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I stumbled across a quote yesterday which crystallised something which had been lurking in the back of my brain for a while.

"Make everything as simple as possible, but not simpler."
Albert Einstein

There have been many threads recently which touched on this. The COP / COF is one, technically different but used interchangeably. There was a clinical question on knee pain where the question and biometric information which went with it was, perhaps, a little TOO simple to be useful. There is the nav drift - drop / planal dominance question. Not the same, but can they be used as such?

I know many very experienced and capable clinicians who have been practicing for decades who would not know what a vector or axis was. Show them a force equation and they'd not know where to start. Yet they understand how the foot works in a way only 20 or 30 years of experience can achieve.

I have also known clinicians make the most horrible mistakes because they don't understand the basics of how the foot works; and who over rely on their experience.

I have previously observed that there may be a difference in what one needs to be an effective clinician vs. what one needs to be at the leading edge of theoretical thought (as the leaders of this forum are). Put allegorically, does one need to be a mechanic to be a driver? Is it enough to know WHAT something does without understanding WHY? Is there a happy medium and if so where is it?

So here are the questions

1. Is there a level of simplification which is appropriate for pure clinicians?

2. Should those seeking to be effective as clinicians (but not to advance the understanding of the profession) accept a lower level of understanding as adequate or should they constant seek the total understanding?

3. Should those who lead the understanding of the profession strive to bring everyone up to the highest level or should they seek to make it more accessible.

What say you? What is "as simple as possible?"

Robert

I strive toward the opposite end of the spectrum: "as complicated as you can understand".

edit: complicated is not the right word,

"as accurate as you can understand" is better. However, accuracy and complexity often go hand in hand.

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Science is the antidote to the poison of enthusiasm and superstition

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No, for the reasons outlined in that thread: http://www.podiatry-arena.com/podiat...ad.php?t=31303

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Science is the antidote to the poison of enthusiasm and superstition

My location

.

Agreed. So how do we impart the complexity of the theories with their clinical application?

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Graham Curryer

None of us know what we are doing, but some of us know more about what we are not doing than others!::

I think the answer is yes to over complicate, maybe a better a question would be is this a bad thing.

Ive spent the last few days getting (or trying to) my head around what you and Simon were discussing with Navicular drift/drop.

Ive then looked at the papers by Arnt, Nester et al, with their bone marking which show that the amount of movement in body planes of the joints of the foot is very small generally. So how are we expected to see 5 degree movements using the eye with all the soft tissue and skin... we can not.

But if the clinical Podiatrist is not challenged by Patient feedback, research, other pods then we will not get greater understanding of the foot and lower limb mechanics.

so I thank you for challenging my understanding with your discussion. But until we can have a computer model/scan of each patients foot during gait that can mark the exact points of axis, direction and amount of movements etc we are just guessing. Some more educated than others.

They say knowledge is power, but to die with knowledge that has not be passed on is a waste of time.

I look forward to reading more complex discussions and hopefully adding to them

Michael Weber

Personally, I think Prof. Kirby has done an outstanding job in this regard. Having had the pleasure of writing a review of his third book of collected newsletters recently, I had good reason to critically examine both the content and writing style employed by him. Kevin has the ability to put across complex principles using everyday examples. The language he uses is plain but precise. The reader is not bogged down with complex mathematics. He builds from the simple to the complex and then goes on to provide useable clinical applications. I suspect that it's partly his up-bringing, partly his obsession with accurate terminology, illustration, grammar and punctuation and partly Pam's influence on him. But I don't care what planet you're from, this guy is an excellent teacher of podiatric biomechanics.

But that's more than enough gas up his ass.

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Science is the antidote to the poison of enthusiasm and superstition

My location

I'm there too Sadly thats a very different point for all of us! But I'm in the happy position that biomechanics is my hobby as well as my job. I guess thats true for many here. Just check the times on the posts . For most its as complex as they WANT to understand.


Not my word. Take it up with Einstein.

Seriously though, the difference between the words can be taken from their opposites. Opposite of complexity is a scale and simple and complex can both be appropriate. Opposite of accurate is inaccurate and thats seldom a good thing.

Yeah yeah i'm going back there now!

Regards
Robert

Good for you!

It's subjective - and I know you'll forgive me for not joining in and making it all complicated!

Cheers,

Agreed. Yet as excellant as Kevin, Eric (whose posts I always find most incisive) Dave and of course your good self are at imparting accurate information there are many who will find them passing several yards above their heads. Only they won't be on here to agree cos they lurk, open mouthed and baffled before their screens, terrified to post lest they be flamed for their lack of understanding.

I've seen em. They're nocturnal, shy and hard to find without infra red camera's, time lapse photography and David Attenbourgh, much like otters. But I suspect they exist in large numbers.

Kind regards
Robert

Agreed.

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Science is the antidote to the poison of enthusiasm and superstition

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Dammit, I keep forgetting to turn off the webcam....

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Belinda Longhurst
Winchester (UK) Podiatry



I know, I know for sure
ding, dang, dong, dong, deng, deng, dong, dong, ding, dang.
.

Like Robert, I couldn't agree more. Kevin's books have steered me through many a potential brain implosion post clinic. I just love his writing style. From the looks of another recent thread I don't think 'Mr Nake' will echo our sentiments...

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My location

And yet, there are others who ask questions which appear straight forward on the surface such as this one:

http://www.podiatry-arena.com/podiat...ad.php?t=31466

The replies thus far say things like hallux limitus, but I challenge you to analyse the question. Why do we "build up" callus? Now there is a complex question that could require a very complex answer. Will Carol be happy with "hallux limitus" response, or did she want us to start talking about the histo-pathology of callus formation?

There are no stupid questions......

Let's see how this discussion develops.

It's very simple. If you don't understand something, you can always ask for it to be explained for you in terms you do understand. The biggest barriers here are pride and the ego.

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See what I mean:
Now how many of you when you read Carol's original post were thinking: "os sesamoidum interphalangeum"

Luckilly, Lucky Lisfranc was Yeah, it was on the tip of my tongue- not. I just got educated.

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Robert:

This could be the best thread of discussion so far this year! Good job, Robert!

When I lecture at seminars, the diversity of background of my audience is still my most challenging problem. I make every attempt at trying to make it interesting for the most intelligent and advanced of my audience while still trying to make most of the lecture understandable for the least experienced or least educated of the audience. For those of you who have lectured to large audiences as I, and many others on Podiatry Arena have on many occasions, it is an impossible task to make biomechanics easy for everyone since some people just don't have the capacity to learn this material quickly and easily as others do.

For example, I try to read all the reviews from my lectures when they are made available to me. These reviews may range from comments such as, "Kirby uses too much engineering and physics terminology and I don't see why he can't simplify things more for the average podiatrist", to comments such as, "Kirby should be presenting much more advanced material since he spends too much time explaining basic mechanics and physics concepts".

In my private discussions with Dr. John Weed when I was a podiatry student, Dr Weed would often say (to paraphrase him) that in his years of teaching biomechanics he had found the following: 1/3rd of his students loved him, 1/3rd of his students hated him and the remaining 1/3rd of his students were still trying to figure out if they loved him or hated him. I was in the 1/3rd of the class that loved the man.

In my quarter century of teaching biomechanics to podiatrists and podiatry students, the bottom line is that unless the student/podiatrist has a better than average ability to visualize things in their mind three-dimensionally, has better than average math skills, has had some basic physics courses and, most importantly, has the desire to learn biomechanics, then these students/podiatrists will not master the subject regardless of who is teaching it. We must not always assume that it is the teachers fault when a subject is not understood well by a student or clinician. I believe the students are just as much to blame for their lack of understanding for either their lack of aptitude for the subject or their lack of interest in learning the subject. Sometimes, there is simply not enough time available to teach a student one on one, hand feeding them the information, so that they understand the concepts completely. This is the nature of medical education, and of life in general, where the most fit, most motivated and ones that are willing to make the extra effort to understand a subject will perform the best and the least fit, least motivated and ones that are unwilling to make the extra effort to understand a subject will perform the worst.

Great discussion.

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Sincerely,

Kevin

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Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
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Robert - depends what you mean by simplified?

There are the reductionist approaches that really 'dumb' it down to what I call a 'cookbook' approach. Ie a basic foot assessment --> 'pigeon hole' the patient --> follow the recipe to prescribe orthotics (problems happen when the patient does not have a pigeon hole to fit in; also a problem with the limited number of clinical test/observations needed to pigeon hole them.)

Then there are the systematic approaches (which still can be 'simplified') in which you do not 'pigeon hole' or 'foot type' and you systematically work through a whole range of clinical tests/observations/etc and each one of those determines the prescription or not of a particular variable in the negative model production and orthotic manufacture (or prefab modifications).

I see both approaches as being "simplified" and not complicated (and prefer the systematic approach over reductionist approaches).

What is complicated may be the understanding of the evidence and theoretical basis for the clinical tests in the systematic approaches (I see little evidence for the 'cook book' approaches).

Maybe you asking something like a physician need to know the steps to go through to work out which drug prescription to give or not give; needs to know the mode of action; but does not need to know the biochemistry of the drug ...

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Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia
http://www.latrobe.edu.au/podiatry
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God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University
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Is that not making it more complicated? Does it really matter to us if an approach is reductionist or systematic? We just want to prescribe orthotics that make patients better.

Having said that, I do appreciate your efforts at trying to sort it all out. I was at the Boot Camp in Adelaide at the weekend when this came up.

I will have to give Ted credit for questioning me on this one when I used the term 'cookbook' ... questions always force me to more clearly think things through. Reductionist is probably a better term to use than "cookbook" for the sorts of prescription protocols and theoires I lump in that category.

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Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia
http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________
God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University
This is where I am, where are you?

From Wikipedia:

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Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia
http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________
God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University
This is where I am, where are you?

From the Merriam-Webster online dictionary:

sys·tem·at·ic
1: relating to or consisting of a system
2: presented or formulated as a coherent body of ideas or principles <systematic thought>
3 a: methodical in procedure or plan <a systematic approach> <a systematic scholar> b: marked by thoroughness and regularity <systematic efforts>
4: of, relating to, or concerned with classification ; specifically

__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia
http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________
God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University
This is where I am, where are you?

Maybe an example here would be the story Craig told at the Boot Camp about the ankle joint range being 10 degrees. Life was good and simple when it was 10 degrees. Now we know its not, life has got much more complicated, because the answer is not going to be a specific range of motion. The answer is going to be different for each person.

We want simple, but to be a good clinician, getting it right for the ankle joint range of motion is not going to be simple.

Hi all

Just came to this thread today and its a good one.

Robert asked
The problem with human knowledge is that it has no limitations, no boundaries, no permanent fixed points of reference. The complete data that describes a certain simple phenomenon can be so huge as to be almost infinite. Hence the 'expert' can spend a lifetime learning more and more about less and less.

At Strathclyde University their Logo was 'Centre of Useful learning' and 'useful' is the focus of all study. We need to evaluate if, the data we collect through study (i.e. process of learning) is useful for the problem we will apply it too.

As an example the data collected by, let's say a force plate, can be extremely complicated but ultimately does describe precisely the action of interest. This data is only from one point of view however, e.g. based on the measurement of the differential of an electrical charge.

To get useful data from this complete set we need to get rid of a lot of it and change the nature of what's left so as it can be usefully displayed as an output that a human can understand. It's not all the data and it's not necessarily a true or precise representation of the collected data and it is only one version or point of view but it does characterise the action of interest in a very useful way for our purposes at that time.

This is the great benefit of education I.E. obtaining the ability to filter out the data we do not require to solve the problem at hand. This skill takes years to be good at and never can be completely mastered. The expert again, filters out, finds or defines useful knowledge for his field of interest that reflects his point of view.

So the clinician can say to his or her self "do I need to have this knowledge or data to be useful in my profession"?. "How much more useful will I become by obtaining more data about my subject of interest"?. Some will be satisfied with what they have and others will strive to filter data till the ends of their careers or even lives.

Now where you lay along that scale and how you feel about your position and rank within and along that scale is a matter for each individual to put to themselves.

Are the data you possess useful for your professional life and are you satisfied with where you are?

Cheers Dave

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Descartes seems to consider here that beliefs formed by pure reasoning are less doubtful than those formed through perception.

The steps after realising the above

1 we realise that things can be so complex and multifactorial that it is impossible to process them all

2 next we remember that our measurements are inaccurate and can be no more precise than +/- 5 degrees

3 Having done that we formulate a simple working practice of "ankle dorsiflexion greater than 10 degrees"

4 Next generation of Podiatrists question why there is an arbitrary rule of "ankle dorsiflexion greater than 10 degrees" when surely things are much more complex and multifactorial

5 repeat steps 1-3