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While in the clinic we judge our work at the moment on the in-session change. More broadly we assess the in between session progression, from HEP and self-management. The ultimate assessment should be progressive improvement that leads to completion of the episode of care with the patient prepared for self-management & independence.
In a teaching role we should be judging our effectiveness in delivering the content to a cohort in a retainable way. There are constraints to how we can teach in any environment and truly a clinical instructoroutside of the clinic may be likened to a virtuoso violinist asked to teach the instrument from behind a computer screen or a podium. We can be told a great deal about creating notes, we can even be shown how it sounds, but we cannot be taught how to handle the instrument, how to manage the bow as it changes angles across the strings and proximity to the bridge. We cannot be told how to develop a sense of how the body must move in synchrony with the hands and the bow to create the sound. We cannot be given a sense of how we must respond to the change that we have created in the tension of the strings to retain the continuum of sound. These physical skills need to be demonstrated by the capable teacher and practiced by the willful & intentional student.
In this age of evidence driven medicine, where the new guru has become the evidence, and the profiteers of that circumstance are the purveyors of the evidence, it is the responsibility of the clinician to remember that in the end this is a clinical art based in science. As such it is every bit as much a detriment to the profession to ignore the clinical art and skill set as it is to ignore the emerging evidence. Dutiful attention to one and not the other is to attempt to play the violin with one hand. Mastery will be a hopeless endeavor!
If you have not heard the conscious competence progression before, it is time that you did. If you have, it is time that you remind yourself that you are somewhere in this paradigm and the object is to never stop progressing.
When we enter PT school we arrive consciously incompetent. Ambitious students in search of elevating capacity do so and emerge from school at higher level of competence. Yet without recognizing it a level of unconscious incompetence is attained. We are dramatically more knowledgeable than when we began. The chasm however, between where we are and clinical mastery is so wide that we cannot envision the other side unless we have actually seen it. If we are honest we eventually run into an awakening that we are in fact at a higher level of incompetence. In the clinic invariably patients will challenge what you think that you know.
This is a catalytic moment as it presents the opportunity to actually build to a genuinely conscious clinical competence. This journey is extremely gratifying as we approach development with an intellectual honesty that comes from within with a very directional focus. Genuine progress moves from the possible to probable.
Most therapists stop growing at this point, as does their practice level. They become content with now being aware of competence and fail to see that mastery eludes them. This is compounded by the fact that most become the best clinician in their environment and begin to accept this as the new norm. No longer challenged by peers or mentors the progression ceases.
The most fortunate get exposed to, or seek exposure to a genuine master who has transcended this level and reached the level of unconscious competence. Once having seen this modeled, there is no quelling of the drive to attain the equivalent level. Further there is recognition that there is no limit, perceiving that we have reached this level and shutting down the drive to further growth is acknowledging that we have not but rather succumb to the desire to consciously perceive a higher level of competence. This is an egoist version of the world that Carl Jung’s work would be good reading for.
The difficulty with our profession is the complexity of multiple components that make up the whole. If we look openly there are 3 overlapping components, all dependent on each other; education, research & clinical practice. It is virtually impossible to be an expert in all simultaneously. Some go to one arena and stay there perhaps expert level, perhaps not, yet blind to the other aspects upon which this component is dependent. Some travel from one to the next, each step adding the recognition of the immense value of the other. If they are diligent they enjoy an expertise in one at a time. Some have a foot in two of the circles at a time and can balance it. Extremely few if any can balance all 3 simultaneously.
The three components are the legs of the stool creating the platform of physical therapy. The profession is not stable without all 3 legs. The practitioner of any of the 3 aspects who is not wholly conscious that the other 2 legs are as essential as their own will at best be hopelessly imbalanced.
Educators have committed themselves to mastery of delivering a new body of knowledge, in a way that students can develop a solid foundation from which to learn how to develop as professionals. It is their task to build the basic framework of the knowledge that without which we could not progress. They are constrained by organizational structure, regulations & the shear volume of that what must be delivered in given time frame. They can no more elevate our clinical skills than the teacher of music who can read & write notes but has never touched a violin can teach us to give that instrument life.
Competent researchers contribute steadily to a growing body of scientific foundation for that which clinicians have been doing for decades. It is a different component of the profession than that which clinicians engage in, and we need the information that they disseminate to continue being produced. Most of us live in a third party payment world and the party footing the bill has the right to know what they are receiving and whether or not it is efficacious.
I know fully where my strength is so I will speak for and to the clinicians in the hopes of motivating clinical mastery for those who can embrace the intellectual honesty required on that path. We have the obligation to deliver masterful care to the public who arrive at our door seeking it. We have the foundation to take what the academicians have given us and apply that knowledge in the novel ways that fit our patients’ needs. We have the benefit of the research findings that have already been established, and we have the obligation to drive new pertinent questions to those who do that research.
Challenges for the clinician are foremost to develop the unique set of skills required to consistently deliver the analysis, physical application, and education that are the fabric of our profession. We have an obligation to stay abreast of the emerging knowledge in our field. We should accept the responsibility of intelligent consumption of research so that we know what was learned and what was not learned, what applies to the patients that we see and what does not, and to not confuse these. Those who seek mastery have the obligation to genuinely seek it in an intellectually honest way and to be willing to innovate with novel patient presentations.
What we do not have is the right to over state what we are. The simple truth is that there is more mediocre PT delivered than there is stellar. We have a choice to be part of the problem or part of the cure. With all of the right minds participating in all of the right places we have the opportunity to be the best providers of musculoskeletal care in the medical arena. For this to happen all parties need to seek mastery and co-operation. We can ill afford to think that the part that we perform is the most important piece, but what a better profession it would be if all parties behaved as if the part they are doing now were the part that all the other parts were depending on.
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