Great expectations…

We all go through life with expectations. We expect our alarm clock to wake us up in the morning, we expect our day to go the way it usually does, we expect a kiss from our partner when we get home, we expect the evening news to be on the tv at the same time. But when something doesn’t go as expected it tends to surprise, upset, and annoy us, this is human nature, and this is no different for our patients.

tantrum

I am seeing more and more discussions on social media from therapists about how they recognise patient expectations are vital to successful outcomes which is great to see and I agree they are. But what is not so great is how some are using this to justify the use of shitty low value poorly supported interventions such as dry needles, stretchy tapes, machines that go bing, and of course manual therapy. I hear some justifying the use of these crappy interventions claiming they are acting under the guise of evidence based practice. To put this simply, this is bull shit.

There is however a lot of evidence that does show how patient expectations strongly predict successful or unsuccessful outcomes for many interventions. For example the strongest predictive measure for successful physiotherapy treatment for shoulder pain was if the patient expects physiotherapy to help (ref). The same was found for chronic pain management (ref), manual therapy (ref), even my beloved exercise therapy (ref). Simply put if a patient thinks an intervention will help them, it did, if they didn’t, it didn’t.

So from this research some clinicians have taken the position that they just need to give the interventions that a patient expects to help them and they will be successful and an evidence based practitioner. This nonsense really boils my piss as it’s a complete crock of shit, a bastardisation of the research, and really dumb arsed clinical reasoning.

To put it as simply as I can managing a patients expectations doesn’t simply mean meeting them.

Just because the research shows patient expectations predict outcome doesn’t mean you do whatever the patient expects or wants, that’s doing your job. For example if a patient expects to feel better with some dubious, weird or dangerous treatment you wouldn’t do it would you?

Simply put there is a line of what you as a clinician will do to meet a patients expectations, and in my opinion this should be drawn by using what the evidence base tells us works significantly and reliably. 

And many, many patients of mine do NOT have their expectations meet, but they ALL have them managed. 

If I can manage them successfully they do tend to get successful results. However, I will be honest here and say that this doesn’t happen all the time, in fact it often doesn’t happen. Trying to manage or change a patients predetermined expectation is hard, really hard.

Occasionally some patients don’t know what they need and have no expectations, these are a lot easier to manage. However, more often than not most patients do have an expectation of what they want or think they need. This will be either due to advice or information from another healthcare provider, or in this day and age, advice that they got from the internet and Dr Google. However in this post truth world of alternative facts and fake news, misinformation is rife and patients get some pretty skewed and erroneous expectations and beliefs.

fake-news

So as well informed, responsible evidence based clinicians it is our moral and ethical duty to inform our patients what the current scientific literature is telling us, and not rely on Dr Google or ‘dave down the pub’. We need to try and remain as unbiased as we can when doing this, which is easier said than done. We need to present to the patient all the options with clear, concise information of the pros and cons, risks and benefits of each option, as well as explain the uncertainty of how these treatments may or may not work.

You maybe thinking that this is a lot of work, and you’re right it is. But its called getting informed consent and is a fundamental principle of healthcare. Simply meeting a patient’s expectations is easy as hell, in fact it’s a piece of piss, you just do whatever they ask. But that’s NOT your job. That’s what a hotel reception clerk does, that’s what a taxi driver does, that’s what a nipple tweaker does, that’s what any good service provider does. However, healthcare professionals, including physiotherapists are NOT service providers, please go and read this by Erik Meira for more on that.

So in summary your role as a healthcare provider is to MANAGE your patients expectations and that often means carefully, compassionately, honestly telling them that they don’t need what they think they need, and they may have to do something they didn’t expect. Yes this is harder and requires more time, more effort, more cojõnes, but tough luck buttercup, it’s what you signed up for when you decided to be a physio, and if you don’t like it then i’m sure there are some nipples waiting to be tweaked somewhere! 

As always thanks for reading

Adam

6 thoughts on “Great expectations…

  1. Thanks for the post Adam. Often lurk but never post. This one hit home as I have recently run into this issue with new graduates who are very uncomfortable with their uncertainty. It may be due to the cognitive dissonance that’s going on in the profession around manual therapy, passive interventions, etc. What the students have seen or heard in the classroom may or may not relate to what they are taught in the clinic. Often they are exposed to do a high standard of science-based practice in one setting and not in the other. To manage this psychological distress, I think many new graduates develop cognitive clinical rationales and/or routines that they justify by stating “I am meeting the patient’s expectations.” In some situations this is further reinforced by financial incentives to over treat and incentives in social media likes and patient testimonials.

    New graduates of PT programs get caught up in the above process early on and it keeps the low value PT care flowing for a new generation of physiotherapists and patients. New graduates quickly develop habits of using interventions that often require little thought, appear specialized, and allow a prepared verbal scripting and narration. Once ingrained, it’s very difficult to overcome this “low value, patient pleasing, intervention inertia” that continues to get reinforced by anecdotal confirmation bias and the reports of pleased patients. I think this same misconception of “meeting v. managing” is true in the “alliance” that the physiotherapist and patient forge as well. We are here to be experts helping educate them and develop a plan of care that is mutually agreed upon after discussion. We do not always give them what they think they want or what they have heard they want.

    In some, by no means all, using a science-based patient decision aide that takes the patient through a simple decision process may be helpful. Decision aids or not, we are teachers, tour guides, and ambassadors of evidence. If we forget these roles and only work to meet the patient’s initial expectations then we offer nothing of substantial value to the patient, or to the nature of our profession. Instead, we just help steer the tour bus of smiling happy patients off the road and into a low value ditch of professional ambiguity. We can and should do better. Cheers!

    • Thanks for the comments JW, you make some great points half of which I’ve forgotten as I’m writing this reply! 👍😜

      We can and must do better for the new grads, we need to give them the confidence of uncertainty and that we can disagree with patients requests as long as we validate them!

      Thanks again buddy

  2. There are times when explaining to the patient that their therapeutic requests may (based on most current evidence of course) lead to an undesirable outcome. I like giving them their choice vs my POC, then inform them of each predicted outcome. If they continue to choose their mostly passive treatment approach , I mention that we were educated to improve patients functional mobility, quality of life, and restore the chance to resume their recreational persuits. Those chances decrease with their requested POC. those patients who get that I am there to give them the very best of what science has to offer actually tell me that I didn’t just meet their expectations, I surpassed them. This doesn’t always happen. Last year, a patient complained to my director that I made her feel guilty and shamed her. I told her that she deserved the very best science has to offer rather than the level 5 (or even less) supported POC that she was requesting. In the last 5 years, I’ve averaged about 5 complaints because EBP can be quite confronting towards biomedical beliefs. There are times when walking into my directors or supervisors office can feel quite discouraging, but fortunately, I cheer right up when colleagues bring up the ratio of people I help being much higher than the ones I piss off. I just wanted to mention that not all patients are ready to receive the very best science has to offer, but those who are can become loyal customers rather than just satisfied customers.

    • Hi Ken, thanks for the comments. And sorry to hear you get about 5 complaints over 5 years but if its any consultation I average about 5 complaints a month… Not doing what a patient expects tends to cause friction and upset, how this is managed is key and I will admit there are times I don’t do it well, but there are more times when the patient is just a dick because they didn’t get what they wanted… yes patients can be dicks, or like 2 year olds when they don’t get what they want. Sometimes its them NOT us.

      Cheers, and keep challenging

      Adam

  3. “Cajones” = drawers In Spanish
    I understand you mean to say “Cojones” (pronounced ) bo***cks

    Great post.

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