You may be thinking, what the hell does Quantum Mechanics have to do with a health blog? Well, I’ll tell you! And if you stick with me, there is some gold at the end of the rainbow. We can actually learn a lot from understanding the make-up of our universe and it can apply to some key principles in clinical practice. I’m going to do a series on Quantum Mechanics, so there’s plenty more where this comes from, and essentially if you don’t like thinking about physics, then you best tune out for a few weeks.. Please don’t.. I’m also most likely going to butcher the science here, so for any quantum physicists reading…..tumbleweed….cough.. OK, so for any of you who know a little bit about this, hopefully this doesn’t hurt the progression of the field too much.
When you think about it and apply some basic principles, the natural world becomes a fascinating, terrifying place of uncertainty and our living experience is a very limited and restrictive phenomenon.
– The world is complex – The world is unpredictable – Quantum mechanics means events are fundamentally immeasurable. – Quantum mechanics means that when two systems interact, observation is only relative to the person observing it. So reality is, truly, relative.
The uncertainty principle and complexity
If you didn’t already know, pain is one of the most pressing global burdens; come on guys I write this in pretty much every blog post.. Keep up. One of things we see in clinical practice, that in my opinion is a major factor in propagating the trends we see in this global pain burden, is the creation of a dependent patient and financialising of those that suffer from very thing we want to treat, cure and manage. Once natural history, treatment seeking, placebo and other contextual nonspecific effects take hold of any clinical interaction, what is fairly clear is that the actual treatment effect may remain fairly small. Clinicians who are not able (or sometimes – worse still – not willing) to (either cognitively – or again – in conversation with the patient) separate themselves from this myriad of effects are piggy-backing their apparent ‘intervention’ onto these factors, essentially rendering all responsibility of the patient in all of this null and void. But I am aware it is called business, and repeat business is good in allied health clinical practice. Business is booming.. Which can be a good thing, but also leads to some more ‘unsavoury’ elements of competitive practices. One of which is promising a ‘quick fix’ to pain – whether this is manual therapy, exercise therapy, or any other therapy you can think of. The quick fix externalises any form of personal accomplishment from the scenario and places it squarely on the clinician’s shoulders. and I want to argue that from a theoretical standpoint, the very structure of our natural world is at odds with these kinds of claims. The very fabric of our reality does not support the ‘quick fix’ claims.
The principle that is at the core of Quantum Mechanics states that we can generally only give approximates about the probabilities of ‘reality’. Watch this video and then report back.. Right, what have you learnt? If you are like me, then about 2m30s in you went cross-eyed and are fully able to appreciate my point underlying this. The human brain is inherently very poor at working in the space of uncertainty and really, really bad at understanding probabilities. From probably the number one book I can recommend, Thinking Fast and Slow by Daniel Kahneman, it is pretty clear we are hard wired to actually ignore probabilities and uncertainty. We have very well established – but very efficient – thinking apparatus, which comes to generally pretty accurate intuitive conclusions, but these conclusions completely miss the nuances and complexities of the natural world and one of these is definitely how uncertain everything actually is.
Human beings want absolutes, we want certainty and control, because it is far more palatable than the alternative. We are horribly ill-equipped to deal with all of the uncertainty, and this is especially true about our physical health. There is nothing more absolute than promising to ‘fix’ a complex problem like pain. And so patients are no different, they absolutely eat that s&*! up! Who doesn’t want a good quick fix! Aside from the obvious fact that it is easier than a ‘long, significantly more effortful fix’, it is concrete and is absolute. It has been shown that, in patients with low back pain, they really do have some concrete expectations on a few matters (Ref):
Clear instructions on what to do next
What the next steps are in the diagnostic process (for example imaging)
It is obviously important that we give consideration to providing these absolutes when warranted by an individual and as health professionals, we do have license to provide these absolutes. But we really don’t have the license to provide anything much more than this.
As health professionals, we are also taught critical thinking and the scientific method. We really don’t know anything is 100% true, even things that have been proven by a bulk of evidence, are fundamentally open to scrutiny and can be disproven at any stage by someone who is willing to ask the question. This is science .. There should always be room for doubt and uncertainty, if there isn’t there is no growth and no one has any chance of improvement. If you look at it this way, uncertainty is actually an amazing positive, because it provides an opportunity for improvement, it allows growth.
So ultimately, the ‘quick fix’ is an empty promise, because you can’t be 100% sure that you did, in fact, cause the reduction in pain that your patient experiences – no one can be 100% sure of anything! It might just be that your intervention’s puny effect size may have added 10% to the general picture of a patient improving; I think being open to this possibility is not only important for our own growth as professionals, but importantly reinforces to the patient how much they did on their own. In a condition that is so inherently complex and uncertain as low back pain, there can be nothing more damaging than providing false absolutes of a quick fix or an easy cure based on your intervention. It creates a false dependence on something you likely have minimal control over. About the only thing that has a high probability in this condition, is that it will likely happen again once you get it and generally most people get it at some point in their lives (Ref). Patients need to understand that they need to be open to the possibility of it happening to them and returning once it does happen – this is the order of the natural world. Low back pain is complex – and like any complex problem – it is emergent without a possible direct prospective link to causation, meaning you may not be able to prevent it 100% of the time. It might just happen – it is a normal product of living in an unpredictable world.
If we absolutely have to get reductive at any point with our patients (which, let’s be honest, we will need to) what do we focus on?
Interventions generally have small to no effect size when all things are taken into account, so it is quite difficult, to pin down any intervention with a high probability of reducing disability and pain once you get it. Most systematic reviews, which pool together all interventions and provide a more representative picture of things that actually move the needle on a population level, come up with underwhelming conclusions for most interventions. Unfortunately, when I concede my own personal bias, even things like movement and advice to stay active are fairly underwhelming in terms of effect size and low back pain (Ref, Ref). So what are we to do?
Be honest and educate our patients that we don’t have the answer might be a start. It might be a start to admit that being reductive isn’t the solution, that there are probably multiple things that they need to begin working on to see any significant change. That is our challenge as professionals, to take the hard road and ensure the patient knows exactly how much they need to do and how little we are doing. And the patient needs to start the journey along the hard road to long-term behaviour change. We need to teach the capacity to not be afraid of the onset of pain (especially low back pain), because in the natural world, it is impossible to predict and if it does happen to our patients, there are probably multiple simple, but hard, things that they can do to reduce their symptoms and have a better life.
What we really need to do is teach and embrace uncertainty with patients. It is the antithesis of a ‘quick fix’, in that there is no guarantee – because there shouldn’t be in an unpredictable world – but that is ultimately a good thing, because it opens the door to improvement and growth. The best thing about teaching to embrace uncertainty is that it gives the power back to the patient – if they have control, they can ultimately change their life! Importantly, we – as clinicians – need to have the confidence to not have certainty about our interactions; a quick fix is nice to say, and sure makes everyone get the warm and fuzzies, but if you’re being really honest with yourself there is no guarantee in your ‘method’. Be scientific and embrace uncertainty, and maybe we will all improve together.