Great result? We shouldn’t take credit for it.

Alternative title: The ‘I Know What Works’ Gambit

At some time or other us therapists see what we consider to be brilliant results.  Someone books in they’ve had a painful thing for years, seen the GP, the physiotherapist, tried acupuncture and now here they are.  We do our thing and one or two session later the pain has gone, amazing.  At this point we therapists face a terribly powerful temptation – the belief that we fixed them.  This is the path to the dark side.

For the most part, we cannot make clinically meaningful physical changes to your muscles, bones or connective tissue and that’s a good thing, it means you’re made of super-strong stuff.  So what’s going on when see a brilliant result?  Well, the only possible honest answer is, we don’t know and can’t know.  We can only make some sensible guesses and ground ourselves by accepting it may have little to do with us.

“Taking credit leads to causation errors, causation errors leads to healer ego, which leads to the dark side” — Yoda

Why?

First up, natural history.  This the term we use to refer to the normal course of any disease or injury with either standard care or no intervention whatsoever.  The good news is that for a great many acute musculoskeletal pains, the natural history – it’ll likely get better in time.  It may be that you want to get it checked out to allay any concerns, we can help with that.  Next up, regression to the mean (yikes!).  This a fancy term in statistics first documented by Francis Galton in 1886 that roughly means if you observe an extreme measurement, the next one will likely be more normal.  Imagine you’re sitting at a train station watching people come off the escalator onto the platform.  The average height of a man in the UK is about 5’9” and you watch people of all heights coming through.  Then comes a man 7’2” towering above everyone.  Regression to the mean would predict that the next man off the escalator will probably be much closer to 5’9”.  Our general ignorance of this phenomenon makes us all susceptible to false conclusions.  For example, it was observed that trainee pilots who were congratulated for a perfect landing often followed this with a bad landing.  Naturally, it was concluded that praise was leading to pilots becoming complacent, but this was completely wrong.  A perfect landing by a trainee would be unusual, and therefore the next landing would probably be not as good – more average for a trainee.  In other words, something extreme will probably be followed by something more usual.  So what does this have to do with healthcare?  It affects all of it.  Wherever a patient is tested or has something measured more than once it becomes difficult to know if improvements are due to treatment or, natural history or regression to the mean.

Beyond these important factors, we still have more obstacles to think about which we call non-specific effects.  If, for example, you have a massage because your back hurts and then you feel great afterwards, you might think, ‘man, that really works for back pain’.  But there’s more going on here…. If you relax in a pleasant and warm room, get treated with respect, are listened to with kindness and empathy, and you trust the therapist and their professionalism, then all of these influence a positive outcome.  Know also that a really strong predictor of positive outcomes, is the belief that an intervention is going to help. In fact, this has been shown in some studies to be such a confounding factor that not testing this in the majority of studies may represent a significant oversight.  These are some important non-specific effects that help and further improve outcomes but further muddy the waters.

Now we get to the really fun part.  When it comes to pain, everything may matter.  One of the challenges in pain research is that influencing factors are myriad and it seems to be growing.  We’re talking inflammation, neuroinflammation, endocrine system, autonomic nervous system, stress, anxiety, depression, beliefs, sleep quality, support networks and how far does this go?  Socioeconomic status is a huge factor in long-term health and pain.  It’s that much of a complicated mess.  It’s the micro up to the macro, it’s the biology, the brain and community.

Back to the perfect client

When we get that perfect client, one-hitter result, our biggest mistake is to think we had much to do with it.  Was it natural history, regression to the mean, non-specific effects?  Did they get out of a bad relationship or into a good one? Do they sleep better because the noisy neighbour moved out?  Did they leave a stressful job?  Did they just need a bit of quiet time away from their lives to be quiet and cared for?  We just don’t know.  The dark side is strong, and our egos are easily led, so be more Jedi.

Thanks for getting to here.