We all go through life with expectations. We expect our alarm clock to wake us up in the morning. We expect the traffic to be bad on the way to work. We expect a kiss from our partner when we get home. But when something doesn’t go as expected it tends to upset and annoy us, this is human nature, and this is no different for our patients.
I see more and more discussions on social media from therapists about how much they recognise patient expectations are vital to successful outcomes which is great. But what is not so great is how some are using this to justify the use of any treatment, even poorly supported interventions such as dry needles, stretchy tapes, machines that go bing, and of course manual therapy.
Predicting Success
Many justifying the use of these low-value interventions claiming they are acting under the guise of evidence-based practice because they are meeting patients expectations. To put this as simply as I can, this is a pathetic excuse.
There is a good deal of evidence that shows how patient expectations are important to predict successful outcomes for many interventions, but this doesn’t justify the use of low value interventions.
For example, one of the strongest predictive measure for successful physiotherapy treatment for shoulder pain was if the patient expects physiotherapy to help (ref). This is the same for chronic back pain (ref). This also applies to treatments such as manual therapy (ref), even my exercise therapy (ref) with higher expectations predicting greater success.
Simply put if a patient thinks an intervention will help them, it will, if they don’t, it won’t. From this, some clinicians have taken the position that they simply need to give interventions that a patient wants or expects to help them get better.
Lame Excuses
This is one of the lamest excuses and a complete a bastardisation of the research, and really daft lazy clinical reasoning. To put this as clearly as I can managing patients expectations doesn’t mean meeting them.
Just because research shows patient expectations can predict outcome doesn’t mean you do whatever the patient wants. For example, if a patient expects you to give them their massage treatment without your top or trousers on because it makes them feel better, you wouldn’t do it, would you?
So there clearly is a line of what you as a professional healthcare clinician will do to meet a patient’s expectations, which is good. However, in my opinion, this line needs to be much, much higher than it is and definitely a long long way from doing treatments half-naked.
Hard Work
Many patients of mine do NOT have their expectations met, but they ALL have them managed, and I have found if I can manage them well even if I don’t meet them they still get successful results. However, I will be honest and say this isn’t easy and it doesn’t happen all the time.
Trying to manage or change a patient’s predetermined expectation is hard work. When patients don’t know what they want or need and have no prior expectations, these are much easier to manage.
However, more often than not patients do have an expectation of what they want or think they need. This will be either due to some advice or information from another healthcare provider or from some advice they got from a friend or the internet and Dr Google.
In this post-truth world of alternative facts and fake news, misinformation is rife and a lot of patients get some pretty skewed and erroneous ideas, beliefs, and expectations.
As responsible evidence-based clinicians, it is our moral and ethical duty to truthfully inform our patients on what the current scientific literature is saying. During this, we need to remain as unbiased and impartial as we can, which is easier said than done.
We need to present to the patient all the options available with clear, concise information about the pros, cons, risks and benefits, as well as explaining the uncertainty of how these treatments may or may not work. You may be thinking that this is a lot of work, and you’re right it is. But its called informed consent and is a fundamental principle of healthcare.
Meeting someone’s expectations is actually pretty easy, but that’s NOT your job as a healthcare professional. That’s what a receptionist, waiter, taxi driver, or prostitute does. Meeting a person’s expectations is what any good service provider does, however, healthcare professionals are NOT service providers.
Summary
Your role as a healthcare provider is to MANAGE patients expectations not automatically MEET them. This means carefully, compassionately, and honestly telling them that sometimes they don’t need what they think they need.
Yes, this is difficult, challenging and requires more time, more effort, often for less reward both financially and emotionally. But, it’s what you signed up for when you decided to be a healthcare professional, and if you don’t like it then I’m sure there are some tables needing waiting or taxis to be driven somewhere!
As always thanks for reading
Adam
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
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
“Cajones” = drawers In Spanish
I understand you mean to say “Cojones” (pronounced ) bo***cks
Great post.
Ah crap… thanks for the spot, amended already
I know I’m a bit late to this but thank you for writing up this post. I am a new grad physio and I was also lost in this world of manual therapy. Since I first stumbled across your blog, I have been focusing mainly on education and exercise with great success. Occasionally I do come across the patients who just want to be poked, pulled, massaged, mobbed, etc. yet I still stick with my education and exercise therapy.
I recently had a meeting with my manager and he brought up this issue of patient’s expectation. Apparently some patients were complaining about me not doing any hands-on stuff. I was advised to resume manual therapy and use it as a “window of opportunity” to buy patients in. I think it’s ridiculous. I don’t want to waste my time doing something that would not help the patient but I also don’t want to upset my manager and lose my job! What do you think is the best course of action for this Adam?
Cheers from down under!
Hi new grad… this is a difficult decision and one I cant make for you. I think its important to remember that you are an autonomous clinician and don’t have to be told what to do clinically by anyone, including your manager. You and your patients decided together whats best, you with your knowledge, skill and understanding of what is and what is not an effective treatment, the patient with their knowledge of what they think will work for them. They often wont align and thats were the skill of a physio really comes into play. Managing expectations doesn’t always mean meeting them. All the best Adam