Most of us practicing clinicians can confidently say that we strive everyday to get the best outcomes.  It helps promote our profession, our private (or hospital-based) practices and honestly, our own ego.  I chose my first job to mentor under a skilled, experienced clinician and continue to strive to become better everyday.  I am seeking additional training opportunities and continue to stay active online to continue learning, just like everyone reading this post. Doesn’t the phrase, ‘if you are not getting better, you’re getting worse’ fit in here?

What got me thinking about this is after scanning a research study by Julie Whitman et al 2004 JOSPT.

Here is the quote from the conclusions:

With the standardized protocol utilized in this study, it appears that the therapist-related factors of increased experience and specialty certification status do not result in an improvement in patients’ disability associated with low back pain.

Without getting into too much detail on this study (as the authors used a standardized protocol of manipulation (the highly unlikely positive results from a Chicago style manipulation) or stabilization exercises (this in itself is known not to improve outcomes).   Plus a standardized protocol limits the clinical reasoning that a more experienced clinician can draw from.

But it does bring up some points.  How much experience and training yields the peak point in getting the best outcomes or do we all hit a ceiling effect?

I always heard though that the more experienced and ‘better’ you get, the more likely you will get referred the more difficult patients and therefore your outcomes level out.  Is this true?

I don’t have the answer but the drawing below may spark some conversation.  What do you think of the 5 year mark showing a plateau?






  1. Really well written my friend. This is a question I think about often as I go through my fellowship program with the Canadian Physiotherapy Association. We believe as new grads that anyone with the FCAMPT or FAAOMPT status is automatically the “best” and can fix anyone (we actually don’t fix anyone lol). But as I go through the system, I realize that there are SO many components to successful outcomes.
    1) Does the patient like you?
    2) Does that patient believe you can help them?
    3) Does the patient want active or passive care?
    4) Did the patient have a pleasant experience dealing with front desk staff..even this can alter outcomes
    …and I haven’t even gotten to the actual intervention you would employ to help the patient. Therefore this study you mentioned is really flawed only because taking into account the whole patient experience is very hard for any study to do. I think some people will not get better regardless of the intervention employed. Some patients don’t “mesh” specific types of people…and that will directly impact outcomes.

    But yeah… does having the OCS matter to patients? Probably not…

    1. Hey Jesse,
      Good to hear from you! Yes, all those factors you mentioned are part of the experience. I can tell you from working in a private practice…the front desk (can be called the ‘welcome center’) is a HUGE part of therapist success.

      I always strive to take out all those other variables, positive or negative, though and provide the best possible care.

      Maybe another post will come but I do think outcomes will improve in regards to
      1. quicker results and less beating around the bush to get the job done. We all see patterns and what has worked for a similar presentation for someone else in the past…
      2. I have been performing manipulation since I came out. It is not necessarily the be all approach, but I can tell you from other therapists…their outcomes have improved through manipulation. Dry needling can fit in here too.

      Oh yeh, OCS…most pts see it on my wall but could care less! It is more respect within the field I think.


  2. Nice post Harrison. I think this is a topic well worth discussing, as many clinicians appear to believe “experience” is the third tier to EBP, when it is actually “expertise”. But what is expertise? I am not quite sure. I recently wrote about it here: ( I am still uncertain if anyone can truly become (or is) an “expert”, considering every patient treated has a unique, individualized nervous system. I do suspect our own experience leads to an enhanced difficulty in adapting to evolving models of physiology, and am not quite sure where that leaves mature clinicians. That stated, I suspect the longer we practice, the better interactors we become, which may lead to improved outcomes. This shouldn’t be mistaken with the interventions we provide, which is where many end up committing logical fallacies regarding why someone got better.

    1. Hey Joe,
      Thanks for responding man. I did enjoy your article and you made very good points.
      I think an ‘expert’ is able to consider the differences in patients and take what has worked for them in the past through interventions, patterns, etc. and adapt the treatment due to the pt’s individual presentation. An expert isn’t just someone who knows a few techniques…I would hope everyone can agree on that.

      It is interesting to see how interaction is really coming back out of the cobwebs into full discussion now. We all know this is important and this is one of the qualities that draw our personality types into this profession….to interact with the patient…not sit behind a microscope per say.


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