Critical thinker or just an arse?

Critical thinking is not just being critical, and just being critical is not critical thinking…

I have decided to write this piece on the subject of critical thinking mainly to reflect on what it is, what it entails and if I’m doing it correctly and not just being a ‘critical arse’…. a trait I have been accused of a few times on Twitter on various subjects, usually acupuncture, manual therapy, SIJs or anything that claims to speed up healing!

Now I do think these accusations are caused in part due to the limiting nature of Twitter with its 140 characters polarising opinion into either a yes or no, so shades of grey can be hard to express, as can subtleties and nuances in tone and expression, making miscommunication rife. I know this from experience on both sides, being mistaken as well as mistaking others intentions or meaning!

However, there are those that view critical thinking as closed minded, negative or disrespectful, which is just NOT the case. If done correctly being a critical thinker is an immensely powerful and positive trait and one that should be encouraged and embraced by everyone.

 

Critical thinking can be defined in many ways, I like this one…

“The intellectually disciplined process of actively and skillfully conceptualising, applying, analysing, synthesising or evaluating information from, or generated by, research, observation, experience, reflection, reasoning, or communication as a guide to a belief and action”

Being critical on the other hand is defined by the Oxford English Dictionary as…

“Being inclined to judge severely and find fault”

That is just being an arse

The key to separating the two is, as the definitions say, the combination and use of good quality evidence from multiple sources as well as observations and experiences to inform a decision. 

An arse wont have these!

The ‘critical thinking community‘ is an excellent site for reading more on what critical thinking is or isn’t and how it should be used and I recommend everyone stop by and have a read.

Critical thinking is something we should all be doing daily, hourly, in every aspect of ours lives not just as physios debating about the merits of ultrasound! For example it should be used in deciding if the new dishwasher you’re going to buy is the best on the market, or deciding if that pot of face cream that costs £75 can really get rid of your wrinkles.

Critical thinking in clinical practice should be used much, much more by many, many more therapists than it currently is. It should be encouraged early on in a therapists training and promoted as they develop! It should not be seen as threatening or negative, rather embraced as positive and challenging, enabling us all to expand our thinking and understanding allowing us to grow and develop our knowledge and skills.

Now critical thinking can be a tricky area to get right and it does take time to get good at it, as I well know, I only class myself as a novice and totally mediocre critical thinker, the traits of a true critical thinker are something I just do not consistently display, such as

  • formulating questions clearly and precisely
  • thinking openmindedly within alternative systems of thought
  • recognising and assessing assumptions, implications, and practical consequences

But I am aware of my faults, and I do try and check myself and my thinking when I feel myself ‘go off on one’, but it can be difficult and my own biases and opinions do cloud my thinking a lot when something goes against what I think is right, this is when critical thinking begins to feel decidely uncomfortable at times.

It’s this uncomfortableness that makes me understand how some can fear and resent critical thinking as it often leaves you more confused, muddled and unsure of what you thought you knew. But that’s no excuse not to use or accept it. We should all try getting comfortable with being uncomfortable, and remember that being certain of anything in this business is normally a sign you don’t understand it enough and are not critically thinking enough!

Being truly certain of anything within the therapy profession is, in my opinion, ridiculous, there is scarce good quality evidence that allows us to make any firm decisions or conclusions. Research and evidence can be of extreme variability in quality and results and conclusions can be manipulated to suit a cause, in both directions, so a critical eye must be used when reading any literature, or on when on any training course or learning any new treatment technique.

We just cant accept something works due to our peers or others say so, and testimonials, anecdotes, even lots of anecdotes and our own observations and experiences are also not reliable as these are highly subjective to biases and without knowing it, it can, and it does lead clinicians astray, blinded by beliefs and ignoring facts and evidence!

thinker

Now, believe it or not I am open minded, despite what you may have heard, or seen online, or at least I like to think myself as being so. I am willing to adjust and change my practice and treatment, and I have done so many, many times throughout my career. What I do, and how I do it in my treatment sessions today is so different from 10 years ago its almost unrecognisable, and I believe that what I do now will be completely different in the next few years, if not sooner at the rate things are changing.

I have to accept this, I have accepted this, as I don’t have all the answers, in fact I have some massive unanswered questions and knowledge gaps, which keeps me searching for more information which keeps meaning I have to change practice the more I learn.

In my opinion, many let themselves down, in the belief that they have lots of clinical experience and done lots of reading and research on an area and so feel they have answers, this is when they stop thinking, critical thinking MUST be a constant ongoing process.

Now I’m not saying that experience doesn’t give an individual a better understanding than others not so experienced, of course it does, but it’s never absoulte, as more and more evidence builds for certain techniques or methods, so our understanding evolves and changes, so must we, it’s as simple as that, and we must be ready to change our thoughts, mindset, beliefs and more importantly change our practice when the evidence demands it.

This is a nice diagram from Hanson et al 2012 in BJSM on how research and practice fit together

In my experience this adjustment process usually involves me discarding treatments and techniques rather than adding new ones, for example I no longer practice acupuncture, cervical manipulation, ultrasound or deep painful manual therapy techniques!

Occasionally however it does mean I incorporate a new method such as enhancing rehab programmes for tendinopathy with isometrics and heavy, slow concentric/eccentric work.

This constant challenging and changing your beliefs and practice can be scary, daunting and somewhat disheartening, as something you believed in so strongly and passionately, that you would have sworn on your mothers life worked, suddenly starts to look not so rosey, believe me I’ve been there many times and I will be there again I’m sure, I use this quote a lot in these situations…

” The more you learn, the less you understand”

This is the nature of working with such a complex and diverse thing as the human body and of course more importantly it’s brain.

It is also important to realise that changing your practice and methods isn’t an omission of error or of wrong doing, far, far from it, it is a sign of an excellent thoughtful clinician with a critical thinking mind. I truly believe that if a therapist hasn’t changed or modified at least one or more treatment method/technique or approach each year they are not reading enough or not critically evaluating themselves hard enough.

Now all that being said, it may come across in this post or if you follow me on twitter that I don’t think much works, especially manual therapy, this is not so…. Ok, ok who am I trying to kid, this is so, not many manual therapies do much in my critical opinion! But I do occasionally pull, poke, prod and rub my patients in an attempt to reduce their pain and get them moving better, but what I do have issue with most of the time is the complete and utter ‘bull shit’ that surrounds manual therapy treatments and the ridiculous explanations given to the patients!

To think that this rubbing and poking does some of the structural, mechanical things that many claim it does is just not critical thinking, I am going to briefly highlight some of the debates I’ve had, that have be the crux of me being called a critical arse, amongst other not so nice things, I will not go into too much depth as much cleverer people have done a far better job than I could, I just want this article to highlight the critical thinking process not the actual subjects themselves but some examples are…

Fascial release: If you think you are ‘releasing’ fascia by rubbing the skin with your hands or other device please have a stop and just think about that, as Paul Ingraham says on his website and via the excellent @painfultweets the stuff is stronger than steel and Kevlar, if it was any thicker us humans would be bullet proof. If you think just by rubbing your hands over the skin you are physcially changing this stuff then you’re just not critically thinking. For excellent more on fascia this read the excellent @greglehman website here

Sacroiliac Joint palpation: If you think you can palpate the symmetry of an SIJ and feel it move a few degrees when it’s covered by adipose tissue, skin, fascia and ligaments then again please just stop and critically think about it, read more on the SIJ in my post here

Psoas: If you think you can physcially touch the psoas muscle that lies deep in the abdomen next to the spine and so effect the physical properties of it when its under so much tissue and intestines, again please, please just stop and just think about that, all you are doing is mushing people’s guts and maybe just maybe doing something neural again, nothing to do with the psoas being released, read more on it here

Bony landmarks: If you think that you can reliably find a C4/5 facet joint or a L3/2 spinous process and can apply a constant uniform pressure to that joint each and every time and decide if it’s stiff or not, again please stop and…

Ok, ok, your getting my point now I hope, so I’ll get down off my soap box, I’m sure you want a cuppa now, or probably a beer if you’ve got this far… Hold on you’re almost at the end!

So there you go, my take on critical thinking, I do hope this blog has made you think about questioning what you and others do more and start critically thinking more often and more harshly than you probably would like to, and realise that its not negative or disrespectful, if done correctly and professionally critical thinking is the most powerful tool you as a therapist can have, not your hands!

I also hope that when I do sound critical via twitter or elsewhere that you perhaps can realise I’m just not being an arrogant, ignorant arse, if not then I’ve realised you can’t please all the people all the time, and I won’t lose any sleep over it!

Finally I’ll leave you with a great quote that I first heard from another critical thinking mind @neiloconnell

“if you find yourself agreeing with everyone, you’re not thinking hard enough”

Thanks for reading

Keep thinking, and try not to be an arse!

Cheers

Adam

 

11 thoughts on “Critical thinker or just an arse?

  1. Not just the Therapy world Adam, this can be applied to Nutrition, Coaching & Teaching. Are people only searching for the magical method/treatment that works on all – rather than what is right for the people they are dealing with?

  2. Hi Adam,

    I really enjoyed reading this post. I am current a physio student in New Zealand doing my clinical placements. As a student i do agree that it is important to critically reflect on our practices to become competent practitioners. Although it can be hard to apply the evidence into context as a newbie! but i guess it will become easier with more experience and knowledge

    I knew someone who had a 5+ year history of SIJ back pain after pregnancy which hasn’t improved. I was suprised to find out that the physio she had been to for 5 years had just been giving her massages and mobilisations! (no exercises given to improve stability)

    Keep up the good writing 🙂

  3. I’ve been practising for 7 years and have come to the same conclusion. Well said! What you wrote down is what’s been in my head for years now. Our bodies have a natural ability to heal and rarely need to be “poked and prodded”. Eat well, rest well and move well and things usually take care of themselves.

    The only thing that I find has consistent results is properly a properly applied exercise/movement prescription.

  4. Well put. It is this vague nature to the job that causes a vast swathe of ttrue critical thinkers to leave the profession; all you have left is the ‘believers at all costs’ – much to the detriment of the profession.

  5. p.s. ”Occasionally however it does mean I incorporate a new method such as enhancing eccentric loading exercises for tendinopathy with isometrics and heavy, slow concentric/eccentric work, shown to achieve better results”… again an example of average evidence being hailed as the next best thing. Konsgaard et al’s work has far too small a sample size to be used in order to alter clinical practice, but it is now being pushed out left, right and centre.

  6. I’m glad you clarified this. I’m a relatively recent follower of the physio blog/twitter scene and I have to confess initially I thought the later of you!

    However I do enjoy your articles and please continue! I find them very thought provoking.

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