Are We Choosing Wisely?

By Rebecca Barnett

“Overdiagnosis means making people into patients unnecessarily, by identifying and treating problems that were never destined to cause them harm. It causes anxiety, brings side effects of unnecessary treatments, and wastes resources spent on genuine need.”

Mary O’Keeffe, Ray Moynihan

The Conversation

A couple of really interesting things happened over the last few weeks.

Thing 1

Those of you who were lucky enough to hear Mary O’Keeffe at AMT’s 2020 virtual conference last October will be excited to hear that she is part of a team that has just published the results of a large global study looking at media coverage of early detection tests for dementia, breast cancer and atrial fibrillation.

The research team performed a cross-sectional study of English language media reporting of five early detection tests. The study included all nonfictional stories from newspapers, blogs, magazines, broadcast and podcast transcripts, and news wires between 2016 and 2019.

Analysis of the 1173 stories examined in the study suggests that the media tends to overplay the benefits of these early detection screening tests, downplay the harms, and ignore conflicts of interest. (97% reported on benefits, 37% reported any harms and 34% reported both benefits and harms. Overdiagnosis was only mentioned in 5% of stories overall and conflicts of interest were only disclosed in 12%.)

So what has all this got to do with massage therapy, I hear you importune. Massage therapists don’t promote or use early detection tests, you further entreat. And we’re not even allowed to diagnose, you penultimately obsecrate. Isn’t this yet another example of an overly paternalistic allopathic hegemony needlessly medicalising people’s lives, you conclusively beseech, laying down your thesaurus with a satisfied flourish.

Well, here is my schtick. What if massage therapists are sometimes guilty of exactly the same paternalism in a slightly different guise? What if we can over-screen with the best of them? What if some of our traditional assessments and protocols are also creating needless anxiety and harm by detecting stuff that isn’t actually a problem? What if we are sometimes seeking to find and treat presentations that are not really MSK ‘conditions’ at all but just normal variations of human ways of being? What if fascia can’t actually be manipulated?

What if I never stop asking rhetorical questions?

My learned colleagues, I give you Exhibit A – upper and lower crossed syndromes; Exhibit B – those pesky sleepy or forgetful glutes; Exhibit C – forward head posture …

OK I am going to stop listing before I reach Exhibit Z, get hopelessly lost in the foothills of infinity, and have to resort to other alphabets. Feel free to add your own Exhibits in the comments. (Ed. – couldn’t wait for comments: pelvic misalignment, leg length disparity and those partying ribs, always going out)

Don’t get me wrong. I am not suggesting that massage therapists are using certain types of assessment and screening to willfully mislead clients into thinking they have a problem that needs (over)treating. Nor am I suggesting that some of the now-debunked MSK presentations that massage therapists have traditionally identified as being the source of pain and pathology weren’t based on apparently sound reasoning or the best available information when they were first developed.

What I am suggesting is that, before we seek to critique healthcare practices, we need to get our own house in order first. I just googled “massage and toxins” and I don’t know what is worse – the fact that the first helpful autofill item is “massage and toxins released” or the 10,000,000 results in 0.41 seconds? I would not enjoy reading the research that unpacks the myriad ways in which we have embedded toxin bollocks into the massage therapy narrative.

Related article: Mythbusting: Does Massage Therapy Flush Toxins? Part 2

When is the last time you critically examined the utility and efficacy of the assessments you perform as part of your treatment planning? Do you know the specificity and sensitivity of the orthopaedic tests you use? Are you choosing your assessments wisely?

Thing 2

The second interesting thing that happened recently is the new initiative of Choosing Wisely Australia to establish a network of “Choosing Wisely Champion Health Services”.

Not familiar with Choosing Wisely Australia? It’s part of a global initiative to improve the safety and quality of healthcare, with a particular focus on unnecessary tests, treatments and procedures. If you follow AMT on other social media platforms, you would definitely have seen one of Choosing Wisely’s key consumer resources “5 questions to ask your doctor or other healthcare provider about tests, treatments and procedures”.

You can see how this initiative might directly connect with a study of the media overhyping the benefits of early detection screening tests.

The new champion health services scheme aims to engage primary care, Local Health Districts and hospitals into local networks of service providers committed to reducing overdiagnosis and overtreatment. Choosing Wisely has already begun to promote champion health services through its channels. The opportunities for massage therapists to establish referral networks with health services and providers who are committed to the Choosing Wisely principles are manifold and surely worth exploring, not to mention the opportunities for massage therapists to embrace a Choosing Wisely philosophy within our own domain of care.

Conclusion

There is no doubt that massage therapists provide care that is highly valued by clients. Given the extraordinary trust that clients place in their massage therapist and the highly personalised nature of the interaction, it’s particularly important to avoid pathologising and overtreatment, and ensure that the care provided is not just valued but also high value. We need to commit to choosing our assessments and treatment protocols wisely because more is not always better when it comes to healthcare, even when that healthcare is massage therapy!

About the Author

AMT CEO Rebecca Barnett really likes rabbit holes. She may have accidentally fallen down one in the preparation of this post.