This post is a side bar discussion from our five part guide to identifying high (or low) value care for an injury or pain problem. A service that provides you with knowledge of your condition’s natural history, and knowledge of the extent to which treatment is expected to expedite your condition’s natural course of recovery will be of greater value to you than a service that fails to do so. But such knowledge cannot provide surety about the value of a treatment received because such knowledge cannot protect you from the consequences of assumptions made (and conveyed to you) by a provider about a treatment’s mechanism of action. It is easy to assume that a given treatment “works” for a specific reason. Even a treatment that is supported by research evidence can fall foul of such an assumption. A given assessment and treatment methodology might expedite the recovery of a condition ahead of its natural history in exactly the time-frame predicted by a provider, but if the basic premise underpinning the approach is built upon erroneous assumptions about how it works, the value of the approach will remain questionable.

If for example, a massage treatment led to the resolution of one’s symptoms, one might by default assume that the physical elements of the massage were central to the subsequent resolution of symptoms. While it might seem that a massage intervention resolved one’s symptoms because a provider really “found the sore spot and freed it up”, it is worth considering whether the same massage treatment would have been as effective if it was performed by a provider who behaved or explained things differently. If you were the patient in this scenario, would it make a difference if the provider was someone you didn’t know, didn’t like, didn’t feel comfortable with or didn’t trust? To what extent would these factors influence your body’s response to treatment? Interestingly, we have research evidence that tells us that in addition to the physical elements of a treatment, there also exists a broad range of contextual variables that are at play during a treatment encounter. This knowledge has broadened, shaped and in some ways clouded our understanding of how any given treatment “works”. The effectiveness of a treatment appears to lie not only in the quality of what a therapist “does” but also in what a therapist says, how it is said and the overall quality of the relationship between a patient and a healthcare provider.

“…are the high value elements of a specific / unique assessment and treatment approach that “works” truly tied to those same elements that define it as a specific / unique approach.”

It makes sense then, that we should question whether the high value elements of a specific assessment and treatment approach that “works” are truly tied to those same elements that define it as a specific or unique approach. If for example, a special muscle stretching technique led to the resolution of symptoms, could we confidently attribute the favourable outcome to the specific stretching effect of the special exercise? Or was it other elements of an interaction with a provider that drove the favourable response? What if a treatment “worked” for a different reason than you had otherwise assumed or had been led to believe? Might this have an unhelpful impact on your understanding of your problem or what you need to do to make a full recovery and stay well?

In short, the answer is- yes, it might. You would be at risk of exiting a clinical encounter with an understanding of the links between your problem, the treatment received and your best options for ongoing health management that was similarly limited. The consequences mightn’t be severe. For some the impact of such misinformation might be limited to an unnecessary but ultimately inconsequential expenditure of time or money. For others though, the unnecessary wasting of time or money could have serious negative effects on social relationships, family relationships or employment prospects. Perhaps worst of all though, for some, the consequences of such misinformation could amount to serious iatrogenic harm.

How might healthcare providers develop a tendency toward misinforming, and thereby providing low value services to patients? Aren’t healthcare providers highly trained, highly educated individuals with all the latest and greatest information at their fingertips? It does seem odd that misinformation might be rife across a range of professions, particularly since many trade on a reputation of being science-based. There are a range of possible explanations. Perhaps a provider is inexperienced or poorly educated? Perhaps a provider has not updated his or her clinical reasoning framework in the light of new research evidence? Or perhaps there exists some doubt over a provider’s motivations or professional integrity? It’s beyond the scope of this piece of work to speculate about the integrity of healthcare providers, except to say that it is our view that the vast majority of providers are well intentioned and practice with their patient’s best interest at heart. Unfortunately, good intentions alone cannot steer a practitioner around the trappings that can lead one to provide low value care.

Assumptions, Cognitive Biases & Evidence Based Treatment 

In our view, there is a twofold explanation for why healthcare providers might provide low value care. Firstly, healthcare providers are people, and people are prone to making assumptions and developing cognitive biases. There is no doubt that the theories and thinking upon which clinical reasoning frameworks are built contain assumptions. And it follows that such assumptions limit the validity of the assessment and treatment regimes they inform. The problem for a healthcare provider, and by extension, you the patient, is that it is easy for a provider to hold up his or her clinical outcomes as a validation of the assumptions that underlie a treatment approach’s guiding theory. Or stated in reverse, it is difficult for providers to resist the temptation to assume that the theory that underlies a treatment approach is validated when said treatment is observed to “work”. When a provider jumps to such a conclusion, he or she has fallen victim to a type of cognitive bias known as confirmation bias. In such scenarios, it is easy for a provider to develop an unwarranted and self-perpetuating sense of certainty with respect to the validity of his or her clinical decision making.

Secondly, healthcare providers are by and large taught that the best treatments are evidence-based treatments. Although it makes sense to argue that an assessment and treatment approach that is derived from scientific research is likely more valuable than other approaches, we need to maintain an awareness of the fact that research evidence is derived from experiments and data analyses that are themselves subject to assumptions and cognitive biases. To the extent that it is born from research evidence that is limited by assumptions and biases, the veracity of an assessment or treatment method will be similarly limited. Unfortunately, where the treatment of injuries and pain problems is concerned, the pool of research evidence that informs healthcare providers is of variable quality and has not facilitated the development of very specific or prescriptive assessment and treatment methods.

Rather, the pool of evidence that guides the practice of an evidence-based provider is born from heterogenous research groups. Across differing research groups there exists a variety of research objectives and focuses. Such variance in research focus is likely influenced by many factors, including the biases of the institutions providing funds for research, and the researchers themselves. This heterogeneity in research focus has produced a pool of evidence from which similarly heterogenous (and occasionally even contradictory) “evidence based” assessment and treatment approaches have emerged. It is easy for a practitioner to look past this heterogeneity and seek out evidence to support their decision to utilise a preferred assessment and treatment methodology.

What does this mean for you, the patient? It means that where a particular assessment and treatment approach is supported by research evidence, it is easy for a provider to not worry about, or perhaps even object to the notion that the value of his or her approach might be limited by questionable assumptions. This should not be interpreted as a wholesale denigration of evidence-based treatments. Nor should it be interpreted as an attempt to draw an equivalence between evidence-based methodologies and non-evidence-based methodologies. Rather, it means that the existence of a supportive evidence base for your provider’s preferred methodology may reinforce your provider’s confirmation biases and facilitate a potentially misguided sense of certainty in the validity of his or her care of your injury or pain problem. It means that as a patient, you cannot necessarily assume that a provider who holds himself or herself up as an “evidenced based provider” is necessarily a provider of high value care.

Given that it is easy for assumptions and cognitive biases to get the better of a provider, and that cognitive biases are by nature unconscious, providers are highly unlikely to be aware of their influence on their clinical decision making. Even a dedicated, well-meaning healthcare provider might end up providing you with treatment of questionable value. This complicates things for you, the patient. If a healthcare provider is not even aware that he or she might be carrying out treatment of questionable value, what chance would you have of identifying it? What criteria could you utilise to assess the value of a treatment consultation? We have already touched on the importance of a practitioner educating you about your condition’s natural history, and the importance of a practitioner providing you with an outline of how treatment is expected to expedite the course of your condition’s natural history. And we have already touched upon the difficulty surrounding any attempt to fact check the information provided to you. What other indicators might you rely upon?

To find out click here.