Sensory Approach to Manual Therapy
Sensory Approach to Manual Therapy
Deep navel gazing with Ruth Werner - Critical thinking is thinking about thinking, so you can think better.
Ever felt underprepared in your professional role and wondered how to bridge that knowledge gap? Join us as esteemed expert Ruth Warner shares her transformative journey from feeling unprepared as a massage therapist in the early 80s to becoming a beacon of knowledge on massage therapy's intersection with pathology. Ruth passionately advocates for therapists to solidify their knowledge base, moving beyond the superficial safety net of doctor's notes. Her insights into the importance of education and her celebrated textbook, "A Massage Therapist's Guide to Pathology," are sure to inspire anyone keen on advancing their professional capabilities and confidence.
We tackle the myths surrounding the infallibility of doctor's notes, clarifying the true legal responsibilities of massage therapists. Rather than relying solely on external validation, Ruth encourages therapists to cultivate a richer understanding of their craft and their clients' needs. By fostering better communication with healthcare providers, therapists can align treatment goals and prioritize client safety, ensuring they remain within their professional boundaries while collaborating effectively across the healthcare spectrum.
The conversation then widens to the broader theme of interdisciplinary collaboration and critical thinking in therapeutic practices. Ruth underscores the importance of overcoming healthcare silos and integrating evidence-based approaches with patient-centered care. We discuss the strategies for building a robust referral network and the ongoing necessity of critical thinking in healthcare. Highlighting her podcast "I Have a Client Who: Pathology Conversations with Ruth Werner," and her interactive webinars, Ruth invites listeners to engage with her in this enriching journey of professional development and continuous learning.
https://booksofdiscovery.com/product-category/a-massage-therapists-guide-to-pathology/
https://www.criticalthinking.org/pages/index-of-articles/1021/
Ruth Werners table for critical thinking:
1 - Recognize and analyze the question at hand = What is this client asking for, and can I provide it?
2 - Identify relevant variables that must inform your decisions = What factors affect this client's ability to safely receive massage therapy?
3 - Challenge your pre-existing assumptions = What more do I need to learn about this client's situation? Do I have a clear grasp of what he wants and needs?
4 - Consider possible solutions to challenges and explore alternatives to those solutions = What skills do I need to bring to this client's session? Do I need to refer this client to another provider? How might other strategies compare with my first choice? What have others done in similar situations? What have I missed?
5 - Plan and execute a course of action that incorporates relevant variables = Based on all this, what is my session plan?
6 - Reflect on how things went after you made a decision = What worked well, and didn't work well, in that session? What will I do differently next time?
Hello everybody and welcome to another podcast of the Sensory Approach to Manual Therapy. My guest today is the wonderful Ruth Warner, who I have the privilege to speak with, and I met at the American Massage Therapy Nationals Convention about a month and a half ago and got on like two peas in a pod and I'm really grateful to have her here. So thank you.
Speaker 2:Thanks, Troy. It's a pleasure to be with you today.
Speaker 1:So why don't you tell us a little bit about yourself? So any listener who by chance doesn't know you might get to know a little bit about who you are. For those of us who have been in the profession for a while, we've definitely read your books or come across your material before. But on the odd chance that we have some new listeners, Great, well, I'm happy to do that.
Speaker 2:I went to massage school a very long time ago.
Speaker 1:The old lady was.
Speaker 2:When I went to massage school which was in the early 80s.
Speaker 2:I got through my very short but to me quite rigorous program very short but to me quite rigorous program feeling inadequately prepared to deal with clients who had health issues, because at that time massage therapy outside of the sex trade was intended for and targeting people who were basically healthy, who had a little money to spend right, it was a sort of a luxury kind of thing. And because of circumstances I ended up working with a lot of clients who are probably were probably younger than I am now, but they seemed older to me then and they had accumulated a number of health issues people who had had knee surgeries and diabetes and you know any number of other things and I just felt really unprepared to be helpful to people who were not completely 100% healthy. And I had continued to work at the school where I was a student and I was a teacher there over a number of years and developed a particular soapbox about how massage therapists really need to know more, about working with clients who are not 100% healthy. And eventually I'm cutting things way way short here, this is a very abbreviated version but eventually came to write this textbook, a Massage Therapist's Guide to Pathology. The first edition came out in 1998. We are now in the seventh edition. It's published by Books of Discovery. Thank you very much to them.
Speaker 2:And by happenstance more than by design, and happenstance more than by design I have become I will go out on a limb and say a subject matter expert on the interface between massage therapy and various kinds of pathologies. Not because I'm a doctor, because I'm not. I never went to medical school, didn't go to nursing school, didn't go to PT school. I went to massage school and I developed a deep, passionate interest in this unanswered question about how does massage therapy influence the healing process in various kinds of ways.
Speaker 2:So that book became the center point of my career. No one, no one saw this coming became the center point of my career. No one saw this coming. And now I work to support the book and I write columns for a trade journal, for Massage and Bodywork magazine. I teach continuing education classes all over the world and when the opportunity arises I also work in core curriculum classes. These days it's more often an occasional Zoom visit, but once in a while I get a chance to actually be face-to-face with new students, which is my you know sort of my target audience.
Speaker 1:That's wonderful and I'm really glad that I have you on, because that plethora of knowledge is something I'm going to I want to talk about today, because right now I'm doing this series on communication and for me there's a lot of different styles of communication.
Speaker 1:You know, I've had one an acupuncturist on who they talk about communication between the therapist and the client, and then I had another one who talks about that, but also therapist to therapist. And one of the things that I want to have you talk about today is the communication from therapists to the outside world, as well as the outside medical world, because I think this is something that a lot of massage therapists have become very either lackadaisical on or never trained on. And the class I attended at National for you was I can't remember the exact title do I need a doctor's note? Something like that and I think what I walked away with from at the end of the class was if you're a educated therapist, you absolutely should be able to make the decision to treat someone based on your knowledge base and should take on but choose not to, for a multitude of reasons that I'm not aware of.
Speaker 2:I can say a lot about why people want to abdicate that responsibility. So the class is called A Doctor's Note is Not Good Enough and, what is Better, it is in fact available as an online self-paced continuing education class. And it arose really out of a sense of frustration between myself and a colleague at watching conversations in social media about you know where? Someone will drop into a massage therapy group and say I have a new client and they have lymphedema. And what should I do? You guys? Which is it just boggles me.
Speaker 2:I am not making that up, that actually happened, right, and a number of people said don't work with this client until you get advanced education, which was appropriate. But a whole slew of them said get doctor's permission, get a doctor's note, get a doctor's clearance before you touch this client. And it just kind of makes my teeth fall out when I see those kinds of conversations happening between massage therapists. And it's not just about lymphedema. I have a client who is on dialysis. Is it okay to work with them? Only if you have a doctor's permission? That's not true.
Speaker 1:And I can hear some of my listeners grinding their teeth, but I can also hear some of them going. This is me. I've done this because we've all done this At one point in our career. We've all said is it safe to do? And we've asked other healthcare professionals for advice, and that advice often is seek higher permission when in reality what you should be seeking is higher knowledge and if your knowledge base is high enough, you would feel comfortable or not comfortable making that decision on your own. But that's a tricky step because that's where how much education is enough for us to feel safe to make that decision without putting our clients at risk this.
Speaker 2:So I mean, you're really singing my song, obviously. Here's you know, when I went, when I went to massage school, we were told if you ever have a question about your client's health and whether it's a good idea, call their doctor, as if that's going to work. I can't call my own doctor, right, and get someone on the phone who can, who can talk to me about a question.
Speaker 1:Um, I can sort of do that now through health medical records, but there's a delay and you know that's and and even, and, even with that delay, you still have to be accepted into the system to have access to it, and which is his whole own challenges of consent and all that kind of stuff.
Speaker 2:Right, right and that's another part of this topic but it is not a doctor's job to tell you whether your work is safe, and that is such an important statement that I want to say it again it is not a doctor's job to know whether your work is safe.
Speaker 1:I love that. I love that.
Speaker 2:That's our job, right? And so you know. Here's an example of how what an impossible position the idea of asking a doctor's permission creates. Dear Dr Jones, mrs Martinez, who just had a hip replacement surgery, you know six weeks ago, wants to receive massage. Is that okay with you, and what do you think I should do? Right, that is not an unheard of kind of communication. That kind of thing happens.
Speaker 1:Oh, yeah, absolutely.
Speaker 2:Not Dr Jones's job to know what you mean by the word massage.
Speaker 1:And I actually think it also happens a lot more than we think, but in another way, in that a client will come in with a note or saying I was told to get massage by my doctor, which is almost the same problem, but from the inverse side.
Speaker 1:From the inverse side, which is the doctor gave me permission, but do they really know? Do they know what kind of I mean? What does abmp put out an article, I think a year and a half ago? There's 350 different recognized massage therapy modalities. Um, are you standing on the table and and doing ashiatsu? Are you putting an elbow into them? Are you doing craniosacral? Like all of these involve different um, are you doing craniosacral? Like all of these involve different. Are you doing Thai, where there's different ranges of motion, like who knows and the doctor's just saying blanket statement massage and for all they know, they're getting it from the one person in the world who could hurt them, as opposed to the millions of others who might be the perfect therapist for them.
Speaker 2:I, uh, I was on the faculty of a massage school that ran a student clinic, as one does, and I happened to be in the building one day when someone from the clinic came and said hey, ruth, there's a person here who's arrived for a student massage, who has a doctor's note saying this person has blood clots. I think she should get massaged to improve her circulation. Oh my God, oh my God. And I was like does your doctor hate you? And here's the thing, troy, is that that sounds so absurd and crazy and we're, all you know, sort of sensitized toward the risk around DVT and pulmonary embolism, as we should be. That said, there are phenomena where blood clots in the legs get completely encased in scar tissue inside the veins. They're completely stable, they're never going to go anywhere. That person can exercise normally, and so why not get massage, even though I wouldn't recommend? You know digging in right. So it's never a black and white choice.
Speaker 1:And I think the blood circulation, the circulation is a great example too, because even there, how much does massage affect circulation? The research on that is so we'll just leave it at that.
Speaker 1:Inconsistent is a wonderful word compared to what I was going to say. So yeah, so, let alone they were encouraging them to get massage for something that may or may not be able to be affected by massage, which is an example of doctors not knowing what we do, and that's understandable. Why would they? They have other things they're thinking of, the same as we may not know what they're doing.
Speaker 2:Exactly, exactly. So to suggest that getting a doctor's permission. Let's go back to a minute ago when you said why do people even think that that's a good idea? They think that that's a good idea because doctors know more about human anatomy and physiology than massage therapists do, and we cannot argue with that. For an entry-level massage therapist in the US, call it 500 hours of education, and if they're doing continuing education, which is wonderful, it's typically hands-on type stuff, not book learning, right?
Speaker 1:So they know more about A&P than we do and they definitely know more about risks. They definitely know more about this is a problem. Those connected dots together go. That's a bigger risk.
Speaker 2:So we appeal to this authority. Sometimes massage therapists think that a doctor's note will keep them safe, will keep their clients safe, keep their clients safe and, as we have already talked about, that's not a hard and fast prediction because, again, not a doctor's job to know if your work is safe. And thirdly, people think that a doctor's note will keep the therapist safe from litigation right, not only from making a mistake and accidentally harming somebody, but from being blamed for it. And you know, one of the things I do because of my position is I sometimes am called on to serve as an expert witness or a consultant in litigation cases where massage therapists have been accused of hurting somebody, of hurting somebody. And I have seen situations where it was very clear to me that massage therapists could have hurt somebody and the doctor's note made no difference to that at all.
Speaker 1:And why would it?
Speaker 2:I mean, as soon as you step back and think about it for a second, of course, it wouldn't you still have to be the one practicing, one within your scope, but two within your knowledge base, you still have to be the one who's responsible for the care given, right, and we call that standard of care, and that's a little bit of a technical term in legal circles, but basically it means are you making choices that would be in alignment with someone else of your community with a similar level of education, in a similar circumstance? Right, are you doing something that's within that realm of possibility? But the idea, and we can say that having a doctor's note is an example or demonstration that we have done some due diligence, right, um, which?
Speaker 1:can be a question a decent defense, yeah.
Speaker 2:However, a doctor's permission is not as useful as we think it is, because it doesn't keep the client safe and it doesn't keep us safe from litigation.
Speaker 2:Um, so let's go back to that first reason people want to get a doctor's note, which is that they know more. So, instead of getting permission, let's get more information, and that was the purpose of that class that we did together at AMTA National, the silos, and establishing lines of communication, to go with your theme, between massage therapists in the field and their healthcare team. And I want to make clear that that healthcare team can include their prescribing physician, their surgeon, their charge nurse, their home healthcare aid, their physical therapist, whoever else is working with them whose knowledge about their body might help you understand how to get to the best outcomes. And there's another aspect of this that I think is sometimes underappreciated, which is that when we ask for more information, when we say, dear Dr Smith, your patient, Mrs Martinez, just had a hip replacement, you know, and she wants to receive massage, what I'd like to do is make sure that I am not putting her at risk and that my goals in working with her and your goals in what you're doing with her align Right.
Speaker 2:I think that's such a valuable point because oh, good yeah, Because your eyes rolled so I wasn't sure whether that was a good thing or a bad thing.
Speaker 1:No, it was a good eye roll. My daughters taught me that that there are good ones, I think. So in placebo care there's something called expectation and expectancy. And then in you know, you and I were talking about this just before we started the podcast about going to Laura Momsley's class, and one of the things that is clear in our understanding of treating people with chronic pain is expectations. Having clear expectations about what our clients are looking for, not only through the entirety of the care, but on a given session as well, through each individual session and it's actually something that I integrate into my sessions now is ever since I did my placebo podcasts with these people.
Speaker 1:I remember them talking about expectation and how that sets up, primes the body for care, and so every session that somebody comes in, we don't just say, okay, I know why you're here, because you've come and see me three or four times for your current problem, but today, what are your current expectations? And I think when you're talking about communicating with other healthcare professionals, that's one of the big questions that is often left, as I assume I know what the expectations are of me as a massage therapist in this situation because they have been referred to me, but that assumption is usually either inaccurate or not 100% clear, and so just simply saying your client you know your Martina, miss Martinez has come to see me for a hip replacement. When you referred her to see me, what was your expectation that I do as a therapist? What is it that I am? What is the communal goal that you would like me to also guide miss martinez towards? To then know?
Speaker 2:is that, within my knowledge and scope of practice, that's great, but and it's a little bit different from the model I had in my head, which is that m that Mrs Martinez is acting independently of her doctor and just saying you know, I'm six weeks out of my surgery. That's when my massage therapist said I can come back. But the therapist might be worried about blood clots or the stability of the prosthetic or, you know, range of motion issues.
Speaker 1:Yeah, and I guess that's that's a really good point, because there are so many therapists who that is the actual case, so the client is acting independent. I happen to work in an environment where I would say, 99.9% of my clientele are part of a team. We, you know, we, we, I work with a lot of physicians in the area primary neurologists but we work as a group and there's a lot of intercommunication amongst each other about our clients and I. I don't think that's as rare as we, we, we think it is. I think it's becoming more common, especially with the VA. I think they had just published something about the interdisciplinary and approach being far more effective than individualized care, and I think that's going to be the future of really efficient healthcare. It'll be costly, but efficient, I think. But it's that intercommunication about expectation of care and I think then the doctor's note becomes irrelevant because we're all working towards a communal path, we're all aligned with our thought process for this specific client and we all have a role to play within her care or his care.
Speaker 2:Right, and. But we won't find out what that is until we can break down those silos and have a useful conversation between the massage therapist who's over here and the prescribing physician and the surgeon and the PT who's working with her post hip replacement. You know rehab right and so you know getting that doctor's note. Again, I want to emphasize it's not about permission, it's about information what if? And you know, I'm delighted that you're working in a situation like this, troy my experience in communications with massage therapists has not reflected.
Speaker 1:It's rarer. It's it's far more rare. I'm I'm in a public system where insurance is a hundred pays for my clients. I'm I'm in Quebec, where it's fully integrated into the healthcare system, like much of Canada. We're of Canada. We're a little different scenario.
Speaker 1:So when you mentioned the silos, I think for me that the next step that a lot of therapists run into is okay, yes, that would be wonderful. They hear this information, they're motivated. That's fantastic. Of course we want that.
Speaker 1:We, as massage therapists, come into the profession and we go. We have a certain amount of knowledge and we are knowledgeable about these single subjects massage therapy but when it comes to hip replacements, when it comes to diverticulitis, when it comes to all these other things that are far more, far different from what we do, we are not educated on them. And so, barring some further education, how do we break down those silos? Because a lot of massage therapists take on that role of I'm. I'm your everything, I'm your dietician, I'm your personal trainer, I'm your massage therapist, I'm your counselor, and we all know we're not supposed to do that, but it ends up happening to many therapists and a lot of that might be okay.
Speaker 1:You live in a small community, maybe they don't have all these resources, sometimes it's they don't have all the money so they can't see all these healthcare professionals, or they don't have the time. Sometimes it's they just have the God complex and it's it's self serving. Sometimes it's completely innocent and they just happen to have this major level of empathy with no transference and counter transference barriers. So, with these silos being something that do exist, how do we as therapists I mean, I've been lucky in that my scenario was one where I'm these silos don't exist very much anymore, but that's a rarity so, as a therapist, what do we do to break these barriers down, besides cold calling?
Speaker 2:Well, there are a number of options. So you know, if, let me start with the idea that there's a therapist and they have a client who has some complex health situation and so they want to get more information about how to bring their best to the table, right, that has to happen because of privacy issues, and so you know we can go through the appropriate mechanisms. But basically, let's say that the client, either in person or electronically, sends a note, gives a note from you to the doctor saying hi, what has to go in that note? Right? How do we begin to establish these relationships? Well, it's in the context of a specific person and in this model, and in that note we need to include things like here's what I understand about this client situation. Here's why I think I can help. Here's a description of my work, using terms that are descriptive and hard to misunderstand, which gets us into the whole myofascial release deep tissue.
Speaker 1:Yeah, we were.
Speaker 2:We were talking about that earlier about what is a clear Using terms that are descriptive, and and and clear and clear to someone who is outside the massage therapy community. Yeah, Including things like depth of pressure, frequency, intensity, duration of the massage and things like that.
Speaker 1:And I got to say even there. You just described those terms as though they were common practice amongst therapists and they absolutely aren't, even though I absolutely think they should be, and I talk about this all the time in my classes. I mean, we have scales that we use. We use oobleck and corn starch to practice different speeds. I do a sports massage class where we talk about different speeds based on activity, pre post, all these kinds of things. But you mentioned them and how many therapists break apart their understanding of what a stroke looks like, to not only pressure, accurate pressure as well, not just descriptive light, medium, deep, but actual pressure, let alone speed, how long they're massaging that area of the body, how vigorously? You know no therapist does that, not that they shouldn't, but very few therapists are breaking that apart.
Speaker 2:And I will argue, troy, that in this introductory letter you don't have to. I see her once a week. I give her pressure on a scale of one to 10 that probably ranges between two and six. My sessions last for 50 minutes. Of that, typically 10 minutes might be spent on this hip. That's giving her trouble. I believe that this will help because of X, y and Z and maybe there's research quoted in that and maybe it's just your own experience. And point number one, here are my concerns. I'm concerned about the integrity of the prosthetic and at what point is it appropriate to explore her range of motion? I'm concerned about post-surgical blood clotting, because she has this in her history. If that's the case I'm concerned about you know, whatever your list of concerns are, can you give me some feedback on these things? And Mrs Martina's goal for massage is to be able to do this, this and this. Is this in alignment with your goals for her?
Speaker 1:I love it. The reason I love it is because that letter would be very good for a medical doctor to read to make sure that they agree with you. But it would also be good for referring PT or referring chro or a fellow massage therapist, or referring personal trainer anybody who's concerned about that individual's health and is trying to have them have a healthier, better lifestyle. That type of message is very clear, cut to the point of here's what I offer, here's why I offer it, here are my concerns about offering it to this individual, and do those align with your concerns and your goals? And?
Speaker 2:I think that's on the same page and all of a sudden, you have a team of therapists working with one individual exactly, and if you can do that in a succinct way, which is harder than it sounds like, as we discovered when we did our class together, because I made people actually write a letter. Um, in, in my there's, you know, I provide a template and I provide some samples. It's not a simple thing to communicate clearly about our work, but it's absolutely critical and one of the and if we want to expand our network, say you know, I personally believe that it's really, really important for massage therapists, at least in the US, where we have this absolutely swear word health care system.
Speaker 1:You can swear on my podcast, by the way.
Speaker 2:Our health care system is problematic, um, but, and, and and a lot. And there's a lot of distrust between people, especially at the lower end of the social economic spectrum to uh. There's a lot of lack of trust that they're going to get the care that they need because they don't have insurance.
Speaker 2:Before being yeah, before being gouged out of it, right, exactly, um and so for a massage therapist to be able to build a network of, I think, dermatologist is absolutely critical, because we see skin stuff all the time. A good talk. Therapist, because stuff comes up that's out of our scope of practice and you know, if we can say I have worked with this licensed social worker or this psychotherapist or whatever in the past and I really trust them, that's more impetus for our clients to seek out the health that they need. If we, you know, if you specialize in orthopedic things and you have a couple of orthopedic surgeons who you think are really above the, you know, above the average, what a great thing to be able to make a referral.
Speaker 2:So I think that massage therapists need to have a referral base, and a way to make that happen is to initiate these really clear and client-focused kinds of conversations.
Speaker 1:I think it becomes hard for a lot of therapists because they might do that introduction. They'll get their group, they'll get their therapist, they'll get their network and then their network fills up. You know like, I have a group of psychologists here in the area who do EMDR. They're all full and I'm still seeing brand new concussion clients and I'm like you need EMDR. I'm quite confident this would be really good for you. The closest one is in Montreal.
Speaker 1:You know like, and all of a sudden it becomes this really big problem and that you know that's our healthcare system, which has other complications to it as well. Being public, there are other issues there. But it's one of those things where, when the network fills up, suddenly a lot of therapists just become complacent in that, oh, I know someone, they give them a call, there's no waitlist, the person is full and they don't have. They didn't think to create a second resource and I think that's that's. That's a tricky thing, that a lot of massage, a lot of therapists not just massage therapists, I'm going to go ahead and say therapists across the board, of different kinds they get very complacent. In here's my network, oh, it's full, use my name, maybe they'll get you in. And then they can't get them in, and then that's it.
Speaker 2:Yeah, you know, hopefully my my next. My next strategy in a situation like that would be to go to the trusted provider and say who am I going to refer this patient to?
Speaker 1:Yeah, exactly, exactly, very much so.
Speaker 1:Yeah, for me, one of the ones that is always on that list that I don't think enough people pay important attention to.
Speaker 1:As a neurologist, I really think, especially the more we understand about the pain system, the more we understand about how stimulus influences behavior, the more we understand about I mean, I just learned something yesterday called chromatic adaptation, which is I'll show you a video after it's mind-blowing how you can stare at a black and white photo and eventually, if you use essentially what's negative image technology the negative color and then you look at the same image, you see it in color and to me, like the brain fills in the gaps.
Speaker 1:That's all neuroscience stuff. And for me, in any healthcare problem where we're going with the future part of the network has to be somebody who understands neuroscience, because it's at the forefront of how we actually interact not only with pain but even behavior and habituation. And why can't you stop eating those foods that are hurting your gut? Well, you might want to see a dietician, but you know what Part of the reason might actually not be the diet, it might be everything going on in your brain that's not allowing you to make these changes. Because it's neuroscience based, and to me I think.
Speaker 2:I think that needs to be the next step. It's none of those things. It's the fact that the brownies in my refrigerator are screaming at me.
Speaker 1:I know right.
Speaker 2:I have to make the screaming stuff.
Speaker 1:Exactly, I have to make the screaming stuff and so, but that? But that is a good example, right? Like not enough. Not enough therapists have the opportunity, I think, to incorporate the idea of the screen, like that's a. It's a joking example and it's a wonderful joke, but it's also a perfect example of why having a psychologist or a neurologist, somebody who specializes in brain behavior, be part of our recovery team it is, it is so essential, I think. Um, yeah, I think, I think. I think it's the next step for the integrative care is the brain portion, more than just psychology, but the actual neuroscience of the brain. Yeah, well, that's wonderful, and to me, that communication is so important. So, thank you, I think that's really valuable and I think it's a big step that has to take place.
Speaker 1:So, with all that being said, what happens now when, let's say, it's someone like myself who I love teaching, I love staying up to date with research and I love reading papers and I, I have opinions, and those opinions aren't agreed with by everybody, and that's fine. But let's say I have an opinion and I have a client who came in just the other day and they go oh my, my rib twisted and I have, I have a sublux, I have a, I have a, I have a slipped disc. That was the sentence. I have a slipped disc and then it bumps up against all my alarms of you don't slip discs. I'm just kidding you don't.
Speaker 2:You don't slip. It's not a thing.
Speaker 1:But it's still very much a cultural thing. It's still very much a thing that people tell me all the time I have a doctor's note and they say I have a slip disc, I have a this that I need my adjustments for XYZ, I need my traction for XYZ. I need my traction for XYZ, I need my deep tissue massage for XYZ, I need my MFR for XYZ. So now you where we are right now. You know I did a podcast a little a couple of years ago with Michael Hamm and we talked about a crisis of faith in massage, about how this divergent nature of massage therapy was. It was a massage podcast on defining massage and essentially it became yeah, exactly, and it became this really interesting.
Speaker 1:Where you know, we have this divergent and convergent process that takes place in science where, when enough of the consciousness agrees to it, it's common, common thought process, and then the people on the extremities are the quacks, but enough people eventually start joining them and it becomes divergent and then we come back together with excommunic thought. And right now we're in this really big divergent place in medicine where it used to be this really intense biomedical model and it was the hip bones connected to this and this leads to that, and put in your orthotic and do this, and when you do your squat, your knees go over your toes and your butt goes back and you don't, you know, you don't. You have a straight spine when you do your, your squats and all these things. And now we see that that divergent thought of humans are variable. Our movement is variable, Our genetics are variable, Our postures are variable, they don't always equate discomfort, they don't always equate pain and they don't always equate dysfunction.
Speaker 1:So now we come up to this barrier of I might want to communicate to somebody here's what I do, here's why I think it'll work, and that other person is sitting there going well, that's all BS. Your questions, your statements are all wrong. Go ahead and do it anyways. So how do we get to that barrier of communication where we might be communicating with people who have different levels of understanding or acceptance of the evidence presented towards them?
Speaker 2:I'd like to paraphrase what you just said a little bit and interpret your question as this what do we do when we are trying to establish a relationship with someone whose opinions we don't respect?
Speaker 1:I was going to say differ from, because I don't know if just.
Speaker 2:I understand that we don't share.
Speaker 1:Because I don't necessarily disrespect these people, because I still think they're coming at it from a place of genuine care that you are not attached to.
Speaker 2:So what do we do when we're getting guidance or feedback from someone who we think has a really different approach to how bodies work than the doctor, the doctor thinking.
Speaker 1:Blood flow is a good example of the circulation for instance yeah so, yeah, that's a fascinating question.
Speaker 2:um, ultimately so, this may not be a relationship that you want to pursue, although it might be. This is this might be a great time to say hey, I have some different kinds of thoughts than yours. Let's go get some coffee and talk about this, right?
Speaker 1:Non-confirmation bias.
Speaker 2:Okay. Or it may be a situation where your response to your communication is gosh. That's an interesting point of view. In terms of your communication with your client, that's a really interesting point of view. I come at this from a little bit different way. I'm going to use my resources to work conservatively and make sure that you're safe.
Speaker 2:And that actually gets me back to something, because I had lost my train of thought a little while ago and we had to restart a bit, because where I was going ultimately is that when push comes to shove, with a validation from another healthcare provider or without it, we need to make our own decisions about how we're going to move forward. We have to think for ourselves and ultimately, you know, that comes down to critical thinking and what that means in the context of making decisions about body work for people who are struggling with health or illness is identifying the key question, which is not is massage safe for someone with Lyme disease? It is, in fact what do you want to do today? What do you hope to accomplish today?
Speaker 1:What are your goals for?
Speaker 2:massage that I can help you with. That always has to be the starter question, right? And then it's a matter of figuring out what are the variables that feed into your decisions, and that's about risks and benefits.
Speaker 1:Go ahead.
Speaker 1:You bring up a really great point you mentioned it earlier about when you started massage and you felt undereducated to deal with people who had problems. In 2015 or 16, I can't remember what it was the MTA funded a paper that Nicky Monk and Blair Kennedy, a couple others and I did, and it was on baseline education and whether or not you felt you know, whether or not therapists felt smart enough to essentially be professionals, and it was a resounding no. I can't remember the exact statistics. I have it on my computer, but it was a resounding no. The people who did feel safe enough usually had higher education previous or unrelated to massage therapy. That gave them their sense of confidence, and I think critical thinking is the key term there. So the question then becomes if critical thinking is key and this is something that, quite universally, massage therapists definitely feel a lack of safety in switching subjects.
Speaker 1:Because you've been around with curriculum, because you've done um, because you've written books, because you're involved in a lot of this stuff, because you were teacher of the year, because you've had all these influences and and seen the profession change and morph, uh, throughout the last three decades, where do we add the critical thinking? We know why it doesn't exist. We know too little education. That's quite simple. We start with less education, not lower levels, but less time in school. That doesn't give us the opportunity to take classes in critical thinking. We don't have to do papers, we don't have to dissect research, we don't have classes on it because the curriculum is only six months instead of two years, things like that. So where do we add critical thinking? Is it mandatory, like, if you're board certified, we have two hours, three hours of ethics? Is it mandatory to do critical thinking classes? Where do we add it into our curriculum design?
Speaker 2:Where do we add it into our curriculum design? To me that's a little bit like asking where do we add. I'm thinking in colors now. Where do we add the green when you're painting the ocean?
Speaker 1:The artist comes out.
Speaker 2:I know Critical thinking is. Critical thinking is not a thing, it is a pattern.
Speaker 1:It's a process that happens.
Speaker 2:It's not a class that you can take and say, okay, now I, now I, now I know what critical thinking is. It's something that needs to be actually this is the word of the words of Sandy Fritz it needs to. It's less taught than it is nurtured. Um, I did a, I did a thing on critical thinking, um, a couple of years ago for massage and body work. In it I interviewed several thought leaders in our profession to ask them what they thought critical thinking is. I forget the name of the organization, but there was something like an international organization for critical thinking, and the guy who was the president of it for a while who has since, I believe, passed said critical thinking is thinking about thinking, so you can think better.
Speaker 1:And I thought that was you know it's a little glib, but it's accurate. I love it.
Speaker 2:I love it. Thinking about thinking so you can think better. It's, it's really. It's about analyzing your choices so that you can come to a better conclusion, Right.
Speaker 1:So I developed I would agree.
Speaker 2:Yeah, I developed a rubric. I developed a flow chart, if you like, about critical thinking, specifically around making decisions in the context of pathology. Can I share it with you, because it's not that hard? Number one what's your key question? And the key question always is what are you hoping to accomplish today? Number two what are the hoping to accomplish today? Number two what are the variables that feed into your decisions?
Speaker 2:And that comes again to risks and benefits and figuring out. You know, if they're ill, what is it, what are they doing to treat it, what are their meds, what are their side effects, et cetera. That's analyzing risks and benefits, right? Number three what have other people learned about this goal? So, if it's someone who had had a hip replacement and they would like to compete in a half marathon, I bet there's some data about this. Right? About manual therapy in rehab for people with joint replacement surgeries, right? So you can look at what people have already learned about. What's your key question? Okay, that's three. Number four is starting to plan. No. Number four is going back and making sure you didn't miss anything. Have I missed anything? Have I left anything out of my thought process? Then it's planning and executing a session or a series of sessions, and then and in my opinion it's as important as the first question, which is what are you hoping to accomplish? The last step in critical thinking, which people leave out so often it makes me crazy is evaluating what happened.
Speaker 1:Did your expectation? Was it met? Did, would you fall short? How did? What are you?
Speaker 2:what did you learn from this and how will it change what you do next time? Yeah, and I. I now often write my articles for massage and body work on disease states and I conclude it with the critical thinking rubric Well, all right, let's have a, let's have a sample client. And here's a little bit of background about them and here are their goals. And here's what we discover as we go through this rubric Right, I think it's great.
Speaker 2:You know, sometimes it's going to be I don't have enough information. I need to refer out, right. But some, very often, even if we don't get the doctor's consultation that we're hoping for, we can glean enough information from a textbook, from going out and looking at what other people have learned, to at least get a start, evaluate results, change your approach and keep going forward.
Speaker 1:I like it. I like it too, though, because if you're critically thinking, a doctor's note becomes irrelevant.
Speaker 2:No, that's not true. I would take permission. Sorry, yes, sorry, thank you yes.
Speaker 1:A doctor's permission, because if you're critically thinking, you're going to come to an answer that you feel safe with and that hopefully, your client will be safe with. But you brought up at the beginning of that something that I think is key and I think something that has to shift within the profession, and I wouldn't say it's just specific to massage therapy. I'd say we might be a little bigger in this, but I think it was also something that's more present globally as a population not as massage as a population which is nurturing critical thinking. So, yes, you're not taking a class on it, but nurturing critical thinking, you're modeling it.
Speaker 2:You're instituting it as you go and you can do that in an A&P class. You can do it for sure in a pathology class. You can also do it in your technique classes.
Speaker 1:So we do it in our class. We actually go through this whole, we go through clinical scenarios, we go through steps, we go through this whole why and how, all these things. But that's at continuing education and that's wonderful because that's why they're there in my class and I love it. But in the core curriculum do you feel that that is lacking? And that's a blanket statement, because there are thousands of different core curriculums. But in general, is that something that is not nurtured enough amongst massage therapists for them to feel comfortable? Absolutely.
Speaker 2:Yeah, no, I believe that that's the case, that people there are some assumptions about things that are happening that aren't actually happening in a classroom and then teachers whinge, which is maybe the nicest verb I can think of whinge about nobody does critical thinking today. Well, we're not modeling it.
Speaker 1:Yeah we're not showing them how to do it.
Speaker 2:There's not enough. Yeah, and what was really fascinating to me, Troy, I'll tell you this is some deep level navel gazing In the earliest edition of my book.
Speaker 1:That might be my new favorite sentence.
Speaker 2:Deep level navel gazing.
Speaker 1:I'm going to do that to my oldest daughter tonight when she gets home she's going to be so confused. I'm absolutely going to do that to my daughter.
Speaker 2:You turn bright red too. In the earliest edition of my book, I developed a sort of a structure of how I present material, and it's a structure that I still use today, and the concluding one was you know, what does this mean for massage? And I wrote a paragraph or something about that and that sort of expanded and expanded and I finally came to realize part of the reason I didn't like writing that part was that doing the actual massage was never my strongest thing. I didn't actually like being a massage therapist very much. I wasn't good at it, way too married to the clock, and that makes me a much better teacher than someone who can just be present in the moment. That's a skill that I admire more than I can say, but I don't have it and I have not nurtured it in myself, right, and I didn't feel confident to write a lot about massage therapy as a as the conclusion of the discussion of these topics, because I don't do massage.
Speaker 2:What gives me the right to talk up to tell other people what to do? Okay, but what I finally came to and it took years, it took many years was that I needed to break it down. What are the actual choices that we're making, if we think of all the bad things that might happen. If someone is not well-educated and not paying attention and not compassionate for your client who has eczema, what could happen? What are those risks? If someone is well-educated and compassionate and paying close attention, what are the best things that might happen? And then how can we create a session, how can I describe a session where we minimize those risks and maximize those benefits?
Speaker 2:And when I started doing that, when I started getting really specific not about Swedish massage for this and deep tissue massage for that and myofascial release for that, whatever those things mean, right, so it wasn't getting prescriptive, but I was definitely saying here are your decision points and there's a finite number. There's a finite number of decision points that turns out not to be that hard to relay and that made my work so much more useful. I was assuming people knew their decision points. Yeah, incorrect assumption.
Speaker 1:I mean, yeah, that's, that's not far off too, not only as therapists. But clients don't know that you know. No, very few people know their decision points in life why, what, how and when.
Speaker 2:Yeah, and so you know, I think, as educators, we can be a lot better about identifying. This is a tipping point. If you go this way, these things are going to happen. If you go this way, these things are going to happen. What do you want to have happen?
Speaker 1:Do it and then figure out if it did I teach a class about integrating evidence-based medicine and patient-centered care, and because the two in definition are at odds with each other but in reality practice very well together. But when you look at them in philosophy they seem to be opposing forces, and one of the things I tell people about all the time. In evidence-based medicine you are gathering a pool of information to tell you the most likely outcome. That is not the individual in front of you. The person in front of you is not the outcome. The person in front of you is the data point that is shifting the outcome but is not the actual outcome. Now I use I use an example in class where I take all the students age and then I average out the students' age of everybody in class and I divide it by the number of students and so far today I've never actually come to somebody being the exact age of the divided number and I go. Well, that's a good example, right, like by chance, the average age of individuals who like taking class on this given day in this location is this, but nobody here is that age and that's statistically what might happen. But it doesn't apply and that's that risk versus benefit If the statistical probability is a high end risk, you need to reevaluate your decision tree process. If the benefit is a high end, the high end likely outcome, then your decision making tree process is doing your benefit and it's doing something good for you.
Speaker 1:And I think that critical thinking, though, is often overlooked because it's, I think, a lot of times what happens is similar to a lot of other professions. We hear this, we get this master disciple type of behavior in massage therapy. Somebody told me you roll your eyes. You roll your eyes so well, but we hear the teacher said X, y, z and therefore it is truth. And you know, like, I just taught in New York last weekend and I think I have nine pages, and I think I have like 360 research papers referenced throughout my, my, my slides.
Speaker 1:And when I'm done, at the end of the class, I go by the way I'm showing you the slides of research and they, I go by the way I'm showing you the slides of research and they are usually looking away the students, because it's the end of class and they go no, no, no, pay attention. These are important because this is my interpretation of these papers. You may come to a different interpretation. My theory is you'd come to the same one, but you absolutely should be looking at it yourself to make sure Nobody I don't know to date yet somebody who's gone and read all the papers. It doesn't mean they shouldn't, but it's a similar example of they don't take the time to do it, they just go. Somebody told me. Therefore, it's true, and that takes them away from the critical thinking, because they said oh for low back pain, this is what we do. For the hip replacement, this is what we do.
Speaker 2:Well, all right. So I have a couple of things I want to point out. First of all, you've used this term evidence-based medicine.
Speaker 1:I like evidence-informed rather than evidence-based, because it's-. I think that's reasonable.
Speaker 2:I mean that's you know. That's what's the thing when you're fussing about words.
Speaker 1:It's a nuance, but it's pedantic, but it's a nuance, but it also has value and I've heard evidence informed before and I'm not opposed to it. I just haven't switched in my brain yet to using evidence informed, even though I'm not opposed to it. But I'm just not there yet either.
Speaker 2:I mean partly. I like it because massage therapists tend to balk when someone tells them what to do. To balk when someone tells them what to do, and evidence-based sort of implies that, in fact, what we're using is evidence, so much as there is, which isn't. It's a lot more than it used to be, but it's not that much about massage therapy to help us make decisions. We use that to not have to reinvent the wheel, right, but it will also, you know, let's, let's, let's, go back to this appealing to a higher authority fallacy and remember that until, as a practice, was entirely based on relationships between a doer and their disciple, right.
Speaker 1:Absolutely.
Speaker 2:And someone right. So we have this long, long history of being. There's a word that I'm searching for, Word loss is the first thing, right?
Speaker 1:For me it's always the sacred cow.
Speaker 2:Yeah, but it's. I mean, there's a mentor and there's apprenticeships, right, yeah, yeah, and there's a long oral tradition that goes along with this. But evidence-based practice was only instituted, even as a concept, in 1982.
Speaker 1:Yeah, not long ago.
Speaker 2:Right, that's Sackett in 1982, who said, gee, maybe instead of saying this is who gets, this is who needs knee replacements, maybe we should look at what knee replacements actually do and for whom they seem to have a positive impact, right.
Speaker 1:Yeah, I mean that was then.
Speaker 2:it was like we have, you know, a long tradition of being rigorously, slavishly limited by what the evidence says. That's wrong. Madison also comes from an oral apprenticeship type of tradition and we're not that far away from it.
Speaker 1:I think for me, the big thing that I see, especially nowadays, is we come from that tradition of you learn from the elder, the master, the apprentice, and I'm not opposed to the idea of learning. I think, when it comes to this vision of, because they said, therefore it is, and for me that's the complication I have nothing wrong with. I mean, I have mentors in my life who I appreciate learning from. When they say something to me, I will give it more weight, but I'm also going to go and fact check. I'm going to make sure that it's not a given.
Speaker 1:I'm 100% with you and we're not disagreeing.
Speaker 2:I'm just pointing out that the origin of this sort of cultural pattern is not long. I mean, it's still right in it, we're still right in it.
Speaker 1:Yeah, and it's not specific to massage therapy. I mean, we see this, you see this in social media, you see it in exercise, you see it in dietitian, you see it in behavior, you see it in social media, you see it in exercise, you see it in dietitian, you see it in behavior, you see it in how we learn. You see it. I mean, it's in every part of our culture. But I think, for me, the thing that is the downside to that is that it takes away this idea of critical thinking, because it can Because someone else will do it for you.
Speaker 1:Exactly. So. It takes away this idea of because, I was told, this is how low backs are fixed, because this is how whiplash is treated, because this is how plantar fasciitis is cared for, because this is how deep tissue massage is done.
Speaker 2:I will do it that way. Everybody knows that massage. That massage boosts circulation by 300%, which is verbatim something I was taught. It's so ridiculous. Everybody knows.
Speaker 1:I've said the research paper to my listeners before on the podcast. But it was this horrible paper in 86. But I'll tell you about it one day. But it was. That paper talking about blood circulation was so it wouldn't even be considered a paper, it wouldn't even be considered a case study. It was so bad and it went around the world so quickly Because, again, it was because someone said so.
Speaker 1:And for me that's, I think, where critical thinking fails and I don't know if it's a, I don't know if it's a result of people being. You know, massage therapists are a different breed. They're a touchy, feely breed, they're an empathetic breed. But I've been to conventions, to so many different things, from PTs to surgeons, and there is a different feel to massage therapy. There is a community that it creates a level of intimacy that is bar none. I've not seen it elsewhere and it doesn't mean that I've seen everything, but for me it's been a very unique experience and I don't know if that level of intimacy brings with it this automatic thought process of trust of, oh, someone told it to me and I feel close to them and I feel like they're family.
Speaker 1:Therefore, why would they lie? And if they, you know like why is it not true? And then it becomes almost self serving oh, I heard it and I like it. And I think that, for me, is part of why that critical thinking isn't there. It's not nurturedving. Oh, I heard it and I like it, and I think that, for me, is part of why that critical thinking isn't there. It's not nurtured enough. Specifically because it comes from that, I feel close to this person. They're in a position of power. I will believe what they said.
Speaker 1:Yeah, and I think that the most effective mentors and teachers are the people who who not only implicitly or explicitly talk about and model critical thinking, but the people who encourage that their learners question their authority so then, all that to say to finish, to bring it back to communication, right, being an educator yourself and quite a few of my listeners being educators how do we, as current educators who are out there in the field, how do we not communicate to our students Because we are already, hopefully, emulating that behavior? How do we communicate it to other educators who may not be presenting critical thinking in a way that gets that to be part of almost every core class?
Speaker 2:Yeah, well, you know, I have access to it through my book. I have access to educators who are in core curriculum and in a position to model this this way. This sort of analysis process that we've been talking about and in fact it is run. It completely runs through every aspect of my book. There's a section on what that flow chart looks like and there are exercises throughout and whatever if people use it. That is beginning a thought pattern, but I will share something really interesting with you.
Speaker 2:Troy, I had a, I had a um. I taught an online class. There's a, there's a school in central Oregon and they had me teach their pathology program last year and I'm getting ready to do it again this winter and it was all online. It was all asynchronous. I never got to talk with people in real time, and one of the things that I had these starter students do I think they were in their second term of massage school every week is they had a choice of three different kinds of activities that would work to solidify some of the things we've been working on right, and so they could find a YouTube video that demonstrates this concept, or they could interview someone who has this disease and make a treatment plan, or they could do the relevant critical thinking exercise that's in the book, which is long and complicated and I don't know that. It's tedious but it's not quick.
Speaker 1:Can I guess how many did it?
Speaker 2:All of them.
Speaker 1:No, I was shocked.
Speaker 2:I was shocked at how many people chose that option.
Speaker 1:I would not have said all of them that is not the answer I was going to give.
Speaker 2:Yeah, no, I mean way more than half every week of the 14 students did chose the critical thinking activity.
Speaker 1:That's wonderful, that is that is. That's generational. That's wonderful, that's going to be I was really.
Speaker 2:I was kind of flattered because it's a reflection of you know this, this way of thinking about decisions now feels like home base to me.
Speaker 1:That's wonderful yeah.
Speaker 2:Yeah, yeah. I was really, I was really, really pleased. So I mean, I think this is how we do, it is we is. We try to influence what's happening. If you can't, you know, get yourself into core curriculum, then you then, whatever work you do with teachers, I'll be. Uh, I just got an invitation to teach at the AMTA school summit on Valentine's Day, so that'll be.
Speaker 1:Oh, that'll be fun. Yeah, well, awesome. Thank you so much, ruth. I really appreciate your time. Is there anything you want to say before you go? I mean, you've already talked about your book. Do you want to talk about your podcast? I know you're welcome to advertise anything that you do here.
Speaker 2:Thanks. I'd like to. I'd love to bring up two things. One is I do have a podcast. It's called I have a Client who Pathology Conversations with Ruth Werner. That comes out once a month under the umbrella of the ABMP podcast. So I am one of four regular podcasts that they publish every month. And the other thing I'd love to just mention it's on hiatus for now, through the end of the holidays. We'll start it up again in January.
Speaker 2:But I do now a monthly live webinar called Stump the Pathology Teacher, and it is approved for NCB credit for one hour of credit. I am keeping class size very limited. Only 10 people can attend and what we do is you give me a heads up about what kinds of interesting or perplexing or confusing things have come up in your practice. It's basically I have a client who, and then in an hour we take it apart and talk about what I understand about these things. People will bring in their other experiences. It's a wonderful kind of peer supervision opportunity and it's a ton of fun. And it's an hour of CE credit, which I think is really great that the NCB was willing to do that, because it's a bit of a stretch, but everybody who's done it has really, really loved it and I would love to see this really take off and, if it, if I end up consistently filling them once a month and I will add classes, because it's the kind of thing where just adding people isn't going to work.
Speaker 1:I think that's awesome and I and I'm really grateful for it. So I'd love for you to come.
Speaker 2:We will next time. Next time it comes around, which will be the end of January, I'll give you a heads up.
Speaker 1:So, yeah, I'll start my travel in the end of January. I'm teaching in Denver but then, depending on the time and the date, absolutely yeah. Thank you so much, ruth, I really appreciate it.
Speaker 2:Thanks, Troy. I enjoyed our navel gazing together. Our mutual navel gazing was awesome. I still love that. Thank you.