Critical thinking is not just being critical!

I have decided to write this piece on the subject of critical thinking mainly to reflect on what it is, what it entails and to see if I’m doing it correctly. I am often accused of being a ‘critical arse’ and not a critical thinker on social media when I express my views on various things such as acupuncture, dry needling, manual therapy, SIJ up-slips or any other bull shit that infests my profession!
Now I think these accusations are thrown at me sometimes due to the issues social media has with expressing opinions and views clearly with subtleties and nuances in tone and expression being lost and so making miscommunication difficult. I know this from experience on both sides of the coin, being mistaken as well as mistaking others intentions or meaning!
However, there are those that view all critique and critical thinking as negative, closed, minded, even 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 as 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 a critical arse, on the other hand, can be defined as always inclined to judge severely and find fault
The key to separating the two is the ability of an individual to use good quality information and evidence from multiple sources as well as observations and experiences to inform their decision. An arse won’t have or be able to do this!
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 should go and have a read.
Critical thinking is something we should all be doing daily, hourly, in every aspect of our lives not just as physios, clinicians, healthcare professionals debating about the merits of ultrasound, needles or fucking massages! Critical thinking should be used in everything we do, such as deciding if the new dishwasher you’re going to buy is the best one for your circumstances, if that pot of face cream that costs £75 can really get rid of your wrinkles, or this yoghurt that’s 2 days past its sell-by date is still good to eat.
Critical thinking should be used much more by many more people than it currently is. It should be encouraged early on in our lives and education to question, challenge and critique things we are unsure or even sure about. And it most certainly should be encouraged in physio and all healthcare professionals training!
Critical thinking should not be seen as threatening or negative by those doing it or by those receiving it, rather it should be embraced as positive and enabling, allowing us 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 know, I only class myself as a novice and 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 open-mindedly 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 when something goes against what I think is right, this is when critical thinking begins to feel decidedly uncomfortable at times.
It’s this uncomfortableness that makes me understand how some can resent critical thinking as it often leaves you more confused, muddled and unsure of what you thought you knew. But it still no excuse not to use it. We should all try to get 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 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 course or learning any new treatment technique.
We just can’t accept something works due to our peers saying so, or due to patient testimonials and anecdotes, even lots and lots of anecdotes. We should also not trust our own observations and experiences as these are highly subjective to many cognitive biases and without knowing it, they can, and do lead clinicians astray, blinded by their own beliefs and ignoring data, facts and evidence!

Now, despite claims, I am quite open-minded, or at least I like to think of myself as being so. I am willing to adjust and change my thoughts, opinions, and practice when confronted with information and data that warrants it. For example what I do today in my treatment sessions today is so different from what I did 15 years ago it’s almost unrecognisable, and I truly believe that what I am doing now will be completely different in the next 15 years, if I’m still practising then which I hope to be.
I know many therapists get tired of what they call fads and changes in practice, I don’t. I have accepted that these changes are what drives progression and our profession forward as we learn more. If you are still doing what you did 15 years, 10 years, even 1 year ago, I think you should take a long hard look at yourself and your critical thinking, as I suspect its lacking.
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.
I am not saying that clinical experience doesn’t give an individual some understanding and information to help reason, of course it does, but it’s not to be relied upon. As more evidence builds so our practice should evolve and change. It’s as simple as that. We must be ready to change our thoughts, mindset, beliefs and more importantly our practice when the evidence demands it.

Anice diagram from Hanson et al 2012 in BJSM on how research and practice fit together

In my experience, this change and adjustment to my practice more often than not doesn’t involve me adding new treatments, rather it often means I abandon and discard treatments and techniques as the evidence shows they are ineffective, low value or a waste of resources. For example, I no longer practice acupuncture, cervical manipulation, ultrasound or any deep painful manual therapy techniques! Occasionally it does mean I incorporate something new such as a new rehab idea such as isometrics and heavy, slow resistances for tendinopathy.
This constant challenging and changing your beliefs and practice can be daunting and somewhat disheartening, as something you believed in so strongly and passionately, that you thought worked, suddenly starts to look not so rosy, but this is the nature of working with such messy, complex and diverse things such as human beings and pain.
It is also important to realise that changing your practice and methods isn’t an omission of fault, error or wrong-doing, far, far from it, it is a sign of a thoughtful educated clinician. 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 critically evaluating themselves hard enough.
Now all that being said, it may come across if you follow me on twitter that I don’t think much works, especially manual therapy, this is not so!
Ok, who am I trying to kid, this is so, manual therapy just doesn’t do much in my critical thinking opinion! I know many disagree and like to pull, poke, prod and rub patients in an attempt to reduce their pain and get them moving better. That’s fine, what I have an issue with most of the time is the complete and utter ‘bull shit’ that surrounds the explanations of how manual therapy treatments work and how they have to be applied.
To think 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 over the years, that has often gotten me called a critical arse, amongst some other not so nice things. I will not go into too much depth on these points because I can’t be bothered, I just want to highlight the critical thinking process…
Fascial release: If you think you are ‘releasing’ fascia by rubbing the skin with your hands or any other device please have a stop and just think about that, as Paul Ingraham says on his website @painfultweets fascia is stronger than steel if it was any thicker humans would be bulletproof. If you think rubbing your hands over the skin can changing this stuff then you’re just not critically thinking. For more on fascia read this @greglehman blog 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 thick layers of 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 reach and palpate the psoas muscle that lies deep in the abdomen next to the spine under muscle and intestines and affect it, again please just stop and just think about that, all you are doing is mushing people’s guts around and will not anywhere near the psoas to release, free, or affect it in anyway, read more on this here
Bony landmarks: If you think that you can reliably find a C4/5 facet joint or a L3/2 spinous process and then think you 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, hopefully, you’re getting my point now so I’ll get down off my soapbox as 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!
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 it’s 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!
Thanks for reading
Adam