Experts in medicine and manual therapy seem immediately struck by key details that are impossibly buried to novices. Beginners are likely to be more searching, overwhelmed by detail, and less sure of a single path. But two experts, co-examining a patient? They often tell completely divergent stories about what they’re seeing.
This event — the collision of exclusive clinical theories — is essential for us to examine. Not just to debride our medical claims of unworthy fluff. But to make more honest and powerful our subjective experience.
We all possess different clinical lenses: different ways to boil down the complexity of the body, and help us decide where to go next and what to contact. These govern what we visualize during treatment sessions, what tissue or system we think we’re contacting, and the connection of cause and effect within a treatment setting.
In psychological terms, we employ a schema that shapes our awareness of incoming sense data. This happens prior to conscious choice, so that our incoming awareness feels like a ground-level reality. It’s not.
A Special Kind of Forgetting
All those years we spent in classrooms, muttering medical lingo to ourselves, staring at anatomy textbooks, practicing assessments, working with patients — all of that has sculpted our attention by swelling some parts and lopping off others. In many ways, expertise makes us perceive less of the totality, in order to sensitize us to those few elements we deem important.
What a debasement of our hard-earned eyes! In an age where Medicine is valued on its objective claims, we find ourselves inescapably bound to our squishy point of view.
What’s the point of studying up on anatomical knowledge or physiologic clues, if our brain can still convince us of falsehoods? Isn’t it possible to grind down that wavy glass and eliminate the artifacts of our mental lens? And if not, how can the observations we make have any meaning when we speak them to others?
Step one: We need to stop pretending to objectivity in situations where it has no basis. Many palpatory observations, for example, are not objective as standalone findings. If another practitioner with similar training standing in the same room would not give a similar assessment, then the assessment is probably not objective.
And that might be OK: Much as we wish ourselves impartial observers of reality, let us recognize that nothing — or at least nothing of value — can be seen without a lens to see it. We can never declare ourselves rid of our different lenses, but we can mill them close enough to have a chat.
Unless we do so, we’re doomed to talk past each other in really annoying ways. Each of us will keep appealing to facts and observations that we can’t imagine the other person doesn’t see. This is like a tennis match whose players refuse to hit the same imaginary ball.
It Begins in the Classroom
A teacher’s first crime is honest and inexorable: “Can you show me how you did that?” comes the question, and we earnestly try to oblige. We reach for any language that communicates what’s going through our heads as we work. We serve up a jumble of factoids, half-formed images, heuristic metaphors, and sequences borne of habit.
Those first lessons are delivered with little ego; nothing on our minds but the doing. We return to our own work with greater acuity. We think more about the how’s and why’s.
The more we teach and see our theories deployed, the more it seems to us that we are uncovering the obscurity of nature. This is the beginning of our blindness to lenses. In fact, the opposite of our intuition is true: the core of our teaching is imparting those modifiers we’ve strung between ourselves and our senses.
The lens we omit from description is possibly the most interesting thing we could convey. But we leave it out because it’s difficult to put in words, or because it sounds to us un-scientific. We suspect that admitting to our model or paradigm is like saying that we don’t really know.
We. All. Don’t. Really. Know.
We can have stronger or weaker theories. We can be internally consistent or contradictory. We can control for biases or let them run wild. But we must all admit that when it comes to this body, this person, this situation, we are all going to miss something.
We must learn to convey meaningful information to colleagues that is uncertain, but is also detailed, actionable, and reasonable. Sometimes a simple turn of phrase helps us ground the discussion, by designating the existence of our clinical lens. May I suggest these translational mad-libs:
“When a patient asks me ______, I usually answer with ________.”
“When you say ______ what comes into my mind is ________.”
“When I palpate for ______, I am visualizing ______ and what I feel is ______.”
“When a patient tells me_______, I tend to follow up with asking ______.”
“When working on ______ I often check for ________ and ______.”
“The evidence I’ve read on ______ makes me think that ______ is important in the function of ______.”
The utterer of each phrase above owns their individual perspective. Lacking is the need for the listener to assign objective truth. When we seed our discussion with statements like this, we ground our ideas in specific times, spaces, informational contexts.
The really weird thing? People listen better when this extra step is taken. Fewer demands are placed on our credulity. The teacher or expert becomes less god-like, and their informational ‘kool-aid’ is thus unspiked. We can all breath easier, learn more, and enjoy the refreshments.