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Evidence based practice
Line 931 of the fist draft states “The scientific process and its importance to evidence based medicine.” Implying the EBP must be based totally in science or it is not objective. This is controversial. I think that while we agree that EBP is based of objectively measure results I believe that the best EBP combines science and Wholistic observations to achieve the best approach. If you reduce something to just what you can measure and fits into a tight scientific theory you are limiting yourself to the very simplistic.
I also believe that are we work on people who are very complex we develop intuitive sense that can be a very valuable part of deciding how to help people if we apply EBP to both left-brained and right brained thinking. In think business when confronted with the unexplainable we either reject it, develop some pseudo-scientific or fantastical explanation for it. Instead we could simply acknowledge that we cannot explain it but we can see what results it produces and objectively test the results of what we do. If we reject it altogether we are reducing the person to a simple set of measurements which give us an incomplete picture. If we dream up an explanation that does not fit we end of following the false theory not the observation. We have intuitive right brained thinking to deal with complex issues and to reject what we cannot reduce to left-brained reason is to use half of what we can.
We need to be trained how to use the right-brain in an objective way. In many ways this is much harder than science.
I also believe that are we work on people who are very complex we develop intuitive sense that can be a very valuable part of deciding how to help people if we apply EBP to both left-brained and right brained thinking. In think business when confronted with the unexplainable we either reject it, develop some pseudo-scientific or fantastical explanation for it. Instead we could simply acknowledge that we cannot explain it but we can see what results it produces and objectively test the results of what we do. If we reject it altogether we are reducing the person to a simple set of measurements which give us an incomplete picture. If we dream up an explanation that does not fit we end of following the false theory not the observation. We have intuitive right brained thinking to deal with complex issues and to reject what we cannot reduce to left-brained reason is to use half of what we can.
We need to be trained how to use the right-brain in an objective way. In many ways this is much harder than science.
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Replies to This Discussion
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Permalink Reply by Mike Hinkle on
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Line 931- Now you are "cooking". It's one of my highlighted areas as well. This does need further explanation.
Now you are jumping ahead, into issues hard to qualify, "intuitive". You will never get a complete picture given all the varibles. We need to stay on task. What line is next? -
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Permalink Reply by Carl W. Brown on
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I think of intuitive as right-brained thought. Just as valid but it must be handled differently.
Medicine does not have a complete picture either. Prescribing drugs for example. They never work exactly the same way on everyone. A friend of mine for example, got clots from heparin losing all his finders and most of both feet. I am still suffering from the side effects of an ADD drug that I stopped taking about 10 years ago.
I think that psychology is a better model for our work. There is science but then to be effective there is a lot of intuition all based on what produces objectively the best results.
For example. I work on lung issues. Putting my hands on a person and expecting something to change in the lungs makes no scientific sense. As part of EBP I feel for the problem first and then check with the person to see if what I am feeling matches their diagnosis and perception. Where is it, is it in the trachea, bronchi lung. Which lung and where exactly is it. I have only failed to help one person and I have work on a lot of people who were real skeptics. I even drained a cat’s lung and have the before and after x-rays to prove it. I have the objective evidence and use the evidence of the results to guide what I do. It is this “doubting Thomas” attitude that needs to be taught.
One must however use good science to insure that if what you do is intuitive, you need to make sure that it will do no harm if it does not work. You must also be open to the idea that if you ignore these “feelings” that you make be missing opportunities. You must also be aware that believing that you can help make in and of itself lead both you and you client to think that you have helped when in fact it is no more than a shared illusion. To prevent this you must control you patient interaction to be able to objectively measure the outcome. -
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"One must however use good science to insure that if what you do is intuitive, you need to make sure that it will do no harm if it does not work."
The only way they will scientifically know this is to be taught this in school or in continuing education classes. No massage therapist, I know, is prescibing any drugs. But in school, kids are learning which drugs will affect their decision about which modality to use. -
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Mike, I don’t think I was equating science and drugs. However, if a person has x-rays I will look at them and read the report to see if there are abnormalities that I need to be careful of when I am doing ROM work. If a person is taking heparin I now to be careful of disturbing clots. If a person has a hip replacement I have to modify some of my stretches as not to displace the joint. People with ALS for example, often to hat have the muscle tension to hold the shoulder in place. Etc.
Then there is adding reason to intuition. If I am working tissue and it start to get warm it may be a sign that I should stop and give it time before continuing to treat.
While I don’t give drugs I use psychology to what I term is “controlling the placebo effect”. I may control my approach to convince the person that they are getting better without them even realizing it. -
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Permalink Reply by Christopher A. Moyer on
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Hi Carl.
"Line 931 of the fist draft states “The scientific process and its importance to evidence based medicine.” Implying the EBP must be based totally in science or it is not objective."
Isn't that true, as you have stated it? For EBM to be objective, it has to be based on objective evidence. Intuition and anecdote are subjective, no?
"This is controversial."
Which part? The assertion that only scientific evidence is objective, or the implication that massage therapy should be based entirely, or almost entirely, on empirical evidence?
-CM -
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Christopher, true scientific practices are objective but EBP is geared on evidentially proven results. The best science does not always produce the best results. The problem with science is that to fit into a set of theories you have to limit your input.
Psychatry is good example sure you can stick someone in a Skinner box but while scientific it is a limited tool. Better to use the soft skills of reading people which while not an exact science can provide better results.
We work in a world in intangibles like the act of touch. While what we do is not all science it does not stop us from evaluating what works and does not work objectively.
For example, I can usually feel pain in a client. This is certainly not science and I have no idea how it works. But I can check to see if it is working and find things wrong with people that medical tools cannot. I know that when I feel the pain disappear that patients feel the pain go also. However, some times I feel something that does not exist or fail to feel what they do. By objectively monitoring what I do I can use this tool effectively.
The problem with extra-rational approaches is that we often assume that they work in all cases without objectively testing the results. This leads us to think we are helping people when we are not or at least not providing optimal treatment. -
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Permalink Reply by Noel Norwick on
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Carl: You might find interesting a book by Beth Crandall, Gary Klien & Robert Hoffman, titled "Working Minds, A Practitioner's Guide to Cognitive Task Analysis", MIT Press, 2006. It's the best book I have so far found explaining the differences between qualitative & quantitative research methodologies as they relate to developing "evidence-based" models of how acknowledged experts actually make decisions in real-world practice and how to teach beginners to develop the same level of professional proficiency.
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Noel, I have not read that book but Cognitive Task Analysis is essentially planning your thinking process. You are only dealing with the left-brained side of you mind.
That the example of driving down the road when you get the feeling that the car in front of is about to cut you off. You cannot say why you have this feeling and cannot rationally justify your hunch. Do you just ignore your hunch? Or is the best driving practice to combine rational and non-rational thinking? I think you will find that if you tak into account that some times your hunches are right and other times wrong that you achieve objectively measurable better results. Such hunches do not fit into Cognitive Task Analysis models. -
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Assuming the BOK is changed to set minimal required values to each KSA. Take 682 Chakras for example. What mastery is needed to meet the minimum requirements of an MT? Obviously just knowing that they exist or knowing the positioning or names has nothing to do with performance. In other words KSAs with too littlie knowledge to affect performance are the same as no knowledge when it comes to setting performance levels. So I would conclude that one has to be able to see them? Being able to just see them without know what to do with what you see also is worthless so one must then be able to take that information and alter how one treats the client.
Is the BOK implying that if one cannot demonstrate how to see and apply what they see to a session that are not qualified to do massage? If this is true can they document the harm and propose a way of testing this ability?
Then we have things like 401 Organs. Knowing what a stomach is depends on the modality. Is it a digestive organ, is it an energetic entity with concerns about yin deficiency or association with the element earth, or is it unnecessary to know anything about the stomach. I think we will find this true for different modalities.
I can just imagine the test. Answers will be a,b,c,d or 1,2,3,4 or does not apply.
I think I will check does not apply for all questions but one that I am sure of and get a 100% score. -
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Carl: Your premise re Crandall's Cognitive Task Analysis book is false. This book addresses the very issue(s) you raise, as well as many others that trouble people performing truly "mission critical" tasks/work.
Re the BOK - My perspective is that tests based on this grandiose project should be limited to what is based upon ongoing review of actuarial records of medical outcomes and documentation of legal trial findings related to what an entry level massage practitioner (regardless of modality) should know about massage related health risk factors and absolute contraindications. Tests that deal with modality specific information (theories, principles & practices) should be used for advanced modality specific certification only. -
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Noel, I agree that if you are determining the entry level requirements you need to start by studying documented non-temporary harm to the public that can be mitigated by proper education. That should be the point of licensing standards. I think we need to contact the insurance companies and examine the claims.
The reason we have licensing is because prostitutes use the term “massage” for acts that are not massage. It is about the work not the practice. However, the law has been perverted to create protectionist barriers in terms of money and time to entry to the professions. But worse they are using the law to artificially distort the profession.
I agree with UC San Diego’s Center for Public Interest law.
For fifteen years, CPIL's theory regarding the regulation of trades and professions has been consistent:
Government should not interfere with the marketplace unless absolutely necessary.
Government should regulate a particular trade or profession only after an honest assessment of the marketplace and any flaws which (a) present a threat of irreparable harm, or (b) prevent normal marketplace functioning from driving out incompetent, dishonest, or impaired practitioners.
Licensing is one form of regulation and it is the most market-intrusive and restrictive form of regulation. It should be reserved for trades and professions in which incompetence is likely to cause irreparable harm that is, harm for which money cannot compensate. If there is likely irreparable harm, then a prior restraint type barrier to entry (licensing) which addresses and prevents that precise harm should be imposed; additionally, the licensing agency should set industry wide standards of conduct and ethics, and police violations of those standards through a vigorous enforcement program.
In the absence of probable irreparable harm, numerous regulatory alternatives to licensing should be considered. These include the posting of a bond to ensure a fund to compensate injured consumers, a certification program which has the effect of disclosing information to consumers about the qualifications of a practitioner and protects the use of a title, a permit program, disclosure requirements, a rule of liability, straight statutory prohibitions on certain activities, tax incentives to encourage certain behaviors, antitrust litigation to restore the normally-functioning marketplace, etc. -
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Carl: Given that I cannot keep count of all the trademarked/registered forms of massage (for me this includes bodywork & energy work) I believe/suggest that the MTBOK project would do well to start with creating/finding a consensus regarding what knowledge an entry level practitioner must have. Additionally, I believe/suggest that massage practitioners who work with people suffering with M.D. diagnosed medical conditions would do well to develop a consensus regarding defining/identifying a legally defensible approach to "evidence-based practice". That is, if they wish to develop a relatively "safe harbor" legal defense against charges of malpractice.
Regarding prostitutes masquerading as massage practitioners: Licensing of massage practitioners has done little to restrict prostitution in Los Angeles while ever increasing minimum educational standards does not appear to have increased practitioner incomes or positive client health outcomes. As a recent graduate of the Los Angeles Police Department's Community Police Academy training program, I'm confident saying that the police find it easy to distinguish prostitutes and whore houses from massage practitioners and businesses. If controlling prostitution was the real concern, politicians would direct the police to investigate and district attorneys to prosecute it rather than continue pretending that burdening massage practitioners with licensing constraints provides a significant social benefit.
Carl W. Brown said:Noel, I agree that if you are determining the entry level requirements you need to start by studying documented non-temporary harm to the public that can be mitigated by proper education. That should be the point of licensing standards. I think we need to contact the insurance companies and examine the claims.
The reason we have licensing is because prostitutes use the term “massage” for acts that are not massage. It is about the work not the practice. However, the law has been perverted to create protectionist barriers in terms of money and time to entry to the professions. But worse they are using the law to artificially distort the profession.
I agree with UC San Diego’s Center for Public Interest law.
For fifteen years, CPIL's theory regarding the regulation of trades and professions has been consistent:
Government should not interfere with the marketplace unless absolutely necessary.
Government should regulate a particular trade or profession only after an honest assessment of the marketplace and any flaws which (a) present a threat of irreparable harm, or (b) prevent normal marketplace functioning from driving out incompetent, dishonest, or impaired practitioners.
Licensing is one form of regulation and it is the most market-intrusive and restrictive form of regulation. It should be reserved for trades and professions in which incompetence is likely to cause irreparable harm that is, harm for which money cannot compensate. If there is likely irreparable harm, then a prior restraint type barrier to entry (licensing) which addresses and prevents that precise harm should be imposed; additionally, the licensing agency should set industry wide standards of conduct and ethics, and police violations of those standards through a vigorous enforcement program.
In the absence of probable irreparable harm, numerous regulatory alternatives to licensing should be considered. These include the posting of a bond to ensure a fund to compensate injured consumers, a certification program which has the effect of disclosing information to consumers about the qualifications of a practitioner and protects the use of a title, a permit program, disclosure requirements, a rule of liability, straight statutory prohibitions on certain activities, tax incentives to encourage certain behaviors, antitrust litigation to restore the normally-functioning marketplace, etc. -
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