Recently, I had a conversation with a medical doctor on social media regarding the amount of unsubstantiated “treatments” being peddled around to mitigate the effects of COVID-19. He was contemplating the possibility of some type of online oversight by credentialed healthcare professionals (HCPs) of these dubious claims. I agreed that something like this would be helpful although its implementation could be incredibly difficult. In addition, one unintended consequence of such a program could be that all innovation was shot-down as not evidence-based.
Fortunately, I discovered that this particular medical doctor and I are like-minded in regards to the extremes of evidence-based practice, and the conversation ended productively. This ending was surprising to me at the time, however, as many similar conversations I have had on social media did not end so positively. It seems that many strong-willed HCPs on social media are so deeply caught in the mainstream of evidence-based practice that independent thought creates knee-jerk outrage.
A good example of this is a recent emphasis among parts of the PT profession to favor active, or patient-controlled, interventions over more passive treatments. I recently set off (unintentionally) a few physical therapists on Twitter with one part of my answer to the question “Why do patients expect manual therapy?” The premise of the question was that since active interventions are superior to passive anyway, and touching a patient may increase the rate of infection during this COVID-19 pandemic, there should be no reason to do any manual therapy at this time.
The crux of my answer to this question involved a respectful disagreement of their premise, with references to clinical practice guidelines, randomized trials, and my own experience to support my treatment approach, while citing the lack of evidence to justify avoiding all contact with a healthy patient. (For context, the reader should also understand that I believe whole-heartedly in the positive benefits of exercise for pain, and I prescribe it to every patient.) But I did add to this question about manual therapy what I felt was a fairly benign additional reason; that is, for most people exercise does not feel good while one is doing it, while many forms of manual therapy are enjoyable during the treatment.
Evidently this struck a nerve with these two therapists, because both of them were outraged that I would suggest it, and proceeded to accuse me of setting my patients up for failure with any self-help interventions. Ironically, however, none of their subsequent rebuttal included any data or anecdote that all their patients enjoyed prescribed exercise. Most of their comments focused on empowering patients to be more active even if it was painful, and by so doing manage the pain toward a more active, healthy lifestyle. When I tried to find common ground with empowering patients through exercise, while using all evidence-based tools to maximize results, they seemed to dig in further that it just wasn’t necessary to try to add additional treatment strategies to PT practice.
Although the conversation became less heated for these two colleagues as we discussed further, I feel that the main dispute we still had was a battle they were raging between innovation and evidence-based practice. For them, exercise and education were active, evidence-based treatments that needed no further intervention. The new idea I presented, which posed a potential flaw in a classic staple of PT practice, caused knee-jerk outrage for them. Additionally, the idea that we could combine passive and active interventions to maximize patient outcomes seemed just as foreign.
Before continuing, I want to mention that I believe these therapists do an admirable job for their patients. Their passion for the profession was clear, and I’m certain they have seen scores of people leave their care empowered with the education and exercise they provide. However, I know that many patients leave medical offices, massage studios, and physical therapy clinics without these results. In part, these things happen because we don’t have all the answers. But sometimes it is because we only provide what seems to be a canned response, or a treatment they have already tried for years with unacceptable results, or maybe just because they just don’t like to exercise.
In conclusion, evidence-based practice and innovative ideas do not have to be at war. I think some practitioners forget that all proven treatment strategies once started as new ideas that were then tested. We should use the best-randomized trial, cohort, and individual case evidence published, but after that use all the tools (including our own innovation, safely and ethically applied) at our disposal to provide the most tailored solutions for our patients. For more information contact us today!
