern themselves mostly about whether pt. actually has A or is it B.

To answer Cory, I'll give you a short version of my views about this, because I think it fits in with the abductive reasoning thread. I don't make any claim of knowing what I'm talking about. I think that by knowing about other people's personality types we can adjust what we present and how it is presented to make it more accessible and interesting to them, but what we cannot do is really understand the way they think; and this problem cuts both ways. I think some of the problems Barrett discusses about reaching the therapists he teaches is that to understand his ideas you have to, to some degree, understand the way he thinks, that is why there is this thread about abductive reasoning. Some of us, those that are still on this forum, are able to do this. This isn't the case for many people. For example, you were able to follow my first post in this thread and interpret it correctly and probably fairly easily. Many people's response to reading that post would have been "Huh?" My wife would have been one of them. Barrett's friend SJ, would have been another. It's not a matter of intelligence or critical thinking skill, it is simply a difference in how we gather and process information. Given the same information, my wife and I often reach the same conclusions, but the roads we take to get there are very different. We are usually mutually baffled if we try to explain our course to each other.

One other thing to keep in mind, us IN** types are minorities, most of the world is different and the *S*J's of the world write the rules, they run our schools, our government and bureaucracies (or EBM). We are used to dealing with them and the way they do things. The opposite isn't true, they are not used to dealing with us, except maybe in some university classes or other academic setting, entering a forum like this one is a type of "bizarro" world for them. I think this is the reason some people say the thoughts presented here are "unscientific" or "strictly intuitive" etc.

[nari]

Randy,

I think it is also a strong reason why so many members don't post anything. They sense this is a different world of thought, and as interested as they may be in another way of interpreting what one finds clinically (viz, the A,X,B?C? logic you mentioned), it may be daunting to explore this world online. After all, at the computer, one is alone, basically, without the supportive conversation amongst colleagues that occurs at a class. (Barrett may disagree here..)

Also, perhaps, there is confusion between the definitions of clincal reasoning and critical thinking. They are not the same, but do some think they are synonymous?

Nari

[Barrett Dorko]

Nari,

An interesting point. I'd love to see the distinctions between critical thinking and clinical reasoning. I would struggle with this myself, but I know they're there.

Randy,

Good to see another Superman fan here. Others see us as "too scientific." We occupy a "A Third Way" of thinking and practicing. There's an essay with that titile on my site.

Thanks so much for reminding me of SJ. I had almost forgotten her but now the nightmares may begin again.

[nari]

I'll have a bash at the difference between critical thinking and clinical reasoning.

Waaay back in the mid 80s, there was huge emphasis on clinical reasoning, in the afterwash of the Maitland/McKenzie mania. One needed to look at the symptoms and signs; test for disc bulges, facet joint dysfunction, wandering menisci, obstructions in the shouder or referred pain confusing the whole issue, and come up with a diagnosis. This was based on the premises made by these guys who had done a great deal towards moving physiotherapy out of the dark ages of electrotherapy, short wave irradiation and flexion exercises.
"Make the features fit" was the logo. Never understood that one...fit what?

There was no actual critical thinking. No questioning of why a bulging disc causes pain, it just did. Compression of a nerve caused parathesia and weakness, but only sometimes, pain. Nuclei pulposi (sic) wandered around and made pests of themselves if people bent over too much, or lifted heavy weights. We didn't question why some people spent their lives bending and lifting and had no problems, while others who didn't, had severe bouts of back pain....

We didn't question the discrepancies, but just accepted they existed. If someone asked:"But my patient today was different and it made no sense, why?"

Nobody knew outside the parameters set by the researchers, and that was that.
Today...quite different. Third year students question and debate the findings of researchers, freqently.

Nari

[Diane]

I'll try: Clinical reasoning can be in/deductive, but critical thinking is abductive.

I remember the Bizarro world (http://www.amazon.com/gp/product/1563896249/sr=8-1/qid=1150815203/ref=pd_bbs_1/002-8776663-3410401?%5Fencoding=UTF8) from Superman comics very well. It appealed to my ten-year old mirror neurons.

[Barrett Dorko]

Diane,

I think that this is a pretty bold statement. At the moment I think you may have hit upon something that has been missed in many previous discussions surrounding the issues of essential diagnosis and the justifications for specific forms of care.

Also at the moment I agree. Perhaps this thread will weave its way in that direction.

[Mike Terrell]

I would agree that abductive thought is not generally thought highly of in the clinic, at least in a practical sense. New approaches to a common problem are welcomed, as long as they don't fall to far from the norm. I think of "trick plays" in (American) football. As long as you are following the rules, a new play is welcomed with open arms and even celebrated. I am allowed "trick plays" by my colleagues, as long as it falls within the standard box.

mike t

[Barrett Dorko]

Mike,

What rules are you referring to? The one that arbitrarily dictates that treatment of any significant length (say, beyond 8 minutes) must be turned over to the PTA primarily for financial considerations? The one that states outcome studies must be completed on any form of care new to this clinic before any changes occur? (This one, by the way, doesn't apply to any treatments we currently do) There are others, of course, and your clinic might not be described in this way at all.

The comedian and political commentator Bill Maher (http://www.hbo.com/billmaher/) has a segment of his show "Real Time" on HBO titled New Rules and it seems to me that this thread might now turn to our proposal of "New Rules" for clinical practice. I'll start.

New Rule - No method of practice, no matter how long its been used, should be performed without the practitioner being able to explain its rationale in terms that are physically possible and biologically plausible. Relevant references should be readily available.

Anybody else have one?

[nari]

Barrett,

That is a good new rule.
But I am flummoxed by the two that you stated -do these 'rules' actually exist? Not that I doubt your words; I am continually surprised by the mega restrictions in the USA.

Might be useful to explore some of the 'rules' that exist as examples of nonabductive thought, for those outside the USA who don't have such restrictions.

Nari

[Mike Terrell]

Barrett,

I agree that the 8 minute rule exists. The other "rule" you stated regarding outcome studies might not be a bad idea considering what I usually put up with. Some of my colleauges seem to be able to rationalize any treatment which looks like it should work by using random bits of unproven info gleaned from CE courses taken 10 years ago (courses espousing treatments which have never really been that beneficial, or no more benefical than a placebo).

Nari,

We Yanks, as a group, do some astoundingly irrational things. Go harder, be more productive, go the extra mile, stress yourself out on a daily basis so that cardiovascular disease sets in early! Hoo-aah! I have thought my personality and natural inclinations would fit better in Australia. Besides, you folk do some wicked cool research.

mike t

[Mike Terrell]

I just read this quote after my last post. I don't know who the speaker is, but I thought it was appropriate to the discussion.

Reality is that which, when you stop believing in it, doesn't go away.

Phillip K. Dick

I think this gets at what Barrett has said regarding the average person's ability to ignore rational thought and solid evidence in order to believe that which sounds pleasant and comforting.

mike t

[Diane]

I think you nailed it Mike. Thanks for putting up that quote!

[Mike Terrell]

Another thought occurred to me regarding in/de/abduction. Some of my colleauges have been practicing for 20 years or more. I have noticed that they seem to view PT through a different lens. Doctors are not to be argued with or questioned. When they give us a dx, that is the problem we treat. PTs use different tools out of their toolbox until we find the right one (results matter, not theory).

I have noted that the newer generation of PTs don't see things this way. They are being trained to be independent practioners (i.e. the DPT trend). I think they will be more likely to be truly scientifically minded in their approach; open to plausible, if novel, ideas. Please note, I said likely, not certain.

mike t

[Barrett Dorko]

Mike,

I appreciate your optimism.

There's a third player in the mix now that didn't concern us 25 years ago as it does today but younger therapists are affected by it even more powerfully than the physicians we used to at least know by name. Of course I'm talking about the faceless, voiceless insurance industry.

How are we going to beat them? Without really consulting us they've come up with a variety of New Rules with just one object in mind - and it isn't the professional growth of any therapist.

Ironically, if we use abductive reasoning to determine that a patient has an abnormal neurodynamic and thus make all the humans involved relieved that a legitimate and treatable essential diagnosis has been articulated, we simultaneously irritate the insurer.

I don't think that's fixable without deception.

[Diane]

Mike, I think that it is important to separate out factors such as age, training, work habits(entrenchment) and independent practice capacity from de/in/abductive reasoning. There might be correlations, but not cause/effect.

I've been practicing 35+ years.. the older I get the more I realize I don't know.
I've been an "independent" contractor (i.e. self employed) since 1983, which is more a governmental designation than something achieved by reasoning or learning..
I've been a sole practice owner since 1994, with direct access, but I look around and see other direct access primary contact PT practitioners still using formulaic outside-in approaches, without ever really trying to understand the living human "creature" with which they are dealing.

I really think it comes apart along different fracture lines somehow than the ones you described, although sorts of thinking that are either suppressed in training or encouraged are obviously very important;

One clinical supervisor/head of department I was unfortunate enough to cross swords with at the tender age of eighteen, tried to have me tipped out of the program for not exhibiting proper obsequiousness to her, or military style overall, bad posture, messy hair, a belt that folded over, not enough smiling at superiors, having a run in my stocking one day, rumpled chubby appearance in general, etc etc etc.. all these terrible character flaws according to her sharp PT sensibilities. (I was always a rebel against those military memes.)
Fortunately the head of the school, who had known me longer, saw things differently and I was allowed to continue.

So here I still am, still trying to figure out why I'm here, still privileged to treat the most sensitive nervous system and yet the most easily influenced/tameable/domesticable in existence, the human one. Still trying to unearth myself from all the mental PT crapola meanwhile.

[Barrett Dorko]

Diane,

Several instructors questioned ny fitness for the profession as well. It wasn't my physicality that they questioned - in fact, that was my main attribute in '71, being a large male - it was the fact that I slept continuously in class. This was reflected in my grades as well. I've made up for this by being "awake" ever since. I think.

One difference between us. I've been practicing nearly as long, and it's taught me how much others don't know. Ha, ha.

[Mike Terrell]

Barrett & Diane,

My comments, of course, are based on those I work with and see on a daily basis. Seeing what they do, why they do it, and how they do it is a frustrating experience. The problem being is that they are in charge (i.e. signing the paycheck), so my pt. care has to fall within a certain mold. Granted, the mold is not excessively restrictive, but an inside-out model of care definitely is not in the mold.

I often feel like a covert operative, trying to sneak in new ideas without anyone else noticing. I have no problems with being subversive.

Earlier, comments were made regarding personality type and whether abductive reasoning was natural or not. Doesn't the motivation to explore and consider alternative explanations have to be present before your type reasoning is even relevant? It seems that many of the PTs I know want to be fed a system, the solution, the "cure". Reading a research article takes too much time, books are expensive, and participating in critical discussion requires effort. I don't meet too many motivated PTs. They like what they are doing and have job security. Horses with blinders on.

mike t

[Diane]

Mike, if they're twenty-something or even early thirties they are still learning how to be adults perhaps. They may not be able to give themselves permission to look over the rim of the box until they're older.

I was thinking about other professions earlier, and it occurred to me that every one of them has the usual assortment of types. Those who make rules, those who are most comfortable following rules, and those who break them or go around them because of how they don't make any sense.

[nari]

Mike,

Just to let you know Phillip Dick is (or maybe was) a sci-fi writer, and I did read a few of his books ages ago. I like the quote, too.

I think you would be very happy in Oz, the UK or Canada - like a cow (sorry, bull) suddenly put out into wide green fields after being contained in a corral. Yet, there is still a lot amiss with clinical practice, as Diane has outlined, and that is probably universal. PhDs are becoming almost too easy to obtain, with some theses that do not actually say anything useful. That is a megaconcern.

I think most PTs can rationalise almost anything they do; and they have the freedom to do whatever they wish within the big picture of 'techniques'. However, the problem then arises with the 'toolbox' theory: if one collects twenty tools, then it becomes harder and harder to fit the tools to the patient's condition. And if one runs out of tools...what then? :eek:

That would make a good cartoon - must go and do that..:)

Nari

[BB]

What then?

More hotpacks? More ultrasound? Maybe a hotpack AND E-stim, that way you can charge for it:thumbs_do.

[bernard]

Cory,

In France, you can't charge the insurance/patient like that. If you're using one or twenty techniques, the fee remains unchanged. :eek:

[nari]

It's the same in Australia. It does not matter what a physio does; that is none of the insurer's business.

Nari

[Randy Dixon]

Nari,

Then how do you charge? By time or a flat fee or..?


and just for laughs:

One difference between us. I've been practicing nearly as long, and it's taught me how much others don't know. Ha, ha.-Barrett

"The INTJ's interest in dealing with the world is to make decisions, express judgments, and put everything that they encounter into an understandable and rational system. Consequently, they are quick to express judgments. Often they have very evolved intuitions, and are convinced that they are right about things. Unless they complement their intuitive understanding with a well-developed ability to express their insights, they may find themselves frequently misunderstood. In these cases, INTJs tend to blame misunderstandings on the limitations of the other party, rather than on their own difficulty in expressing themselves." INTJ PROFILE

http://www.personalitypage.com/INTJ.html

[Barrett Dorko]

Randy,

The INTJ description you cited is exactly the same that we have in Ohio for a certain sort. We don't have an acronym for it though - it's just a metaphor involving a body part.

I see as well that whoever wrote that has a novel idea of "intuition." Modern neuroscience seems not to be involved there.

[nari]

Randy,

Unless there has been a sudden change (have not worked in private pratice for a while) - the patient pays whatever the physio charges per session, usually a flat common fee; the compensation patients' fee is much higher, set by the insurer, and is also flat. Gets complex when the PT has to deal with Veterans' Affairs, sometimes; otherwise straightforward. The amount of time set is anything from 20-60 minutes. However, as in all countries, there are those who see 4 or more patients an hour, which is nothing more than a rip-off.

By the way...I fit that INTJ description rather well.......;)

Nari

[Jon Newman]

In the spirit of rules:

Nari, Diane and others, you'll love this. I know I found it to be hilarious in a pathetic sense (The situation, not the writing). The excerpt if from the always entertaining News from me (http://www.newsfromme.com), a wonderful blog written by Mark Evanier (http://www.povonline.com/About%20ME.htm)

Last night, I went back to my friendly neighborhood Sav-on Drug Store which, to the confusion of elderly patrons everywhere, is becoming a CVS Pharmacy. A sign out front promises that the new establishment will have "More convenient hours." Since the place is now open 24 hours a day, every day of the year, I can't wait to see how they manage that.

I was there to pick up a renewal on a prescription and the man behind the counter fetched it and announced, "That'll be $91.88." I said...well, here. I'll let you listen in on what I said...

ME: What? I've been getting that prescription for two years and it's always been ten bucks.

PHARMACIST: (after consulting his computer) You're renewing it ahead of schedule. Your insurance doesn't pay unless you're within seven days of running out.

ME: And when will I be within seven days of running out?

PHARMACIST: (after consulting his computer again) June 20.

ME: It's 11:54 PM. In six minutes, it'll be June 20.

PHARMACIST: And in six minutes, it'll be ten dollars.

ME: I suppose there's no point in mentioning that I'm not going to be taking that pill tonight. I am just as "out of it" as I will be in six minutes.

PHARMACIST: Right. There's no point in mentioning that. At this moment, it's $91.88.

I went to the end of the line and saved eighty bucks. Makes you wonder what the mark-up is on these pills. And the funny/sad part of it is that this particular drug is also sold over-the-counter without a prescription for $23. I'd hate to think there are uninsured people out there who don't know that and are paying the $91.88, but I'll bet there are.

By the way, I'm told by several folks that not every Sav-on is becoming a CVS. Good for them. This conversion is already becoming way too traumatic for me.--Mark Evanier

[Diane]

Jon, it makes me shake my head.
Ain't life wonderful.

[nari]

A couple of points - from a non-North American..

What is a CVS pharmacy?
Why didn't this fellow just buy it OTC? Or does the prescription automatically confer the massive reduction for everyone??
What sort of insurance pays for prescriptions? Have never heard of that...

Apart from my ignorance of the medicopharmaceutical situation - yes, it is a potential rip-off by the sound of it! :mad:

Nari

[Jon Newman]

Hi Nari,

Here's one source of info for CVS (http://en.wikipedia.org/wiki/CVS/pharmacy).

Many insurances have a "prescription drug benefit". As you can tell by the prices, it is essentially required to be able to afford medications at all. Diane can vouch for those US folks buying their meds from Canada.

The reason the fellow didn't buy the meds OTC was because if he simply waited six minutes he got the same thing for 13 dollars less than the OTC price not to mention that the OTC version of the drug tends to contain fewer mg of active ingredient than the prescription form.

Now think about patients used to have their PT payed for by insurance companies (something I'm not entirely against). How many are willing to buy OTC PT so to speak? How many could afford it? That last question is complicated by a whole other set of rules that would really send you into fits.

[Diane]

The seniors come to Canada literally by the bus load to pick up their cheap no-name drugs, manufactured to standard but non-patented. Bus lines are deep in the black over this to the point where they are offering group rates now. US seniors need a Canadian doctor to sign a perscription, but Canadian doctors are glad to oblige for a cash fee, and make themselves available in border towns for such purposes. Such seniors are referred in this spoof editorial:

Canada's Current Crisis
Manitoba Herald, Canada

The flood of American liberals sneaking across the border into Canada has intensified in the past week, sparking calls for increased patrols to stop the illegal immigration. The actions of President Bush are prompting the exodus among left-leaning citizens who fear they'll soon be required to hunt, pray, and agree with Bill O'Reilly. Canadian border farmers say it's not uncommon to see dozens of sociology professors, animal-rights activists and Unitarians crossing their fields at night. "I went out to milk the cows the other day, and there was a Hollywood producer huddled in the barn," said Manitoba farmer Red Greenfield, whose acreage borders North Dakota. The producer was cold, exhausted and hungry. "He asked me if I could spare a latte and some free-range chicken. When I said I didn't have any, he left. Didn't even get a chance to show him my screenplay, eh?"

In an effort to stop the illegal aliens, Greenfield erected higher fences, but the liberals scaled them. So he tried installing speakers that blare Rush Limbaugh across the fields. "Not real effective," he said. "The liberals still got through, and Rush annoyed the cows so much they wouldn't give milk."

Officials are particularly concerned about smugglers who meet liberals near the Canadian border, pack them into Volvo station wagons, drive them across the border and leave them to fend for themselves.

"A lot of these people are not prepared for rugged conditions," an Ontario border patrolman said. "I found one carload without a drop of drinking water. "They did have a nice little Napa Valley cabernet, though."

When liberals are caught, they're sent back across the border, often wailing loudly that they fear retribution from conservatives. Rumors have been circulating about the Bush administration establishing re-education camps in which liberals will be forced to drink domestic beer and watch NASCAR races.

In recent days, liberals have turned to sometimes-ingenious ways of crossing the border. Some have taken to posing as senior citizens on bus trips to buy cheap Canadian prescription drugs. After catching a half-dozen young vegans disguised in powdered wigs, Canadian immigration authorities began stopping buses and quizzing the supposed senior-citizen passengers on Perry Como and Rosemary Clooney hits to prove they were alive in the '50s.

"If they can't identify the accordion player on The Lawrence Welk Show, we get suspicious about their age," an official said.

Canadian citizens have complained that the illegal immigrants are creating an organic-broccoli shortage and renting all the good Susan Sarandon movies. "I feel sorry for American liberals, but the Canadian economy just can't support them," an Ottawa resident said. "How many art-history majors does one country need?"

In an effort to ease tensions between the United States and Canada, Vice President Dick Cheney met with the Canadian ambassador and pledged that the administration would take steps to reassure liberals, a source close to Cheney said. "We're going to have some Peter, Paul & Mary concerts. And we might put some endangered species on postage stamps. The President is determined to reach out," he said.

[nari]

jon,

Wow...how political can it get? Even more, probably, in years to come.

We're pretty well covered in Australia, with Medicare (open to all, but compensation patients are strngly discouraged from booking in) and private health insurers. Probably around 45-50% of people are privately insured for hospital and outpatients services; and these are the ones who go to OTC PT, and are covered for more than half the cost of PT services. The others mostly go to hospitals and health centres; generally, people are happy to pay to go to a 'private PT', because they believe they are getting better skills and services. Not true, of course.

There is a lot of criticism about free health services - people do not value what is free. So it is up to the individual clinical practitioners to set rigid rules as to the frequency of attendance, expectations and so on. At least we can make all our own rules...

I would be interested in the 'other set of rules' you mentioned....at the risk of straying off topic. But I am sure there is some abductive thinking going on here.

Diane,

A hilarious account; sounds nearly as tricky as the problems with the USA and South of the Border immigrants. No-name (generic) drugs are widespread here, but they are identical in all aspects with the original drugs, and many pharmacies have large notices informing clients of the cost savings for generics. The generic drugs are not permitted to be sold unless they are identical with the originals; our TGA board (therapeutic goods admin) is strict on this. We also wait until drugs have been tested and retested for years in the USA before 'admitting' them into the country.

Nari

[Diane]

sounds nearly as tricky as the problems with the USA and South of the Border immigrants. Yeah, it's a complete sendup of that.

The US drug companies complain about the perceived financial bleed, but hey, free trade and all..

[Jon Newman]

Hi Nari,

The generic drugs are not permitted to be sold unless they are identical with the originals; our TGA board (therapeutic goods admin) is strict on this. We also wait until drugs have been tested and retested for years in the USA before 'admitting' them into the country.

Besides profiteering and outrageous discrepancies in CEO salaries versus the average paid worker your comment is one of the reasons we pay so much for drugs in the US. There is no free lunch so to speak. Anytime there is something unusually cheap it likely has hidden costs (e.g. Externalities (http://en.wikipedia.org/wiki/Externality)) that are borne by others.

I would be interested in the 'other set of rules' you mentioned

A typical scenario in the US is that a PT provider will charge an insurer a certain amount but not actually be reimbursed that amount due to contract negotiations. So for example, a bill will be submitted for $100 for 1 hour's worth of work but the reimbursement will be $50 (I'm making these numbers up but I don't think I'm too far off the mark of reality). Now if someone comes to PT and wants to private pay, I have to charge them $100 too rather than what we actually get paid by insurers. This is clearly a deterrent to the customer looking to private pay (or for the uninsured who have no choice). There are some creative solutions but they aren't perfect.

I'm sure others will be able to give exceptions and clarifications of what I wrote and they are free to do so.

[nari]

jon,

That is weird...the PT gets 50% of the rendered bill. Yikes. In your example, then the PT gets $50 for an hour's work, but if the patient pays privately...yikes again. Too complex for my way of thinking. Don't know how you guys put up with it; guess the answer is 'no choice'.

Although it is simpler here in Oz, I knew there was a reason why I avoided private practice; with my business acumen, I would be broke in a week.

Mind you, one would not want to be living in rural Oz; the system is barely functioning there; many towns are without any doctors. So if one's kid is running a high fever at 8pm - tough.

Nari