Thursday Thoughts: What Would You Do For Patient Buy In? | Modern Manual Therapy Blog

Thursday Thoughts: What Would You Do For Patient Buy In?

Maximizing patient expectation/placebo in our interactions to improve outcomes is very important. Many of us do that without even realizing.

Saying things like, "Oh don't worry, I have just the technique that will help you move and feel better," plus presenting as confident and compassionate really go a long way.

However, what would you do if a patient is not buying into your assessment, explanation, etc?

Even though I have long since adopted a more modern view of manual therapy mechanisms, pain science education backing my standard MDT toolbox, I still have to go old school on occasion if the patient doesn't "buy" what I am trying to explain.

Example 1: Patient has seen a bajillion specialists who are all concerned about their facet joint degeneration, disc protrusions, etc... Every other word out of there mouth is disc.

  • I try to explain about repeated movements and directional preference leading to relief
  • I try not to mention disc or explain about false positives, or that the MRI does not change, but the symptom levels often change, especially when intermittent (most patients have intermittent complaints)
  • however, they are not buying it
  • you can sense this rather rapidly that you're losing them because they're at your office for their "disc problem"
  • so when they inevitably ask, "But is this good for my disc?" 
    • not always!
    • I sigh inwardly, feel a little bad about the explanation, then say, "Yes, this will help your disc problem
  • Pt buys into the treatment plan, no harm, no foul... right?
  • I agree with Moseley's research that shows we underestimate patient's ability to understand Explain Pain strategies and neuroscience, but some just do not have the proper mindset to absorb it
  • or they refuse to "believe it's all in their head" - which I am quick to explain that is just part of it
Example 2: Patient for knee "arthritis" only wants you to treat their knee

  • you explain about regional interdepedence, research supporting looking more regional, but they still want only knee treatment
  • oblige them by doing some local treatment
  • give them repeated knee extension as an MDT based local reset
  • then with some "extra time" offer to work on some other findings that will "help their knee move and feel better"
  • if their doctor is concerned about you working on something other than their knee, no problem, (or if it's an issue with the HMO) 
    • call up the doc, say, "I know you wanted me to work on the knee, but the patient complained earlier about their hip/ankle etc being stiff as well, and they said you thought it would be a good idea if I also addressed this." 'Mind updating the script for me?"
    • inception... now it's their great idea, not yours
It's been a while since the local HMOs started honoring our direct access and covering everything without a prescription, but the second strategy is something I used to do.


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  1. Good thoughts on this Dr. E and definitely a topic worth discussing. I hate to have patients "buy in" to my treatments I am not a salesman by any means! But, we know the buy in can lead to a more compliant least in my opinion. You just need to be ethical and honest and not sell pseudoscience and interventions that lead to longer intervention time (more money, more reliance on a practitioner, etc).

    This is certainly not your approach nor mine, but I do think some may think that if manual therapy is performed or interventions that claim to fix unproven theories.

    I agree with what you said about it is difficult for patients to absorb some of the pain neuroscience. That is my feeling too...even though I try to bring it down to a more simpler explanation too. Even though a biomechanical model is starting to fade is the easiest and most absorbing to patients. A simple explanation of this is posture...everyone walks in saying they know their posture should be better (even though not a direct link for most conditions) but at least it gets them thinking in a self-treatment mindset!

    Since I've been performing dry needling, I have come across barriers of not many people walk in our door asking for this (it is fairly new here) and we have to get informed consent signed, etc. I know there is more to it than just trigger points, but selling the patient on tight muscles and taut bands is MUCH easier than mentioning energy crisis theory, endocrine/neurophysiological/chemical responses, etc.

    We have all had the patient who wants a crack or thinks exercise will help them...and you know what, providing that exact treatment yields better results..


  2. I am very flexible with my explanations, I end up adjusting the jargon levels up or down depending on comprehension and buy in. I think we're all in sales to a point. That's why charismatic confident clinicians do so well even if they're just snake oil salesman. I do lean toward neurological explanations and simplify it as much as possible. I love it when the light bulbs goes on though!

    Patient expectation is very important (unless they're expecting US and Estim - out of luck in my practice). That's why I like the recent CPT for cervical thrust, includes patient positive expectation as a factor.