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.
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.
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