Late last year I made the scariest decision of my academic career.
I made the decision to leave my fellowship program.
Completing a fellowship program was a goal that I’d had pretty much since I learned about the existence of residency and fellowship programs during my second year of physical therapy school. My mentality had been that if there’s something to be learned, some course or training to be taken, I want in.
So there I was, participating in what’s regarded as one of the best programs in the country. Seven months in, only five more to go.
I could’ve finished it. I’d grinded like this before. When I went through residency I was also renovating our first house with my wife. Hustling is nothing new to me. Nor are 16-, 17-, 18-hour days.
But I reached a point where an increasingly louder voice within me was telling me to step away. It was saying, enough is enough.
Enough what? Enough information
We’re surrounded by information
The age of the internet has brought us to a place that we’ve never been before. We have a nearly unlimited amount of information at our fingertips, far more information than we know what to do with.
For example, If you’re a PT nerd such as myself you could easily fill your day, every day, with
Listening to PT-related podcasts
Going on social media and finding more research, ideas, and concepts to explore
Engaging in discussion boards or social media groups
Taking online courses
The list goes on and on.
This is compounded and partially driven by a cultural belief that information is the answer. The solution. The way to better ourselves.
These two factors created in me—as they do in many of us—what I call The Information Problem.
So what’s the problem?
What I’m referring to here is the fact that information alone is useless.
It only becomes useful when we integrate it into our own conceptual understanding of the way things work.
Put simply: the problem is information without integration.
This is what that voice within was signaling to me. This particular fellowship program is structured in a way that approximately half of the weekends out of the year are filled with courses. That’s a lot of information. Imagine taking a continuing education course every other weekend for a year.
At first, I could take in the information, find out how it applied to my practice, and implement it into my practice. But I reached a point about 7 months in where that voice started to get louder and louder. My insatiable appetite for information was being satiated, and then some.
I couldn’t integrate the information fast enough. It was simply too much. I could've pushed on, cramming more information in without having the time or space to integrate it.
I slowly began to realize that my time would be better spent integrating the information that I’d already gained (because I had gained a lot), rather than trying to cram more in.
What is integration?
So what do I mean by integration?
The models we create
We operate largely under conceptual models, frameworks that our minds create based on our knowledge and experiences.
If I say to you, “What do you do as a Physical Therapist?” or “How do you help people?”
You’ll give me an answer.
And your answer is based entirely on your conceptual model of what physical therapy is, what it means to be a physical therapist, and how physical therapy helps people.
This model was created and influenced by:
Your experiences with physical therapy (maybe first as a patient, then as a volunteer while shadowing or working as an aide before starting PT school)
The program that you chose to addend, their curriculum, their philosophy, their instructors, the instructors’ philosophy, your classmates and their various models
Your clinical rotations; the type of setting, your clinical instructor, their philosophy, their colleagues, your experiences working with patients
The job you took after graduating or the training program you chose to attend
The courses you choose to take, by the articles you choose to read, by professionals who you follow on social media
And indeed your PT model is influenced and shaped by the rest of your life, your experiences, and your worldview
You can almost visualize a vast web of information and experiences that have created your individual and unique ‘PT model.’
These models inform the ways that we think, the decisions we make, and the ways that we act.
Reconciling new information
Now, when we’re presented with new information, there will undoubtedly be part of it that doesn’t line up with our current model (or else it wouldn’t be new information).
For this new information to make any sort of difference in our practice, we must sort out these differences. We have to reconcile the new information with our existing conceptual model
This requires 2 essential steps:
First, we need to have some awareness of how & where the new information doesn’t fit with our current model
Then we need to figure out how our model will change so that the new information does fit
This second part can go in a few different directions:
Option 1: We could decide the new information is bullshit, declare it wrong, and hold fast to our current model.
(Though don’t be fooled into thinking that the new information didn’t still influence our model— our model was just updated to include, “This information is bullshit.”)
Option 2: We could alternatively decide that the new information is more true than our current model, take it on board, and leave behind our old model.
Neither of these two options requires much effort. The new piece of information either supersedes the old, or we give it the boot.
But wait! There’s a third option: The third option involves an expansion of our model, rather than a contraction or an exchange as with options 1 & 2. The third option involves sorting out how both pieces of information (the old & the new) are true. This requires expanding our current model to include the new information while also not ditching the old information. Finding the harmony between them, rather than the conflict
Let’s talk through an example
When I was going through PT school, pain science was the last thing we learned before heading out to the clinic.
We’d had two years of education and many musculoskeletal courses that were focused very much on biomechanical principles. Then, at the very end, we learned about pain science. And it was fucking earth-shattering.
It felt like we were told one thing for two years: here’s how the body works. Then at the very end, “Ohhh by the way… here’s how pain works. Good luck!” *
I was lost. I couldn’t see how pain science principles and biomechanical principles could coexist.
So for a period of time, I basically thought biomechanics was useless. After all, if pain isn’t a measure of damage, but rather a measure of the perception of danger, what does it matter how you move or position yourself, or the relative length or strength of a body region? It’s all relative to your body’s perception of threat rather than physics, right?
Clearly, I went for option 2 from above, ditching my current model in exchange for this new model.
In my conversations with several of my classmates, I found that many of them went for option 1, more or less ignoring the new information (pain science), and holding onto their current model (biomechanics).**
But in the years following, I’ve slowly but surely moved into option 3; expanding my model to allow biomechanics and pain science to coexist.
Let’s now talk about the ‘How.’
First, let’s talk through some barriers to this process of integration
Barriers to integration
We invest a lot of time and energy into our understanding of the way things work, so it makes sense that we’d have some resistance to constantly changing that understanding.
Sometimes we even identify with our models (I’m a manual therapist, I’m an MDT therapist, I’m a Maitland therapist, I’m a movement specialist). We can become so identified with our models that we feel like we are losing a part of ourselves when we are called to change.
There can also be quite a bit of discomfort in looking back and feeling like we were ‘wrong’ in the past. This can lead us to cling to the way things are so that we don’t have to admit that we were ‘wrong’ (we’ll talk about this in the next section).
To consciously expand our model, we need to become aware of what our model is in the first place. This is the process of uncovering our beliefs, some of which are very deep and difficult to see.
It takes effort to do this.
Why do more people choose options 1 or 2? Because it requires less effort
It takes no effort to scream Bullshit! at something. And it takes less effort to buy into someone else’s model and become a disciple of theirs rather than sorting it out for ourselves.
Working with these barriers
In order to change, we must first feel safe to change.
Feeling safe to change requires realizing that we are not our models. And that it’s not only OK; it’s healthy for us to change and update our understanding of the world.
A little phrase that speaks to the de-identification with our models is: I’d rather be help than be right.
If my goal is to be right, to have the answers, I will cling to my models and be resistant to change. If instead, my goal is to be help, I will be much more open to change as I allow what it means to help to move and change and shift and morph into whatever is appropriate for the patient.
Feeling safe to change requires realizing that change is inevitable. So instead of investing in certainty and trying to find the ‘right’ answer, we can invest in curiosity. This is the path of the lifelong learner vs. the self-proclaimed expert.
The final piece to reflect on is the importance of honoring our journey and the lessons we’ve learned. Had we not been ‘wrong’ in the past, we wouldn’t have learned what we’ve learned. So when we feel bad or guilty for being wrong, or we feel bad for the patients who we ‘messed up’ with in the past, we are doing them a disservice because we are invalidating the lessons that we learned through those experiences.
The best way to honor our past is by learning from it, not feeling guilty.
The very first step in this process of integration is acknowledging the new piece of information that we’ve been presented with.
A simple question we can ask ourselves is: What is the new piece of information?
Sometimes this is super straightforward and easy to characterize, sometimes it’s not. Either way, writing it down in clear and plain language begins the process of integration.
b. Comparing Notes
Next is the process of comparing notes with our current understanding and past experiences.
Checking with our current understanding is asking questions such as:
In what ways is this new information in line with my current understanding?
In what ways is this new information discordant with my current understanding?
Checking with our experiences is asking questions such as:
In what ways is this new information in line with my past experiences?
In what ways is this new information discordant with my past experiences?
Those of us who are research-focused may downplay our experiences with our own bodies or experiences working with patients. But it’s important to remember that research is but one of the three legs of the evidence-based practice stool. And clinical experience or expertise is another.
The great thing about our profession is that we’re walking laboratories. When I learn something new, I can compare notes with my past experiences, and use the laboratory of my own body to explore the truth of the information.
Personally, I've learned (& unlearned) much about pain through working with people and through my own experiences with pain.
Ultimately, knowledge grounded in experience is much more meaningful than something that we merely read somewhere. Experience brings knowledge from the philosophical to the practical.
c. Asking Questions
After comparing notes with our current understanding & experiences, we can simply ask:
What questions remain?
Where can I look for the answers I seek?
This might be the literature, mentors/colleagues, the laboratory of our own bodies & minds, or hopefully some combination
In what ways can I test this in my own life?
In what ways can I test this with my patients?
d. Finding the Truth in Both
This is really where integration happens.
This entire process of integration can be boiled down to one thing: Context
Everything has its place within a certain context. Everything.
All we’re doing is sorting out when the information applies. Not if it applies. When it applies.
We simply need to ask ourselves:
In what situations might this new information apply?
In what situations might my previous understanding/model apply?
When we name the context in which the new & the old apply, we have just expanded our model to include both.
e. Applying the New Model
And finally, after acknowledging the new information, comparing notes, asking questions, and finding the truth in the new & the old, we can bring all this back down to earth by asking the final question:
How will my practice be influenced by my new expanded model?
The more descriptive we can be with our answer, the more likely it is that we will come to practice within our new expanded model rather than reflexively returning to our old model when we return to the clinic.
The last barrier that we discussed above is effort.
The main practice here is to simply take the time to engage in the process that we discussed. To put in the time & energy to sort all this out. Check out my article on Habits for help making this seamless.
I see information as clay. The more you can get your hands on it, mold it, see it from different angles, manipulate it to see what it means to you and what it shows you, the better.
My rule of thumb for information integration: For every hour you spend taking in new information, give yourself two hours to integrate it.
Other Thoughts & Applications
A word on discernment:
The more we see how we are operating largely from within our conceptual models of how we believe things to work, the more we will see how other people are doing this as well.
Put another way, we’re largely dealing here with the relativity of truth.
When we understand this, we naturally become aware of the influence of the source of information, and we take everything with a grain of salt because everything is relative, meaning that everything is context-dependent. At least everything that can be spoken about.
Keeping this in mind when we learn new information is essential to be a discerning consumer of information.
Applications to patients:
Another thing to realize is that this conceptual expansion is happening all the time when we’re working with patients.
They come with an understanding—a model—of what’s going on. We develop a model of what’s going on through working with them. And when things go well, we weave together our model with their model to create a new model that is some combination of both.
In narrative-based practice, there’s this analogy of weaving a tapestry together with the patient to create a new story from the patient’s understanding and experiences as well as ours
Information alone is useless
It only becomes useful when we integrate it into our own conceptual understanding of the way things work
This is because we operate largely under conceptual models, frameworks that our minds create based on our knowledge & experiences
These models inform the ways that we think, the decisions we make, and the ways that we act
To integrate new information, we must
Have some awareness of how & where the new information doesn’t fit with our current model
Figure out how our current model will expand to include the new information
The steps to expand our model and integrate new information include:
Feeling safe to change
Acknowledging the new information
Comparing notes with our previous understanding & past experiences
Finding the truth in both
Applying the new model
Putting in the time & effort
Click the image below to download the FREE
integration worksheet to guide you through this process.
*No shade whatsoever; I’m grateful that we learned about it at all because some programs weren’t teaching it then, and the program has since woven it throughout the curriculum.
**Which makes sense, given that we’d just spent a good chunk of two years on that model, so we had quite a bit of time & energy invested into it.
Thanks so much for reading,