How do patient preferences dictate rehab?
How should patient preferences for care dictate what we do for treatment?
Best available research, Clinician Expertise, Patient Values
These are the three fundamental components of evidence based practice.
This last one – patient value – has created a lot of arguments in the field.
There are many people who think that patient preference should be considered highly and that if a patient requests a certain type of care, such as manual therapy or dry needling, we should provide it.
As well, there are many people who use this argument as a fall back on why he/she chooses to practice the way they do.
This is usually in arguments of providing low value care – things that do not make much difference in the long term and have moderate effects in the short term – particularly in comparison to their cost.
Most of the time patients hear about low value care interventions as being sexy and having amazing results, and then request them as their rehab. I’ve had my share of patients come in requesting laser, ultrasound, diathermy, e-stim, or manual interventions where the evidence did not support it.
In these cases many clinicians will state that they provide the intervention as a means of building therapeutic alliance, or due to evidence based practice having that three legged approach (future blog).
I would argue that this is both unnecessary and inappropriate.
The aspect of evidence based practice where patient values or patient preferences comes in, shouldn’t be taken as just do what a patient asks.
Patient preference is not what does the uninformed and uneducated patient want, but what does the informed and educated patient think would be helpful in their rehab process.
Our patients are relatively uninformed and uneducated on these topics. It is our job to provide them with information and education on these topics, being the subject experts. Once the patients are more informed and educated, knowing why something would be considered appropriate or inappropriate for their care, why something would be considered low value or high value, etc. then taking in their preference for what to do.
This can be a tricky thing to navigate, but if a clinician is armed with good knowledge and confidence, it can usually be handled well.
As much as possible in the rehab I try to have the patient involved in the decision making process. I want them to have as much autonomy, self efficacy, and internal locus of control as can be structured. However, it is not my patient’s job to read research and provide up to date information and care to them.
In my experience (for what that’s worth), patients are very receptive and can buy into the process more when given relevant information. When I share information about base rates, natural history, contextual effects, internal and external locus of control, lifestyle factors, etc. they begin asking about what interventions show benefit in the long term. As I explain my rationale as to why I think X,Y, Or Z is best, they further agree with me.
At that point, I’ll chat with them about what they think is going to be the most impactful things WE can do for them. It almost always comes back to high value care and starting there.
A few tips on how you can try and implement this:
1. Provide them with the most relevant information first that will have the greatest impact on de-threatening the situation.
a. This is usually about base rates, anatomical abnormalities, pain not equaling damage, etc.
2. Introduce a Biopsychosocial approach.
a. Be realistic, we can’t convert everyone from a traditional biomedical model system to a BPS framework in one chat. However, you can introduce some ideas so that when they are gone they start to acknowledge things and you can discuss it in the next treatment – sleep, stress, nutrition, volume of walking, etc.
Hopefully this helps a few people in gaining some traction with patients and transitioning over to more evidence based high value care!