"‘If a cold is treated energetically it will get well in seven days, while if left to itself it will get well in a week’. Put more cynically, ‘Nature cures, but the doctor takes the fee.’"- Testing Treatments
The same is true for many conditions. Even acute low back pain often resolves on its own without any intervention. Furthermore, many treatments provided lack research support but are used regardless. Why is that?
This narrative review addresses many of the biases and cognitive fallacies that cause us to overvalue ineffective treatments. It discusses why we believe ineffective treatments are helpful and why we continue to use them.
There are three common and related components causing deductive malfunction.
- The natural history of the disease, regression to the mean, and the placebo effect cause real signs and symptoms to improve--regardless of the type of treatment (or presence of any treatment)
- Patients and clinicians often convince themselves that treatment was effective--when it was not. Often due to
confirmation bias and other biases (I'll throw in outcome bias and sunk-cost fallacy)
- Personal evaluation of efficacy is quick and convincing but properly controlled, scientific determinations can be slow, complex, and costly. (system 1 vs. system 2 thinking; fast and frugal model can help in triage situations and initial assumptions but reflection should occur later)
The author addresses Post Hoc, Ergo Propter Hoc fallacy - "after this, therefore because of this" - which assumes a cause and effect relationship.
Any medical provider must start with high-quality randomized controlled trials to determine if something has an effect. They can use systematic reviews and meta-analyses to gain a broad view of current research findings on a specific topic - such as the effectiveness of exercise for low back pain.
From there, providers use their experiences and the patient's values to fine-tune treatment (timing, dosage, context, etc.) No matter how many times a treatment has "worked", without controls conclusions cannot be drawn.
The author of the study also touches on the influence of desires and expectations which can influence the perception of the outcomes.
Expectations can largely be grouped into one of four categories:
What the individual believes will occur.
Many studies have highlighted a link between expectation and clinical outcomes for individuals experiencing musculoskeletal pain. Predicted expectations, both positive and negative, have a direct relationship with musculoskeletal pain. These expectations will be heavily influenced by the information the patient receives — such as from their referring physician or social media — prior to starting physical therapy.
This applies to any situation. If you believe an interaction will be negative, such as a crucial conversation, then your awareness will have a negative frame. You will focus more on negative information and filter out the positive.
An individual’s desire and hope.
Ideal expectations are what an individual wants to occur, while predicted are what an individual thinks will occur. Many patients will not share these as they believe they are not attainable and will lead to disappointment. The clinician must ask if they wish to learn and strive to achieve the ideal expectations. If they are attainable, and the clinician helps the patient achieve them, they will have an advocate for life.
Do you share or dare to strive for ideal expectations?
What an individual believes should occur.
While little is known of the impact normative expectations have on clinical outcomes, it does appear to play a role in patient satisfaction (or dissatisfaction if you fail to meet it). These are heavily influenced by the value proposition. If the commute time is long, the cost of care is high, or the clinician comes highly recommended, the patient will likely expect rapid, superior outcomes.
If you pay more, you expect a higher quality product or service.
The expectations an individual is unaware of or is unwilling or unable to express.
This could be to a lack of previous experience or education necessary to form an expectation, or it could be the result of an activity being habitual and the patient hasn’t taken the time to develop an expectation.
Sometimes we need to reflect and spend time determining what our expectations are.
Expectations Influence Treatment Decisions
It is important to remember that expectations often change over time. What providers and patients expect to occur in the clinic or hospital influences what treatments are received. Even if the treatment is not supported in research - such as surgery for chronic pain - our bias and expectations often cause us to seek that treatment.
There are many conditions and ailments that benefit from a healthcare provider's help, but treatment decisions should be made as a team, based on current evidence, clinician expertise, and patient values.
If all of these qualifications are not met, ineffective treatments may be used.
"The clinician’s expertise lies in diagnosing and identifying treatment options according to clinical priorities; the patient’s role is to identify and communicate their informed values and personal priorities, as shaped by their social circumstances." - Testing Treatments