The Blog Strikes Back

I prefer Silverback to Dinosaur

The average lifespan of a physio is somewhere between 5 and 7 years, depending on what you read. There are many reasons for this. A stepping stone to medicine, keen on sport but couldn’t make it as an athlete, then realising being the physio isn’t the same as being in the arena. Or, graduating and realising that nearly all of your mates get paid more than you do.

Then you get the apparent outliers.

Next year is my 20th year as a physio. So in physio years I'm a dinosaur.

This has gifted and burdened me with the curious thing called experience.

So the combination of being wise and grey haired, a physio, a business owner and me means that I am compelled to put my thoughts into blog form to send out into the ether for the betterment of humanity.

Now every experienced person feels their experience is valuable. And on the whole I would take the advice of someone with grey hair over someone with none (grey hair, that is. Not hair generally. Bald people are generally bigger and stronger than me and so I would at least give them the impression I am taking their advice)..

Conditional on surviving and being successful, there is something in it.

But we have only seen our single path emerge from history. By definition we do not see a lot of alternatives, therefore we don’t think they do or could exist. This gives us a false sense of confidence in our quality. We may very well be excellent, it’s that we just don’t know.

It is with such a disclaimer that I dust off the quill and ink and re-unleash my blog upon the world. There is a previous iteration of this particular Death Star, you can find it on the internet easily enough if you so choose.

I looked at it myself recently and somewhat cringed, somewhat smiled.

This gives me some hope that my opinions now may actually be worth reading - as they have changed. And, if you have spent any time reading, contemplating and discussing the fabric of the universe, you will guess how, i’m sure.

No? 

Well, I am now more uncertain. 

About literally everything.

It drives my wife fucking bonkers.

“What does this mean”

“What do you think”

“I don’t know, that’s why I'm asking you, dickhead”

“How do any of us really know, though”

“......................... FML”

Conversely though, I probably appear more confident, and get better results, with clients.

And here I AM confident, not perhaps about the exact truth - be it pathology, diagnosis, pain behaviour, and certainly not about the future, but I am around how to ACT.

And I can still be wrong, but generally I’m pretty good.

What is the secret?

To understand firmly where the limits of our knowledge are and what to do when we encounter them.

Specifically as a physio, know when I am in my domain, and know when I’m not - and who to send them to.

Here is the “Experience Paradox” - Or The Phenomenology of Dave’s Blog

What do I mean by this? Well, like most things in this blog, in my mind and in the universe, it’s about to get weird. 

Here we have 3 axes, creating 8 boxes. You can be from high to low on each axis, namely Experience (hopefully obvious), Domain consistency and Evolution.

What do these other 2 mean?

While experience is generally linear over time, the other 2 are more emergent.

Domain consistency relates to the predictability of the area in which you work. Given we deal with humans, in pain and injured, with multiple influences and permutations, I'm going to say any of us have fairly low domain consistency. However in my own clinic, the people I see, the ankle sprains have more domain consistency than the low back pain. Across the profession, my feeling is, merely as an example, an elite basketball team physio will have a much more homogenous and predictable experience than a paediatric physio in a public hospital.

That is not to say elite basketball is easier or curveballs never happen. Just that the set of problems and people are more the same, whereas literally everything would change, every time for the paeds physio, hence their ability to predict what comes next is less reliable.

Evolution relates to our constant updating and improvement of our practice. A prerequisite of registration, but in reality, is as variable across the profession as the profession itself. So someone who has worked for 5 years can have gone through an evolutionary process and improved their practice while someone who has done the same thing for 20 years and is still doing the same thing has not.

So now we combine this onto our 3 axis graph and it gives us a way of analysing the information that we come across. Or, in Dave vernacular, we work out whether someone is worth listening to, in what areas are their opinions valid, or if they are completely up their own arse.

Some worked examples.

An experienced physio of 20 years, has done a course every year for the first 5 years, now owns a clinic and mentors team members

A physio with 10 years experience in sporting teams, not doing any external PD as there is enough exposure

A recent grad who has read every paper and done every online course in existence, has their own instagram page and works in private practice 

If we hear their opinion on a topic and they disagree, how do we weigh this information?

The funny thing is all of them will likely be confident, and all of them will have aspects of their opinions that will be valuable.

The trick is looking, somewhat counterfactually, at where their blind spots are.

Health professionals are pretty good at telling you how right they think they are.

It’s like that joke (that I have reframed for my own humour purposes) - how do you know when a health professional thinks they are right? Don’t worry they’ll tell you.

But where can they be wrong?

The clinic owner will have developed their way and will act like the Mandalorian - This is the Way. What if there was something newer that challenged the way, or at least the reasons behind it?

The sports wizard doesn’t understand anything outside the sports model, where there are limitless imaging, inputs and supports. The risk/reward ratio changes in the real world between people.

The recent grad has not seen how evidence and clinical practice are different. They conflate absence of evidence and evidence of absence and do not understand ergodicity. (Lots of people don’t and to be honest that’s a word I threw in to make me seem smart. Basically the average of lots of people will differ to the experience of one person over time).

So whether we listen to their opinion or not comes down to - where does their opinion apply? All can be valuable, and all can be useless. Discounting based on demographics, or believing without critique can lead you astray.

In the information age the ratio of noise to signal is exponentially increasing in the wrong direction. We must get better at being critical of what we are bombarded with and more diligent with what we consume.

An interesting by product of this is often the opinions of those with the greyest hair are the fastest to be discarded. There is probably some age related bias in this, mentions of Dinosaurs, boomers and the like. But also, it tends to be the group of health professionals least likely to be on social media, so their voices are often heard the least. Familiarity breeds trust and the more likely you hear a voice the more likely you are to believe it (particularly when it already agrees with you and your bias). So even though one may have years of experience in the real world, be a practitioner that applies their craft and adapts, largely by coming to know what NOT to do, has helped thousands of people and not just survived but built a successful career, they still may be ignored because of a lack of technological presence.

Interesting. 
So my approach is doubt everything - especially myself. Look for triangulation of evidence and opinion. Do your fucking homework, look deeper than a reel for a scientific approach to improving your knowledge. And when in doubt remember, grey hair means survival. There has to be something in that. That is what I tell myself when I look in the mirror at the grey beard, the wrinkles. Some people may see irrelevant and outdated. I see the silverback.