March 31, 2020

CP Online Health

Eat Well, Life Well

Intuition is one of two main modes of thinking, according to Daniel Kahneman. Intuition is fast, considers the whole rather than components of the whole, and intuition feels effortless. Intuition can also be wrong – but often isn’t (Gruppen, Woolliscroft & Wolf, 1988).

We use intuition well when we’ve been exposed to many examples of the phenomenon under consideration – for example, if we’ve seen a lot of patients with similar health problems. We don’t use intuition well when we buy into biases or stereotypes.

The alternative to intuition is slower thinking, that typically breaks the considerations into smaller pieces, often following a linear process where data (information) is collected and assembled. This kind of thinking is reasonably easy to investigate, whereas intuition is much more difficult to study (it’s fast, people can’t describe how they arrived at a conclusion, so it’s not amenable to self-report).

Why worry about it? Well, intuition is the key strategy described by allied health, particularly physiotherapists, when considering whether a person needs further assessment for those pesky psychosocial factors (Man, Kumar, Jones & Edwards, 2019). What this means in practical terms is that a patient who doesn’t fit the stereotypical “risky yellow flags patient” may have to fail at conventional treatment before being directed towards a multidisciplinary, or biopsychosocial, approach.

What might be an alternative?

I’m pretty fortunate in that I work in a service where participants to my group programme have already completed a series of questionnaires as a requirement to participate in pain rehabilitation and management. So everyone I see will have some information I can draw on without my needing to add anything more. Of course, I can argue that some of the questionnaires don’t help me very much because they’re fairly biased towards a CBT model of chronic pain management. But the principle is pretty clear: everyone gets to complete the questionnaires ahead of time.

Practically, this isn’t always easy. Many people don’t have good literacy skills, don’t have a computer, hate the thought of paperwork (even in electronic form), and some of the questions don’t work very well/aren’t relevant to the people I see, so they choose not to fill them in. There’s no opportunity to discuss the responses with a clinician, so it’s not easy to decide whether the questions apply.

But what happens when we leave the questionnaires to luck, intuition or “the psychologist”?

Firstly, we know the relevance of psychosocial risk factors. We know this so well – it’s been a theme throughout the years I’ve worked as a clinician in pain rehabilitation and management. If we don’t include these in our formulation (treatment planning), we’re probably not including them as key predictors for outcomes…

We can’t rely on our intuition because for many of us, those people who do have risk factors will only overtly show these once they’ve failed to progress – it’s at that time they’re more distressed, frustrated and afraid, so behavioural markers for psychosocial risk factors are more evident. This also means someone will have to work with the person who is now more distressed than they needed to be.

We don’t use our team to best advantage. Why refer someone to an occupational therapist, to a psychologist, to a counsellor if we don’t know why the person needs to see them? This can lead to a distinct lack of briefing or information about the referral to the person with pain – and sometimes, it seems, to the person deciding they don’t need, or want, that referral even when it would be in their best interests.

Mostly, though, I think it begins to bias our thinking. We can become judgemental – why doesn’t this person do their home-based exercise programme? Why are they just going through the motions? Why do they keep on complaining about their pain? We can begin to question the person’s motivation, their lifestyle, the validity of their perspective.

The real problem?

Our clinical reasoning models don’t help us very much when it comes to synthesising psychosocial factors. When we’re dealing with those factors using “intuition” we don’t have to incorporate them into our models – because intuition isn’t explicit, it’s quick and difficult to articulate. To date there are very few transprofessional models of pain management, and even fewer that attempt to link theoretical constructs with what we see in front of us. That synthesis of biological, social and psychological constructs that uniquely explains why this person is presenting in this way at this time, and what factors may be maintaining this person’s predicament. It’s no wonder that, in a recent study my colleagues and I have been conducting, we’ve found very few clinicians collaborating on a case formulation.

My suspicion is that until we develop a collaborative case formulation clinical reasoning approach that can integrate these many factors in a sensible and logical way, our “intuition” is likely to leave us floundering. The casualties of this particular mess are the people we hope to treat. I wonder if it’s time to work together, physiotherapists, occupational therapists, psychologists and medical practitioners (and all other variants of health practitioner!). Do we need to create a synthesis that works as a transprofessional model of pain?

Gruppen LD, Woolliscroft JO, Wolf FM. The contribution of different components of the clinical encounter in generating and eliminating diagnostic hypotheses. In research in medical education: proceedings of the annual conference. Med Educ. 1988;27:242‐247.

Man, Isabella, Kumar, Saravana, Jones, Mark, & Edwards, Ian. (2019). An exploration of psychosocial practice within private practice musculoskeletal physiotherapy: A cross-sectional survey. Musculoskeletal Science and Practice, 43, 58-63. doi: https://doi.org/10.1016/j.msksp.2019.06.004

Widerström, Birgitta, Rasmussen-Barr, Eva, & Boström, Carina. (2019). Aspects influencing clinical reasoning and decision-making when matching treatment to patients with low back pain in primary healthcare. Musculoskeletal Science and Practice, 41, 6-14. doi: https://doi.org/10.1016/j.msksp.2019.02.003