About 25 years ago I was teaching a week long Dynamic Nervous System course in Nevill Hall Hospital, Abergavenny, Wales with Louis Gifford. It was our early and admittedly crude attempt to introduce pain treatments via exposure and education. At the end of day three, as we were leaving the hospital, we noticed three young women still in the classroom – they were visibly upset and one was crying. We went to them and one asked, “Well what now, what will we do in the clinic, is all that stuff I have done before just rubbish?”
I have never forgotten this moment. Clearly, at that stage of the course, we had brutally deconstructed deep frameworks and beliefs of many members of the class, but we were not able to adequately reconstruct new ones at the same time. I wonder if any of these three are still working. I would love to hear from them or anyone who was on that course.
Looking back now I can recognise that we had torn down their clinical mileage. By clinical mileage, I mean all the processes, techniques, thoughts, principles, reasoning, and interventions -successful and unsuccessful- that a clinician has brought with them to this point. We all have clinical mileage that we should reassess from time to time. I believe that to achieve better treatment outcomes, where for example, pain recovery rather than pain management is the expectation, many of us need to shed some of our clinical mileage. And at the same time, perhaps realise we also carry around a lot of useless clinical baggage, picked up along the way. This is not about a skill fade or decay, but the recognition that deep in your heart (brain!) you realise that some of your thoughts and beliefs may not be accurate, that you could have helped more people, some of what you did may have been based on dodgy science , or perhaps your reasons for why someone got better or worse were not correct.
And I’d just mastered the cervical lateral flexion manipulation…
I remember, about 15 years into my career, the moment of realising my clinical mileage was not quite right, and it hurt – and I had just got the C2/3 lateral flexion manipulation down pat! I know some get elated by the shift, the revelation, the freshness of new ideas, but for many I reckon it hurts. In my case I was completely unsure of direction for a couple of years and I rejected and disliked some of those purveying new material. The shift I am talking about here is taking the biopsychosocial mental framework deeply “into the marrow of our bones”.
In Kuhnian talk – a clinical mileage shift comes from a crisis in your thinking, which leads to a realisation that you weren’t quite right, then a search for and adoption of other paradigms.
So shift, educate, re-educate, reallocate resources, refresh.
It’s good for your brain and the brains of others.
What are your experiences of clinical mileage shifts? Were they painful or pleasant? Your stories welcome in the comments below.