Certainty is Fragile

Cycles and Pendulums provide apt metaphors for the steady swing of Physical Therapy (along with the rest of Healthcare and Medicine) toward a seeming certainty of data-driven science. Which point in this arc we presently occupy is debatable and difficult to specify with strong convictions. The present, however, will influence the future; and developing an approximate sense of our present location definitely helps. As Howard Marks wrote (Nov 20, 2001) [pdf],

In my opinion, the key to dealing with the future lies in knowing where you are, even if can’t know precisely where you’re going.

Evidenced Based Practice is gaining momentum; as it should! Data-driven and Research-driven potential propels the pendulum from a haze of “traditional” patient care into the shining light of stark evidence. Social media spheres continuously pepper the digital landscape with phrases similar to “…the fall of postural, structural, biomechanical models…” and “Manual therapy, pretty much debunked…” The pendulum swings with unwavering certainty – riding the latest “in vogue” explanatory model. A model. A model of the way things work. A model representing our latest approximation of reality. Reality is too beautiful and complex for complete representation by the most complex models. Science evolves (as it should!); and models change. Kathryn Schulz said it well in The Pessimistic Meta-induction from the History of Science:

Because so many scientific theories from bygone eras have turned out to be wrong, we must assume that most of today’s theories will eventually prove incorrect as well.

Good Scientists understand this. They recognize that they are part of a long process of approximation. They know they are constructing models rather than revealing reality. They are comfortable working under conditions of uncertainty – not just the local uncertainty of “Will this data bear out my hypothesis?” but the sweeping uncertainty of simultaneously pursuing and being cut off from absolute truth.

… all of our theories are fundamentally provisional and quite possibly wrong.

Extreme confidence and unshakable convictions have their drawbacks. Howard Marks again (Aug 5, 2013) [pdf],

When people conclude that all the merit is on either the positive or negative side of the argument, they reach extreme conviction regarding their view of the future and become certain they know what to do. But all-good or all-bad attitudes area rarely right, since there area invariably valid points on both sides and they mustn’t be ignored. Mark Twain said, “It ain’t what you don’t know that gets you into trouble. It’s what you know for sure that just ain’t so.” Most of the time, limits on confidence are more desirable that cocksureness. Overconfidence in one’s judgement is very dangerous.

The pendulum will eventually slow before stopping and changing course. While the particulars of the pendular swing may be difficult to understand, maintaining a nimble and adaptive stance might be more fruitful than the current zeitgeist suggests.


P.S. – This post was born out the following email (made public at request of the recipient):

Hi Kyle,

As I read through your post one concept reared itself repeatedly: the concept of fragility. As I’m sure you know, science progresses on uncertainty. Certainty requires just one piece of “anti-evidence” to knock it off it’s throne. Certainty is non-adaptive; it’s ways are set in stone, and new information is either excluded based on contemporary certainties or included based on ideas that rhyme. Healthcare is both a social science and a business. Social sciences constantly swing on a pendulum of “physics envy,” and Physical Therapy is on the same pendulum. Medicine has repeatedly evidenced the pitfalls of staunch “scientism” and we would do well to allow for shades of grey is what is becoming a very black and white delineation.

Here’s an interesting fact: history shows “facts” can (and often do) change; especially in medicine! Avoid ideology; move beyond Dualism.

Applying terms such as “Snake Oil” and “pseudoscience” invite sharp reaction. It’s not my preference to promote/provoke change via prickly blog-posts; perhaps that’s part of your style. I have no intention to change your style, but an adaptive stance would benefit everyone.

“Financially motivate” is a bit of a straw-man. Isn’t financial motivation an inherent part of every business? No finance, no business.

I’m incredible excited to see such passionate fire within our profession; just don’t turn into the arsonist who burned down his own house.

Best Wishes & I look forward to more of your work,


Find me on Twitter @Cinema_Air


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