Actually, the heading should read ‘I’m experimenting on with patients!
Does that not help? Sorry, perhaps I should unpack what I mean!
Chronic pain, or actually, chronic disability associated with pain, is multifactorial. What that means is there are many different factors that influence how and why a person has chronic pain and disability. It also means that each person is likely to have a different set of factors that is contributing to why they are having this set of problems in this specific situation.
And the implications of this are that it’s highly unlikely that any one single treatment will ‘work’ to ‘fix’ the problem! In fact, the only time we can be certain about our treatments is when the following conditions are met:
- a reliable and valid diagnosis
- with a well-defined explanation for the cause of the pain
- and known patient selection criteria
- that predict a positive response to treatment
- with known mechanisms of response
This doesn’t happen often, especially with chronic low back pain – and as a result, we’re probably using a working hypothesis when we’re choosing a treatment. And guess what? That’s exactly what an experiment is – following a systematic process to establish whether the results support a specific hypothesis.
Oooops. Are you guilty too?
Now the ethics of this situation haven’t eluded me. It’s unethical to experiment on an unsuspecting patient. We have an obligation then, to let our patients know that we don’t have ‘the answer’! I think the best way to do this is to work with our patients to develop a set of potential explanations (that is, hypotheses) that are then used to generate treatment options. They become an essential part of working out what options to choose, and become active participants in identifying whether the hypotheses are confirmed.
What I like about this approach is
- it’s collaborative
- it allows for individuality
- it ensures we as clinicians never think we know it all
- it means we can be completely honest and have an open mind throughout the entire process
- the ‘solutions’ are always open to new hypotheses or explanations – and better treatment
I love this approach too because I am always engaged in clinical discovery and have to be completely involved with my patient as we journey together.
The process I’ve just described is called ‘case formulation’ – and is not something we encounter in a typical medical model (in which so many of us have been trained!). It’s usually part of cognitive behavioural therapy, although that doesn’t mean it’s purely the domain of psychologists! In fact, most health professionals carry out this activity as part of clinical reasoning – but it can often be an almost ‘intuitive’ part, especially when the clinician has been doing the job for a while.
I’m hoping to write a few posts on case formulation, because in chronic pain management (and probably any chronic health condition where the biopsychosocial model is used) it’s such a helpful way to circumvent some of our human cognitive limitations.
What are those limitations?
- We make decisions often on the basis of how easily information comes to hand. For example, if we’ve seen a lot of people with a similar presentation, we’re more likely to arrive at whatever the diagnosis was for them. We’re also likely to overlook less obvious features of a presentation in favour of more readily accessible features – eg the sleep problems rather than the fear of movement.
- We tend to focus on information that comes first chronologically, and to ignore information that comes later. So, if we have a favourite theory, we’re likely to ask diagnostic questions around this rather than alternative explanations – then find it difficult to notice information collected later.
- We tend to look for confirmation of our initial hunches, rather than look for disconfirmation.
- We also tend to over-estimate how closely a patient ‘fits’ our preferred belief – for example, the natural history of low back pain is to fluctuate over time, while many clinicians view each fluctuation as a ‘new injury’
- Finally, if we’re working in teams, we tend to share common knowledge, rather than knowledge that is not shared
While case formulation can’t completely solve these problems – it can help. Read more over the next few days!