As Adam Meakins has stated, “Just doing what ever a patient wants is prostituting yourself!”. A typical argument for letting the patient choose the choice of treatment is this: “I agree we should advocate for patient education on EBP but that comes at what cost? We’ll never know. Some patients may not return.”
Often there is a hidden “false dichotomy” within the argument being made; people think that they need to do whatever the patient “wants” or they will not come back… or they believe that only doing what “they” want is the only other option. Using shared decision-making, providing (high) quality care options, and making a reliable and effective long-term plan, is also a valid option.
But yes, that is a risk that patients may not return. But this is more a salesman view (with the fear of a missed sale) than the view a health professional with considerable formal university training should have. As health professionals, we should uphold certain ethical standards, not just give the patients what they want! We need to think a lot more self critically about this, and it’s much more complicated than most therapists (that use this flawed argument) think. There are multiple problems with this line of clinical reasoning:
1. Why did we go to university if the patient is made to choose his treatment?
The fact that this type of question often comes up is really sad, and sad that the skill set of healthcare professionals and the quality of clinical reasoning are so low.
What happened to our skill in helping and guiding patients? Looking at the patients’ needs, not only what they want?
What happened to our clinical skills in managing care in the most effective and appropriate way?
What happened to work together with patients to meet their goals? (and not only offer quick “fix” solutions that are not based upon trustworthy and sound research)
What happened to build a solid and firm therapeutic alliance with your patients? and using Shared Decision Making?
Sadly, most of these things are ignored and overlooked when we start focusing on having a satisfied customer and not trying to help a person by giving them what they need and not only what they “want”.
2. If a patient goes to the doctor, does he get to choose which medicine he gets?
The choice of intervention is the choice of a professional, not a layperson. The patient goes to a professional to get the professional’s expertise. This is the reason we go to a doctor, a surgeon, or a psychologist, or a mechanic, or a lawyer, or a carpenter, an engineer, or a builder.
When the patient does try to get to choose what they want us to do to them (or better worded with them), it is, in my view major sign of distrust in our ability. Distrust is why they try to take control in the first place and try to choose what they think the “solution” to their problem is because they do not trust us to do it. A critical question I ask myself if this happens is, why does the person in front of me not trust me to use my expertise?
“Our role as evidence based healthcare professionals is to educate, inform, reassure, motivate, and encourage patients to do things they don’t want to do” Adam Meakins
3. What do therapists think happens when the patient does not get any results?
Most likely, patients will not get results from a low-quality pseudoscientific intervention. The patient will then also not come back, and often he will cast blame on the therapist! “I have tried physiotherapy, it does not work!” But upon scrutiny, what the person has tried was all the low-hanging fruit, then did not get one high-quality treatment. They were served a smorgasbord of passive low-quality modalities, like laser, acupuncture, dry needling, kinesiotape, TENS etc.
Using modalities that do not have any evidence, or are highly implausible, or based upon imaginary belief-based explanations only supported by confirmatory thinking is not being a professional – but a scam-artist. This is not being a healthcare provider; that is just plain bad clinical reasoning. Giving a person that you are supposed to help something that we know most likely will not help (even if they think it will help) is not sound clinical reasoning. This could potentially backfire, and the patient will become a great spokesperson for not doing therapy with you if what you “choose” does not work.
In my view, if you take a higher stand and say you will only provide the highest quality of care, or they can go to another healthcare professional, they will not go away. They are not in any way used to somebody to show that level of professional integrity, and they will often not go away but will become your greatest promoter.
4. Did the specific intervention lead to long-term improvements?
Logic would also dictate that if they have tried a specific intervention and still have a problem, the particular treatment did not “work”. The problem is still there; otherwise, they would not seek to get help again. So should we as a professional with considerable formal training provide care with no evidence that did not work longterm? Taking a piss in your pants will also get you warm in the winter, but it is not an excellent long-term solution!
5. Is doing placebo “medicine” what a health professional is supposed to do?
Typical clinicians vastly misunderstand what the placebo effect is. A placebo effect is a non-specific effect, which is largely uncontrollable, uncertain, variable, and short-termed. Our interventions should be better than a placebo effect! In a medical trial, the test medicine has to beat the placebo effect, to be shown to “work”, we should hold ourselves to the same standard. An often-ignored fact is that placebos do not cure but can reduce symptoms (Benedetti 2019). As health professionals, we should try to cure if it is possible!
“It seem to me that placebo treatments ought to be paid, with a placebo payment” Dr. Harriet Hall, MD
The placebo effect is an uncontrollable, highly uncertain, variable, and short-term effect. The placebo effect is not a magical “black box” with therapeutic effects. The size of the effect varies depending on how invasive the treatment is and what the context is. The placebo effect is a small clinical effect (mostly) on subjective outcomes; that cannot be distinguished from biased reporting.
“The idea of a magical black box from which unexplained therapeutic effects spring up is archaic and also unhelpful” Kamper at al. 2013
6. Should we base our care on biologically plausible interventions or implausible?
As a health professional, we should focus on biologically plausible methods, not getting a satisfied customer! As stated by Ingram et al. 2013: “We recommend making a greater effort to focus our attention on biologically plausible methods that are congruent with our accurate patient-focused education processes”.
A paradox behind this is that the erroneous argument is typically used when a clinician wants justification to do a low-quality “quick fix” treatment or get “buy-in”. Not when the choice of intervention is something that the clinician does not want to do!. We could replace the therapy’s name with faith healing, bloodletting, magical charms, and it sounds the same in these arguments for justification. Matthew Woodard made an important point; we probably shouldn’t use interventions with the same supportive arguments (and low-level of supporting evidence) as the arguments that charlatans, snake oil salespeople, and scam artists use.
As a health professional with considerable formal training and a university degree, we should easily be able to support our interventions with reasoning supported by a much higher epistemic level, like scientific research. As a professional, our focus should be on providing the best possible quality of care to help the person. That means using biologically plausible methods that are congruent with current research knowledge.
“Nothing could be more humanistic than using evidence to find the best possible approach to care” Rothstein 2001 7
7. Is informed consent granted from the patient before they are given an implausible intervention?
As noted by Paul Ingram, the patient’s informed consent is usually broken in the cases mentioned above. Patients are typically never correctly informed. They are spoon feed self-serving claims and are made to believe that passive and low-quality “operator” treatments (Jacobs et al. 2011) are a good option, and sometimes they are even told it is the best option. A therapist’s choice of intervention should be based upon the patient’s representation, goals, and needs of the person with pain. It should not only look at what the patient prefers.
8. Satisfaction is not the same as effectiveness.
Clinicians who use the above-flawed argument; typically have a misinterpret focus on patient satisfaction. They often seem to care more if the patient comes back than if they get better!
“The fact that patients swear by us does not mean we are actually helping them. Satisfaction is not the same thing as effectiveness” Prof. Preston Long, PhD, DC
Patient satisfaction and positive long term outcomes are two different things. The patient’s needs may not lead to instant satisfaction but can lead to positive long-term results. As professionals, we should have the professional integrity to have crucial conversations with the people under our care. People’s normal and appropriate adaptive behavior to acute pain may paradoxically be a poor way of coping with persistent pain. Safety-seeking behavior may worsen the problem in the case of long-lasting pain (Leeuw et al. 2007, Linton et al. 2011).
As a health care provider, we should have the integrity and courage to have a conversation with the people under our care when their behavior and beliefs are part of the problem and act as a barrier for positive long-term outcomes. At the moment, they may not be satisfied, but they are more well-informed.
“Patients can be very satisfied and dead an hour later. Sometimes hearing bad news is not going to result in a satisfied patient, yet the patient could be a well-informed, prepared patient.” Clinical instructor
Let me end this article, with a very good statement made by Dr. Jarod Hall (DPT) about what our mindset as an evidence-based clinician should be:
“Its my strong opinion that we need to understand and adopt the mindset that our value is not in the things we can do to patients but instead our value lies in our knowledge, our education, our ability to guide patients, taking the role of steering the direction of care in the most appropriate manner, and working together with patients to meet their goals.”
“Our value comes in screening out serious pathology, calming fears with positive affirmation, building a long term rehab plan, understanding injuries, understanding healing, and understanding pain. Our value comes in saving unnecessary medical care, nocebo, and iatrogenic healthcare effects.” Dr. Jarod Hall, DPT
References:
Benedetti F. The Dangerous Side of Placebo Research: Is Hard Science Boosting Pseudoscience? Clin Pharmacol Ther. 2019 Dec;106(6):1166-1168.
Ingram T, Silvernail J, Benz LN, Flynn TW. A cautionary note on endorsing the placebo effect. J Orthop Sports Phys Ther. 2013 Nov;43(11):849-51.
Jacobs DF, Silvernail JL. Therapist as operator or interactor? Moving beyond the technique. J Man Manip Ther. 2011;19(2):120-121.
Kamper SJ, Williams CM. The placebo effect: powerful, powerless or redundant? Br J Sports Med. 2013 Jan;47(1):6-9. Epub 2012 Aug 14. PMID: 22893511.
Leeuw M, Goossens ME, Linton SJ, Crombez G, Boersma K, Vlaeyen JW. The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. J Behav Med. 2007;30(1):77-94.
Linton SJ, Shaw WS. Impact of psychological factors in the experience of pain. Phys Ther. 2011 May;91(5):700-11. Epub 2011 Mar 30.
Rothstein JM. Thirty-Second Mary McMillan Lecture: journeys beyond the horizon. Phys Ther. 2001 Nov;81(11):1817-29.
