Great Expectations

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