Choosing a High Value Practitioner
If you had an injury, pain problem or symptoms affecting your day to day activities, which healthcare professional would you seek treatment from? What about a problem affecting your occupational, sporting or recreational activities? Would you seek out a mainstream, regulated healthcare professional such as Doctor, Physiotherapist, Chiropractor, Osteopath or Eastern Medicine Practitioner? Perhaps you might choose to engage the services of a fitness or wellness provider such as an Exercise Physiologist, Massage Therapist, Pilates Instructor, Personal Trainer, Yoga Teacher or Group Fitness Instructor? Or perhaps you'd prefer a less mainstream, more esoteric provider such as a Naturopath, Herbalist, Craniosacral Therapist, Rolfer, Reflexologist, Reiki Therapist, or Homeopath- to name but a few.
"Choosing a practitioner who will provide you high value for your time, money and health related goals is no small task."
Deciding which of the many available services is right for you is difficult because different professions tend to have their own philosophies and sets of guiding theories on how best to provide care to patients. Some professions are heavily grounded in science. Some far less so. Some have a strong supportive research evidence base. Some far less so. Some are regulated by a responsible governing body. Some far less so. Some are very cleverly marketed and appealing to consumers. Some are widely popular and have numerous supportive testimonials. Adding confusion to your search process is the fact that in addition to a lack of consensus between professions, there also exists disagreement over what constitutes optimal care within professions. The approach of one Physiotherapist for example, may differ significantly from the approach of another Physiotherapist. Complicating the issue even further is the fact that even where there is agreement on how best to manage your condition, the variety of personalities and bedside manners among practitioners arguably influences the suitability of any given practitioner for you. Knowing which practitioner will provide the best value for your time, money and health related goals is no small task.
Why do so many options exist?
The demand for a wide range of services is self-evident. The various professions simply wouldn’t exist if significant proportions of our communities didn’t find value in them. It strikes us as odd though that a demand for such a broad range of services exists, particularly given that the professions in question tend to provide treatment for a relatively narrow spectrum of conditions and symptoms. Isn’t it strange that the therapeutic needs of a relatively narrow range of conditions are served by a disparate array of services? Does it really make sense that the “cure” for a relatively narrow spectrum of injuries or pain problems can take on so many forms? Surely, they can’t all be uniquely “right”, right?
"...personal preferences of patients are central to the development and sustenance of a broad ranging demand for a disparate array of services, what can we conclude about the objective value of any single service itself?"
What might better explain the demand for such a disparate array of services? It makes sense that different people, with different priorities, motivations and past experiences are attracted to, and find value in differing models of care and treatment methodologies. Perhaps you find the narrative, or if you like, the “sales pitch” offered by a Physio to be more convincing, genuine, scientific or believable etc, than that offered by, for example, an Osteopath or a Bowen Therapist? Or perhaps you prefer the “bedside manner” of your local Chiropractor more than your local Osteopath? We don’t think anyone should deny you your right to decide for yourself which service suits your needs best. But if it’s true that variations in personal preferences of patients across and within our communities are central to the development and sustenance of a broad ranging demand for a disparate array of services, what can we conclude about the objective value of any single service itself?
"... perhaps the demand for a disparate array of services arises from practitioners' ability to “read” patient's needs and engender a sense of "perceived value".
Is the demand for a given profession dependent upon a patient’s preference for it? Does a healthcare provider simply need to have a decent bedside manner and an impressive enough “sales pitch” to get you to buy into a proposed treatment plan? If so, perhaps the value you place on a service has more to do with the extent to which a practitioner has been able to “read” your (perhaps only subtly expressed) view of your therapeutic needs than it does about any objective value of any proposed treatment? Perhaps the demand for a disparate array of services is linked to the ability of practitioners across many professions to tailor their sales pitches and bedside manners to suit the expressed needs of patients, thereby engendering a sense of "perceived value".
True Value versus Perceived Value
The perceived value of a treatment for any injury or pain problem refers to a patient’s subjective appraisal of the quality of a proposed (or already received) service. Separate to, but not necessarily mutually exclusive from “perceived value”, is the concept of “true value”. The “true value” of a service for an injury or pain problem refers to a more objective appraisal of the quality of a treatment service. The idea that there exists a difference between the perceived value and the true value of a service might seem objectionable to you. You might argue that a truly high value service is whatever you decide it to be, and that therefore there is no difference between perceived and true value. After all, you get to decide if a service was worth your time and money, right? And you get to decide if you think a service will be (or has been) valuable to you, right? And in any event, who can offer a purely objective appraisal of service anyway? Who gets to decide what a “truly valuable” service looks like?
"Is there a difference between the "perceived value" and the "true value" of a service?"
These points are worthy of consideration. We acknowledge that no one can offer a purely objective appraisal of the quality of a service for an injury or pain problem. Despite that, we contend that there can (and commonly does) exist a discrepancy between the true value of a service and your perceived value of it. And we contend that this discrepancy arises in scenarios where the dynamic between the practitioner and patient is such that the practitioner is positioned as the knowledge holder and the patient the knowledge seeker. While it’s possible that you might engage the services of a healthcare provider with no interest in learning about the cause of your problem, or how best to either fix it or manage it (e.g "just shut up and massage my back"), we doubt that you would disagree that far more often than not, the most important reason for engaging the services of a healthcare provider is to gain knowledge about your condition. Knowledge of the cause of your problem, knowledge of what needs to be done to fix the problem and knowledge of how to prevent a recurrence or better manage your condition in the future.
"...you are most likely to enter a course of treatment with a healthcare provider seeking knowledge about your injury or pain problem means that you are unavoidably vulnerable to the quality of information provided to you."
Given that you are most likely to enter a course of treatment with a healthcare provider seeking knowledge about your injury or pain problem means that you are unavoidably vulnerable to the quality of information provided to you. And it is from this vulnerability that a discrepancy between your perceived value and the true value of a service may arise. It might surprise you to learn that it is easy for a practitioner, even if only unwittingly, to provide you with misleading, redundant or superfluous information that can ultimately be unhelpful (or even harmful). The ease with which shaky theoretical underpinnings can be used to explain how your body “works” or how your problem emerged is disconcerting. So too is the ease with which doubtful theoretical underpinnings of a treatment methodology can shape your understanding of why a treatment does (or doesn’t) “work”, and what you need to do (or not do) in order to stay well. Perhaps most disconcerting of all however, is how difficult it is for you, the patient to vet the information provided to you.
"How would you know if your practitioner had provided you with misinformation?"
If you were subject to such misinformation, where would you be left? Would you even know you had been misinformed? What if you had a good rapport with your provider, and he or she had framed your problem and your treatment plan in terms that made sense to you? And what if you had found that the course of treatment was working? You would no doubt value the service highly, no? Why wouldn’t you? But would it truly be a high value service? What might the consequences of such misinformation be? Perhaps the consequences would be minimal or even negligible. On the other hand, the consequences might be significantly negative and long lasting. The problem is not just the potential for negative consequences, but the fact that you have limited means for identifying such misinformation. The problem for you and other patients is that you don't have any reliable means to identify discrepancies between the true value of a service and your perceived value of it.
Developing Criteria for Identifying a High Value Healthcare Service
The challenge for you, the patient, is to find a way to identify the true value of a service. How might you go about doing that? One option is to assess the factual merits of the information provided to you, but in practice this would prove very difficult. Keep in mind that there is an absence of consensus among industry leaders and experts, both across and within professions, on what constitutes optimal care for patients. Fact checking a proposed assessment and treatment methodology will likely send you down a google search rabbit-hole from which there is little hope of gaining better clarity.
Another option is to use the outcome of a course of treatment to make a judgment about the quality of information that a practitioner has passed onto you. On face value it might make sense to assume that a high value service is the service that resolves one's symptoms, or if you like, the service that "works". And that conversely, a low value service is the service that "doesn't work". It is obviously important that a treatment leads to a reduction, if not a full resolution of symptoms, but in our view it doesn't make sense to value a service against this singular criterion.
"Are the benefits of a truly high value service plain to see?"
It's our view that at best, it is short sighted to conclude that a service is high value because it "works". And at worst, such a view could be harmful to you. Assessing the value of a service against the singular criteria, “does it work?” won’t protect you from exposure to misinformation. Put simply, a truly high value service will usually, but will not always "work" in the sense that it brings about a resolution of symptoms. Likewise, a service that "works" will not necessarily represent a high value investment in your personal health. The extent to which an intervention "works" is obviously important, but assessing the true value of a service for an injury or pain problem requires us to consider additional criteria, in part because the benefits of a truly high value can be intangible, if not hidden from view.
"...assessing the true value of a service for an injury or pain problem requires us to consider criteria beyond the question "does the intervention work?""
If we don't recommend that you attempt to check the factual merits of the information provided to you, and we don't recommend that you place too much emphasis on the influence a treatment has on your symptoms, what criteria should you rely upon to identify a truly high value service? It might seem that you are left with only one option, that being to simply trust that you are receiving the most appropriate treatment for your condition. Does that sound satisfactory? Doing so would limit you to a frustrating and potentially expensive trial and error vetting of different practitioners. Is this the best option you have?
"There are some key features of a service for an injury or pain problem that can act as a reasonable proxy measure of a service's value."
In short, no. Things are not so grim. Although there will always be a degree of experimentation in your effort to seek out a high value practitioner, we argue that there is a way to make the whole process easier. We argue that there are some key features of a service for an injury or pain problem that can act as a reasonable proxy measure of a service's value. And the good news is that these features are relatively easy for you to identify. Our hope is that by reading what follows you will be better positioned to judge the value of your next (or previous) trip to a healthcare professional for an injury or pain problem.
So where to start? Perhaps we could start by outlining the key features of a low value consultation. If your provider is not up to scratch, you’ll likely observe;
A failure to educate you about your condition’s “Natural History”
A failure to outline a timeline over which treatment will expedite your recovery above and beyond your condition's natural history
Poor interpersonal communication skills
Interventions that are not individualised to either your expressed needs or objective goals
Failure to prioritise the preservation of your self-efficacy throughout and beyond the clinical encounter.
In subsequent posts, we will walk you through each of these points to explain why their presence lowers the value of a course of treatment. We will also provide you with practical strategies for identifying these features so that you can make a better informed decision the next time you are searching for a practitioner to provide you with care for an injury or pain problem.