“Expectations were like fine pottery. The harder you held them, the more likely they were to crack.”
― Brandon Sanderson, The Way of Kings
Meeting Patient Expectations – Should This Always be a Goal in Therapy?
Patient expectations are an interesting and important aspect of clinical care recently becoming a hot button issue in discussions of evidence based medicine and patient centered care. The patient should of course always be at the center of our care, and often clinical decision making is heavily influenced by patient expectations, but what happens when those expectations don't coincide with what the research supports?
This leads us to an interesting conundrum. Should we perform interventions that may not have solid evidence to support them (or even evidence to state we SHOULD NOT perform it) “anyways” because we know the patient could obtain a meaningful response, or do we risk upsetting the patient by informing them that their expectations are misled?
A variety of factors need to be considered when making these judgements, and before doing so it is important for us to truly understand the foundations of what led to these expectations.
Where Do Expectations Come From?
We often do a great job of asking patients what type of interventions they believe will help them, but miss the opportunity to ask them why. Did their belief come from a friend or family member? Was it something they had done previously? Maybe their primary care provider is telling them that “X” intervention will help.
Prior research supports the idea that a majority of patient expectations are incepted by a provider’s beliefs and biases. From the European Journal of Pain, four large multi-centre randomized trials were analyzed and results found that physicians’ high expectations at baseline were able to influence outcomes regardless of treatment.
Similarly, a secondary analysis performed by Bishop et Al. 2013 examined patient expectations receiving treatment for neck pain from one of five physical therapy clinics. Results suggest that these patients expected manual therapy and exercises to be the most beneficial with manual therapy having the highest proportion (87% for massage and 75% for manipulation).
However, with these studies we need to be careful to remember that a biased sample size may exist, and we are unaware of the clinical equipoise of those clinicians in the study. In these studies, patients were seen by physical therapists who were specifically trained in manual therapy and then randomized into both groups with the expectations of improvement. A nice analogy may be to consider a study performed in McDonalds asking people already inside the doors of Mickey Ds if they like hamburgers and expect to receive one at McDonalds. You may also ask the person if they like McDonalds or Burger King better, and due to the inherently biased sample size you would likely find that the McDouble would be a clear winner.
Understanding what has led your patient to these specific expectations can dictate how you go about treating them, but that doesn’t necessarily mean you have to give them what they want.
Aren’t Patient Values a “Pillar” in Evidence Based Practice?
One concept we must consider is that many expectations patients have for what care should be, actually often originate with providers. This form of “inception” occurs more than we can imagine through countless paths. We can see these expectations emerge in a person’s perception through influence from providers from the past who have themselves influenced the current state of clinical practice. Providers the patient has seen before. Providers the patient’s friends and family have seen before. Providers on TV and in pop culture. What the patient has read on the interwebs. Etc, etc, etc. You may be asking yourself now, “Well, so what if the majority of expectations people have, have come from other providers’ biases. Why does that really matter, who cares? Patient values are a pillar of evidence based practice. Right?”
Unfortunately this claim arises all too often when certain clinicians are arguing why they still perform unsupported interventions and we’ll discuss why that reasoning is flawed.
Evidence based practice has been previously defined as a three legged stool supported by our best literature, clinical experience, and patient values. If one of those legs were removed, the whole stool would collapse.
This analogy was challenged by Erik Meira back in 2017 where he suggested the pillars of evidence behave most similarly to a funnel. His theory described how we should begin with the best available evidence that funnels into our clinical experience and then finally will funnel into participating in shared decision making ensuring our patient values are obtained. For more information on the funnel analogy, check it out HERE.
The reality is that we can often find “support” for any intervention when taking a look through the current body of evidence. However, our goal should never be to find evidence that supports or confirms our beliefs, but rather understand the relationship each bit of information, research related and expectations, play in current clinical practice, the extent to which that aspect of care is clinically meaningful, biological plausibility of our theories and approaches, and how isolated studies fit in with wider breadths of evidence.
Using manual therapy as an example, many claim less than realistic mechanisms for the effects of manual therapy and often the claim is made that patients expect to have some sort of hands on treatment. Combining these together, one can make a “strong” case for consistently using manual therapy under false assumptions and explanations, which of course contributes to the propagation of a specific type of patient expectation.
Although, when investigating further into the mechanisms of manual therapy, we see many of the common narratives are often misleading, and when we dive into patient expectations in relation to manual therapy interventions (HERE) (HERE) and (HERE) , we also find that prior messages before receiving the treatment can influence the response of the patient.
This, then, begs the question of whether we are truly benefiting the patient with the intervention or just obtaining a meaningful response. If it is about obtaining a meaningful response, then there is likely a chance that the same patient could obtain a similar meaningful response with other interventions.
There Must be a Balance?
With this information, there is always a balance with incorporating what our patients firmly believe and what types of interventions we should perform. It is up to us to best understand why our patients have specific beliefs, and do our best to pivot those beliefs towards a better understanding.
This is where a majority of clinicians take on the “yes and…” approach. “Yes, we will manipulate your spine, but also I want to show you why you may not need this in the future and build your strength up in the meantime.”
The end goal should inherently be to avoid perpetuating dependence and building a patient’s self-efficacy towards independent management. Many patients will obviously come in with fallacious misconceptions in what they think they need, and in order to gain their trust you may need to provide that specific treatment. But once you gain their trust, if you don’t take the opportunity to update their beliefs and reframe their narrative you are simply reinforcing the problem.
Where Do We Go Next?
So where do we go from here? Well we can either take the route of 1894 Society of Trained Masseuses that led down a path of always giving patients what they wanted and ended up with scandals of being associated with prositution, or we can do our best to educate our patients on what our best understandings are of treatments we believe will help.
In order to accomplish this, it is important we view each patient as a n=1 and stop trying to provide blanket treatments. Eliciting and understanding the specific beliefs they hold can help us in shifting those beliefs towards a more reasonable explanation.
We also need to make sure we stay up to date with the evidence and apply it appropriately towards our clinical practice. Viewing evidence based practice as a funnel with research being the foundation helps up ensure our clinical experience is obtaining supported techniques which fundamentally trickles down in helping our patients achieve their goals.
And finally, maybe even most importantly, we need to nudge our patients towards an active approach where they stop relying on people to “fix” their pain and start having the confidence to manage their experience independently.
Keep in mind, there have been times where certain physicians believed washing hands wasn’t necessary for surgery, and that using beaver testicles had a purpose in medicine. It wasn’t until further evidence came along to refute these widely held beliefs before individuals stopped believing in them.
Before you know it, it won’t be long before a variety of our wide held beliefs are likely proven false and other treatment interventions will be implemented that patients will be expecting. Until then, know that you have done your best to properly educate your patients on your most informed understanding and provide them the tools necessary to instill confidence in owning their condition.