Eric,

Thanks for this post. I am very excited about this series from JOSPT, as I have always had a hard time reading and interpreting literature. It is definitely not my favorite part of being a physical therapist, but I certainly recognize that it is my duty to be an informed consumer of current literature for the optimal care of my patients. I am looking forward to seeing what other segments they produce.

In regards to the discussion of bias, I think confirmation bias is something I am 100% guilty of. I am much more likely to implement an intervention that I have had success with with a previous patient as compared to an intervention that was not successful with a previous patient, regardless of the current patient presentation. I then find myself in a bit of a rut, doing the same things, and have to balloon back out to make sure I am not missing things.

I thought the part on recall bias was interesting and maybe isn’t something I had considered. It made me think about how I may not need to always use the “sexy” techniques with patients, often times the basic, impairment based interventions (and therex**) are what patients need most, and that should not be overlooked.

I really look forward to seeing where JOSPT goes with this new series. I enjoyed reading this first entry and found aspects of this that unfortunately reflect some bias in my practice.

Though I cannot recall just one specific instance of confirmation bias, I think this is something that I have had to consciously work to limit in my practice. Especially being this new in my career, I have been guilty of conveniently skimming over information in an eval that does not fit my picture of what the patient SHOULD present with. Especially earlier in the residency, I tended to latch on to specific pieces of information, form a diagnosis in my head, and then only ask questions and perform tests that would confirm the diagnosis that I had made. Over the second half of the residency year, I have been more aware of this bias and tried to maintain a larger differential list and focused more of my time and attention on ruling out other potential pathologies first before shifting my attention towards ruling in a diagnosis.

I think recall bias is something that has led to a great deal of frustration for me personally in certain instances. Early in the residency, I had a string of patients with subacromial impingement who did really well in a short period of time. As I have begun to see more individuals with this pathology, I often find myself second guessing my choice of interventions or diagnosis if they are not completely better in the first few visits, which is likely an unrealistic expectation. With more experience in the profession, I hope that my expectations will regress to the mean with regards to prognosis with patients with certain pathologies.

Reading and interpreting the literature can be difficult for me. Deciding the quality of the study, if it applies to my patient (per demographics, condition, co-morbidity), how to apply in my setting (incl time and equipment limitations). My own biases are something that becomes even more apparent every time I work with a new PT student. I find myself going back and questioning myself with common conditions I see, i.e. shoulder impingement and low back pain. I think this is especially true with treatments that I have found effective in the past for these conditions. Confirmation bias is hard to overcome as we are hoping treatments our treatments are effective, and I try to rephrase my questions during eval and/or treatment to avoid leading the patient and allow for a more open ended answer that may be more truthful.

I thought this article was interesting and thought-provoking. I racked my brain for specific patient examples that illustrate my biases, but cannot come up with anything specific. I’m certain I have biases in my clinical decision making.

I can think of a bias that has affected my selection of strengthening and balance training recently. Jay Dicharry made an offhand comment during Running Medicine that stuck – he said something to the effect of “why would you put an athlete on an airex pad when their foot needs to get better at controlling motion on a flat surface; I use the balance board, not an airex”. I’m pretty sure I haven’t used the airex since as a way to add challenge to an exercise. What type of bias would you call that? I’m sure I should be weighing evidence on the subject instead of Jay’s opinion, but it made good sense to me, so it stuck.

Similarly, I stopped giving people the sleeper stretch after seeing many videos of Mike Reinold explaining why he rarely utilizes it. This example is different in that he conducted the research that found horizontal adduction stretching was more effective in improving internal rotation ROM than the sleeper stretch. However, it was likely his status as a credible expert that most impacted(biased) my thinking.

This is a very eye opening to me and I have definitely found myself conforming to confirmation and recall bias situations. I think my personal bias comes from familiarity of techniques in research and the more familiar I am the more bias I tend to be. I also find myself recognizing certain patterns and utilizing techniques that have worked previously even though ALL of the features do not fit. I feel that at times I have tunnel vision and I need to start taking a step back and remembering that all patients are not the same and the same sequence of techniques are not applicable to every patient despite my past experiences.