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No blame, no shame

Commitment in the therapeutic encounter: You can have anything you want, but you can't have everything you want

Submitted by RST on Sat, 10/06/2012 - 22:52
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It's a lovely idea to think that there are no limits, and that we can have everything we want.

Certainly, a massive part of the US advertising industry is dedicated to selling that dream, precisely because it's such an appealing one. There is no shortage of people who will pay good money for the hope of living without limits.

In the realm of dreams and ideas, there may well be practically no limits to what we can imagine. But the material physical world imposes constraints, or limits, on what matter and energy are capable of, and what they cannot do.

We don't understand everything about why matter and energy behave the way they do, but over the centuries, we've observed them in enough different situations that we're pretty good at describing how they behave in those situations. It's very much like the situation with gravity--there are several different and mutually exclusive proposals for what gravity is, and why it works the way it does.

But we don't need to wait until those questions are decided to be able to predict how gravity will behave well enough for hundreds of thousands of airplanes worldwide to take off and land safely (for the most part) every day. We can predict its behavior so accurately that in 1970, when the Apollo 13 spacecraft suffered an explosion and fire on the way to the moon--an explosion which left the spacecraft badly damaged, and low on fuel to get back to earth, and oxygen for the astronauts to breathe--ground control was able, on the fly, to improvise a plan that took advantage of the Moon's gravitational field to act as a "gravity slingshot" to propel the spacecraft and all 3 astronauts safely back home.

Source: http://upload.wikimedia.org/wikipedia/en/f/fd/Gravity_Assist_analogy_Kohlhase_Hovland.jpg accessed 7 October 2012

 

Source: http://upload.wikimedia.org/wikipedia/commons/f/fc/Apollo_13_timeline.svg accessed 7 October 2012

 

The same is true for matter and energy. These behaviors are so reliable that their descriptions are called "laws of physics"--metaphorically, it's as if they "know" they have to "obey" certain "laws", so they always do so.

Of course, science never says anything is definitively, 100% certain. Some things are very uncertain, and they're likely to be revised as we learn more about them.

Other things, while not 100% certain, can be almost 99.9999% certain--so the effect is as though it's perfectly certain, even though there's always that tiny 0.0001% chance it will be changed someday in light of new evidence, if that new evidence ever does show up on the scene.

The limits of the material physical world around us have been observed, described, and discussed for thousands of years, and, because they are so reliable, you can see, many times, the same description of the consequences of those laws of physics being discovered independently in different cultures far away from each other in time and space as ancient Greece and medieval India.

Source: http://upload.wikimedia.org/wikipedia/en/8/89/Panini%2C_the_great_Sanskrit_grammarian..jpg accessed 7 October 2012

 

One of those consequences, borne out time and time again by the behavior of matter and energy, has been described as the "principle of non-contradiction"--that, in the material physical universe, something cannot both exist and not-exist at the same time, or that something cannot be both true and false at the same time.

Did that statement make you think of Schrödinger's Cat? If so, then that's an excellent question you raise!

At first glance, it seems as though the cat might provide an exception to that rule: the cat is both dead and alive at the same time in this thought experiment.

Yet it doesn't really, and here's why.

Source: http://upload.wikimedia.org/wikipedia/commons/9/91/Schrodingers_cat.svg accessed 7 October 2012

 

It is typical of these cases that an indeterminacy originally restricted to the atomic domain becomes transformed into macroscopic indeterminacy, which can then be resolved by direct observation. That prevents us from so naively accepting as valid a "blurred model" for representing reality. In itself, it would not embody anything unclear or contradictory. There is a difference between a shaky or out-of-focus photograph and a snapshot of clouds and fog banks.--Wikipedia, "Schrödinger's cat" accessed 7 October 2012

—Erwin Schrödinger, Die gegenwärtige Situation in der Quantenmechanik (The present situation in quantum mechanics), Naturwissenschaften
(translated by John D. Trimmer in Proceedings of the American Philosophical Society)
 

 

When we're talking about the cat being simultaneously dead and alive, we are talking about a phenomenon at only the subatomic level of organization--what Schrödinger called "an indeterminacy originally restricted to the atomic domain".

When we're engaging with clients in a therapeutic encounter, however, we are not engaging solely on a subatomic level--we're engaging at many levels, up to and including the organism level: Schrödinger's "macroscopic" level.

To confuse the subatomic level of organization with the organism level is to make the same mistake as to assume that--because both sodium and chloride as elements are immediately and painfully deadly to humans at the atomic level, then their compound--salt--also shares those properties. (Although it is true that too much salt over too many years can wreck your health, but only in a very different way from elemental sodium and elemental chlorine.)

To confuse those levels of organization with each other is to "naively accept...as valid a 'blurred model' for representing reality". At the subatomic level, without an observer, we can use words or images like the previous one to imagine a cat that is simultaneously dead and alive.

In our macroscopic material physical reality, the moment an observer looks at the cat to see what is going on, the subatomic waveform collapses--it definitively commits to one state or the other, but not to both at the same time--and we have either a dead cat, or a live cat, but never both simultaneously.

Unlike the poor cat (sometimes), the law of non-contradiction is still alive and well at the organismal level of material physical reality, where our therapeutic encounters with our clients take place.

Our metaphorical "waveforms" also are forced to collapse in one direction ot the other at this point, but--unlike the electron--at least we get to choose which of the two mutually-exclusive options we commit ourselves to.

This principle shines a spotlight on where a number of the most heated battles in massage's culture wars are currently taking place.

We have to decide one way or the other on the following question--because of the law of non-contradiction, we can't just say "both", and hand-wave our way out of the profound philosophical and scientific questions it raises.

As a first principle, do we accept or reject the reality of the material physical universe?

 

We have the freedom to choose either answer, but--no matter how much we may want it--we can't have it both ways.

The answer we choose to that question will determine what we have to offer to clients, as well as how we relate to one another.

This, in turn, will set in motion what history will tell about how our future of massage turned out.

What Seth said

Submitted by RST on Wed, 10/03/2012 - 17:04
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Seth Godin writes, on the natural human tendency to deny facts we don't like:

The problem with Orwellian talking heads, agitprop, faux news and Ballmer-like posturing is that they take away a foundation for a genuine movement to occur, because once we start denying facts, it's difficult to know when to stop.

 

Still, it's understandable--when reality seems overwhelming, the temptation to deny that reality, and avoid the pain of dealing with it, can be very strong. Barrett Dorko also has an excellent take on that phenomenon and this article, over at SomaSimple.

We've got a lot of massive problems in massage--for example, at the same time that we have the chance for a place at the healthcare professional table under Obamacare, and that we say we want to be taken seriously as professional members of the healthcare team, our major credentialing organizations grant recognition to courses that take money for teaching claims like "body cells carry emotional memory", "craniosacral therapy moves skull bones", and "all past traumas are stored in the fascia".

Anyone who had a decent education in anatomy should be able to debunk those claims after the first day of the first class.

Yet our major professional organizations visibly sanction the teaching of claims like these and grant CE credit for them, at the same time we say we want to be real healthcare professionals.

Our walk doesn't match our talk, and the problem's not going to go away just because we refuse to face it.

If we refuse to face it and discuss it in a civil and professional way in an attempt to reach solutions, history's going to make us eat the decisions that others make for us about these problems.

And if we claim we want to incorporate the latest neuroscience findings into massage as a healthcare profession, and we start that process off by being Neurophysiology 101 denialists, how, exactly, is that supposed to work?

No one's denying the fact that this shift to accepting facts and material physical reality is going to cause a great deal of disruption and moral distress. The world has entirely shifted out from under us, and the old social contract that we were comfortably used to just does not work any more.

That fact is going to cause an unforeseeable amount of pain and distress, and we need to be extra kind to each other as a result.

But denying reality is not a sustainable choice anymore, and the only real question is whether we'll make the change in time to make use of these new opportunities, or whether our process will make us too late to accept the invitation, and we'll totally miss out.

Godin provides an aspirational ideal to assist in that process:

Transformational leaders don't start by denying the world around them. Instead, they describe a future they'd like to create instead.

 

We can't change the larger universal material physical reality that confronts us. What we can change is how we react to it, and that reaction--what we commit to--will sow the seeds for the future we want to create.

Source: "13 Plus Myths of Massage Therapy", by Lee Kalpin RMT http://www.massagetherapypros.ca/wp-content/uploads/2012/03/Myths-of-Massage-Therapy.jpg accessed 3 October 2012

What Seth said

Submitted by RST on Wed, 10/03/2012 - 07:38
Posted in

Denying reality is not a sustainable choice anymore, and the only real question is whether we'll make the change in time to make use of these new opportunities, or whether our process will make us too late to accept the invitation, and we'll totally miss out.

Godin provides an aspirational ideal to assist in that process:

Transformational leaders don't start by denying the world around them. Instead, they describe a future they'd like to create instead.

 

We can't change the larger universal material physical reality that confronts us. What we can change is how we react to it, and that reaction--what we commit to--will sow the seeds for the future we want to create.

Click here to join the discussion.

No blame, no shame: How we got here is not as important as finding ways to fix the problems

Submitted by RST on Mon, 09/24/2012 - 09:56
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The world has shifted out from under us.

And although we're not the only ones it's happened to, that's cold comfort as we have to go through the disruption that shift causes us.

That disruption can cause us to lash out in pain sometimes. Additionally, it's very easy to decide that someone else is that cause of all the problems, and to paint them as a cardboard cut-out depiction of a villain.

Although those reactions are understandable, we're not going to indulge in them here. No matter how intense our feelings of distress, we are going to behave better than that. We are going to start with the principle that we need to fix the problem, rather than fighting with each other over the past.

As humans, we often share meaning with each other by means of stories. There is a traditional story in Buddhism which carries some of the meaning I'm trying to convey here:

The parable of the arrow (or 'Parable of the poisoned arrow') is a Buddhist parable that illustrates the skeptic and pragmatic themes of the Cula-Malunkyovada Sutta (The Shorter Instructions to Malunkya) which is part of the middle length discourses (Majjhima Nikaya), one of the five sections of the Sutta Pitaka.

..

"It's just as if a man were wounded with an arrow thickly smeared with poison. His friends & companions, kinsmen & relatives would provide him with a surgeon, and the man would say, 'I won't have this arrow removed until I know whether the man who wounded me was a noble warrior, a priest, a merchant, or a worker.' He would say, 'I won't have this arrow removed until I know the given name & clan name of the man who wounded me... until I know whether he was tall, medium, or short... until I know whether he was dark, ruddy-brown, or golden-colored... until I know his home village, town, or city... until I know whether the bow with which I was wounded was a long bow or a crossbow... until I know whether the bowstring with which I was wounded was fiber, bamboo threads, sinew, hemp, or bark... until I know whether the shaft with which I was wounded was wild or cultivated... until I know whether the feathers of the shaft with which I was wounded were those of a vulture, a stork, a hawk, a peacock, or another bird... until I know whether the shaft with which I was wounded was bound with the sinew of an ox, a water buffalo, a langur, or a monkey.' He would say, 'I won't have this arrow removed until I know whether the shaft with which I was wounded was that of a common arrow, a curved arrow, a barbed, a calf-toothed, or an oleander arrow.' The man would die and those things would still remain unknown to him."

— Cula-Malunkyovada Sutta: The Shorter Instructions to Malunkya" (MN 63), Majjhima Nikaya

--Quoted in Wikipedia, "Parable of the arrow" accessed 24 September 2012

 

Granted, we're not totally subscribing to this principle, because understanding how we got into a situation is sometimes useful in figuring out how we're going to avoid a similar situation in the future.

So we'll temper that story's strong pronouncement a little bit, and go with the idea that--for our purposes--most of the time, the most important aspects are not assigning blame for anyone's past actions, but accepting that we have a problem in the present, and committing to assessing and describing the problem, so that we can proceed to address and resolve it.

Ralph Stephens is correct that a lot of current instructors are unqualified. But no child aspires to be an unqualified teacher when they grow up; the situation is the result of historical forces, not the goal. Back when we were in an economy that could not supply MTs fast enough to meet demand, "see one, do one, teach one" looked like a reasonable way to promote instructors to graduate students to address that gap faster.

Things have changed, but that doesn't mean that past efforts were the deliberate result of bad intentions. It just means that those earlier solutions are no longer working for us, and we need to fix them.

Similarly, he's right when he points out the risks of monoculture (systems with little or no diversity) when students have only 1 or 2 teachers for their entire curriculum. But I'm willing to bet my right kidney that no school owner ever said, "Let's deliberately expose our students to a single-point-of-failure system.".

That that turned out to be the effect is an indicator that we need to modify the course we're on, but it doesn't mean that small school owners are to blame for all our problems. Once again, it's an artifact in the present of a solution tried to address a problem in the past, and although we need to fix it, we don't need to cast aspersions on all small schools.

(UPDATE, 11:29 AM PDT: I've modified the next paragraph to make clear that what I originally stated as though it were a fact is actually my impression of the situation. I thank Matpardini for bringing my attention to my original overstatement.)

It's my understanding, although I don't actually have the evidence to back it up for sure, that many small schools have a good track record, as measured by pass rates on licensing exams. If this is true, then I believe that it further underscores the point I'm making that, if we are going to look at the issues, it's only fair to include the good aspects they bring to the table as well as we consider what needs to be done in massage education. And if I am mistaken, then I think that that means I am mistaken about that particular fact, but I stand by the moral principle that we should look at all aspects of the situation. Not that it means we're not going to fix a problem--I still believe we need to do that--but to avoid falling into the trap of bogging down in blaming an oversimplified depiction of a group of stakeholders of massage.

If we're going to actually address the problems we're facing in massage education, I suggest the following first principles to ground the discussion in:

  1. We need to understand how we got to the present situation, so that we don't fall into the same problems in the future, but right now our highest priority needs to be recognizing and addressing the immediate problems, for the sake of clients and students who don't have the time to wait. We have serious structural problems that we need to commit to fixing.
  2. We recognize that no one individual or single group of MT stakeholders is to blame for the current situation--that it's the result of historical and structural forces in a period of massive disruption--and although we need to speak frankly about the problems to find a solution, we are not going to indulge in blaming and shaming of anyone. It hinders our efforts to find solutions. We start from the principle that--unless someone actively demonstrates a very, very good reason to modify that assumption--that everyone is coming to the table in good faith and with the best of intentions, and deserves the benefit of the doubt.
  3. We acknowledge that there are critical problems that need fixing, and we recognize as well that fixing these problems is going to cause further disruptions that MT stakeholders will have to bear the brunt of. We start from the principle that we are all in this together, and that we are operating from a client-centered perspective, and that any change that causes disruption needs to occur for a good reason that supports this client-centered mission.

 

These principles will, by no means, guarantee that the road ahead of us will be smooth, nor that we will succeed. It's possible to do everything right, yet still fail, and I'm not going to lie to you about the reality of the situation.

But, I argue, they do provide us the best possible basis for frank, honest, open, and transparent discussion of issues that we cannot afford to remain in denial about any longer.

Source: http://www.lexphoto.co.uk/laosblogimages/buddha%20park%20archer.jpg accessed 24 September 2012

The Seven Deadly Sins of Ralph Stephens

Submitted by RST on Sun, 09/23/2012 - 09:48
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Hmmm--that title sounds like I'm accusing Ralph Stephens of committing seven deadly sins. :)

But the more precise and accurate title, "The Seven Deadly Sins of Massage Education In The Way It Is Currently Practiced, As Described By Ralph Stephens", doesn't exactly roll off the tongue, does it?

There are many things that Stephens and I disagree on, often to the point of having diametrically opposite assessments of a situation, and recommendations about how to proceed.

However, it is a positive joy to engage with someone who remains professional and civil, even in strong and passionate disagreement on the issues, and I thank him for the high level of good-faith discourse that he brings to collegial discussions about shaping the future of massage.

And in this post, we don't even have to be concerned with how we handle disagreement, because I am going to argue that he is dead-on with his assessment of the problems in massage education.

 

The full title of Stephen's article in Massage Today is "The ELAP Project vs. The Seven Deadly Sins of Massage Education".

The ELAP (Entry-Level Analysis Project) is a very important topic, and deserves a dedicated post at some future point. For the moment, we'll concentrate just on the problems in massage education that Stephens has identified, and what I think we need to be talking about as a result.

So right now, we'll address only the part of his article from the heading "The Seven Deadly Sins" to the end.

There is a German expression, "Er nimmt kein Blatt vor dem Mund"--literally, "he doesn't hold any (flowers and) leaves in front of his mouth". In other words, Stephens speaks his mind, and is willing to call it as he sees it.

Colleagues, here comes the real truth of the situation that no one has had the courage to put on the table until now. Standardizing the number of hours or the curriculum content (ELAP) will not improve educational outcomes as long as our massage educational institutions are allowed to:

  1. Employ unqualified instructors.
  2. Deliver the curriculum in a disjointed "modular" system that prevents sequential learning and integration.
  3. Have just one (or maybe two) instructors teach the entire curriculum.
  4. Use stock courses off the shelf that serve a variety of career programs, instead of courses designed specifically for a massage therapy program.
  5. Enroll students who lack the interpersonal skills or the cognitive, physical, and emotional resources to be competent and ethical practitioners.
  6. Keep students in a program whose performance is marginal, just to get their Federal Student Aid disbursements (tuition).
  7. Allow students to graduate who cannot perform a competent massage, or create a secure therapist/client relationship.

The (ELAP) is a further diversion from the long and challenging work that will be needed to address these "sins." Two things are needed to "heal" the problem, money and moral conviction. ABMP, AMTA and FSMTB must be persuaded to give substantial and ongoing financial support to COMTA and AFMTE to assist them with their respective missions. COMTA because we need a strong accrediting agency dedicated to the field of massage therapy. That is the natural place for educational standards to live. AFMTE because their Teacher Education Standards Project (TESP) is the trail that the entire education sector must follow if we are to truly "elevate" the profession from the sad state in which it currently exists.

 

Let's stipulate for the moment that we're going to put off the discussion of ELAP for a dedicated post.

Other than recognizing a need to engage in a little more discussion of ELAP, I would argue that Stephens is exactly right in his identification of major problems in massage education as it currently stands.

He continues with recommendations:

These organizations also need to take a public stand - an unequivocal position - that the operational practices listed in the "Seven Deadly Sins" are no longer acceptable in the massage therapy field; that we expect better from our schools and programs. They may not have the force of law, but such moral courage on the part of community leaders, consistently stated, can and will instigate a change in institutional behavior.

We must take up these challenges for the sake of the massage seeking public and for the lineage of our profession. Want to be part of the solution? Get involved. Thank you for your caring for our profession.

 

I wholeheartedly join Stephens in his call for these goals, and the posts that follow this one will explore in depth how we can address the challenges and obstacles that lie in the way of our solving these problems.

 

Source: http://upload.wikimedia.org/wikipedia/commons/0/03/Hieronymus_Bosch-_The_Seven_Deadly_Sins_and_the_Four_Last_Things.JPG accessed 23 September 2012

 

Looking into the abyss (#26/31)

Submitted by RST on Sun, 08/26/2012 - 06:56
Posted in

It's not easy to face the realization of having been misled.

And the misleading does not have to be intentional; it could have been done with the best intentions in the world.

But those good intentions don't change the facts that, as a result, the student is launched into real-life practice operating with poor information, is bringing misinformation into the relationship with the client, and is being publicly evaluated on the basis of that misinformation by other potential partners in a unified healthcare team.

It could have happened to any of us--the field of massage is notorious for promoting teachers out of the ranks of students who have simply passed the class they're now expected to teach. Biomedical physicians have nothing on massage when it comes to "See one, do one, teach one".

No blame, no shame: one set out to create that situation; it just evolved that way, undirected. And there was an unspoken social contract that allowed it to continue, because the need for teachers was so high.

But the social contract has changed out from under us, and the current situation is no longer sustainable in light of the responsibilities expected of healthcare professionals.

Ralph Stephens names the problem as the very first one in his list of the educational "seven deadly sins":

Standardizing the number of hours or the curriculum content (ELAP) will not improve educational outcomes as long as our massage educational institutions are allowed to:

  1. Employ unqualified instructors.

...

Two things are needed to "heal" the problem, money and moral conviction. ABMP, AMTA and FSMTB must be persuaded to give substantial and ongoing financial support to COMTA and AFMTE to assist them with their respective missions. COMTA because we need a strong accrediting agency dedicated to the field of massage therapy. That is the natural place for educational standards to live. AFMTE because their Teacher Education Standards Project (TESP) is the trail that the entire education sector must follow if we are to truly "elevate" the profession from the sad state in which it currently exists.

These organizations also need to take a public stand - an unequivocal position - that the operational practices listed in the "Seven Deadly Sins" are no longer acceptable in the massage therapy field; that we expect better from our schools and programs. They may not have the force of law, but such moral courage on the part of community leaders, consistently stated, can and will instigate a change in institutional behavior.

 

Stephens is right about going forward--but what about all the students, practitioners, and teachers who are coming to grips with the fact that much of what they were taught is exaggerated, counterfactual, or simply wrong?

It takes a great deal of courage on their part to stare unflinching into that abyss, and to engage with what's needed to collect, assimilate, organize, and share good information.

The upheaval and disruption in the process is causing a great deal of moral distress and pain in people who are re-evaluating where they are, and how far away they are from where they need to be.

One thing that they do not have to worry about here is being blamed for having been taught wrong.

The policy here is, "no blame, no shame": it is not someone's fault that they did not get the education they deserve, and if they are trying to fix that situation, they deserve--and will have--our support in that journey.

The Buddhist concept of samma-vaca--"right speech"--is a useful guide to discourse here at POEM.

It's often summarized as, "Is it true? Is it kind? Is it necessary?".

We'll examine those questions in a slightly different order than they're usually posed.

"Is it true?": The standard at POEM is that we will not pass along misinformation here.

Massage stakeholders can depend on POEM for accurate information about massage.

If someone is making a factual error, it's ok to correct that error civilly and professionally. That means focusing on the facts, not on the person--no personal attacks, just connecting the dots on what the facts are.

Not everything is a matter of fact, of course--there is no scientific answer to the question "Is chocolate or vanilla better?"--and interpretations, creativity, and imagination are welcome topics for discussion, as long as active misinformation doesn't ride along.

"Is it necessary?": There is a wide consensus that something is rotten in the state of massage education, so yes, having a portal to the shared body of biomedical knowledge that members of a unified and client-centered healthcare professional team all draw upon to varying degrees is an absolutely necessary--and as-yet unmet--niche that POEM is being developed to fill.

"Is it kind?": Absolutely: everyone who participates here can expect to be treated kindly. Kindness does not mean letting misinformation go uncorrected; it means that misinformation will be corrected in a civil, professional, and kind manner, without attacking the person.

When someone does not have access to good and high-quality information, because of gaps in their education, the kind and considerate thing to do is to offer them a bridge to obtain that information.

Giving them an opportunity to correct themselves is far kinder than leaving them--and their clients--to the consequences of misinformation.

We're in really deep waters here, as a result of a number of historical, social, political, and cultural factors all coming together and synergizing.

But if POEM has any say at all in the matter, then we will get through these difficulties, because we'll support each other in learning and growing along the way.

 

Source: http://www.education.noaa.gov/images/article_ocean_floor_2.jpg accessed 26 August 2012

It happens to the best of us--we all make mistakes

Submitted by RST on Mon, 08/06/2012 - 05:40
Posted in

Kelli Wise has issued an August Blog Challenge, and this post is part of the my response to the challenge.

Can I write 31 blog posts in 31 days?

 

We'll see. I'm getting a late start, coming in on the 5th of August, but I think that's not going to be a problem. As she said, there are no blog police enforcing this goal.

 

Can I keep those blog posts to less than 350 words?

 

No, I can't--asked and answered. What I will aim for is to stay on point, and provide valuable information, rather than just indulging my long-windedness.

You'll be the ones to let me know how well--or not--I have succeeded at that task.

 

 

The Renaissance artist Leonardo da Vinci is famous for, among other things, his sketches in which his eye for detail and his technical proficiency are immediately evident.

The veterinary medicine program at Colorado State University offers tons of information for free about comparative anatomy, physiology, and pathology in different species of animals, enough information to lose yourself in hours of reading, learning, and imagination.

In the reproductive biology e-Book, Richard Bowen has a post called "Leonardo's Error", demonstrating how even an artist as meticulous as Leonardo da Vinci can make a mistake--in his case, one that continues to this day, since he's no longer in any position to correct it.

No blame, no shame: we all make errors, and if we are fortunate, then we get an opportunity to correct those errors. The most important thing is to learn from the errors we make, and use them to do better in the future.

To understand Leonardo's error in his embryological drawings, we'll first talk a little bit about the placenta, and then go back to see how and why he got that confused.

In mammals, including humans, the placenta is an organ shared by a pregnant female and the developing fetuses.

The shared blood supply between the mother and the fetuses permits food, other nutrients, and oxygen to be delivered from the mother, and it also takes waste products away from the fetuses to be disposed of. 

Source: http://upload.wikimedia.org/wikipedia/commons/f/f1/Placenta.svg accessed 6 August 2012

 

That's where the comparative anatomy and physiology comes it--what we just said about the placenta is true for mammals in general.

But when we look more closely at how the placenta does that job in specific mammals, then we see very real differences in how it goes about doing it.

Bowen describes the different structures in this way, with a couple of explanatory notes added in brackets:

Classification Based on Placental Shape and Contact Points

Examination of placentae from different species reveals striking differences in their shape and the area of contact between fetal and maternal tissue:

  • Diffuse: Almost the entire surface of the allantochorion [the membranes between the mother and fetuses] is involved in formation of the placenta. Seen in horses and pigs.
  • Cotyledonary: Multiple, discrete areas of attachment called cotyledons are formed by interaction of patches of allantochorion with endometrium. The fetal portions of this type of placenta are called cotyledons, the maternal contact sites (caruncles), and the cotyledon-caruncle complex a placentome. This type of placentation is observed in ruminants.
  • Zonary: The placenta takes the form of a complete or incomplete band of tissue surrounding the fetus. Seen in carnivores like dogs and cats, seals, bears, and elephants.
  • Discoid: A single placenta is formed and is discoid in shape. Seen in primates and rodents.

Source: http://www.vivo.colostate.edu/hbooks/pathphys/reprod/placenta/plac_types.jpg accessed 6 August 2012

 

The discoid placenta--the kind we humans have--is one discrete organ, and looks kind of like a single disk, which is where the name comes from. You can see it in the previous drawing of the mother and child--it's drawn in a uniform red color.

By contrast, a cotyledonary placenta, like sheep and other similar animals have, looks like this:

Source: http://www.ansci.wisc.edu/jjp1/ansci_repro/lab/lab12_03/images/cotelydonary_lec.jpg accessed 6 August 2012

 

And now, you can see Leonardo's error. He drew the human fetus like this:

 

 

 

Clearly, he envisioned it having a cotyledonary placenta. He confused it with the kind of placenta cows, sheep, and other similar animals have--probably because he had access to dissections of those animals, but opportunities to observe autopsies of pregnant women were relatively rare or non-existent for him.

There are, I think, 2 lessons for us here. The first is:

Consult the final authority, the human body itself.

--Stephen W. Carmichael

 

Even more than that, though, don't be afraid to make mistakes.

Errors happen to the best of us, even to famous artists like Leonardo da Vinci.

We can't hope to never make a mistake--they're unavoidable, simply by nature of our being human.

What we can do is to approach learning with a certain amount of humility in the face of that fact, and to hope that, when we inevitably do make errors, that we get an opportunity to correct them and to continue learning.

 

 

 

 

 

Lifelong learning: Is lymphedema toxic fluid?

Submitted by RST on Sun, 07/08/2012 - 11:21
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It's a brave thing, when you're out in the world practicing, to ask questions.

So many times, we think we have to have all the answers.

There is no blame, no shame in not knowing something--after all, that is a condition quite easily addressed by accurate information.

No matter where you are in your study and in your career, I hope that you never stop asking questions. If you are unclear on something, chances are there are many other people who are also unclear, but who are afraid to speak out and ask.

"Now I'm really confused. Lymphedema is toxic fluid?"

 

No worries--you're raising a very good question. I hope that by the end of our discussion, you don't feel confused any more.

Lymphedema is a condition.

It results when too much fluid builds up in the tissues, because--for whatever reason--the lymphatic system cannot keep up with the demand put on it by the cells releasing their waste products for the lymphatic system to carry away.

If someone has lymphedema, then you know that the lymphatic system cannot keep up, but that is not enough information for you to know *why* the system cannot keep up. There are many different diseases, syndromes, mechanical causes, and other things that can cause lymphedema.

For example, I had cancer of the uterus. The surgeons saved my life by taking out my uterus, my cervix, my Fallopian tubes, and my ovaries.

Along with those major organs, they also took out lymph nodes. Now, as a result, I have lymphedema in my legs, because the surgery that saved my life also removed abdominal and inguinal lymph nodes.

Think about what the jobs of the lymph nodes and lymphatics ducts in the abdominal and inguinal areas are. They drain lymphatic fluid from the legs, right?

So when they are removed, they can't do their job. Think about what would happen to the garbage cans on your block if the garbage collectors were no longer there. The houses (cells/tissues) would continue to put out their garbage (fluid), but it would just stay stacked up there and accumulate (lymphedema), because no one ever took it away.

So that's what lymphedema is--a condition that results from some cause (there can be many) in which the lymphatic system can no longer carry the waste fluids away from cells/tissues fast enough, and the fluid accumulates.

Cancer did not directly cause my lymphedema. Cancer caused me to need surgery, and the surgery took out some of my lymph nodes that drain my legs, and so I have lymphedema as an indirect result of my cancer.

Other people living with lymphedema will have other stories, so just to know that someone has lymphedema does not tell you why they have it.

So what's in these metaphorical "garbage cans", the lymph fluid that carries wastes away from cells and tissues?

The largest component, obviously, is fluid--when it's inside the cells, it's called intracellular fluid. When the cell is done with it, and it's ready to be transported away, it passes out of the cell and into the space between cells.

It looks the same, and it contains the same things, but at that point, it's called interstitial fluid, because it lives in the interstices, or the spaces between cells.

It is made up of water, proteins, glucose, clotting factors, triglycerides, white blood cells, metabolic waste products, and other things, depending on what kind of cell it came from, and what happened to that cell--was it healthy, injured and recovering, dying, or what?

Are any of those things toxins? No, they are not. If you really have toxins in your tissues, you should be getting medical care to treat it, not just walking around with "toxins" in your body.

But what happens when the kidneys fail, and metabolic wastes build up in the blood to levels that doctors call "toxic"? Does that mean that metabolic wastes are toxins?

No, the waste products built around nitrogen molecules are not toxins in themselves; when they are at normal levels, the body handles them just fine.

As Paracelsus said, "Alle Ding' sind Gift, und nichts ohn' Gift; allein die Dosis macht, daß ein Ding kein Gift ist.--All things are poison, and nothing is without poison; only the dose permits something not to be poisonous./The dose makes the poison."

Even water will kill you if you drink enough of it. So does it then make sense to say that water "is a toxin"?

No, because water is not inherently poisonous. Nor are metabolic wastes. They are not inherently poisonous at normal levels of function.

Only things that are inherently poisonous at normal levels of function, like botulin toxin, or bee or snake venom, or ricin from castor beans are toxins.

So a bee sting is painful or ricin will kill you at normal levels of function--they are toxins.

Metabolic wastes or water or lymph fluid are not toxic at normal levels of function--only if another underlying problem causes them to become too much for their environment--and so they are not toxins.

It's a real biochemical difference, although there is no bright and shining line in how they can be applied--look at how botulin toxin is used in medical treatments, for example.

But a good rule to go by is if it is naturally produced by cells, it's in the right place (not from outside you, like bees or botulin, but in you, from your own cells), and it's not toxic at normal levels of function, then it's not a "toxin".

 

Source: http://upload.wikimedia.org/wikipedia/commons/5/53/Skull_and_crossbones.svg accessed 8 July 2012

It's not just us it's happening to--critical-care nurses and evidence-based practice

Submitted by RST on Sat, 06/30/2012 - 08:15
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As Yogi Berra observed, it's déjà vu all over again.

We are not the first ones to grapple with what evidence-based practice means to us, nor will we be the last.

Except for some details specific to critical-care nursing (like injection technique), this article could have been written by an MT in the last few days, although it was actually written in 1993 by a nurse-educator.

When the American Association of Critical-Care Nurses identified their research priorities for the '90s, two lists of research topics were generated, clinical and contextual. The incorporation of research findings into critical care nursing practice was identified as the highest contextual priority.[1] In recent years, critical care nurse researchers have done an excellent job of expanding the scientific knowledge base for critical care practice. Yet, scientists and clinicians alike acknowledge that much of the research being generated is not being effectively disseminated or incorporated into practice. Many of the interventions used by critical care nurses continue to be based on tradition rather than research. Why?

Although it seems a logical expectation, the incorporation of research findings into practice is a difficult and time-consuming task. Experts in the field of research utilization often agree that in many ways utilization is more difficult than the actual conduct of research. Is it reasonable then to expect the average critical care nurse to forge ahead, basing her practice on research? Not without some form of support!

This symposium provides critical care nurses with a resource to support the implementation of research-based practice in critical care. The symposium contains two types of articles. The first five articles address the processes associated with research utilization. Discussions of how to overcome the obstacles and gain the necessary support are included. Exemplars from successful research utilization programs provide strategies that can be adopted in various settings.

The remaining seven articles provide research literature reviews on clinical topics ranging from sleep promotion to injection technique. Topics were selected based on their generalizability to a variety of patient types and critical care settings. In addition to reviewing the relevant research on each topic, the authors have made recommendations for practice based on a summary of the research.

We hope this symposium will stimulate critical care nurses to question whether their practice is truly research-based or ritual-based. We hope to provide a foundation of research literature related to some common critical care nursing interventions. Finally, we hope to provide helpful strategies to overcome the obstacles and facilitate positive and professional changes in practice.

Suzanne S. Prevost, PhD, RN, CCRN

Guest Editor

Reference

1. Lindquist R, Banasik J, Barnsteiner J, Beecroft PC, Prevost S, Riegel B, Sechrist K, Strzelecki C, Titler M. Determining AACN's research priorities for the 90s. Am J Crit Care. 1993 Mar;2(2):110-7.

 

This all sounds very familiar: Research priorities identified--check!

Research findings not effectively disseminated or incorporated into practice--check!

Many interventions based only on tradition and nothing else, rather than seeking outcomes and findings from validated research--check!

But perhaps the most important point she makes, relevant to our situation, is this one:

Is it reasonable then to expect the average critical care nurse to forge ahead, basing her practice on research? Not without some form of support!

 

We, too, need to find support and to support each other along this pathway we find ourselves on. We have not, for the most part, had the education and evidence base we need to base our practices in validated evidence, and that's a reality that we need to meet head-on, and to remedy.

Some of us have persevered and done so, despite obstacles. They've made their learning experiences available to others to benefit from, and we need to appreciate and encourage more of us to share in that way.

As we've discussed in this space before, don't forget that we are not alone--we have many allies on this journey.

We can learn and draw support from what they have done before us, and we can reach out to mentor those who follow us later on.

Source: http://www.abilities.ca/independent_living/2009/02/13/j0438369_530.jpg accessed 30 June 2012

Metaphysical boundary collapse

Submitted by RST on Wed, 06/27/2012 - 14:01
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One of massage's biggest culture wars at present arises out of the dispute between monistic and dualistic philosophies. It has implications for how we practice with clients, and how we teach our students in our schools.

Although we're experiencing this culture war every day in our own field, this argument is centuries-old and is not limited to massage. Throughout human history, great minds have tried--and failed--to resolve it. I don't expect us to resolve it anytime soon, but we do need to resolve whether those of us on opposite sides of the philosophical divide can work together, or whether it divides us irreconcilably.

The argument goes back much further in history, but in the early 1800s, advances in the relatively new science of chemistry caused a seismic shift in the evolving field of medicine. As Siddhartha Mukherjee describes the experiment that shattered previous thought on dualism in health and medicine:

Early interactions between synthetic chemistry and medicine had largely been disappointing. Gideon Harvey, a seventeenth-century physician, had once called chemists the "most impudent, ignorant, flatulent, fleshy, and vainly boasting sort of mankind." The mutual scorn and animosity between the two disciplines had persisted. In 1849, August Hofmann, William Perkin's teacher at the Royal College, gloomily acknowledged the chasm between medicine and chemistry: "None of these compounds have, as yet, found their way into any of the appliances of life. We have not been able to use them...for curing disease."

But even Hofmann knew that the boundary between the synthetic world and the natural world was inevitably collapsing. In 1828, a Berlin scientist named Friedrich Wöhler had sparked a metaphysical storm in science by building ammonium cyanate, a plain, inorganic salt, and creating urea, a chemical typically produced by the kidneys.

--Siddhartha Mukherjee, The Emperor of All Maladies: A Biography of Cancer, Scribner 2010, p. 83.

 

This drawing shows a molecule of ammonium cyanate, a compound that doesn't come from living things. It's made up of:

  • 2 nitrogen atoms, shown in blue;
  • 4 hydrogen atoms, shown in gray (since this is a 2-D drawing of a 3-D molecule, one of the hydrogens is hidden behind a nitrogen, but it really is there, even though we can't see it in this arrangement);
  • 1 carbon atom, shown in black; and
  • 1 oxygen atom, shown in red.

Source: modified from http://upload.wikimedia.org/wikipedia/commons/8/8c/Wohler_synthesis.gif accessed 27 June 2012

 

Urea, a kind of waste product produced by the kidneys in many different species of living things, forms molecules that are made up of:

  • 2 nitrogen atoms, shown in blue;
  • 4 hydrogen atoms, shown in gray;
  • 1 carbon atom, shown in black; and
  • 1 oxygen atom, shown in red.

Source: modified from http://upload.wikimedia.org/wikipedia/commons/8/8c/Wohler_synthesis.gif accessed 27 June 2012

 

These two very different substances, one found in living organisms and one not found in them at all, have exactly the same atoms in exactly the same amounts. The only difference is the arrangement of those atoms in 3D space.

 

 

Source: http://upload.wikimedia.org/wikipedia/commons/8/8c/Wohler_synthesis.gif accessed 27 June 2012

 

 

The Wöhler experiment--seemingly trivial--had enormous implications. Urea was a "natural" chemical, while its precursor was an inorganic salt. That a chemical produced by natural organisms could be derived so easily in a flask threatened to overturn the entire conception of living organisms: for centuries, the chemistry of living organisms was thought to be imbued with some mystical property, a vital essence that could not be duplicated in a laboratory--a theory called vitalism. Wöhler's experiment demolished vitalism. Organic and inorganic chemicals, he proved, were interchangeable. Biology was chemistry: perhaps even a human body was no different from a bag of busily reacting chemicals--a beaker with arms, legs, eyes, brain, and soul.

With vitalism dead, the extension of this logic to medicine was inevitable. If the chemicals of life could be synthesized in a laboratory, could they work on living systems? If biology and chemistry were so interchangeable, could a molecule concocted in a flask affect the inner workings of a biological organism?

--Siddhartha Mukherjee, The Emperor of All Maladies: A Biography of Cancer, Scribner 2010, p. 83.

 

In one way, Mukherjee is right--this experiment showed that the vitalistic claim that a distinction based on vital essence existed between living organisms and non-living things had no basis in material physical reality. By "dead", he means that its foundation was shown to be false, and that there was therefore no basis to continue to use it as a basis for explanations in medicine or science. His usage refers to the "referent" part of the Semantic Triangle--no referent means no vitalism.

But in another sense, he's prematurely pronouncing it dead. There are still many people who believe in vitalism and dualism, not only in their own personal belief systems, but also by bringing dualistic concepts such as "spirit" and "energy healing" into the therapeutic encounter. The fact that there is no material physical referent in support of the idea does not prevent them from operating in the "concept" and "terms" part of the Semantic Triangle.

Whoever wrote the Wikipedia article on vitalism correctly observed that vitalism didn't disappear just because of that one experiment:

The concept of vitalism in chemistry can be traced back to Jöns Jakob Berzelius who suggested that in the division of organic and inorganic that a mysterious vital force exists in organic compounds.

Vitalism played a pivotal role in the history of chemistry since it gave rise to the basic distinction between organic and inorganic substances, following Aristotle's distinction between the mineral kingdom and the animal and vegetative kingdoms. The basic premise was that organic materials differed from inorganic materials fundamentally; accordingly, vitalist chemists predicted that organic materials could not be synthesized from inorganic components. However, as chemical techniques advanced, Friedrich Wöhler synthesised urea from inorganic components in 1828.

Further discoveries continued to marginalise need for a "vital force" explanation as more and more life processes came to be described in chemical or physical terms. However, contemporary accounts do not support the common belief that vitalism died when Wöhler made urea. This Wöhler Myth, as historian of science Peter J. Ramberg called it, originated from a popular history of chemistry published in 1931, which, "ignoring all pretense of historical accuracy, turned Wöhler into a crusader who made attempt after attempt to synthesize a natural product that would refute vitalism and lift the veil of ignorance, until 'one afternoon the miracle happened'". However, in 1845, Adolph Kolbe succeeded in making acetic acid from inorganic compounds, and in the 1850s, Marcellin Berthelot repeated this feat for numerous organic compounds. In retrospect, Wöhler's work was the beginning of the end of Berzelius's vitalist hypothesis, but only in retrospect, as Ramberg had shown.

In fact, some of the greatest scientific minds of the time continued to investigate the possibility of vital properties. Louis Pasteur, shortly after his famous rebuttal of spontaneous generation, performed several experiments that he felt supported the vital concepts of life. According to Bechtel, Pasteur "fitted fermentation into a more general programme describing special reactions that only occur in living organisms. These are irreducibly vital phenomena." In 1858, Pasteur showed that fermentation only occurs when living cells are present and, that fermentation only occurs in the absence of oxygen; he was thus led to describe fermentation as 'life without air'. Rejecting the claims of Berzelius, Liebig, Traube and others that fermentation resulted from chemical agents or catalysts within cells, he concluded that fermentation was a "vital action".

 

but he/she ends the chemistry section rather abruptly with Pasteur, rather than following through continuously to the present. This, too, is premature--vitalistic thought persists to this day. The developments in chemistry and other sciences that--among people who are familiar with the subject--convinced them that vitalism is no longer a compelling alternative explanation.

I think this overlooks a great number of people who aspire to be healthcare professionals, but who have not had access to an in-depth scientific and biomedical ethics education.

The issue of vitalism/dualism in MT is a huge issue for us. To continue to insist on vitalistic mechanisms as explanations is an obstacle to integration with other members of the healthcare team in fields that have long ago accepted the scientific consensus that--as a source of explanation in the lab and in the clinic--vitalism is dead.

And it directly contradicts established consensus of what belongs in an MT body of knowledge. As we've seen, vitalism contradicts chemistry and pharmacology.

Yet MTs are expected to know basic principles of pharmacology in order to practice.

The Massage Therapy Body of Knowledge (MTBoK) calls for the following required knowledge:

Pharmacology

  • General classification and types of drugs, herbs, supplements, their effects and their side effects.
  • Massage therapy considerations and potential responses to general classes of drugs, herbs and supplements.
  • Use of authoritative, medically accepted drug reference to look up drugs, their effects and their side effects.

--MTBoK, p. 18

 

while the Massage and Bodywork Licensing Examination (MBLEX) states the following expectations:

PATHOLOGY, CONTRAINDICATIONS, AREAS OF CAUTION, SPECIAL POPULATIONS (13%)
...

E. Classes of medications

--Massage and Bodywork Licensing Examination Candidate Handbook, Content Outline, p. 15

 

and the National Certification Exam in Therapeutic Massage and Bodywork/National Certification Exam in Therapeutic Massage lists the following topics:

III. Pathology (13%)

...

L. Drug interactions with massage/bodywork
1. medications (e.g., prescription; over-thecounter)
2. recreational drugs (e.g., tobacco; alcohol)
3. herbs
4. natural supplements

--NCETMB/NCETM Candidate Handbook, pp. 21, 23

 

and yet, at the same time, they require vitalistic concepts on the very same test--concepts that directly contradict the science on which these learning expectations are based.

This puts our students in an impossible position for learning, when one set of expectations directly contradicts another, as well as putting the teachers and schools in the position of being required to teach mutually contradictory information, and to assess students on how well they perform the impossible task of integrating that knowledge.

We need to figure out what this means to us as a community and as a developing profession. As Mukherjee observes, the metaphysical boundary collapsed a century and a half ago, but not all of us have quite gotten word of the collapse yet.

We need to address, at the very least (there may be even more issues that I have overlooked here):

  • how do we balance ethical standards and best practices in the client's interests in the therapeutic encounter with the practitioner's freedom of conscience?
  • how do we--schools, teachers, mentors--provide an education to our MT students that prepares them to build bridges to integration with other members of the biomedical healthcare team?
  • what do we do about the sunk costs in the previous unsustainable path, and the tremendous investment that it will require for us to practice as an integrated healthcare profession?

 

Source: The 7 November 1940 collapse of the Tacoma Narrows suspension bridge, http://upload.wikimedia.org/wikipedia/en/5/5c/TacomaNarrowsBridgeCollapse_in_color.jpg accessed 27 June 2012

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