Finding the love between scientists and clinicians – a response to Dr Butler on noijam

I am thrilled that Dr David Butler; he of the custard tart; the Duke of Irreverence; the internationally acclaimed clinical revolutionary, has started a blog. I am chuffed that he showed me his first post before it went live. And I could not help but respond because it takes two to tango and I have a few thoughts on this issue myself.

I have both ‘clinical’ and ‘scientist’ in my job title. This is not an accident. This is a reflection of the shared intent that my University, the University of South Australia, and I, have to foster engagement between the two.  In reality, like most people in my role, I am nearly all research – I see about 4 patients a week for clinical consults. My research group is now nudging 30 people and 22 of them are qualified clinicians, several with extensive experience and a top-shelf reputation. I am not half the clinician they are, or David is, or that most of you reading this are, but my research is always driven by clinical problems.

So Dave senses an unhealthy straining of relationships between clinicians and scientists in rehabilitation. I have an alternative view – I agree about the straining but I don’t think it is unhealthy – it feels more like the straining that goes on between siblings while they find their own place in the world and work out how to be different but compatible, or between a tightly committed couple who are having to negotiate their way through unfamiliar tensions. There is no doubt that the context in which science and clinical practice are driven places a huge strain on both scientists and clinicians and, clearly, on the relationship between them. As Dave points out – there is value here in understanding the strains on both sides. I will speak for the scientist first, in response to David’s Lament of The Angry Clinician.

The key performance indicators for a scientist are (i) Impact, (ii) Service to the field, and (iii) Service to science.  Impact is conventionally measured by articles and, moreso, how many times those articles are cited by other articles; and grant income (although this is daft as a measure of impact and rewards inefficient research teams – the UK either has, or is considering, a metric based on cost per article, which makes a $1million randomized controlled trial (this is about the going rate), for a return of 3 – 4 papers, a pretty poor option). The Australian medical research council (NHMRC) is blowing a trumpet about diversifying what is considered to be impact. For example, policy reports, clinical guideline documents, web and social media presence are all on the record, but I am yet to see them taken seriously by peer review panels. I expect they will in time, but not just yet.  Service to the field is conference talks, committees, clinical review panels, engagement with clinical and consumer groups, community service (eg public lectures) and giving professional development courses. Service to science is editorial boards, conference committees, peer review of other people’s articles, grant review panels etc.

Put yourself then, in the shoes of a scientist. Remember that a scientific path is all about discovery, innovation and rigour – it is about truth and possibility. One might say that people don’t choose to be a scientist, science chooses them. Now imagine that your chance of getting support to do your science is about 20%. Your chance of getting a salary to concentrate solely on your science is about 8%. And you know that unless you show in the next 5 years that you have made an impact, served the field and served science, with documented evidence (you can’t talk your way into this club), you are out.  These are immense pressures – pressures that will lead researchers to maximise impact, for example strategically presenting their findings. Indeed, ‘clinicians see scientific arrogance emerge, of proclamations of what to do in the clinic by clinically immature researchers’. I don’t think that giving clinical advice is necessarily a bad thing – the biomechanist who tested the motorbike helmet would seem well placed to tell you which one to wear. But spinning an article in order to give clinical advice is, to me, a clear piece of impact boosting. But are clinicians always disappointed by this? How many times have you complained about scientists saying ‘more research is needed’. I reckon the disappointment in a scientist’s clinical recommendations would relate pretty well with how strongly you disagree with them.

But are clinicians any different to scientists on the impact issue? Impact is again the key performance indicator. A great clinician has great impact – both on the patient in front of them, but also on their own audience, at a conference or professional development course. I think we both face the challenge of seeking impact but remaining precise and honest. Being precise as a scientist means we simply must accept the limitations of what we have discovered – speculation and extrapolation MUST be labeled as such (this is the lament of the University media department – ‘but can’t we say we give hope to the millions of diabetics out there?’…etc etc). Being precise as a scientist means less spin, which means less impact, and we need to take that on the chin.

Being precise as a clinician means the same thing – the clinical guru has, in my view, no less responsibility than the clinically naïve scientist. Perhaps the clinically naïve scientist should be careful when telling people how to treat, but the scientifically naïve clinician should not take the ‘this works – trust me I am a guru’ line. Last year I heard such a ‘guru’, author of many books, state ‘if your patients are not responding, then you need to come to one of my courses – my latest book is included in the fee’ and then proceeded to put a list that had him teaching clinicians how to treat nearly every day of the year.  In my view we both have conflicts of interest – impact versus precision and honesty – that are very difficult to keep in check.

In final defence of the scientists – scientific training puts precision and honesty at its core. Precision and honesty are goals in themselves. We are accountable to one another.  That we are doing this on a ridiculously competitive playing field reinforces the need for these core values and the need for accountability of process.  Are clinicians similarly bound with regards to process? I suggest not, what matters most in the clinic is whether patients get better, not necessarily how they do.

I like Dave’s suggestions for scientists (although beware – to get a name on a paper requires a huge time and energy commitment), but would like to add, and finish, with this advice to scientists AND clinicians alike:

Do not compromise precision or honesty in the pursuit of impact.

About Lorimer Moseley

Lorimer Moseley1 280x300 Finding the love between scientists and clinicians – a response to Dr Butler on noijamLorimer is NHMRC Senior Research Fellow with twenty years clinical experience working with people in pain. After spending some time as a Nuffield Medical Research Fellow at Oxford University he returned to Australia in 2009 to take up an NHMRC Senior Research Fellowship at Neuroscience Research Australia (NeuRA). In 2011, he was appointed Professor of Clinical Neurosciences & the Inaugural Chair in Physiotherapy at the University of South Australia, Adelaide. He runs the Body in Mind research groups. He is the only Clinical Scientist to have knocked over a water tank tower in Outback Australia.

Link to Lorimer’s published research hereDownloadable PDFs here.

Comments

  1. Well stated Lorimer, and to flip the your last sentence into another important one … we should be judging our clinicians and scientists on these same things – honesty and precision. So often clinicians who make part of their living by ‘selling courses and resources’ are judged first as evil entrepreneurs by scientists and academics. We all have potential conflicts of interest. Just think of the researcher competing for the grant money or for tenure, or the clinician competing to get the sweetest job. Integrity is the key. When we hold that as most important, we listen to the people who really matter. Regardless of clinical outcomes, or numbers of research papers completed, or years in academic service the people we should listening to are the ones who demonstrate precision and honesty.
    To go a huge important step further, let’s start demanding this of the advertisements we see in our professional magazines and journals. Are we really okay with people selling ideas and products, when there is not honesty and precision in regards to something as critical for us to know as whether there is biological evidence supporting the effects of this treatment, whether there is good research supporting positive clinical outcomes, or whether it is as yet an unproven theoretical premise?

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  2. David Nolan says:

    Neil,

    You have picked up on another conflict of interests. The advertising and running of courses. The professional magazines need advertising revenue, and the courses with the big headline and ridiculous testimonials, that prey on the vulnerability we feel as therapist, sell. After thumbing through the UK’s latest professional magazine (frontline), if we applied the biologically plausible test, what would we have left? Not many, certainly Frontline would be missing a huge chunk of revenue. Should they hold themselves to a better standard?

    Dave N

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  3. Frédéric Wellens, pht says:

    Kudos to you Lorimer for this excellent perspective from your vantage point.

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  4. Great question Dave. I don’t know the answer beyond what I would do if ran the zoo, but it is one that should be asked. The biologically plausible argument is huge, but I believe it is the right direction for us to go – expecting those who teach us to make it clear how plausible this is from what we know of human biology and outcome studies. Theoretical premises are much more acceptable when they are stated as such, and with open curiousity of whether they are true. If nothing more, we should be demanding that our professional associations do not print advertisements that include claims that are obviously imprecise (and dishonest).

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  5. Thanks for the response to the noijam post Lorimer – I agree with most of it, but I am not convinced of your assertion that “precision and honesty is at the core of scientific practice”. To use a good Australian term – “you’re dreamin’ my friend ”. You have just copped it yourself in my view and it ultimately affects us at the retail end of science, i.e. the patient battlefront.

    I am an avid consumer of as much of the CRPS based literature as I can and I have just read a review paper (Bailey J, Nelson S, Lewis J, McCabe C 2012. “Imaging and clinical evidence of sensorimotor problems in CRPS: utilising novel treatment approaches” J Neuroimmune Pharmacol DOI 10.1007/s11481-012-9495-9) that provides an incredibly selective review of CRPS literature. This is a review that would leave the reader who does not know the field with a very inaccurate picture of the state of the science, and a reader who does know the field (and that includes a growing number of good clinical scientists), baffled that several of the most important studies are conspicuous by their absence. That a review on sensorimotor findings in CRPS could mention no more than one of your many landmark studies is intriguing. How can one discuss graded motor imagery without mentioning it? How can a ‘review’ cite the only published paper with a null result and miss the several with good results, better methods and better reporting? How can one ‘review’ neglect-like findings in CRPS without mentioning you, Gallace or Spence? How can one review tactile discrimination training without mentioning the only rigorous studies on that topic? How can one ‘review’ mirror therapy without mentioning any study that is not overwhelmingly positive?

    You argue that precision and honesty are integral to scientific training and practice, yet here is a paper (and there are others too) that clearly does not survive your challenge to not compromise precision or honesty in the pursuit of impact. Is this an example of the “research niche protection” that I referred to in my blog? It is certainly an example of science being held back from the clinic and its clinicians and patients who ultimately suffer.

    It’s ironic to me, that in this case, your work is that which is most obviously missing in action. The authors seem to bend over backwards to avoid citing you. This is surely a failure of scientific process that extends to the review process as well and I am not convinced that all scientists hold precision and honesty at core of what they. Maybe we need clinical scientists to monitor the review process as well, but at the moment we’re too busy at the clinical battlefront.

    David Butler

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    Bill Vicenzino Reply:

    Thanks Dave and Lorimer for sharing your thoughts on the clinician-scientist matter.

    Dave, have you questioned the authors regarding citations that you feel ought to have been in their paper? Be interesting to hear their reasons.

    …on the review side of things – it isn’t that uncommon to have a clinician review manuscripts in the peer review process, is it? But then there is always the challenge of matching expertise and experience of the reviewer to the manuscript within a timely fashion etc etc.

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  6. Hello Dr. Moseley,

    I wonder if you would mind clarifying a portion of your response? When you state:

    “In final defence of the scientists – scientific training puts precision and honesty at its core. Precision and honesty are goals in themselves. We are accountable to one another. That we are doing this on a ridiculously competitive playing field reinforces the need for these core values and the need for accountability of process. Are clinicians similarly bound with regards to process? I suggest not, what matters most in the clinic is whether patients get better, not necessarily how they do.”

    What did you mean by that final sentence? It seems it has created some confusion in terms of it’s interpretation. When you say ” I suggest not”, is that in reference to clinicians accountability with regards to process?

    It appears to some who have read this excellent exchange, that you are suggesting that (in your opinion), what matters most in the clinic is whether patients get better, not necessarily how they do.

    Thank you for your clarification,

    Glen

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  7. Thanks David and well spotted. Such intriguing things do happen in the literature and your point is well taken – the system sometimes doesn’t do its job, despite our best intentions. I guess it is the responsibility of those of us in the field to alert editors and readers to such things, and if I hold up the mirror I can see I am obliged to do just that. Not a very enjoyable part of the job description!
    Glen – I apologise for not being clear. I was suggesting indeed suggesting that the bottom line in the clinic is whether patients get better. I meant to imply that it is more important than how they get better, but clearly there are boundaries on this! Perhaps a better way to contrast the scientist and clinician mode of operating is that there is a clear outcome that is the goal of clinical practice. Whereas in science the goal is to implement the best process in order to find out an outcome. In a puristic sense, science is about constructing an hypothesis and then trying to disprove it. Imagine that in the clinic – your hypothesis might be that a particular exercise will solve the problem, so, instead of doing the exercise, you work out methods that will prove that this exercise does not solve the problem or that something other than the exercise will solve it. That wouldn’t win you clients….

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  8. I like this line of chatter – we need this – for PTs in the clinic, in education and in the lab.
    As an experienced PT I have been down the “burn out” road and have looked for anything seductive and fun to jazz up my choices for those hard patients who have tried everything. Some of it has been clearly NOT biologically plausible regarding the marketed rational behind the technique. I can’t support those classes anymore – and BiM has much to do with that evolution in my clinical practice. Mostly because I can read the actual research here instead of just abstracts.

    Even if I could read all the research (there are too many paywalls to get to some good articles), many tell me that what I do in the clinic is not much better than placebo.

    So am I a “walking placebo”? Is my ability to charm my patients and get them to trust me what really works? Or is it the careful return (graded exposure) to important activities that is the thing that works? I don’t know. I was challenged recently by a researcher (SK) that “what you do in the clinic is crap”…. Correct. There isn’t much by way of quality research to defend targeted manual therapy. And I admitted that I get creative. My less than graceful answer was “yes, because you are slow”.

    And I think that’s the thing, we need more direction… I want to be as efficient and effective as possible in my treatments. I want my patients to not need me anymore. I get frustrated when research studies come out that are too specific for me to use (needing special, expensive equipment) or vague, or vaguely negative. That doesn’t help me. It has to pass the “so what?” test – can I use this to be a better, more effective, efficient clinician? If not, it’s wasting my time – and more importantly, the time and money of my patient – who has been hurting for about 12 years and would like to stop.

    I love reading the research. But you people are seriously slow. (Keep it up… )

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  9. Thank you Dr. Moseley for your response to my query. Although, I remain somewhat confused with the message recieved by that final sentence. It remains vague in my mind and potentially empowers clinicians who provide treatments and explanations void of scientific process (manually correcting spinal subluxations, centralizing leaky discs, correcting fascia tightness, gouging tissue with a metal object….etc etc). It seems some interpret the final statement to mean that in the clinic, at the end of the day, process does not matter. It’s the outcome that matters. Of course any clinician absolutely must be concerned with outcomes, but not at the expense of a defendable explanatory model. As a clinician writer I read often put it:

    “The veracity and validity of the explanatory model is more important than the outcome.”

    As a clinician for 15 years, I’ve learned outcomes are relatively easy. Provide a treatment that is consistent with a patients understanding, ensure patient expectation and confidence is high, throw in a dash of novelty in technique and a caring and empathetic clinician and generally a good outcome will follow. Is it sustained? How about future episodes of pain even in areas not relating to the body part that was treated? Is the patient still in the dark about how pain physiology works? Do they believe that a verebrea in their spine requires adjustment? Do they believe that they once again, require a metal instrument to settle the problem?

    I read your comment to mean that while outcomes in the clinic remains the driving force (as it should be), clinicians should be bound by the process of “how” in a much more invested way then many currently are.

    It seems others did not read it that way and I’m not sure that a good thing.

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  10. Lorimer states:
    “In final defense of the scientists – scientific training puts precision and honesty at its core. Precision and honesty are goals in themselves. We are accountable to one another. That we are doing this on a ridiculously competitive playing field reinforces the need for these core values and the need for accountability of process. Are clinicians similarly bound with regards to process? I suggest not, what matters most in the clinic is whether patients get better, not necessarily how they do.”

    This statement is a bit difficult to decipher. My interpretation of this selection is this (using my own words):
    I suggest not that clinicians are similarly bound to (precision and honesty); what matters most in the clinic is whether patients get better, not necessarily how they do it.

    Based on my interpretation of this statement I am forced to ask this question: Are these values (honesty and precision) what we (clinicians) should be aspiring to uphold at the apex of our practice?

    If not these values then what values replace this in the clinic world: the bottom line, patient satisfaction, making the patient feel good? I don’t think it is too much to ask for an appropriation of these values (honesty and precision) at the top of the clinician value set. Admittedly, they take a different functional form in the clinician setting than that of the researcher. However, we are not simply put, purveyors of good feelings. That is the implicit negativity excluded by the aforementioned statement by Lorimer; because of the looseness in the clinicians world between honesty and precision: that the promotion of a feeling of well-being trumps knowledge of well-being.

    I argue—a case for the primacy of honesty and precision in clinical practice– people do not, and should not come to us to feel better. Saying this does not rule out the potential that people will not feel better after seeing a physical therapist. People should come to a therapist to understand themselves better. In order to do this I think the clinical should adhere to an ethical core values that holds honesty and precision as it highest values.

    Why not just make people feel better? Well because there are a whole host of conditions where pain is a valuable source of information. This information should not be discounted, ignored, or covered up. Speaking from personal experience the clinical picture can be a messy one. Various, infectious, immunological, oncological, neurological conditions can present as typical patterns of musculoskeletal complaints. Some of which pose grave threats to a persons health. To appease someone’s symptoms at the ignorance underlying etiology is paramount to dishonesty.

    Further, it has been argued, rather convincingly, that the placebo–an artifact of the most evolutionary recent adaptions in maintaining the body’s health especially within the context of a social species–results in a whole host of changes in the patient’s perception of their body based on the expectation of the result (see: Fabrizio Benedetti and Nicholas Humphery). The snake oil salesmen, the less illustrious medical practices of bygone eras, the modern expansion of complementary and alternative medicine have all proliferated and profited from this artifact. As physical therapists we should engage the patient, in a manner that humbly respects this process. Engage in a practice that honestly tries to bridge the gap of information inequality between clinician and patient. That we make precise choices in the interventions we choose and we monitor the responses of the patient. If we choose to ignore the information inequality then we run the risk of being no better than the most ignorant of the adverts of health promotion.

    Contrary to Lorimer’s response:
    “science is about constructing an hypothesis and then trying to disprove it. Imagine that in the clinic – your hypothesis might be that a particular exercise will solve the problem, so, instead of doing the exercise, you work out methods that will prove that this exercise does not solve the problem or that something other than the exercise will solve it. That wouldn’t win you clients….”

    Each client interaction gives the therapist n=1 study. Where the therapist and patient can come up with a hypothesis of treatment, selected interventions, and monitor results. The aggregate, of this process across numerous interactions, patients and encounters can create a very powerful heuristic reasoning model. And that heuristic reasoning model should be an isomorphism of the deep reasoned science informed model. Further, I would argue that doing this with open empathetic communication will “win” you just as many patients as needed to sustain a clinical practice. The functional form of honesty and precision take slightly different forms between the two expressive endeavors of knowledge seeking, but hopefully I have clearly articulated a case for clinicians maintaining this same value set as researchers.

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  11. For clarification, post #10 listed as “Anonymous”, is in actuality Glen. I clicked post comment before filling in the identifying information. My apologies.

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  12. Thanks for the discussion. I think that the work by scientists (thanks Lorimer and David) has helped to provide a better framework (with tools) for working with patients. The complex relationship that occurs with working with a patient (with complex pain) hopefully ends with the patient understanding themselves better (thanks Eric) and having a basic toolbox to help themselves but also for the clinician to understand themselves better. What I really appreciate with this site is a helping hand for seeking out the more precise and honest research. On that note, what are the more rigorous studies with tactile discrimination training ? As well, could someone provide me with the latest review article (concise/honest) on descending modulation of nociceptive input ? Thanks !

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  13. These comments are exactly what BiM is trying to facilitate – thanks a million for taking the time to articulate this stuff. I wholeheartedly agree with you Glen – that there is a very important place for precision and honesty in clinical practice. You ask:
    “Are these values (honesty and precision) what we (clinicians) should be aspiring to uphold at the apex of our practice?”
    This is not really for me to answer – it is in some ways far from a trivial question. You do detect that my point was that these two things are not enshrined in clinical practice like they (supposedly) are in science. I, like you, am very interested in why something might work or not, but I am not sure that is quite as widely held as you suggest. During the 8 years I worked full time clinically, one of the most difficult things for me was concluding that some things I did worked because I thought they would, or because of some mechanism currently not even thought of, not because there was magic in these here hands – I had got my technique perfect, or because I was correcting a particular misalignment or similar. As soon as I concluded that, I found it very difficult to justify doing those things and I was struck with what I felt was a tricky ethical dilemma. There were times when I would be faced with a question like this: lie and they will probably get better, be honest and they probably won’t.
    You hit the nail on the head with this:
    “I read your comment to mean that while outcomes in the clinic remains the driving force (as it should be), clinicians should be bound by the process of “how” in a much more invested way then many currently are.”
    I might get you to ghost write my next blog post….
    Eric – I agree with your line of argument too in that you seem to be promoting the same approach to clinical practice that Glen is promoting and which I endorse. Could you clarify however, this:
    “that heuristic reasoning model should be an isomorphism of the deep reasoned science informed model.”
    Do you imply by ‘isomorphism’ that the heuristic model should emerge from the deep reasoned science informed model and be a copy of it in shape and form? Or perhaps you just mean that it should be the same?
    Do you imply by ‘should’ that this is a moral obligation of the model builder, or that it is a predictable result?
    Stuart – there are studies on tactile discrimination training by Flor (lancet 2001), and by our group (see articles page on this website and look for ‘tactile’).

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  14. Andrew McMullan says:

    Great discussion.
    I did prefer the more collaborative model of relationship suggested here. However I find myself wondering why the relationship is one of such “tension” or even division given both parties are working for and need each other in order to be effective for the end user?
    What else is hidden in the subtext?

    ANdy

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  15. Thanks for the response Lorimer. In response to your question on isomorphism…hmm…I reckon that I chose isomorphism because it implies similarity across modes. For example a music composer such as Chopin, may correspond the representation of music in visual form (notes on a page) with the auditory (sound of the music). Much as the mind corresponds the auditory percept with the synaptic electro-chemical reactions that occur within the brain. The use of isomorphism—mapping that preserves the structure of the mapped entities–also goes further to describe the process of research/science mapping the intellectual terrain which the clinician—ideally albeit–should represent in their brain of the patient-therapist relationship. I don’t merely want to say they (research and clinical practice) are the same things because I think it is clear they are not. Yet they are, or more appropriately should be, representational of each other—in an ideal world. Much like a map represents possible roads taken by a traveler, science represents the possible ways of representing the path for patient and therapist while in therapy.

    I would say that in the therapist’s heuristic model of the patient response does not necessarily evolve purely out of the science exactly, or vice versa. To extend the map metaphor a bit further: the explorer (therapist) informs the cartographer (researcher) of the accuracy of the map, the cartographer makes the map; once made, the map, is represented in and further directs the explorer. The researcher informs therapist, the therapist informs the researcher; round and round the process goes. Yet, the process only goes when there is discussion/interaction between vested parties.

    When that communication breaks down the process and ultimately the product—accuracy, veracity, fidelity, quality– on both ends suffers. Speaking from the point of view as a clinician only, I am not sure where the current state of the process is—obviously there are many opinions on this. Both parties can be susceptible to corruption; the researcher with “research niche protection”; the therapist with being directed by the bottom-line and not patient response—to name only a few. None the less, this process is contingent on honesty and precision being valued by both parties (therapist and researcher).

    So yes, in the face of corruption in whatever form, it is the ethical obligation, of both clinician and researcher to uphold these values. When values are maintained and discussion/interaction occurs between researcher and clinician, I would presume that isomorphism between models (heuristic and deep reasoned) is the predictable result. I surmise that due to journal pay walls, method and distribution of grant money, physical/geographical barriers between clinicians and therapists, and the other competing values within each environment (clinic and lab), all serve to constrain the ability for discourse to occur between clinician and researcher.

    Perhaps I am suffering from a bout of idealism, but without ideals we would be left without direction to strive.

    P.S. I am less sure how the explorer/cartographer metaphor works in corruption. Perhaps if the explorer embellishes his claims of discovery in order to aggrandize their appeal to those whom may desire them…well you know.

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    Eric Kruger Reply:

    Ugh this line should read: “I surmise that due to journal pay walls, method and distribution of grant money, physical/geographical barriers between clinicians and researchers…”

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  16. I don’t believe there could be tension between scientists and clinicians. These are two different field of expertise. For the last 40 years I’m practicing medical and sports massage as it was initially developed by Russian physician professor of medicine Anatoli Sherback MD.

    It always was and should be sequenced as follow:
    First scientists develop clinical applicable protocols and then practitioners learn and implement it in a treatment room. Any clinical procedure should lead to clinical outcome, and if the development of hands-on protocol was done well and precisely, the clinical outcome would be evident. Of course a practitioner has to be well trained in how to perform the protocol step-by-step. If research for protocol development is done, let’s say, sloppy, no clinical outcomes should be expected. All theoretical concepts underlying the protocol must be and would be rejected, because again of the lack of expectation for clinical outcome. As you can see this is cut and dry arrangements and no tension should be expected.

    I believe this is a very important discussion because nowadays overwhelming number of “new methodologies“ develops. Some of massage therapists try to be or pretend to be scientists. As I stated above science and massage therapy are different fields of expertise. A lot of my colleagues became experts in to search of ”new data” and then based on their own interpretation of this data, develop “new methods” of treatment. This is like building your own flying saucer based on the newly available UFO data.

    In my view this is spreading yourself thin and making unsustainable claims that can damage the clinical field. The main evidence base practice, was and should be clinical outcome, and not scientific data only.

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