Draft:

A Medical Environment of Poor Thinking: Problems with Being Skeptical as a Physical Therapist and a Trainer

Epistemic Status: frusturated, but hopeful. Considering options for how to market evidence based rehabilitaiton.

TLDR: as a person trying to be an evidence based clinician that still thinks and isn't adherent to dogmatic beliefs about physical rehabilitation and training, it is frusturating to see practioners engage in various specific forms of poor reasoning and low effort thinking as hinted to in the title.  Blind acceptance of studies, inability to appropriately generalize, excessively high confidence, there is no truth, and other woes. Some suggestions for making progress on said problems are also outlined at the end.

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Since licensing as a physical therapist, and having tested for that license twice internationally (two countries), I am increasingly alarmed by the low levels of skepticism and empiricism I see amongst clinicians. This is not to say that no clinicians retain a sharp scientific edge to their care, but I unfortunately have run into a fair number of patients and clients who decribe to me a totally rote approach from their treating clincians or from clincians in the past. This takes shape in a few ways:

1) RCTism: The patient approaches with a problem, and that problem falls into the bucket of problems that is well tested by randomized control trial (RCT). If the clincian has identified that it is well tested by RCT, they treat according to the conclusions laid out by that RCT on a relatively surface level, without actually considering the implications of that RCT for other conditions that they treat, or the limitations that RCT actually has on the condition that RCT is supposed to be about. This is problematic in two ways. 1) The condition may not actually be represented well by the RCT or RCTs being referenced. This can happen due to many different things: insufficient statistical power, meaning not enough people were tested to really get a sense of if the intervention in quesiton actually works on this condition, from a sampling bias, e.g. the training intervention in quesiton was only done on college age males and therefore does not generalize to other demographics, or even that RCT itself is not a good methodology in isolation for testing the effect of the intervention, which is common in situations where blinding is impossible (think dietary pattern shifts or adding in cardiovascular training 3x / week), or a control protocol has not really been established or is hard to establish (total time spent with clincian, for instance. Clinical attention is a sort of intervention by itself, and that time should probably be considered when evaluating evidence). 
2) The clincian does not really adhere or take into account the limitations that the RCT or body of RCTs actually has on the condition in question, and thus overstates their importance in their own mind, and even to their patient. Effect sizes are one way to look at this. If something has a good statistical power, but a small effect size, how seriously should we be considering other interventions? Should the clinician be saying that this definetly will work, or rather saying that it may be of some use and perhaps express their certainty in some scaled way?

Clinicians who engage in RCTism may also engage in other forms of studyism wherein they adhere to the belief that just because an RCT or metaanalysis or heaven forbid a case series has been done, no further thinking is needed, and the findings from those studies doesn't need to be engaged with critically, and if selected as the epistemic source for their treatment, still tested on their patient with the possibility of serious modification or moving away from the treatment option if it fails to deliver. They also have a habit of speaking to patients in absolutes and engaging in black and white reasoning: this will work, that won't. This does not seem to be a reasoned approach to medicine, or physical rehabiliation, because we still have to gather evidence, patient history and data, formulate a clincial hypothesis, communicate it to the patient, communicate the plan of care that emerges from that clinical hypothesis and begin treatment accordingly.

The same criticisms broadly apply for physical training.

What is worrisome to me in medicine is that doing all of these things: reading and appraising studies critically and using them to update our algorithms, gathering all of the information from the patient you really need to rule things in and out, formulating and executing plans of care, modifying accordingly, and keeping up a good stream of communication with your patient to make these things actually happen *takes time*, and time is something most clinicians are increasingly be pressured not to have. Additionally, even if the time is taken, the modern compensation environment in the United States can cause, directly, burnout, as clincians are not really compensated for all the time they take to do these things, or try desperately to cram it all into a 15 minute - 1/2 hour visit, without the frequency really needed to get the whole thing moving.

These clincians are in support of science, and on the strong right end of the bell curve actually understand methods relatively well, but are simply burnt out or under too much pressure to produce billable hours to do science based medicine properly, or on the strong left end of the bell curve, like science the way people like a meme or a brand, and do not have a strong understanding of methods. I am not saying my understanding of scientific methodology is perfect by any means, but I do care about my level of understanding and work on it directly, but that isn't something my field encourages enough.

Unfortunately, even clinicians with a good understanding of their own field (which I am increasingly finding to be a somewhat rare thing in my own field as evidenced by things I will talk about later) usually do not have a strong enough idea about the capabilities of people in other fields, and thus fail to see how utilizing someone else's expertise may allow for the solution to a problem their field cannot solve.

I am choosing to broadly refrain from the dismal bitter pill conclusion that these clincians simply have egos so strong that they find other evidence based fields detestable, and thus are unwilling to admit that clincians from those other fields may be the right people for the job.

An additional problem I see is a lack of feedforward into other areas. There is not a great deal of thinking about if claim A from such a body of literature is true, and the studies well constructed enough, etc.

What does that actually mean about the condition in question? How about related conditions? 
Where else do these conclusions actually apply?

It goes both ways, both not seeing what the limits of a group of studies or a study, are, being clear with yourself and patients/trainees how confident you are about the conclusions, and also not figuring out where else the conclusions generalize to. It is a kind of blanket yes/no work/doesn't this condition/nothing at all type of thinking.

2) Lack of Skepticism / High Credulity Practioner: I also hear a fair amount of basically blind credulity about very dubious claims, either weirdly persistent old ideas, or difficult to impossible to falsify, shakey new ones and a generally unjustifiable epistemic certainty from certain practioners of various sorts. This takes shape in the form of essentially lay practioners, such as casual coaches, people with certifications, such as strength and conditioning professionals, and even licensed medically relevant practioners like medical doctors or licensed physical therapists.

I came into this field expecting a certaint level of baseline lack of knowledge from patients and clients. That level of ease of belief was met, and then surpassed.

I was sort of expecting it from some coaches and trainers, having come into contact with coaches, instructors, and trainers before that did not really have any scientific background to speak of and dealing with the results of their generally high confidence in things that at best didn't work well or work at all but were harmless, and in some cases were actually harmful.

What I was not expecting coming in, was the tendency amongst some clincians, possibly even a majority of clincians, to simply adhere to memes, concepts, and ideas that do not hold up to even a fairly basic critical examination. There should not be any sacred cows in medicine, just increasingly well validated ideas and models, and we sometimes need to be willing to scrap a concept that really just isn't true. Some ideas are a kind of zeitgeist in a given field, and people simply believe them, without delving into the underlying literature and they then believe this with a very high level of projected confidence.

This produces what I will call Epistemic Contamination, in that people who are supposed to be scientifically trained, or at least evidence based, often believe things that have not reproduced, and are not supported by science, or even worse, when a strong contradictory body of evidence has been unearthed, they do not move their belief needle accordingly.

This means that a smart patient or relative of a patient can look these things up, find out they are essentially false or unsubstantiated, and engage in reasoning of the following sort: my clinician, a mainstream institutionally trained person, believes nonsense with a high level of confidence. Other apparently trained people from a similar background also believe this hocum and go to bat for it when questioned. Perhaps the entire field is broadly not that well thought out or actually scientific? Maybe I should look for smart sounding alternatives. Said smart person, if they are indeed very smart and logical, may go and build up a body of knowledge on the subject, and carefully look for alternative narratives that actually check out, or farm out their thinking to a more evidence based / skeptical practioner / clinician. Or, they may be a merely clever but not thorough person and look for an explanation that seems better and more logical, easier to implement perhaps, but fundamentally flawed because they do not have the context afforded by an academic education or a great deal of reading, and then walk around believing something false with a high degree of certainty, because they were motivated to find the truth, by noting the high degree of certainty around a false thing projected by an institutionally trained person. Having debunked the first false thing, they arrive at a new belief around a false thing with a high degree of certainty because some amount of leg work was invovled in them doing so. Some leg work however, is neccasary but not sufficient to improving your understanding of messy topics such as medicine.

Unfortunately, the place I see this the most, other than my own field, physical therapy, is in psychology. Some fairly smart people I have met are skepticial about the benefits of mainstream psychological therapy, because of high confidence claims that rest on relatively transparently poorly done or biased studies that don't really reproduce, that have wormed their way into the zeitgeist of modern mainstream psychology.

The clincians that I mentioned before, and even the people that I am talking about responding to those low skepticism clincians 'love science' but in the way noted by the now internet famous Cyanide and Happiness Comic (linked: https://files.explosm.net/comics/Kris/same.png) and are simply staring at science's butt without realizing it. They "believe in science" but science is not a belief, or even body of beliefs, it is a method.

3) It's Impossible to Treat Effectively (TM): these clinicians can come from the broad two categories outlined above, but essentially adhere to a pattern of throwing their hands in the air if no RCTs or other standard form of study exist, and ignore the basic science and tech oriented physiological, anatomical, psychological, or other training they have and just say, hmm no studies can't treat effectively. This is a problem because often there are underlying systems they *have* been trained on that are germaine to the problem, and they could make useful conclusions from other studies or at least engage in useful risk reward thinking and hypothesis formation, which they could again, communicate clearly to their patient, negotiate a plan of care / inquiry, and begin from there.

I think that this sometimes happens due to a fear of being sued in the United States, because at least in my field if what you did is not in line with the accepted narrative about how to treat a problem you may be open to a malpractice lawsuit. I think that obvious neglect and demonstrable harm might need to be the new standard for non-life threatening cases, because it a) might be easier and clearer to prove b) could allow serious clinicians the room to treat in a conservatively experimental fashion with patients that have conditions sufficient science has not been performed on yet, and draw useful conclusions which could fuel more research and c) close the door to frivolous lawsuits to some extent. If you have to prove harm and or neglectful care, it also puts all fields in a similar playing field. Alternative medicine practioners, coaches and trainers (not that all of those are the same, I am merely pointing out one similarity) don't have to demonstrate any kind of standard of care in court to my knowledge, they merely have to prove no wrong doing.

4) Bad actors? I express this with a question mark because I do not think all of these people went into evidence based fields with the express intent to decieve, but that is what they are functionally doing, and I think that taking on the mantle of a licensed professional should call for a higher standard of behavior.

A person I am talking about does not performatively / actually believe in reason, reasoning, logic, science, evidence, or empirical medicine / training. Those things are not an actual part of their values. They went in, because having a license or certification affords this person the social standing to treat or train.

They range from people who genuinely and without malice believe in arguably fictious narratives about the workings of the human biopsychosocial system, are prone to very magical thinking that they try to shoehorn into a science flavored vocabulary, or are too cool for school, and adhere to some anti-truth narrative, and believe that nothing can really be learned about the body or mind or social system. They think we should just try to make people feel better and get paid to do it, because what's the harm in that and other people are already doing it. The harm is that your patient or trainee just handed you money and you have done less than you could have, and you also are eroding people's ability to trust your field at all once they eventually figure out you're a well intentioned hustler at best, or a lemon seller at worst.

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I am not saying that I am some perfect clinician or trainer. I am sure I will be embarassed by specific interventions I utilize now later in life. I actually hope that happens, because it will mean I improved. I want to find out I am wrong and correct. I do not have any beliefs about the human biopsychosocial system I consider sacred, I merely a spectrum of believes some that I am more confident in because there is overwhelming evidence in their favor (things like strength training improves strength, and balance training improves balance fall at the far end of this curve), some things I am ~70% confident in because the body of evidence on them is quite convincing (combination eccentric concentric resistance training through the complete range of motion is likely to produce more hypertrophy and more robust local joint and tendon / ligament health), things I am not confident in but would consider prescribing because they are very low risk (self soft tissue work for the temporary alleviation of pain in a variety of conditions), and things I am fairly or totally confident are bullshit and would be worried about a fellow practioner seriously using in any way (please don't make me list all of these it makes me angry that this stuff is still prescribed with a straight face).

I don't believe in raising problems without some suggestions for solutions if you have some, and I do actually have some.

Clinicians and certified trainers are frequently required to engage in some kind of post licensure / certification continuing education. Maybe:

-Those should be cross field more often? Get perspective from other types of practioner.

-It would be helpful to allow scientifically trained people from multiple fields to be reviewers on papers from different fields. Rather than explain it to me like I'm five, how about explain it to a physicist, or explain it to a doctor etc.

-You shouldn't only read papers in your field? Desiloing information could be very helpful. Some fields, including non medical ones if you are a medical person, may have solutions to specific problems you haven't considered, or tools you could use to solve problems you are currently dealing with now.

-There should be some kind of broad, skepticism and scientific reasoning certification / post grad curricula one can get post licensure or just in general in physical therapy the same way people can go out for an Orthopedic or Sports Medicine certification

-This cert should be open to the entire public, because what kind of person wouldn't be interested in having some skeptical, scientifically and logically literate people on their team for most fields that have to interact with the real world.

-The testing for physical therapists and other licensed medical practioners should put a much much higher emphasis and weight on the skill of scientific reasoning (which on both the US and Israeli exams I passed, was seriously lacking and laughably easy lob types of questions) and ability to look things up and less on highly specific interventions for fairly rare conditions which they aren't even likely to see depending on their area of practice, and which they probably have already been tested on under rigorous conditions in university or at least should have been.

I am concerned about the future of my field, and medicine, broadly. I think that we need to move increasingly towards medical skepticism, or rather skepticism for medical professionals by medical professionals. There are people with influence out there peddling poppycock, whether out of personal interest or because they have been fooled, or what have you. It strikes me as defeatist to simply say that we will do our best to be evidence based, treat, and other than that simply hang out on the sidelines.

I have also noticed that the general acceptance of the background levels of nonsense thinking is probably not something we have to replicate personally. The public no longer believes in blood letting or leeches, broadly, or alchemy in the old sense. Progress can be made. We do not have to resign ourselves to a medical environment of poor thinking.