I can’t remember why I raced to book a ticket to the CauseHealth Conference in Nottingham in May. It might have been because it only cost £35 (lunch included!), it might have been because lots of keen-minded people I follow on twitter were excited about it (sports physio Adam Meakins, Neil Maltby, Chews Health…), it might be because the word philosophy excites my brain, but whatever the reasons I found myself walking into an old wood-panelled courtroom, (usually a museum) in Nottingham’s Lace Market, not having a clue what it was going to be about. All I knew was that I suspected it was at the cutting edge of health care, particularly for manual therapists. And I was right. It was intense, it was highly learned, it was powerful and I couldn’t take most of it in. So get ready for a mishmash of partly understood fragments. This was one of those questions-not-answers kinds of days. I felt like my brain was being softened up and put into a confused but receptive state, maybe to get ready for seeding with new ideas and directions, all of which could ultimately help us treat our patients better.
The man in the photo is Roger Kerry, PhD, who explained that CauseHealth is a funded 4-year project, based in Norway, into causation, complexity and evidence in Health Sciences. It is in its first year. He explained that physiotherapy was not as well-defined as other health care. It appears that physios also grapple with questions about their profession like “What defines us and what we do?”, just like osteopaths. He talked about the question “Does it work?”. This is always a difficult question, not because we think what we do doesn’t work, but because, as Roger put it, it depends what you mean by “Does”, “It” and “Work”. Well, before you laugh, and think we are merely philosophizing common sense out of existence, think again about it. This very question used to exasperate a patient of mine who worked in a health food shop, and who found it very difficult to answer. She would equate it to “Does chemotherapy work? Does paracetamol work?”. Well, in certain conditions, for some people, some of the time, to some extent etc, etc…(i.e. it is context-dependent, a bit of a buzzword of the day, along with patient-centred, causation and disposition).
Evidence-Based Medicine has Taken Over
The occasion of this CauseHealth activity is the rise to dominance of EBM (Evidence-Based Medicine), whose date of inception seems to be agreed upon as the very recent 1992. EBM is seen broadly as a good thing, but there is a concern that it is too black-and-white, and that the ‘person’ has been lost along the way. I was taken aback when the ASA (Advertising Standards Agency) was described as having a “very old-fashioned view of EBM”. I didn’t think physios would have even heard of the ASA. Being under the orthodox umbrella evidently does not render you immune from attack or criticism. The preeminence of the RCT (randomized controlled trial) is regarded as problematic, especially for non-pathological symptomatology. RCTs are relatively new, and in medicine the first one only happened in 1952. But now we have a highly RCT-centric style of EBM,, and this has both helped and hindered practitioners. As one physio explained, the feeling that everything they do must be backed by RCTs has become something of a straitjacket, making physios feel therapeutically impotent, even if that was never the intention. (Apparently it was never meant to be about telling people they can’t do things until there is RCT-level evidence for it, although this is how it was perceived by many in practice.)
The problem with EBM might lie in philosophy
It seems that central to the problem of EBM is the concept of causation. Causation was a philosophy espoused by David Hume in the 18th century. Stay with me. Hume was a Scot, and was a highly important philosopher. He is cited as a great influence on thinkers such as Darwin and Kant. He thought that causation was elusive, and we could only infer that one thing caused another, we couldn’t know. He said to say something has caused something else, the cause and effect must be close in space and time, and must happen in order. (Or, causation must have contiguity, temporal priority and constant junction.) If you want to understand it properly Stephen and Rani, the philosophers, have actually written a Very Short Introduction to Causation which sounds like a very straightforward read. This might all be sounding a little removed from tomorrow’s patient list, but it could somehow help to explain why it is so hard to produce RCTs which conclusively demonstrate the efficacy of our treatment.
Where do we look for the cause?
Perhaps, suggested Roger, it’s time to “reconceptualize the nature of causation”. Well, I’m game. For years I’ve heard the argument that RCTs are no good for measuring what we do; finally I’ve found someone who seems to be coming up with a reason. But the fact that a team of philosophers are devoting 4 years to studying this, suggests that the answer is not that simple. The RCT apparently gives us a clue to causation, but not a complete picture. Roger asked if we could see causation as the process between cause and effect, with the human being that is being acted upon, being the source of evidence of therapeutic effectiveness? I was a bit confused. Is it a gross simplification to infer that we can see anecdotes as acceptable evidence? Before you abandon this piece, I know it sounds abstract. It sounded abstract to me. But he gave us an example. If a glass is knocked over and smashes on the floor, perhaps the causation of this event was the fragility, or smashability, of the glass, not whatever knocked it over. I might be misinterpreting what he said, but can the cause of a condition be viewed as an inherent property of the patient?
Why was there a need for EBM?
We were then treated to some talks on the history of EBM. In brief, physiotherapists needed EBM to assert themselves as a profession, to legitimise their authority and autonomy. They developed a physio evidence database, they instituted degree level courses, and improved the quality of their discussion. Tracey Bury gave us the interesting information that when Darwin talked about survival of the fittest, he meant the ‘one most responsive to change’. I wonder where that puts the osteopathic profession. Apparently there used to be a lot of gurus in the physiotherapy world. Oh my goodness they are just like us! And EBM helped to reduce this culture. Did it? What about the social media celebs in the room? Someone had already commented that looking round the room was like scrolling through Twitter. And there are the superstars of the pain science movement, the David Butlers, the Lorimer Moseleys. Are they not gurus now because they use science? (I’m not being facetious, I’m really not sure of the definition of guru). And a speaker again brought up the issue of definition, saying she used to have to fire off letters to the BMJ to explain that physiotherapy is the title of a profession, not what they do. (I might use that myself). It was a surprise to me that, like osteopaths, they have faced similar demands to justify their existence and what they do. As osteopathy is finding, EBM was a useful political tool in that effort.
But where is EBM heading now?
But EBM has not fulfilled all its expectations. Significantly it hasn’t saved much money, something it was expected to do. And physios now see a need to preserve values and beliefs despite EBM. They think that EBM risks erasing human experience. It sees the patient as a passive recipient of an intervention. They point out that nurses are more likely to see ill-health as a personal subjective experience, and find narrative and qualitative findings important, (and they approve of this.) They regards the patient’s own understanding of an experience as legitimate knowledge, but EBM ignores the existential nature of illness. At the start EBM was all about outcome measures and RCTs, but now physios have moved beyond that stage, They feel they have taken ownership of EBM, and are now learning to live with nuance and ambiguity.
So now EBM is less about the politics and more about decision-making with patients. EBP is not simply an “algorithm process for execution of guidelines and procedures”. It is a “conjoined relationship between science and decision-making”. Shared decision-making is a very NOW phrase, but what does it really look like? They said it is about managing feelings, emotions, context and applying motivational interviewing. They reckon the cost saving for complex patients could be HUGE. (As an aside, this motivational interviewing was referred to quite a bit, and I don’t know what they mean by it.)
The Challenges of Physiotherapy now
So we have some very similar challenges, which arguably physiotherapy has risen to a little more swiftly than osteopathy, and some very different challenges, – but a speaker handily listed the challenges of physiotherapy as
- pay and working conditions
- lack of esteem
- improving understanding
- lack of autonomy
I found this very interesting – I’m not sure what they meant by encroachment, but it might be about the fact that amongst the professions there are processes of bleeding, blending, and cross-fertilization. Are they worried we are encroaching on their territory? Are we worried they’re encroaching on ours, with their craniosacral courses and manipulations? And what about direct access? We have that, but they want it, because it is “empowering”. You can say that again. The fact patients can get direct access to us, sometimes even same day treatment, is in fact something that is one of our great advantages, although we take it for granted. Sure they can go to private physios, but what if patients could get direct access to NHS physios – self-referred and self-directed free treatment? What impact would that have on us?
And where is osteopathy?
What I find just a teensy bit galling, is my suspicion that all those phrases we have used for decades, about treating the whole, and treating the person not the disease, and looking for the health, are going to be demonstrated to be correct. They will be regarded as the latest, cutting edge approach to pain and ill-health, but we will lose ownership. We could be left on the sidelines weakly shouting out “But that’s what we’ve been saying all along”, while we try to catch up with the demand for EBM that physiotherapy has already met and moved beyond. It wouldn’t matter – after all we are all in favour of widening beneficial approaches to patients, whoever does the treatments – but I don’t think osteopathy is ready to be subsumed. I would argue that we have techniques, knowledge, skills and approaches that need to be preserved and disseminated. But although we have a core of highly intelligent researchers, we’re only just beginning to get outcome measures and PhDs in place across our profession, while the physios, healthcare researchers and academics are talking about a post-EBM world and holding conferences based on philosophy. Do we need to go through the steps that they have been through to arrive, like them, at this promised post-EBM land? Or are we going to be able to skip it on the basis that other people have done the groundwork? Just questions….just questions..
to be continued………………….