So I've started reading for fun again, finally. I enjoy reading about incentives and decision making. The human capacity to fool itself amazes me. My first brain-toy is this: You Are Not So Smart. It started as a blog written by @davidmcraney. He's a journalist who writes about things that are fun and interesting. I recommend checking out the blog or book!
One chapter in his book stood out as relevant to some of the #SolvePT discussions. Craney pointed out that brand loyalty is created from buying (or buying into) unessential things - iPads or your favorite brand of smart phone. To oversimplify his point, spending a lot on something you don't need forces you to create a narrative in your mind about why you made the best decision for you. A higher cost means a stronger internal justification. It sounds to me like the effect lies somewhere between cognitive dissonance and confirmation bias. Your unconscious interests in justifying your decisions tie directly to your own self image. You are forced, after making the decision, to create a narrative supporting the decision. And ownership reinforces the emotional connection to "stuff."
Can physical therapy be stuff? Should it be? Probably NOT. I feel like the fact that we do not create the same brand loyalty to PT is a testament to our USEFULNESS. Not to say that an iPad can't be useful, but when you need physical therapy you definitely NEED physical therapy. You never really NEED a new tablet. I am probably reaching here, but the idea of entitlement to PT via health insurance, and a client/patient's reluctance to pay for PT out of pocket definitely hurts our cause. You lose the benefit of cognitive dissonance. I am paying for PT, so I must value it!
What's weird to me is the attachment people have to their chiropracters. Does that the kind of brand loyalty Craney describes insinuates an unthinking devaluation of chiropractic care? Craney also points out that for brand loyalty to occur, you must have OPTIONS, or a decision to make. Reducing the # of options reduces buyer's remorse. People LOVE their chiropracters and accupuncturists, and pay out of pocket for other services because they KNOW they have a choice! The public is aware that they can go to a chiropracter first.
Is anybody having success trying to create a self-paying base of patients/clients?
...should have to be checked in!
I just finished reading my National Physical Therapy Exam again courtesy of the FSBPT. 5 hours of stress, headache, and suicidal ideation and I decided to take a few days off! Flying from Cody to Denver for the first time. Hard not to chuckle a little at the stacks of carhart jackets and boots people are trying to squeeze into those little plastic bins.
6am flight. That's all I have today.
- Structure of Scientific Revolutions - Kuhn
- Still Alice
- A First Rate Madness: Uncovering the Links between Leadership and Mental Illness - Ghaemi
- All The Strange Hours - Loren Eiseley
- Start with WHY - Sinek
- Phantoms in the Brain - Ramachandran
- Battle Royale - Rowaiaru
- Doctors: The Biography of Medicine - Nuland
- The Drunkard's Walk: How Randomness Rules Our Lives - Mlodinow
- Ready Player One - Cline
- How Doctors Think - Groopmman
- Look Me in the Eye: My Life with Aspergers - Robinson
- Second Opinions - Groopman
- One for the Money - Evanovich
- Every Patient Tells a Story - Sanders
- The Fifth Discipline - Senge
- Only What They Could Carry - ??
- Under the Banner of Heaven - Krakauer
- Hippocrates Shadow - Newman
- Consciousness Explained - Dennett
- Death of the Guilds - Krause
- Painful Yarns - Lorimer Moseley
- The Best Practice - Kenney
- The Black Swan: Impact of Highly Improbable - Taleb
- Dan Brown Books - The Da Vinci Code
- Checklist Manifesto - Gawande
- Blink - Gladwell (re-read)
- One Step at a Time - Bliell
- Courage to Teach - Palmer
- The Seven Laws of Magical Thinking.. - Hutson
- Blindness - Jose Saramago
- The Road - McCarthy
- The Postman - David Brin
- Oryx and Crake - Margaret Atwood
- A Canticle for Leibowitz - Miller
- Alas, Babylon - Frank
- Z for Zachariah - O'Brien
- Answer to the Question: What is Enlightenment? - Kant
Rule #2: You Reap What You Sow
Rule #3: No One Can Help Your or Be Helped By You if You Won't Help Yourself
Rule #4: You Do Not Know Everything
Rule #5: Pull When Possible
Rule #6: First Seek to Understand, Then to Be Understood
Rule #7: Do The Job, And Do It Well
Does anyone reading know PAXScript?
function LowerFirst( InStr: String ): String;
begin result := LowerCase( Copy(Instr,1,1) ) + Copy(Instr,2,1000);
begin IF SF.GetFieldText('ExamMeasurement','ZZTRNSTYPE')='' THEN
FOXTROT:='Patient is able to perform ' +
SF.AssignFieldText('ExamMeasurement','ZZTRNSNOTE',FOXTROT+NOTES); END; END;
Fast forward several years. Things I've learned to do on my car (in no order):
- General maintenance/service:
- Replace the brakes.
- fuel filter
- spark plugs, wires
- air filter
- oil change
- anti-freeze change
- rotate tires
- serpentine belt replacement
- Take apart and clean out the EGR valve
- Replace fuel pressure regulator
- Service brakes/rotors
- remove fuel injectors/fuel rail
- recharge A/C
- remove/install coolant tank
- remove/install AC Compressor
- clean mass airflow sensor.
- remove/install water pump
- remove/install radiator
- remove/install alternator (ugh)
- remove/install wind-shield wiper assembly
- remove/install belt tensioner for serpentine belt
- remove install belt tensioner & pulley system for water pump (other side of engine!)
- remove/install manifold intake, service gaskets.
- remove/install starter (under the manifold)
- remove/install Blower Motor
- replace serpentine belt with shorter belt to run car without broken AC compressor
- remove/install rear suspension, replace with passive system
- remove/install front bushings
- there is a problem with the oxygen sensors to fix related to codes PCM p0171, p0151, p0154, p0174.
- HEADGASKET!!!!!!!! DAMN IT! Looks like I'll be removing the engine again. Maybe. So far, it runs without overheating.
- Rough/long start when engine is cold. When taken up to running temp, and then allowed to sit for 40 minutes to an hour and a half with the engine off after being at running themperature, the car doesn't turn back on!!!!!!!!!! WTF?
The Best Argument in Favor of Open Access Science is All Of Them @Kevbonham I shouldn't have to explain why this matters. More information here: Open Access Publishing
Develop a Web Presence - tips and ideas for boosting your web presence, from social networking to blogging. I'm still on google. Maybe I should make a switch to boost my street cred. @adachis
Ridgeway & Silvernail 2012. Innominate 3d Modeling: Biomechanically interesting, but clinically irrelevent. @Dr_Ridge_DPT
Dr. Ridgeway was kind enough to supply with the full unedited prior to submission full text here. Thanks!!
These info graphics are so cool: Mobile Healthcare or validation for my interest in developing software.
More digital information: HIPAA Devices: 2 Myths Debunked, 1 Proven True from @WebPT. Ipads are HIPAA compliant. Cloud storage is safer than hiding money in your mattress. Digital storatge is safer than paper storage.
Baby steps. I've already identified 3 or 4 resources now for coding my goal project. A thanks to Paul Burton for showing off his code for using the android BT to connect to a L2CAP connection (wii hardware - think balance board). The purpose, or goal of all of this, for me, is to learn to code and build OPEN SOURCE tools clinicians an use, and involve more CLINICIANS in the building process. I'm learning. And will blog about my learning, and share resources as much as I can. Would love to find more, or involve more people.
This is going to be awesome.
My next project is gait analysis.
PT Complaint: Unusable software.
Plan: Finish narrative code, build gait analysis form.
But that isn't what this post is about... Our models for understanding pathology are too primitive to be meaningful. The background of what I'm thinking:
This article is a perfect example of how remarkably complex human motion really is. And all I can help taking from it is that after explaining the mechanism to 3 people now, all have fired back with "So, how is that functional?" Without even giving a minute or two to try to think about a circumstance when something like that might actually be functional.
"This is what I've observed." "It has to be this way because of the origin and insertion."
Besides the actual function and clinical relevance discussed in the article, I like to think more about how many other parts of everything I've learned act as functional oversimplifications.
These over-simplifications are the basis, for instance, for much of how we model and explain very complex evaluative tools. I wrote this post a couple weeks ago, and have been thinking about it since then, with a little feedback from a mentor. At the same time, not too soon after, a friend of mine (@RGWooderson) forwards a blogpost to me called "A Few Tests To Toss". It is a great post that actually offered ANSWERS to some of the questions and things I've been thinking about. A recommended read, for sure.
Now my purpose:
The Low Back. We try to model the mechanics of it, in all the spine's complexities. And evaluate the "motion" people perform by merely touching and observing. I'm not bashing touching and observing. I think touch and observation are our greatest tools - just extremely inaccurate, or inconsistent at best. And seem to fail to achieve proposed/described biomechanical influences. And in the end we are frustrated or confused - as a freaking profession! - about why we can't cure back pain. Or why our outcomes for certain sub-populations aren't better than surgery.
Bad joke. Let me explain.
Spent my whole life ignoring things like metacognition, because I preferred more discrete sciences. Love answers. Real answers. But have, slowly, become enamored with social science and why we think and do the silly things we think and do, and how behaviors and thinking change over time. Like a playground for my brain! Errors in thinking... I make a great many errors.
What caught me about this, and why I decided to join the conversation on soma, is a book I've been reading about cognitive errors in the assumptions we create constructs of ourselves and the world around us. The chapters on Hindsight bias and Confirmation bias have taken a lot of my brain power lately. The book is "You are Not So Smart."
I suspect that some errors in clinical decision making come from the minds innate need to make sense of the world quickly to move on to the next stimulus.
Clinicians are trained (I just finished school, but hope never to finish training) to rely on "clinical decision making." Human make decisions, which are subject to every kind of bias I've ever heard of. Confirmation bias and hindsight bias (narrow spectrum, I know) work together to affirm our mistakes in thinking. A perfect storm for error! Hindsight works like this: an event/result/outcome happens. In reflection, certain events stand out leading up to the incident. You, being the reflective practitioner you were trained to be, try to construct patterns from randomness. This is where it falls apart. Hindsight bias is "I knew it all along". It's ignoring how you were wrong previously - taking from coincidence facts and ignoring other data to convince yourself you expected the outcome. Confirmation bias is "I bought a honda, now all I see is hondas! I must have bought a great car!"
The worst errors are of oversimplification (for the intent to do good!) of complex models to simpler ones. This allows them to "see more" and explain more, and rationalize their own clinical decision making. To say "I knew that you would respond to ____" all along. And a strong bias from then on to find evidence to SUPPORT instead of refute their newly constructed world view. Confirmation bias is the reason my dad woke up every morning at 5AM to listen to Rush with his morning news before work (politics aside). People look seek out things that agree with their world view to validate what they are already thinking. Couple that with a strong hindsight bias and you have the recipe for a guru. I will explain. A guru isn't believable because they are good liars. They whole heartedly believe that what they are telling you about piezoelectric effect when, in reality, most of what they are saying sounds very plausible because of a very plausible sounding model of electricity. Or biomechanical models of spine pain. Or justification for ultrasound. Craniosacral therapy. I digress.
I am intrigued by the capacity of the brain to justify just about everything. Including writing this post.
It's worth noting that I have not even passed my board exam yet. Turns out I know a lot about neuro, musculoskeletal, and "other systems." But less about the foundational sciences of the cardio/pulm system and next to nothing about modalities. 3 of those things are interesting to me. 2 of them bore me to tears. One of them, as a category of intervention, is mostly crap (so far as my education is concerned, but more independent research on my part should be done). Care to guess which one it is?
Also, I could use a good recommendation for a "review cardio for the NPTE" book, if anyone has anything. Thanks.
|Who's driving this thing?!|
Appledorn et al. 2012. A Randomized Controlled Trial on the Effectiveness of a Classification-Based System for Subacute and Chronic Low Back Pain Current treatment based classification schemes do not improve outcomes in patients with subacute or chronic low back pain.
An Essay for Physical Therapists: Lets Move Forward... An inspiration to move forward, and some issues that are very relevent to physical therapy right now. There are some great discussion points about manual therapy, and the abuse of modalities. Comments at the end of the article are worth reading too!
Mannion 2001. Increase in strength after active therapy in chronic low back pain (CLBP) patients: muscular adaptations and clinical relevance. Three treatment groups, 1 outcome. Strength changes through training for chronic low back pain did not appear improve outcomes.
How bad could she be?
I took the alternator out of my cadillac deville myself. I don't hate myself and I wasn't looking for a challenge. I was just broke. The instructions are as follows:
Negative battery cable
Upper front bolt.
Front engine splash shield.
Radiator support access panel.
Loosen rear generator bracket from engine.
Remove top bolt.
Front lower bolt.
Lower rear bolt.
Upper rear bolt.
Duct from back of generator.
Heated windshield (if equipped).
Front generator/ A/C bracket.
Rotate generator and remove.
Rotate the generator and remove.
Rotate the generator and remove.