Monthly Archives: November 2013

I Don’t Get Paid Enough To Think This Hard

For well over a decade, I have been teaching healthcare professionals, mainly physiotherapists, about stuff. Although wrapped up in many guises, this “stuff” has essentially been thinking. Thinking in healthcare professions is packaged up as clinical reasoning.  I’ve always thought this to be a good thing: that we work out possible diagnostic hypotheses with our patients, use the best of our knowledge, experience and evidence to test those hypotheses, and judge from a variety of evidence sources the best treatment options. The alternative is either blindly following set guidelines, or making random decisions.

I really enjoy teaching this stuff.  I love working with students to get the best out of their brains, and see their thought processes and their clinical practice develop.  I love the literature on this stuff, and have indeed often published about it myself. I have a pop-art poster of Mark Jones in my bedroom (Fig 1).

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Fig 1: My pop-art poster of Mark Jones, Clinical Reasoning guru.

I ran “Clinical Reasoning” modules at my place of work for undergraduate and postgraduates for years.  I have helped develop reasoning tools. I guess I think it’s fairly important to what we do as clinicians.

However, a few years ago whilst teaching on a course, halfway through a case study exercise, one of the delegates turned and said “I don’t get paid enough to think this hard”.  At the time, and for several years since, this struck me as astonishing – in a negative way. What? This is part of your job! This is how you can strive to get the best out of your patients; it’s demanded by your regulator; it’s a necessary condition of clinical practice; blah blah blah. But recently it struck me that he might have a point.

What is our price, and does this reflect the measures we go to to achieve our end? What absolute difference does it make investing the time, energy, resources necessary for “advanced thinking” to clinical outcomes? (we don’t know). Could we drift through our careers following guidelines and making random decisions, and still do OK for our patients? (maybe). How does our price compare with other “thinking” professions, Law, for example? (poorly). What is the impact of all this stuff on our emotional, social, and psychological, and physical status? (significant) How has doing this stuff changed in an era of evidence-based practice? (dramatically).

On the last point there, clinical reasoning may once have been a process of applying a line of logic to a patient contact episode: “they said they twisted this way, it hurts there, therefore this is the problem so I’ll wiggle this about for a bit”. Clinical reasoning is becoming more-and-more synonymous with evidence-based practice (EBP), and EBP looks very different to the above scenario. EBP is about integrating the best of the published evidence with our experiences and patient values. How do you do that!? Well, this is the stuff that I try and teach, and this may have been the tipping-point for our friend’s critical statement.

Consider the state of thinking in the modern healthcare world: First, the published evidence. There are at least 64 monthly peer-reviewed journals relevant to the average rehabilitation physiotherapist (that’s excluding relevant medical journals, in which there is a growing amount of physio-relevant data). These have an average of around 30 research papers each, each paper being around 8 detailed pages. That’s 15,360 pages of ‘evidence’ per month, or 768 per working day. Some, of course, won’t be relevant, but whichever way you look at it, this is an unmanageable amount of data to integrate into everyday clinical decision making. Many of these papers are reviewed and critiqued, so the clinician should be aware of these too. Many of these critiques are themselves critiqued, and this level of thinking and analysis would also be really useful in understanding the relationship between data and clinical decision-making. EBP does have tools to help with data-driven decision making. These require the clinician to have a continually evolving understanding of absolute and relative risk, the nuances of the idea of probability (don’t even get me started on that one), a Vorderman-esque mind – or at least the latest app to do the math for you, and time.

Arrhh, time. The average physiotherapist will, say, work an 8 hour day, seeing a patient on average every half-an-hour or so. That half-hour involves taking important information from the patient and undertaking the best physical tests (which are..?) and treatments (which are…?), then recording all of that (don’t forget the HPCP are on your back young man – a mate of a mate of someone I  know got suspended last week for shoddy note-keeping. How would I pay the mortgage?). So when is that evidence read, synthesised, and applied? No worries, in-service training sessions at lunch-time will help (no lunch or toileting for me then). What about evenings and weekends – yes, lots of thinking does occur here (but what about the wife and kids).  I know there is no training budget for physiotherapists, but you can do some extra on-call or private work to pay for those courses can’t you? (Yes. When?) You get annual leave don’t you? That’s another great opportunity to catch up on your thinking education (Cornwall will wait).

Thinking this hard costs. It costs time, money, energy, opportunity and health. Do we get paid enough to think this hard? Maybe our critical friend had a point. However, the pay isn’t going to change, so the thinking has to. Is this a signal that we are at a stage of development in healthcare when ‘thinking models’ need to be seriously revised in a rapidly evolving, data-driven world? Thinking was, is, and will always be central to optimal patient care, but how we do it needs to be re-analysed. Quickly. Think about it.

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Argument formation for academic writing

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Many students find it difficult to identify what it is that makes a good piece of academic writing. At the core of such writing is the nature and structure of the intellectual argument. Here is some information that we share with our Physiotherapy students at the University of Nottingham to help with their understanding of arguments. I hope you find it useful.

Argument formation

The idea of a basic argument is fairly simple. An argument is formed of ‘premises’ and ‘conclusions’. For a valid argument, in order for the conclusion to be true (which is what you want in an essay, i.e. you don’t want to draw false or unstable conclusions), the premises must be true. So, the classic example is:

Premise 1: All men are mortal

Premise 2: Socrates is a man

Conclusion: Socrates is mortal

Do you see that if P1 and P2 are true, then the conclusion HAS to be true?

So, if it REALLY IS true that all men are mortal, and it REALLY IS true that Socrates is indeed a man, then it HAS TO BE THE CASE that Socrates is mortal. Yes? Do you get that?

Make sure you fully understand this basic principle before reading any further!

OK, so let’s look at another example:

P1: Lucy is a physio

P2: All physios wear white tunics

Conclusion: Lucy wears a white tunic

Get it? Of course you do.

So the two examples above are cases of a good, robust deductive argument – the conclusion is deduced from the premises. We’ll come onto how this looks in an essay in a moment.

Now, here are four types of poor arguments:

Type 1: false premises

This is a simple mistake. Consider the above ‘physio’ example. You would have most likely noticed that the two premises are full of assumptions: 1) that Lucy is in fact a Physio, and 2) that all physios do in fact wear white tunics. The actual truth of the conclusion not only relies on the logical flow, but the accuracy of the detail within that flow. So, an argument can be logically correct – i.e. its logical form is robust, but the factual accuracy of the premises may render it poor.

This is very important in essay writing, and will be address again below.

Type 2: The inductive fallacy (over-generalising)

P1: I have seen 1 white swan

P2: I have seen 2 white swans

P3: I have seen 3 white swans, and so on….

Conclusion: all swans are white

This is a poor argument because it could always be the case that there is a black swan which you haven’t seen. Therefore the generalisation that “all swans are white” is false. So a Physio example:

P1: I have seen ultrasound work on ankle pain once

P2: I have seen ultrasound work on ankle pain twice

P3 ….n: etc etc

Conclusion: Ultrasound works for ankle pain

Type 3: another type of over-generalising – ideas and data

P1: There has been a lot of music in Nottingham lately

P2: Lots of people think that Nottingham is the music capital of Europe

Conclusion: Nottingham is the music capital of Europe

So the conclusion is not necessarily true, even though the premises might be true. Why?  Well, there are two issues:

i) Although the premises might be true, their relationship with each other, and the conclusion, is tenuous. Compare the robustness of the relationship between components in the first Socrates example, with those here.   See how the concepts of ‘mortality’ and ‘Socrates’ are distributed between the premises, linked by the idea of ‘man’.  Notice that ‘man’ does not appear in the conclusion – that idea has already done its job. ‘Socrates’ and ‘mortality’ are the only ideas that re-appear in the conclusion.

In the music example, there is no such pattern. Both ideas of ‘music’ and ‘Nottingham’ appear in both P1 and P2. They are not linked by a central, meaningful idea. P1 and P2 are simply independent commentaries on a similar theme.

Also note that in the Socrates example, both P1 and P2 are necessary conditions for the conclusions, as well as being independently insufficient for it, i.e. they are needed by each other, and by the conclusion. These relationships do not exist in the music example, e.g. that a lot of people thinking that Nottingham is the music capital of Europe is not a necessary condition for Nottingham being the music capital of Europe.

ii) There is missing data! To claim that “Nottingham is the music capital of Europe” relies on something other than what has happened in Nottingham and what people think. It relies on the music rate in other European cities.

MUSIC BREAK: Da da da da da da da da daaaa

As it happens, Nottingham most likely is the music capital of Europe! For example, here’s a great band which comes from Nottingham:

https://skiffleshow.bandcamp.com/album/escape-this-wicked-life

and you can “like” their Facebook page here:

https://www.facebook.com/dhlawrenceandthevaudevilleskiffleshow

MUSIC BREAK OVER.

Type 4: alternative explanations

Premise 1: Contraceptive pills prevent unwanted pregnancy.

Premise 2: John takes the contraceptive pill and he isn’t pregnant.

Conclusion: The contraceptive pill prevented John’s unwanted pregnancy.

Here, again, both P1 and P2 may well be true, but the conclusion isn’t true because there is an obvious alternative explanation for why John does not get pregnant – he is a man.

Constructing arguments in essay form

Now, how does all this relate to your academic writing? Simple. This basic line of reasoning is what we look for in your overall writing piece.

Here’s an over-simplified example: Let’s say you set out to write an essay on the effectiveness manual therapy on neck pain. You might structure your argument something like this:

P1:  Manual therapy for neck pain has some RCT-level evidence

P2: RCTs give good evidence of effectiveness

C: Manual therapy is effective for neck pain.

This seems fairly simple right? But let’s break it down:

The conclusion is wholly reliant on the truthfulness of the premises. In other words if P1 or P2 were false, so would be the conclusion. Further, P1 and P2 are both necessary yet individually insufficient conditions for C.  Notice that the ideas of ‘manual therapy’ and ‘effectiveness’ are linked by the idea of ‘RCTs’ in the premises, and the ‘RCT’ does not appear again in the conclusion.

The argument has avoided the induction fallacy of over-generalisation. There is no obvious over-generalisation of the conclusion. So, you could have said:

P1: 10 case studies show that manual therapy is good for neck pain

Conclusion: manual therapy is good for neck pain

This would have fallen into the induction fallacy

The premises and the conclusion are satisfactorily related (unlike the music example), and have this avoided the ‘lack of robustness / missing data’ issues. So, you could have said:

P1: 10 case studies show that manual therapy is good for neck pain

P2: a number of authors state that manual therapy is good for neck pain

Conclusion: manual therapy is good for neck pain

This would have been a mistake, as per the music example. There is missing data, e.g. no consideration of tests of effectiveness.

So we can see how easy it is to develop a valid and robust argument to build your essay around. If you have avoided the common errors in logical form, all you need to do now is to test the truthfulness of the individual premises. This means, in the case given here, you would be discussing the relative quality of different types of manual therapy studies, and trying to show that manual therapy has some RCT-level studies, before drawing your logical conclusion. Once you have those conclusions, you can then go on to discuss the consequences / implications / context etc of them.

Remember two main things:

1)      Make sure you have a VALID LOGICAL STRUCTURE

2)      When you have that, the aim of your essay is to DEMONSTRATE THE TRUTH OF THE PREMISES.

If you show these two simple things, you are half-way there. The other half is how clearly and concisely you can write!

And finally, I recommend to buy “Rulebook for Arguments” by Anthony Weston. You can get it for about £4 of Amazon.

Happy arguing 🙂

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