There isn’t a month, a week, sometimes a day that goes by where I don’t get accused of being biased when I post or discuss things in and around physiotherapy on social media, the last one just yesterday. Now when others point out my bias it isn’t a shock or a revelation to me as I am aware of my biases mostly and I am very comfortable with them. However, in an attempt to avoid repeating myself when I next get accused of bias I thought I would write a blog on it, and explain what bias is, how it affects us all in some strange ways, but more importantly how I think some bias can be positive.
Bias is usually defined as “an inclination or prejudice for or against someone or something in a way that is considered unfair”. Bias is a human condition and no-one, and I mean no-one, is infallible to it, not even the best critical thinking online social media warrior who likes to point them out all the bloody time. Simply put if you have a brain, you have bias. However, bias is often seen as a negative or harmful trait yet despite its reputation some bias can be very advantageous.
Bias can be explicit or implicit meaning we harbour them intentionally or unintentionally. Usually, our unintentional implicit biases are the tricky little buggers that tend to make fools out of us, and before I discuss some positive intentional biases I want to go through some of the sneaky implicit biases can make you look like an idiot…
We all love to agree with people who agree with us and it is why we only tend to talk to and hang around with people who hold similar views and ideas. Confirmation bias is without a doubt one of the most difficult bias to be aware of and then overcome, as most of us tend to be put off by and avoid individuals or groups who hold different views and opinions. When we do engage with those we disagree with we often tend to blame them for the uncomfortable feelings we get rather than recognising it is our own confirmation bias making us feel insecure.
A perfect example of confirmation bias that I hear and see daily is when many moan about how nasty and confrontational social media is. Well, there is no doubt social media can be nasty at times but mostly it’s not that bad, it’s just that it’s not the nice, comfy, cosy, safe, echo chambers many are used to. Social media is a public domain where people will disagree with you in various different ways, and personally I think more need to stop whining about a difference of opinion online and start recognising that it’s their own confirmation bias that is being kicked around a bit.
Status Quo Bias
We all hate change, everyone does, it makes us feel uncomfortable and awkward no matter how flexible, open, and receptive to change you think you are. Humans are evolutionarily hardwired to be apprehensive, wary, and resistant to change, this often leads us to make choices and decisions that try to keep things the same. A classic example of this status quo bias that I see on EVERY course I do is that without fail is about 99% of people will sit in the same place on the second day despite having a choice to go to a different location.
Status Quo bias is also why most clinicians stick to their preferred assessment and treatment choices instead of changing or abandoning them when confronted with evidence to do so. The destructive nature of this bias in healthcare is the unwarranted assumption that change will make things worse and that if it works then why do I need to change.
Have you noticed that as soon as you finished that weekend pelvic course suddenly everyone who came into the clinic had a pelvic asymmetry? This is a classic example of observational bias, the effect of suddenly noticing things we didn’t notice before. This is not because these things are appearing more frequently, it’s just that you’ve been primed to look for them.
The trouble is, most don’t recognize this as a bias and actually start to believe these items or events are happening with increasing frequency. It explains how some therapists start to think things like poor posture and other modern-day behavioural habits are to blame for issues such as an increase in pain levels in the general population. It’s also why we often think that the appearance of certain things or events can’t possibly be a coincidence even though they are, such as when our patients get better after seeing us.
We tend to pay more attention to bad news and it’s not just because we’re morbid, its because we perceive negative news as being more important or profound. We also tend to give more credibility to bad news, perhaps because we’re suspicious of constant claims to the contrary. Also again evolutionarily, heeding bad news has tended to be more beneficial and adaptive than ignoring good news (e.g. ” sabre tooth tigers suck” vs. “this berry tastes good”). However, today, we run the real risk of dwelling on negativity at the expense of positivity and this is true in our day to day lives, the media, and of course healthcare and physiotherapy.
In the world of research, a positive bias is a negative thing as it refers to the preference for publishers to publish research that has a positive or eventful outcome over research that has an uneventful or negative outcome. This can lead us to make errors in our judgement and thinking when choosing treatments and it is a huge problem in all aspects of healthcare, physio included. Without publishing the research that shows little, no, or even detrimental effects we tend to get a skewed view of the effects of some treatments such as dry needling, manual therapy, symptom modification procedures and so think they are more effective or safer than they actually are.
My Positive Bias
To finish this blog I want to discuss the bias that I most often get accused of which is my clear, obvious, and intentional bias towards the use of exercise over and above passive treatments such as manipulations, massage, electrotherapy, taping, needling etc for all painful musculoskeletal conditions and complaints.
The evidence on exercise for helping painful conditions although cannot be called strong does consistently outperform all passive treatments. I will be the first to admit that the how and why exercise-based interventions help for many painful conditions is not well understood, and I am aware that the process of doing the exercises may be more beneficial than the outcome for many patients we see.
We know exercise can create both physiological and psychological effects and trying to determine which or what of these effects is working more or less for some is near on impossible, but just because we can’t say what is helping with exercise-based interventions, doesn’t mean we can’t say what is not helping.
The addition of passive modalities to exercise also doesn’t seem to significantly enhance the effects of exercise when given alone, and so it is these factors which is why I have abandoned all passive modalities from my practice completely and often try to encourage others to do the same.
This is what often causes a lot of anger and accusations of my bias from many who continue to use them, but even more so from those who continue to teach things such as spinal manipulations, myofascial release, and dry needling. This is often due to their own biases and fears, and to combat this they are quick to rebuke and reject my views and opinions by accusing me of my own bias and stating that my arguments against passive treatments are flawed and therefore invalid.
This is simply ridiculous, having a bias doesn’t automatically make an argument flawed or invalid. For example I have a bias that all racism and sexism is abhorent. I also have a bias that putting your hand into a fire is not an effective treatment for back pain. So are these bias flawed? Of course not! Some biases are formed on information so strong and plausible that they are positive bias. Those that attempt to appeal to the middle ground and argue that we need to be as critical of all our biases are simply not true.
So, in summary, to accuse someone of having a bias towards exercise over passive treatments is an example of a positive bias and one that I am proud to have. To be frank it is one bias I wish more in healthcare and physiotherapy would have. Could you imagine what our healthcare system would look like if every doctor, surgeon, therapist, nurse, assistant had a bias towards using physical activity and exercise over drugs, surgery, bed rest, tapes, braces, needles, massage, etc?
If being biased towards exercise is wrong, then to put it simply, I don’t want to be right!
As always thanks for reading