“The cost of a thing is the amount of what I will call life which is required to be exchanged for it, immediately or in the long run.” – Henry David Thoreau

Have you ever changed your mind? Your patients do it all the time. Furthermore, they do it throughout their plan of care. You may have nailed the initial visit by asking all the right questions, developing well-reasoned goals, and fostering the beginning of a magical patient-therapist relationship, only to have it all come crashing down in a couple of weeks because the patient changed their mind on everything.

Sometimes this is the result of you being so awesome at your job and Exceeding Expectations that they develop new expectations they previously thought were unattainable. If you keep striving for the original goals and never discuss the updates with the patients, you will find their frustration mounting and frequently stating “it’s fine” when it is clearly not fine (in case you were wondering, it’s never fine when someone uses that phrase…ever).

Patient and therapist expectations often differ

Now, this does not mean we should strive for mediocrity to protect ourselves from setting up a patient with unreasonable expectations. Instead, this highlights the importance of continually seeking to understand your patient throughout the plan of care. This is different from constantly asking them their status with negative framing. Frequent use of “how does that feel?” or “how are you feeling today?” routinely fosters hyper-focus on any unpleasant sensations or difficulties. Instead, ask them about their perceived progress, highlight the areas they have improved upon, and revisit their goals.

You may find hidden frustrations around the perceived lack of progress despite your assessment that the patient is on track. The patient may expect the same rapidity of improvement while you expect more of a leveling off in the next couple weeks or perhaps even a temporary small step back with the increasing difficulty of exercises. You will find greater trust and engagement if there is alignment on the plan of care of expected outcomes. This is only scratching the surface of patient expectations and their drivers.

Would the patient classify your treatment as valuable?

Brain imaging shows that when someone perceives they were ripped off; they have activity in regions associated with disgust and pain. Conversely, when people perceive they received a good deal, it is a pleasurable event. How does this apply to physical therapy? Simple, we provide a service in exchange for money, time, and effort.

While we may want to avoid the financial piece of PT, it is a primary influencer of every treatment session, especially if the cost of care stretches the patient financially. The cost and value of a service are relative to each patient. A $25 copay may be expensive and challenging for one patient while a $300 payment (prior to meeting their deductible) may not faze another. I am not saying the quality of our care should be influenced by this perceived value, as we should provide the best quality possible each session, but we must understand patient expectations may shift with the relative cost. The patient may expect to be cured in one visit if they perceive the cost to be high. You want to know if you are fighting an uphill battle from the onset.

Negative emotions often outweigh positive ones

When assessing a patient’s expectations of care, we need to consider their current emotional state as well. Negative emotions and negative feedback often have more impact than positive ones, and negative information is processed more thoroughly than positive ones. The self is more motivated to avoid negative self-definitions than to pursue positive ones. Negative impressions and negative stereotypes are quicker to form and more resistant to disconfirmation than positive ones. In a nutshell, negative emotions are typically stronger the positive emotions.

While this is not universal to all people and all situations, we have likely experienced this during patient care and witnessed patient perseveration on the negative information they received (e.g. their MRI report). The information a patient receives prior to starting PT (e.g. imaging report, the media, their referring physician) and the information a patient receives in PT (how weak they are, poor mobility, crappy squat mechanics) can weigh them down and reshape expectations. There are many ways a patient can decide to cope and respond to this information. One of these strategies is loss aversion.

“I knew I shouldn’t have done that”

Could of, should of, would of…I heard this phrase often as a kid. My father would say it after my incessant complaining about some boneheaded move. Instead of focusing on the past, we need to learn from it and focus on the current situation and future investments. This is easier said than done. As Richard Feynman said,

“A rational decision-maker is interested only in the future consequences of current investments. Justifying earlier mistakes is not among the Econ’s concerns.” We can all benefit by channeling our inner economist.

Frustration can mount rapidly when reviewing an undesirable outcome and knowing you were responsible. Often the frustration is greater for the outcomes we are able to control versus the ones we cannot. This phenomenon is referred to as loss aversion. When directly compared or weighted against each other, losses loom larger than gains. It is important to define a “loss” and a “gain” as those can be subjective.

We have to define success to measure it

Outcomes better than the reference point are gains, while outcomes worse than the reference point are losses. Reference points are key for most assessments. For example, our assessment of a test grade substantially changes once we know what the grading scale is (i.e. an “A” being 90-100% vs. 94-100%). In treatment, the reference point may be predicted improvement in FOTO outcome measures or the MCID of a pain scale.

Daniel Kahneman wrote that “Loss aversion implies only that choices are strongly biased in favor of the reference situation (generally biased to favor small rather than large changes).” So, how does this apply to patient care? It can lead to very reserved expectations as a means of psychological protection. Instead of using an outcome tool’s MCIDs or patient goals, we use the status quo, or current medical condition, as the reference point. If the patient improved at all, we deem the treatment a success rather than needing to meet a specific level of improvement.

The more challenging the goal, the easier it is for us to fail to achieve it. It is easier to justify not achieving a goal by failing to act than by trying and failing. Loss aversion is a powerful conservative force that favors minimal changes from the status quo in the lives of patients and clinicians. People expect to have stronger emotional reactions (including regret) to an outcome that is produced by action than to the same outcome when it is produced by inaction. Going back to patients, this can impact their willingness to fully invest in PT, especially if they have experienced failed treatment before. It is easier to justify failure when we don’t make the effort.

How to combat loss aversion and hesitancy

One method to address loss aversion is broad framing, which is approaching a situation with a ‘big picture’ lens as opposed to looking at each event in isolation. For example, loss aversion typically homes in on a single reference point, such as returning to the soccer field. Broad framing would highlight all of the progress made and frame setbacks as opportunities and lessons for future development. Conversely, loss aversion and narrow framing is a lethal combination. While loss aversion and negative emotions can significantly dampen expectations, there are instances where a lack of expectation ‘control’ can negatively impact the assessment of the true benefit or harm of intervention.

Patients often over-estimate treatment benefits and underestimate treatment harm. This can lead to rash decisions (such as pursuing a risky intervention or prematurely ending a plan of care).^[1] Many studies have demonstrated individuals work significantly harder to achieve a goal compared to exceeding one. One is success vs. failure (achieving the goal) while the other is a cherry on top (exceeding the goal). This can impact the desire of a patient to resume PT once they achieve a primary goal, despite your knowledge they can achieve even greater outcomes or vice versa. On the flip side, a clinician may lack interest in a case if they perceive the patient has achieved sufficient improvement.

When trying to determine a patient’s expectations of PT, it can be helpful to understand how they developed those expectations and what information may assist or hinder the development and refinement of new expectations. Let’s take a look at four categories of expectations.

Predicted Expectations

The first is Predicted expectations, which are what the individual believes will occur. Many studies have highlighted a link between expectation and clinical outcomes for individuals experiencing musculoskeletal pain.^[2] Predicted expectations, both positive and negative, have a direct relationship with musculoskeletal pain. These expectations will be heavily influenced by the information the patient receives – such as from their referring physician or social media – prior to starting physical therapy.

Ideal Expectations

The second is Ideal expectations, which refer to a patient’s desire and hope. Essentially, they are what an individual wants to occur, while predicted are what an individual thinks will occur. Many patients will not share these as they believe they are not attainable and will lead to disappointment. I recommended asking. If they are attainable, and you help the patient achieve them, you will have an advocate for life

Normative Expectations

Normative expectations are what the patient believes should occur. While little is known of impact normative expectations have on clinical outcomes, it does appear to play a role in patient satisfaction (or dissatisfaction if you fail to meet it). These are heavily influenced by the value proposition. If the commute time is long, the cost of care is high, or you come highly recommended, the patient will likely expect rapid, superior outcomes.

Unformed Expectations

Lastly, we have Unformed expectations. These are the expectations an individual is unaware of or is unwilling or unable to express. This could be to a lack of previous experience or education necessary to form an expectation, or it could be the result of an activity being habitual and the patient hasn’t taken the time to develop an expectation.

Addressing expectations in the clinic

It is important to remember that expectations can change, even if you do everything right. For example, you may exceed a patient’s expectations and achieve one-month goals in only two weeks.

Great!

Then the law of unintended consequences strikes. Know the patient will expect the same rapidity of improvement the rest of the plan of care. This is why constant communication and reviewing of goals is necessary. Not just on progress note days but instead every session.

Everyone will have unique tweaks to their methodology for developing rapport with patients and assessing their expectations. Additionally, it is important to recognize your own expectations. Patients can be quite perceptive, and our body language often betrays our words. Studies have shown that when our verbal information, visual cues, and body language do not match, it sows distrust in the patient-therapist relationship.^[3] Like motivational interviewing, understanding and assessing patient expectations is a skill to develop. It can have significant impacts on the compliance with a plan of care and the outcomes a patient achieves.

References
Hoffmann TC, Del Mar C. Patients’ expectations of the benefits and harms of treatments, screening, and tests: a systematic review. JAMA Intern Med 2015;175(2):274-86. doi: 10.1001/jamainternmed.2014.6016 [published Online First: 2014/12/23]

Bialosky JE, Bishop MD, Cleland JA. Individual expectation: an overlooked, but pertinent, factor in the treatment of individuals experiencing musculoskeletal pain. Phys Ther 2010;90(9):1345-55. doi: 10.2522/ptj.20090306 [published Online First: 2010/07/02]

Daniali H, Flaten MA. A Qualitative Systematic Review of Effects of Provider Characteristics and Nonverbal Behavior on Pain, and Placebo and Nocebo Effects. Front Psychiatry 2019;10:242. doi: 10.3389/fpsyt.2019.00242 [published Online First: 2019/05/01]