I Just Want Clear Answers
By Rob Sams, Author of the must read Social Sensemaking – Click HERE to Order
I woke recently while staying in a hotel room with a feeling that I’ve not experienced before; I couldn’t walk. As I went to get out of bed, ready for what was to be an action packed day ahead, I just couldn’t do it. I tried to straighten my leg and stand up, but I was in that much pain it was a real challenge to move. It felt as though there were several large daggers being plunged into my lower back and down my leg. Unfortunately, the niggling back pain that I had been experiencing for some time now had flared up and boy was it causing me some grief.
I appreciate that this story is not terribly ground breaking news for many people around the world who experience, and live with, back pain (or any other pain for that matter) every day of their lives. Pain, is part of what it means to be human, it can teach us so much, it can slow us down when we may be going at a pace that our bodies cannot handle, or it may just be an indication that something is not quite right. However, while we know this about pain, it doesn’t mean that we welcome it when it comes our way.
Thankfully I have ‘come good’, and while I’ll live with niggling pain for the rest of my life, it’s no longer impacting much on how I go about things. Importantly though, I’ve learned a few things about why the pain got so bad in the first place. While I can appreciate this learning now, on that morning a few weeks ago, learning was the furthest thing from my mind.
However after a week or so since the worst pain, I can appreciate that most of my learning was through my reflection of this experience; about the thinking, the feelings, the expectations and about the decisions made throughout when the pain was at its worse. This is what I will reflect on in this piece. So what do I mean by this?
It would be easy to assume that decisions made about medical treatment were mostly scientific, logical and evidenced based; symptom A requires treatment B? It would also be easy to be seduced into thinking that because these can be serious decisions, that they ought to be made without the involvement of emotions, without bias and without the influence of anything other than evidence and science. But are they?
The point to be made here, and the thesis of this piece is, that medical decisions are just as prone to the impact of bias, of emotion and are based on heuristics, just like most other decisions we make. As Schwartz and Griffin note in their useful book Medical Thinking; The Psychology of Medical Judgment and Decision Making:
“Although much of the information used in clinical decision making is objective, the physicians values (a belief that pain relief is more important than potential addiction to pain-killing drugs, for example) and subjectivity are as much a part of the clinical process as the objective findings for laboratory tests” (1986, Preface)
So let’s reflect on what I have learned about some of the decisions made over the ‘week of pain’, by going back to when this pain started to really bother me.
I have had back pain for few years now and have a bulging disc in my lower back (which according to this study so to do around 52% of the population) that sometimes causes me pain and discomfort. I occasionally seek some minor treatment, but I mostly get on in life without my back pain causing me too much inconvenience.
However, on a particular Monday a few weeks back things were a little different. My back was really sore and had been getting worse over the weekend. That’s when I decided to visit a local Physiotherapist and where I learned some interesting things about both my own, and others decision making.
My first observation was when the Physio told me in a clear and uncertain way that “you’ve got the tightest lower back and hamstring muscles that I ever felt” (priming). This was perfect for me, it confirmed that the pain I was experiencing was bad pain and I was not imagining it. It’s great when people confirm our thoughts isn’t it? This can provide us with relief from any unease we might be feeling about whether we are on the right path or not.
But this advice from the Physio did also leave me feeling me a little concerned that I may have done something serious. I mean I had the tightest muscles she has ever felt. While I did wonder how many other people she had said this to and what her unconscious messages may have been (e.g. you need to continue to see me for weeks; or, you really need to see me in order to get better; or, was it just the truth?). How could I know? I really wasn’t that interested at the time in exploring these points. What I do recognise, in retrospect, is that it did impact on my thoughts about my injury; it must be a serious one. I was concerned.
In order to explore this further, I phoned my good friend and Physio James and asked for his thoughts. James suggested tight muscles were a pretty common thing and that it might not be too bad and the pain may settle in a few days. That was a relief and my feelings changed and I then thought that the injury might not be that bad after all. I realise now, that I quickly latched onto only the positive points James made; and even though James had not examined me, and his answers were in response to my question of whether he thought my injury was serious. How could he know? We only spoke for a few minutes and I gave him limited information.
Of course in retrospect, I recognise that I am also incredibly bias about listening to James’ views, he is one of my best friends after all, and I quite possibly only heard what I wanted to hear from James. That is the positive news (information and exformation). James recommended a combination of pain killer and anti-inflammatory medication had worked for most others he talks to with similar pain, so that’s the path I went down. I also did stretches that the Physio suggested and as I went to bed that night I was feeling a little better. It seemed that all would be good, and maybe the Physio was exaggerating and James’ advice was right? Maybe the injury was not so serious, phew.
That’s when I woke the next morning and couldn’t walk; how frustrating. That Physio was right, maybe I’d done some serious damage. Was James’ advice wrong? Did I make the wrong decision in doing the stretches? Did the Physio treatment aggravate things? What should I do next? How long will this last? What caused the injury to happen; I couldn’t remember anything specific? I remember thinking; “I just want clear answers”.
There were many questions, but there were no clear answers. That was frustrating me, I just wanted to know.
I eventually worked through the pain I was feeling in the hotel that morning and caught a cab to see another Physio I had previously seen (in Sydney). This again confirmed things perfectly for me that this injury was a bad one. They told me that I was “experiencing a very serious acute flare up and the best (and only) thing for me to do was to get some serious pain relief and anti-inflammatory medication; and rest”. Rest and medication were the answer.
I was then taken to a doctor and prescribed some pretty serious pain relief that effectively knocked me out and kept me off my feet for most of the next two days. My wife De and good friend Max came and picked me up from the hotel and drove me home. After a few days it became more comfortable to walk.
That’s when I went back to my local Physio who said that she wasn’t surprised that the flare up happened. I wondered why she did not predict this when I first saw her? To be honest, I was a bit annoyed by this, why didn’t she warn me so I could do something to prevent it?
But why should I have been annoyed and how could she have really known in the short time that I saw her what was going to happen? Her years of experience, biases (e.g. hindsight) plus her own heuristics and ‘satisfycing’ were driving her decision making. The pain and expectation of being healed, along with the hope that this would go away quickly, were driving mine. Decision making can be grey and messy at times, but that doesn’t stop us wanting black and white (clear and predicable) answers.
I also spoke with James several times as he ‘checked in’, and as we so often do, we talked, reflected and became comfortable with the idea that the answers to so many of my questions were really just guesses and hopes. Not that this means people were flippant or careless, it just means that there really is no way of predicting with any certainty how any injury will progress. We just do our best based on the information at hand, within the time we have. This is at the heart of all human decision making, why would it be anything different for an injury?
While I could continue with my reflections on this experience, I think the key points have been made. What became apparent as I reflected on these experiences is how many of the decisions made, by both me and others during this experience, were made non-consciously. They were made with limited time and information, they were based on expectations and assumptions and certainly in my case, based on emotion, feelings and hope. This challenges our often considered notion that most of our decisions are well thought out, deeply considered and logically developed.
This is also another case study where understanding our decision making and our actions really can only be made retrospectively, and socially. The reason that I am able to write this story today is because I shared in ‘social sensemaking’, reflecting on this experience with others where the ideas shared in this piece surfaced in my mind.
I’m continually amazed by the number of factors that impact on our decisions and judgments. I’ve been involved in supporting people with injuries for most of my working life. I now contemplate and think about how I had some pretty unrealistic expectations of both people who have experienced injuries, as well as those who support them (e.g. Doctors, Physios and the like). I know there were times when I expected clear answers to questions like “how long will it be before they are better?” or “what does this mean for their work?”
We can be pretty impatient and expectant as we strive to ‘care’ and look after others. Perhaps it would be worth finishing this piece with a further note from Schwartz and Griffin’s book to prompt your own further reflection on this topic:
“…medical judgment is also subject to social, economic, and interpersonal influences. These include not only the cost of medical cover but also the ethical strictures governing the medical profession, social norms, and the quality of the patient-doctor interaction.” (1986, p.216)
What is your understanding of decision making?