After 30 years of practice and development of technology for patient care, there is little left to protect in terms of my “ego”. This will not be a denigration of “ego”, mine, or anyone else’s. This writing will though be a discussion from a perspective of an “in the trenches physical therapist”, who started his profession graduating with a Bachelor of Science in Physical Therapy. Who returned to school 10 years later for 3 years. Very long years to train as a doctor in this field. This was before online only education. So, there were long drives and weekend stays. I became addicted to caffeine as a result. Love the fix every morning to this day.
In 2012, my wife (also a physical therapist) and I made a decision to develop technology that would provide the information the clinician and patient needed to retrain to normal parameters of balance, gait, and selective control. To do this overall in a daily and cost effective manner. This was a major research and development undertaking of hardware, software, and systems. I had never done anything like this. No one I knew well or even casually had ever done anything like this. I was by necessity going to have to learn a great deal many things. I was going to have to on a regular basis suspend my impressions, ideas, opinions, and judgments, even if deeply held during this process. This was not easy and to this day I am used to this process, but it has never been comfortable.
As a clinician working with very challenging patients, they had very severe and sometime long standing impairments. Researchers and the research oriented clinicians always struck me as "pompous". There I said it. I never said this before, but emotionally felt it. Why is the question?
The answer was because there always seemed to me to be an additional barrier placed upon me and the patient. Their mantra, “Prove it!” It struck me at times to be on some level as “lazy”. They seemed to be on the sideline, “talking the talk”, but unwilling to “bleed in the arena”, to do something, anything. They were not “Bleeders”. The other more clinically oriented but still research minded clinicians seemed, and sometimes did, spend an inordinate amount of time testing, and very little time treating. How could the patient get better if you never spend the hours of treating needed so your testing will show the improvement(s)?
I even had the experience of research minded people saying you need to research the technology spending millions of dollars before the technology was completed. This struck me as obtuse. As the technology was literally being developed, what would have been researched presently would not be what was being researched 6 months in the future. The system was evolving that much. Further, I am not a trained researcher. So, the type of research they were talking about was not even possible if there were the funds to do this. Also, researchers seemed to have forgotten the basis of field research. Simply, observation, testing and replication of results. This leads to compelling case study(s), which then leads researchers to engage in the more rigorous research. People who have the time, skill, resources, and impartiality necessary to conduct truly valid research and determine accurate results.
Self-reflection with the passage of time does indeed alter perceptions. I have learned that lesson repeatedly. The technology would be novel. The foundation of the system was based upon the individual’s predominate weight or Center of Mass(COM) as it interacted upon the balance field. The software would bring the ability to retrain gait, balance and select control on a level that was scientific, objective, accurate and reproducible. The “rules” of biomechanics are universal, so the system is universal. It just has not been done before. So now I had to “prove it” at least on some level. So, outcome testing would be for the first time, an ally. Of course, this would not be a published study by a major university or other endowed institution, but it had to be compelling.
What I found at first was that even consistently collecting the data was challenging. The system was changing and sometimes fundamentally (improving). The problem was that as it did, I found I could not compare “apples to apples” when retesting. So many details had to be attended to and this was very basic observation and outcome testing.
I chose the Berg Balance scale for a number of reasons early on. It was sensitive enough to capture improvement over time. The test itself has been used a great deal and shown to be reliable. I professionally was comfortable with it. At the time I chose it, the test was recommended by the APTA as a superior outcome test. I found it’s prediction of fall risk to be reliable and accurate. The gait tracer and balance field assessment tests seemed observationally to correspond to changes in the Berg score. Later I started to add as a second outcome test from a functional perspective, the Elderly Mobility scale. I could have just as easily used the modified physical mobility scale, the physical mobility scale, or a host of other tests.
What I really “learned” though was how attentive to detail I had to be. I had to first and foremost be honest to myself. I came in contact with bias, my own personal bias. The impulse is truly powerful to “fudge”. At times I felt like “Adam” in the garden when tempted by that big juicy apple. I already knew I was “bias” because the system was in large part my “baby”. I conceived it, advocated for it, and put a mortgage on it just on what I believed to be the merits. No concrete proof, just the potential. Now, I had to be honest to myself and others. I had good stories to tell that I could not, because I initially had to learn to be consistent. That really hurt. The system initially was unstable and very valuable data was lost. Do I reproduce what I believe to have existed, but no longer does? No… but I sure wanted to. This is the way of the world. This is the frustration of research and researchers. Now I was beginning to understand.
More transformation was to occur. As I became better at collecting the data and understanding the nuances of the tests as well as their importance, I found myself saying to myself, “prove it!” Not talking retrospective double or triple blind studies with statistical analyzes and equations that would cause nausea here. I merely have to be clear at least observationally and with a few outcome tests to accurately capture what happened. Positive outlook, wishful thinking and eternal optimism all by necessity had to perish. I had to know the truth. I still had to be sensitive to the patient and deliver “bad “ or “disappointing news” to them, but it was so that I could learn what was and was not working, and so they could as well.
Later when working with clinicians in the field, I came face to face with my past self. Problem was, I was the pompous jerk demanding that testing be performed and retested so that proof could be had. I could feel and even hear the disdain. It would have been easier to drop it, but I did not. It seems that I was now privileged to walk in the shoes of folks I did not care for emotionally but accepted intellectually. Except now I felt gratitude for these folks and their hard detailed oriented work. They were not to be distained. They were to be appreciated as any clinician who “bleeds in the arena” with the patient. The Researcher and the “Bleeder” in fact are ideally, a symbiosis.
I do not see a future occupation of hard core research. However, I have changed fundamentally as a result of my experience. What I learned most was that I never could have developed at my present level professionally, and more importantly, I could have never developed processes to help my patients so profoundly without the discomfort of having to "prove it!"
Dr Michael J. Malawey, PT
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