Mindset
“Humpty Dumpty sat on a wall, Humpty Dumpty had a great fall; All the king’s horses and all the kings men couldn’t put Humpty together again.”
Every once in a while, I have a conversation on the podcast that stays with me long after we stop recording. That happened when I sat down with my old friend and colleague Darren McConaghy on the Leave Your Mark podcast EP 496 out this week.
Darren and I first worked together more than twenty years ago when I was with the Montreal Canadiens and he was working with the Hamilton Bulldogs. We were both much younger practitioners then, although we had already started developing some fairly strong ideas about how we believed people should be cared for.
Since then, our careers have taken us in different directions. Darren continued through Athletic Therapy and strength and conditioning, eventually spending years studying osteopathy and developing his own approach to working with people. I continued through professional and Olympic sport, performance, Reconditioning, teaching and now, somewhat unexpectedly, find myself back inside a large organization working as the Head of Rehabilitation at Cirque du Soleil.
As we talked, I was struck by how often our different journeys had brought us to the same place. Perhaps that’s not surprising because there were similarities in how we looked at things even when we were younger. We were both curious and probably a little stubborn. Neither of us was particularly comfortable accepting an answer simply because that was the way something had always been done.
As I thought about our conversation afterwards, I kept coming back to that old nursery rhyme about Humpty Dumpty, and the difficulty of putting something back together once we’ve broken it into pieces.
Twenty-five years later, what seems even clearer to both of us is that the human being is rarely as simple as the problem they present with, and yet much of the system we’ve built to care for them requires us to pretend they are.
Someone walks through the door with knee pain, so we look for what’s wrong with the knee. Someone has back pain, so we investigate the back. An athlete tears an ACL, so we pull out the ACL protocol. Someone gets an MRI that shows a meniscal tear, and suddenly the conversation becomes about whether they need surgery. None of these are unreasonable responses. Sometimes they are exactly where we need to begin. The problem occurs when they become the end of our investigation rather than the beginning.
Darren talked about something that has frustrated him for much of his career and it resonated with me deeply.
Our healthcare systems aren’t really designed to reward time spent understanding people. Appointments are short, insurance systems require classifications, patients understandably want answers, and practitioners need to make decisions. The entire environment pushes us toward identifying the problem as quickly as possible and doing something about it.
Darren contrasted that with his own process, where he might spend an hour and a half simply talking to someone about their injury and health history and then continue thinking about the case afterwards, trying to understand how the pieces might fit together.
I think there is something important in that distinction.
The system rewards answers, but understanding a human being requires questions.
At one point in our conversation, I suggested that one of the great misconceptions in our world is that spending more time at the front end of a problem necessarily makes the process take longer. My experience has increasingly taught me the opposite. Taking more time initially can get us to a meaningful solution faster because we have a better chance of understanding what we’re actually trying to solve. Greater due diligence on the front end can save an enormous amount of frustration later.
I’ve watched the opposite happen countless times throughout my career. We identify the painful area, find a weakness, prescribe an exercise, treat a tissue, increase the load and follow the expected progression. Often that works beautifully, and when it does, there is no reason to make the process more complicated than it needs to be.
But sometimes it doesn’t work.
We add another exercise, another treatment, another practitioner or another opinion. Eventually, perhaps another scan. Weeks become months, and what appeared to be the most efficient approach at the beginning becomes incredibly inefficient because we may never have taken enough time to understand the problem in the first place.
This doesn’t mean endlessly assessing someone or searching for an obscure explanation when a straightforward one is staring us in the face. It means gathering enough context to create a reasonable hypothesis about what might be contributing to the person’s problem, doing something based on that hypothesis, and then paying close attention to what happens next.
If the person responds the way we expected, perhaps we’re moving in the right direction. If they don’t, the appropriate response isn’t to keep forcing the same idea onto them. We need to reconsider our hypothesis.
Darren used a phrase during our conversation that I really liked. He said that when he’s trying to understand someone, “everything’s on the table until it’s not.” Their story matters. Their injury history matters. Previous surgeries might matter. Their physiology, training history, lifestyle, stress and the physical demands they’re trying to return to might all matter. None of those things should automatically be assumed to be causal, but neither should they be dismissed simply because they sit outside the traditional boundaries of the body part we’re treating.
This is where I think our education can sometimes work against us. We have divided human beings into professional disciplines so that we can study them more effectively.
Orthopaedics, neurology, psychology, physiology, nutrition, biomechanics, strength and conditioning, physical therapy and Athletic Therapy have all developed tremendous bodies of knowledge. We absolutely need specialists, and part of being a responsible practitioner is understanding the boundaries of your own expertise and knowing when someone needs another level of knowledge or care.
But the person standing in front of us doesn’t experience themselves in professional departments. Their nervous system isn’t separate from their psychology. Their physiology isn’t separate from their nutrition. Their movement isn’t separate from their injury history. Their ability to recover isn’t separate from their sleep, and their training isn’t somehow isolated from the cumulative stress of the rest of their life.
“All the king’s horses and all the king’s men, couldn’t put Humpty together again.”
We separate these things so we can study them. The human being puts them all back together. We need to do a better job of serving human beings.
This is one of the reasons I think there is still tremendous value in the generalist. I don’t mean someone who believes they are an expert in everything. That’s both foolish and potentially dangerous.
I mean someone who has accumulated enough knowledge across multiple areas to recognize that something outside their primary area of expertise may be relevant, and who knows when to explore further or bring someone else into the process. The value of the generalist isn’t knowing more than the specialists around them. It is being able to integrate what the specialists know into the context of the person standing in front of them.
The discussion eventually moved toward imaging and surgery, another area where this distinction becomes important. Darren talked about what he believes has become an increasing reliance on imaging to drive clinical decisions. An MRI shows a torn meniscus, for example, and the conversation quickly turns toward what should be done about the tear. But Darren asks another question first: does what we’re seeing on the image line up with what we’re finding clinically?
That question doesn’t diminish the value of imaging or suggest that surgery is unnecessary. There are structural problems that require structural solutions, and imaging has transformed our ability to understand pathology. But an image is still information. The presence of a structural abnormality doesn’t automatically tell us how much it matters to the person, whether it explains their functional limitations, or whether changing that structure is necessarily the first thing we need to do.
Sometimes the image becomes so compelling that we stop looking at the person. The MRI effectively becomes the patient.
We eventually wandered into some of the emerging areas of healthcare, including peptides, stem cells and other interventions that may eventually change some of the ways we manage injury and recovery.
I’m fascinated by much of this, and there will undoubtedly be advances that significantly change what is possible. At the same time, I find something about our current fascination with advanced interventions a little ironic. We can become incredibly interested in sophisticated solutions while doing the basic things poorly. Someone wants to know which peptide might improve their recovery while they’re sleeping five hours a night. They may be searching for a biological intervention while under-nourishing themselves, barely moving or carrying an enormous amount of stress every day.
That brings me back to an important distinction. Looking at a problem more comprehensively doesn’t necessarily make the intervention more complicated. In fact, sometimes complex thinking leads to remarkably simple solutions. Someone may need to sleep more, eat better, move differently, get stronger, reduce a training load, restore a missing capacity, change something in their environment or simply give something more time. The sophistication isn’t necessarily in what we do. It is in understanding why we’re doing it and whether it actually matters to this particular person.
There is another side to this discussion that I think is important to acknowledge. It would be easy to blame healthcare systems, insurance companies, professional sport or practitioners for reducing complicated human problems into simple ones, but I’m not sure that would be entirely fair.
People want simple answers too, and I understand why. When you’re hurting, you want someone to tell you what’s wrong and how to fix it. When an athlete is missing games, everyone wants to know when they’ll be back. When a parent watches their child struggle, they want an answer. Sometimes the deeper explanation isn’t particularly attractive because it may require us to consider things we’d rather not change.
Not everyone actually wants the complexity that sometimes comes with solving a problem, particularly when lifestyle, stress, training habits or other factors begin entering the discussion. Maybe your back pain isn’t going to disappear because someone manipulates your spine. Maybe your knee problem isn’t simply because your glutes are weak. Maybe the solution requires changing how you train, how you recover, how much you sleep or something else in your life that isn’t particularly convenient to change.
Sometimes people simply aren’t ready to do that.
Perhaps, then, we’ve collectively created the system we have. Healthcare wants certainty because it needs to make decisions. Insurance wants certainty because it needs to determine what it will pay for. Professional sport wants certainty because athletes need to play. Practitioners want certainty because people come to us for answers. Patients want certainty because uncertainty is uncomfortable. Social media has amplified all of it because certainty is much easier to sell than nuance. Meanwhile, biology remains stubbornly individual and complicated.
After nearly forty years of working with human beings, I find myself less certain about many things than I was twenty years ago. I don’t see that as knowing less. If anything, I think experience has made me appreciate how much there is to know and how dangerous certainty can sometimes become. I’ve accumulated knowledge, developed systems, learned techniques and created frameworks, and all of those things have helped me become a better practitioner. But they can also become blinders if I start believing the person in front of me has to fit what I already know.
Experience hasn’t necessarily given me more answers. I think it has given me better questions. What am I missing? What happened before this? What does this person actually need to be able to do? What changed? What capacity might be missing? What are they protecting themselves from? What does their environment demand of them? What happens if I change something, and most importantly, does the person respond the way my hypothesis suggests they should?
If they don’t, I need to be willing to change my thinking rather than force the person to fit my model.
Maybe that’s one of the real lessons of experience. Expertise isn’t simply accumulating enough knowledge to always have an answer. Perhaps expertise is developing the humility to recognize when you don’t yet understand the problem, the curiosity to keep asking questions, and the willingness to change your mind when the person standing in front of you gives you a reason.
The system may reward answers, but human beings still require us to ask better questions.
