TLDR/Key Takeaway of this blog: ‘Patient Mileage’ is an inadequate description of how we learn and develop as physiotherapists. Seeing more patients gives us experience but the actual development comes from the cognitive process of those experiences. The fallacy isn’t that experience matters, it’s that experience alone produces development.
For nearly 10 years I’ve become accustomed to patient mileage as a concept – see more patients and you’ll get better. It was present when I studied, while I worked clinically and now I work in education. I’ve never experienced the term used maliciously. Interestingly, it’s always been a reassurance tool. So when I was working with a colleague and I just couldn’t get myself in the headspace to understand or action something and I grew frustrated with myself – ‘don’t worry, you’ll get better, just need more patient mileage’…
I guess I’m now in a position where I question whether more experience makes us ‘better’ or better at repetition. I appreciate repetition improves fluency but is it better? Do we need to get better at applying the same algorithm? Communicating in the same way? Regurgitating the same subjective verbatim? Using the same treatment modalities with the same verbiage?
I absolutely value experience, but I’m not sure I value experience without genuine engagement. Seeing 100 patients with COPD for airway clearance absolutely helped me to understand repetition and refining the same approach. But it’s not inherently developmental. The premise of patient mileage doesn’t communicate how I’d learned over those 100 patients to interpret the nuances. The subtle look they give me when I ask them to breathe in really deeply when they know they’re going to cough and are unsure if that’s what I want or they know they’ll experience pain/complications. I’d learnt to work with these nuances because I’d cognitively and meta-cognitively interpreted these subtle signs, not just because I’d seen it 100 times. The latter completely dismisses the cognitive process.
The reason I’m writing about this now is because I’ve become really interested in the concept of expertise over the last year. I’ve read Peak, Expert and Bounce (see below for reference) and it’s really made me consider the application to physiotherapy practice. They all agree that practice matters (being true to the work, we mean huge volumes of sustained practice) but they also stress the nature of the practice matters too. Feedback, adjusting, purposeful repetition, mistake-making, meaning-making, challenging preconceptions. All these things are happening for that actual development to take place – that’s where understanding the nuances comes from – not simply seeing it more often. The deeper discussion here though is that the cognitive skill needs to be practised too but we’ll save that for another blog.
Hopefully you can see that what I’m getting at is that patient mileage is one tiny element of the development process. The actual key elements are the conditions within which patient mileage happens – and that’s where supporting yourself and others is important. This is of course where CPD and reflective practice come into play – but my provocative question is what are you doing with the CPD/reflective practice? If nobody is reading, guiding, challenging or helping to use the CPD/reflection to change our next engagement – what was the point?
So this is not a plea to stop saying patient mileage – not a hill I care about enough to die on. I’m stressing that patient mileage simplifies the learning process, we don’t learn directly from experience. We learn from engaging with an experience. My next thoughts are now about how we get better at engaging with experiences…
Recommended Reading:
Ericsson, A. and Pool, R. (2016) Peak: Secrets from the New Science of Expertise. Houghton Mifflin Harcourt.
Kneebone, R. (2020) Expert. Viking.
Syed, M. (2010) Bounce. Fourth Estate.
