Using the Socratic Method on the debate about passive treatment

Author: Carl Davies

Follow @CarlDaviesPH

“He who establishes his argument by noise and command, shows that his reason is weak.”
― Michel de Montaigne

All my life I’ve been fascinated by philosophy, the complex world in which we live and the questions it poses to us. About 7 years ago I started studying complexity and systems. An understanding and appreciation of complexity provides a paradoxical ability to view things more simplistically, but without over-simplifying them.  Socrates taught us that “the only true knowledge, is knowing that we know nothing”, but there is a particularly loud and hostile group of ‘anti-passive treatment’ physios that are adamant that they are right.  They apparently know what will ‘transform and save physiotherapy’ from the perils it faces, due to its supposed heavy reliance on ‘low-value’ treatment (something I am actually yet to see any evidence of during my time in the NHS).

In an earlier blog I wrote about having a balanced approach to the debate around passive treatments. I did this not because I believe that passive treatments are ‘good’, but because I don’t believe I ‘know’ them to be intrinsically and absolutely ‘bad’.  Whilst one of the justifications for this was based on my beliefs around behaviour and building deeper connections with patients through ‘reciprocity‘, another argument is that it presented a complex ‘Ethical Dilemma’ which changed my views about healthcare provision, and indeed my own understanding of my role within the healthcare system.  It was because of this that I left my ‘career’ as a physiotherapist behind to enter the world of management and system engineering in healthcare.

Before I start discussing the ethical dilemma, I should first pose some questions for the reader to consider:

1. Do humans differ in their level of self-efficacy, self-esteem, and locus of control?
2. If so, is it reasonable to expect all patients to choose ‘active’ treatments?
3. Do we believe that we have a clear method of converting ‘ALL’ of these patients to ‘buy-in’ to more active treatment simply through ‘rapport building’ and ‘motivational interviewing’ and do we have a right to define that as a ‘target’?
4. In conditions such as Fibromyalgia, patients suffer with complex pain and there is a high rate of drop out/disengagement in ‘active’ treatment interventions.  Are those treating clinicians that try to ‘activate’ just not very good at engaging patients or are there more complex biopsychosocial factors that lead to this?
5. Are there patients who suffer with pain and in order to maintain their function actively choose to use ‘passive’ treatment, to help them on ‘their’ journey, that allows them to function but does not ‘fix’ them?
6. Is the research to date sophisticated enough in its design to have explored that question?
7. Are there clinicians who exploit patients who choose passive treatments, without employing a concurrent focus on active interventions, either for their own benefit or under the genuine belief that they are ‘fixing/helping’ their patients?
8. Is there variation in the ‘levels’ of harm that the different interventions can cause?

Hopefully, readers are making genuine attempts to ponder those questions and consider the implications of making black and white decisions on ‘choice’ of intervention.  To be definite, you would need to be sure that you could answer all of those questions and understand the impact of your decisions.  In an ideal, simplistic world, cause and effect would be very obvious to all and there would be no disagreement from any party on what constitutes ‘value’ or ‘best-practice’. In the ideal, simplistic world, all patients would simply need ‘educating’ on the new behaviours and would all change accordingly.  The world is unfortunately, as Ben Goldacre would say, “a little more complicated than that”.

I am about to embark on writing up a case study in systems and complexity, using MSK healthcare as my topic of study. Peter Drucker once described a hospital as “altogether the most complex human organisation ever devised”.  If one of the greatest thinkers on complex systems describes a single hospital like that, what does that make the health & social care ‘system’ as a whole? When a system is complex, and cause and effect are unclear, decision-making is also extremely complex.  In a complex world, when good health-care depends on good decisions, we must be very careful attempting to take a reductionist approach.  As humans, we struggle with complexity.  We struggle because we have an innate desire to ‘make sense’ of the world around us, but try as we might, this complex world will not fit neatly into boxes.

In a different blog I wrote about value, and I do believe value to be a good place to focus energies and minds when making decisions across healthcare systems. Commentators offered an excellent challenge though, that being “who decides ‘what’ value is”….and “whose value”?  I chose ‘value’ because if done correctly, using effective balancing measures, we can determine if we are genuinely providing improved outcomes for ‘all’ parties – i.e. patient, commissioner, provider and society as a whole.  However, to truly understand value, we must first appreciate the complexity of the situation. I hope this blog goes some way to explaining my decision to offer ‘value’ as the best option and why we the decision is far more complicated than many would have you believe.

In the English NHS, the decision on which treatments to procure sits with Commissioning Groups.  For those who are ‘certain‘ that passive treatments are low-value, there is much frustration that Commissioners continue to procure the non-evidence based interventions.   They are adamant that the ‘evidence-base’ is clear, suggesting that the best outcome would be to eradicate all passive treatments because (somewhat patronisingly) “we can and must do better” they say.  However, from a Commissioning perspective it is impossible to expect (often non-clinical) decision-makers to determine what provides value, when we have not first achieved consensus in the medical community.

This brings us to discussion of the ethical dilemma of treatment choice. If the fact exists that some people will ‘actively’ choose not to manage their own condition and will ‘actively’ choose passive treatments (e.g. opioids through to reiki) should we perhaps discuss which passive treatments offer the ‘least harm’ and how to use passive treatments to support reactivation and facilitate active management?  I believe there perhaps is merit in doing that.

So rather than go round in circles and try and ‘settle’ the debate, I wanted to use the Socratic method to explore this further and test the logic behind eradicating the use of ‘passive’ treatments in MSK healthcare:

• Even if we had the power to ‘ban‘ all currently labelled ‘low-value’ passive treatments being provided by the medical community, should we also have the right to dictate that people should not be allowed to choose and pay for those treatments?
• If the answer is ‘no’ and people have the right to choose and pay for those treatments, will people choose them?
• If the answer is ‘yes’ and the people who deliver them make no attempt to ’empower’ or ‘reactivate’ patients, are we in fact exposing them to more ‘harm’?
• Can we therefore do less harm, by providing low-value treatments and offering them as part of a package of care aimed at empowerment and reactivation?

I don’t have the answer, I just think we need to explore many more questions before we make definite decisions.  The truth is, in a complex world, with complex problems and complex people….and in systems, within system, within systems, the answers and decisions we make within healthcare are not black and white. Every decision we make, that tries to draw definite lines and distinctions, has unintended consequences that may in fact cause more harm than the ‘problem’ we believe we are solving.  The more I learn, the less I know.

Author: Carl Davies

Follow @CarlDaviesPH