Jared Powell:
Jared Powell:
Today's guest is Jarrod Hall. Jarrod Hall is a physical therapist out of Texas USA. Jarrod has diverse intellectual interests in and around physical therapy of which a particular interest is that of cognitive biases. What is a cognitive bias? What are some examples of a cognitive bias? Why should we be aware of them and how can they affect our clinical practice? These are some questions that I pose to Jarrod, and he does an expert job providing thoughtful and articulate answers. Before we get into the nitty gritty of the conversation. I've just returned from Sydney, where I ran my first shoulder workshop. In two years, I had a great time talking all things, shoulders and judging from the feedback. So did the course attendees. My next workshop is in Melbourne on the 4th of June, and there are still a few tickets remaining for this event, but you're better getting quick.
Jared Powell:
The course offers a complete distillation of the evidence base for shoulder pain management, equipping you with up to date, knowledge, techniques, and clinical reasoning skills that are clinically actionable. If this is something that you are interested in, check the show notes for more information without any further delay. I bring to you my conversation with Jarrod Hall. Okay. Welcome everybody. I am here live, uh, now with Jarrod Hall, another Jared Jarrod and namesake, we won't argue about the semantics or the pedantics of, of how best to spell, uh, our name. Although my, my spelling is obviously superior. Jarrod, thank you very much for, for coming on and having a, a chat with me.
Jarrod Hall:
Yeah, no, I, I definitely appreciate you inviting me on. I was surprised to get the invite. Uh, you know, I, I thought that you'd be intimidated and intimidated by inviting somebody with a superior spelling onto your show,
Jared Powell:
Jarrod, this is, this is, we're not gonna, we're not gonna get into that, but, uh, I am always prepared to match my spelling with any other variations, cuz there are a hell of a lot of variations and nobody ever spells my name. Right? So maybe you have more luck over there in Texas anyway. So, so mate, thanks for agreeing to come on and have a chat. We're gonna talk about some interesting stuff and not, not your classic physiotherapy conversation. We're gonna talk about critical thinking and, and cognitive biases. So before we get into all of that for today, how about you just give, uh, our audience a, a brief introduction as to who you are and what you do and where you're based and what you like to do, who is Jarrod Hall?
Jarrod Hall:
Oh man. Well, I guess, uh, professionally who I am is I'm a physio in Texas. If you're familiar with Texas, I'm from the Dallas Fort worth area on the Western side, the Fort worth part of the Dallas Fort worth duo, I've been outta school just a little bit under a decade and practicing in the outpatient orthopedic setting. Primarily somewhere along the way, I kinda developed a, an interest in, or became known as somebody who, who talks a lot about, uh, pain science or chronic persistent pain, the whole concept of pain neurophysiology and that sort of thing. So I, I run modern pain care with my co-owner and, and partner in crime, mark Carla, uh, and we run a mentorship and some courses online courses and weekend courses through that. In addition, I, I teach a little bit at the local physio uni, so I am kinda an adjunct part-time adjunct faculty for their orthopedic coursework.
Jarrod Hall:
And I, and I do a little bit of their health and wellness curriculum and a little bit of their, uh, their pain science guest lecturing type of stuff, which, you know, I know that a lot of this that has developed out of Australia. So it's, it's newer to the states and especially being implemented into the curriculum is a little bit of a newer thing over here. So, uh, I'm, I'm glad to be able to do that when I'm not doing all things physio, I like to read a ton. And I think that that's probably one of the things that got you. And I interested in, in, in things and maybe doing this podcast is back when you came onto the modern pain care learning academy, we, we talked about what books we were reading and kind of got into some of the philosophical discussion on cognitive biases and, you know, different thought processes.
Jarrod Hall:
And, uh, you know, I it's, it's just something that I love to learn a lot about psychology sociology, just the way that we interact as humans and personally I'm married, uh, just, just celebrated my eight year anniversary of being married. So I, I no kids yet. So my wife and I, we just, you know, in all of our free time we like to travel and we like to try out new restaurants and, you know, we like to just spend time with each other outside as much as possible. And, uh, you know, as we were chatting about before we came on, I like to play a little bit of golf as well. So I think that when I do get the opportunity to come to Australia, I'll have to you and we'll to play a couple rounds.
Jared Powell:
Yeah, absolutely. I'll I'll hold you to that, Jarrod. And we can, we can see who has the superior spelling after all as to who wins that game. Uh, yeah. Golf is one of those, it's a game that is so addictive is so rewarding. You can never master it. It's depressing in equal dose as satisfying. It's, it's one of those, it's one of those games. And you were saying you are, you are blessed to have a number of different courses, uh, within a, a three to four kilometer radius of you over there in Texas. So how often do you try and get out to play golf?
Jarrod Hall:
You know, up until recently I was, uh, it was terrible. I was only playing about once every three months and then with COVID actually, you know, gyms shut down everything we weren't able to, you know, to exercise as usual. So golf courses were still open just without the pens or you couldn't touch the pen. So I just strapped on my bag and I took off walking and over the last year, I've played more golf than I did in the previous five years combined. So now I've gotten to the point where I really try to, uh, you know, if I'm not terribly busy or we're not traveling, try to play, you know, maybe once a week, once every 10 days or so is, is about what I can get now. I would love to play two or three times a week, but life just doesn't permit it at this point.
Jared Powell:
Yeah. It's a time consuming recreation, isn't it? It's I, I've got a young baby and a wife and I reckon I can get out once a month and that's that's okay because I, it's hard to justify six to eight hours out chasing a white ball around in a park where I can go for a 30 minute surf out the front. So that that's one of the negatives of golf and it's a positive as well. It's good to get out there for, for a bunch of hours, but it does take some time.
Jarrod Hall:
Yeah, it definitely does. And my, my wife is not the biggest fan of it. Uh, you know, if I, if I'm gone for that long, that's why I try to play bright and early, let her sleep in, you know, maybe tee off the very first tee time of the morning so I can come back and we can still spend the day together. So that that's usually how I'm able to squeak it in.
Jared Powell:
That's a very wise move, Jarrod. All right. So cognitive biases and critical thinking. How, how on earth did you become interested in this obscure, esoteric, uh, concept, especially it's not the, the day to day, day to day pursuit of, of most physiotherapists or, or anybody in healthcare really. So how, how did you, how did you come to get interested in this sort of stuff? Did you have a moment in your clinical practice or in your education that made you start thinking about all this? Or is it, did it, is it just something you've always been interested? What's the story, the,
Jarrod Hall:
Uh, you know, now that I reflect on it, nobody's ever asked me that, but thinking about it, uh, I guess my temperament, my personality type, my whole life was always kind of the kid that asked why I asked a lot of questions, why I wanted to know why people did stuff, why people chose to make certain, you know, decisions or do certain things and wanted to know how things work. But at the same time, I was also that person that absolutely detested to be wrong, uh, which in some ways that's good because it, it, it causes you to strive to learn more, but in some ways it's bad because we're all always going to be wrong all the time. And it's, it's a regular part of human life to be wrong. Uh, and I guess when I got to the point that I realized how frequently I was wrong, uh, and how little I knew when I, when I ran across the mentors that were really cHallenging, the way that I thought they were putting me in my place, as far as my ego and that sort of thing, it, it lit a fire under me to better understand why humans think the way that they do, why we most often just automatically think that we're right.
Jarrod Hall:
Why we think that our experience of, of the world is objectively correct. And it's, you know, our truth is more truthful than other people's truth and that sort of thing. So, uh, you know, I, I think that some combination of all of those things just led me down this cascade. And once I got out of, uh, school and, you know, I got a couple of years under my belt and maybe clinical practice wasn't as mentally draining as it was that first couple of years, when you're really trying to, to find your stride. I found a passion and an enjoyment in recreational reading that I had lost because when you, when I was in school, it was just all didactic reading its textbooks, it's research articles. And, you know, that kind of burned me out on reading. And then I, I guess I got a little bit of a renewed sense of enjoyment from recreational reading and in particular, I just, I, I absolutely love reading, you know, cognitive neuroscience and sociology type things, because it's immediately relevant in everything that I do and everything that I see it's relevant in the, my relationship with my wife and family and my friends, it's, it's relevant in interacting with coworkers and patients it's relevant when interacting with referral sources and just anybody that you come in into contact with, we're all humans, and we all have these brains that work somewhat similarly to each other.
Jarrod Hall:
And, and trying to maybe learn a little bit about, it seemed like a good, good direction or a good way to spend my time.
Jared Powell:
Yeah, there's nothing there's, there's, there is something fundamental to every human being in regards to biases and cognitive biases. And so, so if we go back cognitive Biase was, was probably termed by, by Danny Carman in the seventies. I mean, I think it's been, it's probably been studied and, and been a thing in the literature, but I think Danny Carman, uh, certainly coined the term cognitive bias. And then obviously his book thinking fast and slow came out maybe a decade or so ago, and it sort of took off from there. So Jarrod do your best. And we can, we can talk about this, and this is not a, this is not a Q and a panel, but what is a cognitive bias and why should we care about it? And let's try and relate it to healthcare or physiotherapy as best we can.
Jarrod Hall:
Yeah, well, I mean, I think, I think it's probably important to, to say that cognitive biases or a cognitive biases, maybe like an umbrella term for a lot of different shortcuts in thinking or, uh, you know, assumptions that we make in the way that we think that are probably most often driven by, you know, a subconscious nature, which is a, a decision making process that happens below our level of conscious awareness that influences what we come to think and what we come to realize. So, I mean, a cognitive bias, I guess, would be probably an on average, an incorrect assumption about the way that the world works or what it is that you actually know and how you came to know that thing that you came to know, or that you think that, you know, so some sort of heuristic or, or, or shortcut process that works really well, uh, evolutionarily speaking for, um, you know, being successful and surviving and, and, uh, thriving in the world, obviously, because, you know, we have 7 billion people on the planet. We're, we're doing something right. You know, our brains do work really effectively, but they also create some errors in those shortcuts and thinking that help us cope with everyday life and help us cope with the massive amounts of information that, that is out there and that we have to deal with. And I think that some of these cognitive biases arise from some of those shortcuts that we take, or some of those assumptions that are subconscious makes, or the dialogue between our, if you wanna call it that between our subconscious and our, our conscious mind.
Jared Powell:
Yeah. So, so Ave bias or cognitive biases probably adaptive from an evolutionary perspective, they do serve a role and has indirectly led to the prospering of the human species. We have conquered this earth rightly or wrongly, but it can go awry. And there can be areas that are made by our overreliance perhaps on these cognitive biases or, or heuristics. And I was just, I was just reading a paper before I'll look away for a moment. And it suggests that up to 80% of areas that occur in medical practice are due to cognitive errors or, or cognitive biases. And this is more, uh, with, with doctors and lots of, lots of the areas that they make are due to, uh, due to relying on this almost subconscious biases towards the information that is out there and what they want that information to represent. So that, so that's the dark side of these cognitive biases. Um, so, so how about we go through a couple of examples which might be helpful. We'll go through a number of examples that might be helpful for everyone to try and conceptualize or visualize what we're talking about here. So I'm gonna, I'm gonna reel off a, a couple and we can, we can just spitball around those. So the first one I'm gonna talk about is availability bias. So availability bias is what, according to you, Jarrod Hall,
Jarrod Hall:
Uh, you know, if I had to put it in a short sentence, I would say availability bias is the tendency to rely on the most recent information or the highest frequency of information that you've encountered recently, uh, in a decision making process. So if you've recently encountered a thought process or a theme, or you've recently learned something new in it's front of mind, well, that's highly available to you. That is something that hasn't been locked away and stored and forgotten. Uh, and you're going have a higher likelihood of implementing that into your decision making process. So, one of my favorite thought ways to talk about this in clinical practices, let let's say the new, uh, bells and whistles, whatever the hot thing, continuing education course comes out, whether it's spinal manipulation or whether it's dry needling or whether it's, uh, you can't go wrong getting strong type of thought process, right?
Jarrod Hall:
So these things come out and you go on a weekend course and you learn all about dry needling and you see all the ways in which it can be used. And you're taught this massive amount of information over a weekend or a weeklong intensive course. Well, you go back to clinic and that's highly available in the front of your mind. And you're seeing this information with marketing, you're seeing it on social media posts. You're seeing it in, in podcast episodes. And you just took a course on it. It's highly available relevant information. So guess what you're gonna, you're gonna start to think that dry needling is the solution for all of your patients, or you're gonna start to think that heavy strengthening is the solution to all of your patients, whatever that available information is, uh, there, there's gonna be a tendency to call that forward in your decision decision making process much more frequently and probably far too frequently.
Jared Powell:
Yeah, that's a great example. I remember doing a, a hip course, uh, I don't know, 10 years ago, Andi was sort of the buzz at that point of the hip Monday, Monday morning, four outta six patients magically Hadi . And thank God I did that course, right, because I would've missed them. Whereas in reality, I was giving them an incorrect diagnosis, probably so everybody with, with vague groin or low back pain Hadi. And so, so that's, that's an example of the availability bias. Another way I like to think about it is not, not so much, um, going to a course, and then applying that in, in clinical practice, but major recent examples of a patient that you may have had that sort of stuck in your mind. And so for me, I'm gonna relate this to the shoulder because I do shoulders frozen shoulder. You are suspecting this, you, you send them off for a routine x-ray and then, you know, one in a thousand come back with a neoplasm or a metastasis in that shoulder, you are never going to forget that mm-hmm . So every single person who you suspect has a frozen shoulder in the future, you are going to send for an x-ray. That's just how it's going to be, because you don't want to miss that 100 a thousand chance. So, but that might not be best practice. And we know from the data now that's being increasingly cHallenged for frozen shoulder routine x-rays so, but that's, that's an example of Ava availability bias in practice there. Do you, do you agree with that or have any other, anything else to say?
Jarrod Hall:
Yeah, no, I, I agree with that completely. And what, what I think is the most interesting about it is, uh, typically we'll, we'll tell ourself the story that we don't wanna miss that one person, that one out of a thousand with a neoplasm, but we will kind of forget about the 999 out of a thousand who didn't. And we'll definitely forget about, I don't know, let's say the 50 out of a thousand or, or a hundred out of a thousand that ended up having maybe advanced osteoarthritis of the shoulder or what it, what it looked to be advanced osteoarthritis of the shoulder via imaging. And then they're told, well, it's time for a total shoulder replacement, especially in the United States where it's a very lucrative, uh, business endeavor to, to be an orthopedic surgeon in, in, in a capitalistic healthcare society. The more surgery you do, the more money you make, right?
Jarrod Hall:
So you, you have now done an unnecessary imaging, uh, you know, intervention on a patient, which may be leads to a surgical intervention, which maybe leads to something with significant side effects. We know that there's, there's more than a non-zero risk of, you know, very significant side effects from, you know, infection to even death when going under anesthesia. And we don't think about those other deeper layer effects that might, might come into that. And I know I'm getting on a little bit of a tangent, but that that's just something that stuck in my head because I was recently reading, um, there was a journal published in the emergency medicine journal of Australia, Asia, or something like that. It was 2018 articles called don't just stand there or don't just do something stand there. Uh, you know, and trying, trying to send the message of not over medicalizing patients in the emergency setting in particular. But I think that that actually goes across all medical fields that are all specialties that there's this tendency to, uh, not just stand there, but do something when instead, sometimes we should not just do something, but we should stand there, but it's our bias.
Jared Powell:
Yeah, this is perfect. So you're taking us right into the commission bias, which is our tendency to act versus observe or, or wait and watch. And I literally did a post about this this morning on Instagram. So the comm the commission bias, and I'll read it here is a tendency towards action rather than in action and, uh, phrases such as better to be safe than sorry. Uh, uh, what sort of comes in under this bias. So let's talk a little bit more about the commission bias. Why are we so geared towards action in healthcare,
Jarrod Hall:
Man? how much time do you have?
Jarrod Hall:
I think that there's probably a few different reasons. Number one, and, and this is cliche, but we want to help people, right? We want to physically do something that helps a person. And, and some of that is, you know, is truly altruistic. And some of that is self-serving as well that we want to do something that helps somebody because it makes us feel good. And if you read some, some of the different literature and some of the books, maybe from Paul bloom and that sort of thing against empathy, and you get to the concept that maybe human beings don't actually have all that much empathy, but we have a self-serving bias to make ourselves feel better by feeling something or doing something for other people.
Jared Powell:
We're not altruistic
Jarrod Hall:
, I'm not going to go so far as to say that, but I'm going go so far as to say, we might not be as altruistic or empathetic as sometimes we like to think that we're right. Uh, and I think that sometimes if you really, why you do something that helps somebody else a lot of times it's because it makes you feel good. Mm-hmm uh, so I think that's probably one aspect of it. I think that patients seeking care from us, you know, I I've come to the physio. I've, I've come to the, I've come to the doctor and, and they're supposed to help me. You guys are supposed to help me. You're supposed to do something for me. I'm paying money. My insurance is paying money. I I've come here. And now we are compelled to meet that patient's expectations or that person's expectation. So I definitely think that that, that plays a role for sure. And then of course there are some of us that just love to have the healer mindset that we, you know, that we are this, this kind of guru person, and it's not even, it's not altruistic or empathetic at all. It is, it's completely self-serving in that fact that we, we want to do things to fix people. And we, we kind of get our self worth from doing rather than interacting and coaching
Jared Powell:
Absolutely the status and the claim and the prestige and all these things that come along with it that I can fix this, this pathology that nobody else can by my own movement, screen and palpation skills and my, my magic hands. Absolutely. And that we've all been, we've all probably seen that with our own eyes. And we certainly have colleagues perhaps down the line or colleagues of colleagues that we've seen treat like that and conduct themselves, which is, which is kind of horrifying really, um, in this day and age. But sadly, I don't, I don't know if it's ever going to go away. I think there's always gonna be a place for these healers because there will always be people suffering with pain who are desperate and therefore when perhaps mainstream medicine or, or, or whatever it is, is not helping that person adequately well from their perspective.
Jared Powell:
Anyway, then they're going to seek alternate avenues anyway. So that's, that's, that's kind of besides the point. So the commission bias, if we have, if we have an example or a clinical example of a commission bias, we can probably bring it back to a frozen shoulder again and say, look, if we have, if we are suspecting a frozen shoulder, do we need to intervene here? , it's a self it's a, it's a self-limiting condition. It might not be a self resolving condition. It might not get a hundred percent better within two years without any intervention whatsoever. But we do know that it is self-limiting. So perhaps frozen shoulder is an example of watchful neglect or the wait and see approach. You certainly, in my practice, people with a frozen shoulder actually do want to do stuff for their sore shoulder. So it's a bit underwhelming when I say there's nothing you can do. Just do nothing for two years, come back in two years. If it's still, if you're still dysfunctional pain associated with it, they do want to move their arm and do some strengthening or do some movement, which is fine. So I'll facilitate that, but we don't have to, do you have any other examples off the top of your head, Jarrod, about the commission bias in, in clinical practice? Our proclivity towards action?
Jarrod Hall:
Well, yeah, I mean, let's take low back pain. That's the, uh, that's the most common musculoskeletal complaint in the world. And we have a lot of really good data across a lot of guidelines that say, well, you know, about 70 or 75% of acute bouts of low back pain, get most of the way better within at least six weeks, if not two to four weeks, but we have this tendency to, to treat people to either manipulate their low backs or massage their low backs or give them some sort of hyper-specific exercise. That's blowing into a balloon with their feet on the wall, or, you know, drop some needles into their motif eye because it's, it's certainly the cause of their back pain. And, and that sort of thing. When, if we did just look at the data, it'd be very easy to say that, you know, three outta four of these people are going to naturally resolve pretty well on their own.
Jarrod Hall:
And if we did a little bit more watchful waiting with those people provided a little bit more guidance and assurance, and that doesn't mean we don't have to ever see those people, but it means that maybe we don't have to put them through these rigorous intensive, you know, three times a week for six weeks courses of physio, uh, because what happens is three out of four patients that 70, 75%, well, they get, they get quite a bit better in that six weeks. And that reinforces that commission bias that we need to do something because we're using post ho reasoning, right? To justify the interventions that we chose, because we saw seven, you know, 75% of the people that we worked with get better in six weeks. So we, we come away with this false assumption that the interventions that we choose we chose and the care path that we did was highly effective and highly successful. When in reality, it was a similar course of care and a similar natural history of a condition that, that would've just resolved somewhat on its own. So I think that there is this commission bias that we wanna do things, but there's also, you know, a really common, you know, implementation of post reasoning to justify those same things that we did. So it reinforces our desire to, to, to actually do those things to that patient and to act upon them.
Jared Powell:
Yeah. So let's go to, let's go to post ho reasoning. It's not on my list, Jarrod. So you're making me think of my feet here. A little bit. Post ho reasoning is, is a, is an interesting one. And we're all, I've been very guilty of post ho reasoning. And I probably still am actually, uh, in my clinical practice where I apply an intervention, whatever that may be, or a, I prescribe a set of exercises. And I assume, uh, those sets of exercises let's say strengthening, right? So this is a paper that I've just published recently. And we, we used to think that by prescribing strengthening exercises makes people stronger and that's what makes people better. But the reality of that is far more nuanced. You don't really have to get substantially stronger in order to improve pain and function. So that that's some post-hoc reasoning that I was employing in my clinical practice falsely for five to 10 years up until I actually did, did a literature review on it. So any other examples, Jarrod? I know there's millions, but what about, is there something that you have been guilty of perhaps in your clinical practice over utilizing post ho reasoning? Or are you immune to
Jarrod Hall:
It? Oh man. , I am not, I am not immune to it. And anybody that thinks that they're immune to it is they're just wrong. , let's just say we're nobody is immune to postdoc reasoning. And I've spoken about this quite a bit. When I came outta school, I was a big time manual therapy junkie. I took every manipulation course in every dry needle, in course that I could within a one year span, which amounted to about 10 courses within one year 10 weekend courses, I was just loading them up. I wanted to be able to crack every neck and back. I wanted to be able to needle every hyper specific spot. And I took that to clinic and I used it with patients and patients got better. And I thought to myself, it absolutely had to be because I was doing these treatments. Uh, and then I had some of those mentors that slapped me around a little bit, the Jason silver nails and, you know, way back when like Barrett doco on Soma simple.
Jarrod Hall:
And mark Parlow was one of my mentors and the Sandy Hiltons and the Greg laymans and the BIM Corma, you know, all these people, they were all really, really smart people that were kind enough to show me how off, off, off the, you know, beaten path I was, it really made me start to, you know, step away from manual therapy. And I gradually chose to use it less. I made a conscious decision to use it less and attract some of my outcomes to see if my patients got any less better, you know, and they didn't really do any worse. And in some cases, I, I almost felt like they maybe did a little bit better cuz the discharge process went a lot smoother. It, people didn't feel like they needed to, to hang around to get that treatment from me. And of course that's anecdotal and that that's my bias in, in this particular perspective, but I'm gonna, I'm gonna drop in another cognitive bias.
Jarrod Hall:
I did not wanna let that stuff go because of the sunken cost that I, I had devoted to it. And, and for those of you listening, it's the sunken cost fallacy that it is really, really hard to cut ties with something that you've spent a lot of, either time, energy, emotion, or finances, and either, you know, acquiring, learning, refining, whatever it is. If you've spent a lot of time, money and effort on something, there's a lot of cost that's gone into that. And it's really difficult to cut loose from that because you, you, you feel like you've wasted your time. You feel like you've wasted your effort. You feel like you've wasted your money. If you, if you cut ties away from something or reduced how much you're using that thing that you spent so much on.
Jared Powell:
Yeah, no mate, that's, that's, that's fantastic. The, the financial, uh, or intellectual investment that we make in these, these interventions that we define ourselves by, we identify with, you're a manual therapist, you're an SNC coach. You're a cognitive functional therapist. You, you do PNE pain, neuroscience, education, whatever it may be. We come to define ourself by these, these interventions. And then, and then we, we kind of select the, the evidence that we, we look for out there, right. To confirm, or to verify that that method of practice, which kind of getting us into confirmation bias perhaps a little bit here as well. So let's just go there. Let's just, let's just go where the win takes us. So what's confirmation bias jar
Jarrod Hall:
well, you did a good job of just alluding to it. But confirmation bias is the tendency to only seek the information that confirms your own pre preconceived ideas or preexisting ideas. So you actively seek to confirm what you already believe with information that is like what you already believe. And this actually goes a layer deeper because it's not only information that you seek out, right? It's not just that. I only read research articles that confirm my biases, but you mute your social media with people who don't agree with you, you build your, you build your friend circle around the people who only agree with me, with you to confirm your biases. You, uh, only go to the conferences and courses that reinforce your biases. So you continually create, you know, what they call an echo chamber where you're self confirming your biases all the time.
Jarrod Hall:
And, um, a little bit less known kind of cognitive bias, I guess you could call it it's the inverse to the confirmation bias is the concept of active information avoidance. And I dunno if you've, uh, been exposed to this one or you're familiar with active information avoidance, but it is the actual act of actively avoiding information that would disconfirm your biases or would make you feel uncomfortable, right? Make you feel that cognitive dissonance. So they've done some research where they went and you know, it was, it was fake. It wasn't necessarily the participants thought it was real, but they did a whole bunch of screenings on, you know, blood, blood tests and that sort of stuff on people in one particular study. And they let them know they gave them the study results that said, Hey, you know, 10% of the people in this study tested positive for sexually transmitted disease.
Jarrod Hall:
We're sending you your own personal results in an envelope to know if you were one of those 10% of people that, that tested positive for this STD in a tremendous amount of people would actively avoid opening up that envelope because they didn't want to encounter the information that may have told them that they were positive for an STD. So they would just let that STD continue to be present in their body. And they would also potentially risk spreading that to other people because they would actively avoid engaging with that information that uncomfortable. So you have confirmation bias where you seek what is comfortable to you and then information avoidance, where you avoid anything that may cause cognitive dissonance or make you feel uncomfortable.
Jared Powell:
Yeah. That's getting some, that's getting into some deep psychological sort of, uh, almost concepts there. I I've just read one of Jordan Peterson's books recently about, and that kind of, it kind of alludes to that. If you've got a problem in your life, if you've got something that you are avoiding or you are neglecting, it's just gonna grow bigger and bigger and bigger and bigger until it starts to occupy all of your life or all of your room. I think he uses a dragon analogy anyway. It's, it's interesting. It, it eludes exactly to that. It's this, it's this intrinsic implicit adverse reaction to, to information that will cHallenge us or make us feel momentarily chaotic. And I've, I've got a bit of a principle. I've got a, I've got a thought about this, about confirmation bias. So are you aware of, uh, Cal Friton and his free energy principle, which sort of underpins predictive processing at
Jarrod Hall:
All? So, um, I'm aware, but I would not classify my classify myself as super fam super familiar.
Jared Powell:
So, so Carl Friton is a English neuroscientist that there's a, there's a hot tip that he's going to be, he'll win a, a Nobel prize within the next five to 10 years. He's the, probably the most foremost neuroscientist of all time, he kind of invented functional magnetic resonance imaging. And he's moved on from that to this thing called the free energy principle, which there's so much mathematics in physics involves in it. That's okay. But we can understand it from a qualitative perspective in effectively. What it means is that humans or any biological system, which we are one, a complex, one seeks to reduce or minimize free energy within us, what that is it's minimizing entropy or minimizing chaos or minimizing surprise or prediction error. So being wrong if we were wrong too often, if we were walking around the world and we just constantly had surprise and prediction errors coming into our system, we wouldn't get out the front door because it would, we would be overwhelmed.
Jared Powell:
It would be too much for our system or our brain or whatever to handle. So we use, we have this inbuilt free energy principle within us where we seek to minimize surprise or minimize being wrong. So I think that feeds into confirmation bias in, or, you know, your world view is always more right than somebody else's and it's it's, I think it's to suppress or to minimize free energy or, or being wrong. Otherwise it's chaos. We wouldn't, we wouldn't have prospered as a species. So, so I think confirmation bias whilst we can be aware of it and try and reduce it, whether we can or not as a species. Well, at least I don't think we could. I think there's always going to be an instinct towards it. So you might just have to think a bit slower and maybe we're getting back into Danny Carman's book here in terms of thinking fast and slow, but there might always be a gut reaction or a visceral reaction to information that let's say for information that doesn't agree with you or with your worldview. Let's say a journal article comes out that doesn't agree, your hypothesis. You're gonna go through that journal article. You're gonna go through the method section, aren't you with a fine tooth comb and say, well, this is only this. They use this inclusion criteria. So it's not a pragmatic trial. It doesn't apply to everybody else. Why did they define the injury like this? Or it's only a six week follow up or this outcome measure is not valid. Do you do the same thing with information that you agree with?
Jarrod Hall:
No does. Cause cause it automatically, it automatically jives with your, with your inherent ideas that you have. So you don't need to go through it with a fine, you don't need to really vet it out because it, it confirms what you think.
Jared Powell:
Mm and that's, and that's exactly right. So we're getting, it's a self-fulfilling prophecy there. It all gains momentum over time. And as you suggested a moment ago, that's how we get into these echo chambers. And that's how we, we follow the same people that agree with our beliefs and then so on and so forth. And that, that sort of exponentially increases over time. And as soon as you are confronted with somebody who has a different worldview, then you start thinking, well, how can this person think that, how can they live like that? You know, let's say America in the west or Australia in the west or, or Western Europe or whatever. And then we're exposed to somebody in the east and they have a different philosophy, a different religion, or a different way to live or different political system or whatever it may be. We think we've gotta liberate these people, right. We know how to live, how, and, and it gets into politics and it gets into all these things around the world. And it it's when you reduce it, it's, it's coming back to a very well known, cognitive bias. It, it's funny how the world can operate like that. And these things can get outta hand.
Jarrod Hall:
Oh yeah. We'll throw in a couple of more biases, right? The appeal to authority. When, when you have people in places of authority that, uh, have a lot of power, they have a lot of influence. They have a lot of spotlight. Well, their cognitive biases can shine through that much more. And then there will be those of us who really have a strong appeal to authority. And then what happens is another bias, which is, you know, the appeal to crowds or the appeal to, you know, the size of crowds. There's a bunch of different names for it, but the more people that appeal to popularity, they' more people that believe something or think a certain way that we're exposed to well, that way must be the best that that way must be. Right. Uh, and you mentioned that we're in a Western society who functions a very specific way.
Jarrod Hall:
So, uh, if we take this away from hyper specific minutia of physio, or even the healthcare professions we're in, we're like in, you know, enveloped within a certain social culture, uh, that is highly westernized, right? Uh, I guess I was reading, I just finished homo by UV all Noah Harari today and was talking about weird people, white, uh, educated, you know, independent like westernized and all this sort of stuff. Um, democratic people. These are the people that are in a bulk of the scientific, you know, evidence, especially in the Western world that we're trying to apply across every, you know, every, to every person and to every culture in the world and to every, uh, ethnicity and to, you know, across both, uh, well, all genders and everything like that. So we're, we're taking this hyper, you know, specific research base and applying it to everybody because we think that best way it must be because that's what we're most exposed to. So, uh, it just, it just snowballs. And I know that we're getting a little bit off topic, but it just, I can't keep it in. It just, it goes layers and layers and layers out.
Jared Powell:
Yeah. You have to follow these, these, um, thought experiments through, because if you just stick to physio or stick to medicine or stick to whatever, or scratching the surface, it, because it's inherent to humans, it's inherent to all human endeavors. Right. And so that's not just physio, like science is, is very much it's like science is as exposed or as vulnerable to all of these ideas, in my opinion than all the other pursuits or all the other professions, or what have you out there. And this is why, this is why I love philosophy of science as well, because philosophers of science really go after science and they go after, you know, just how perhaps infallible it is. And it's something that I've, I'm coming around to I'm coming from such an empirical background. Uh, you know, if somebody, for me was a science denier or science skeptic two years ago, a year ago, I, I, I really couldn't have seen where they were coming from.
Jared Powell:
And I'm not, I'm not a science denier at all, in fact, quite the opposite, but you, we have to be aware of its limitations. And we also have to be aware of the biases that are baked into science, as well, as you just said, a moment ago, the, with the weird principle and the Harari book, it's the same thing with scientific experiments, right? They're usually in what undergraduates at a university 20 year olds, especially in these psychology experiments. And then we extrapolate all of those findings to every demographic in every culture, from every background all around the world. And we expect that to hold. And again, it's, it's a, it's flawed, critical thinking there anyway. So let's, can we like, can we go to a different bias for a moment please? Yeah. Yeah. So this is a really cool one for me, self-serving bias the tendency to claim more responsibility for successes than failures.
Jared Powell:
And this, this is so relevant and this resonates for me as a physiotherapist. It's the classic thing we've heard about it before you, you, you are more likely to remember the successful patients that you had with a certain intervention versus the ones who fall off the radar, perhaps don't rebook or come back once or twice, and then you forget about them, but you certainly remembered those ones who really responded to your pain, uh, neuroscience education, or to your specific pain metaphor, but you don't quite remember the ones who don't. Do you have any anecdotes or stories around this one jar
Jarrod Hall:
oh yeah. I, uh, I definitely, uh, I definitely have plenty of, of failures and, you know, I can think of, I can think of one person in particular. Uh, she was, you know, maybe a 65 year old lady that I was treating three or four years, but it was probably four or five years ago. This is when the pain science stuff was really new to me. And of course it was highly available. So I was over utilizing it. Right. Uh, I was just inundated with it. And I was in a point in my career where I thought that it would be a really good idea to sit down on day one and lecture people for 30 or 40 minutes about pain and tell them how it's this highly complex thing. It's, you know, it's created by the brain. And I did my whole spiel and I had my marker and my like, you know, my whiteboard out and I was doing, I was doing the whole thing.
Jarrod Hall:
And I was so involved in what I was doing that I didn't realize that this person had just completely glossed over they're they're not interested in what I was saying, but they were polite enough to wait until I was done. And she just looked at me and she said, are you done now? . And, and I said, yeah, like, doesn't make sense. She said, well, that sounds like a crock of to me. My back hurts because I, you know, X, Y, and Z. And if you're not gonna do X, Y, and Z, and you're just gonna talk to me, then I'll go ahead and leave right now. And that was, that was a little bit of a gut check. That was a wake up moment for me. Uh, that, that was one of the times that helped me realize that, um, may, maybe we shouldn't be lecturing at people about pain. Maybe it's a little bit more nuanced and a little bit more complex than that. Maybe I shouldn't forget about the person on the other side of the conversation. It's not a one it's not a one way thing.
Jared Powell:
Really. It's not, uh, okay. I gotta change how I'm gonna practice jar. Yeah, no, you're right. The, the pain education revolution as it were, you know, over the past decade has been generally a good thing. Uh, but it certainly can have, uh, a dark side as well. And these you're right. And I'm, I'm, I've been guilty of this in the past too. And it sometimes fall into a bit of a trap. I just give too much information about something that a person probably doesn't give a about. So trying to gear your education towards that individual in front of you is it's a key Le lesson in being a, a good clinician. But again, it's sort of your, our biases or our self-serving biases is coming into play the as well. You, you remember where pain science education was maybe effective for some, it just doesn't mean it's going to be effective for, for all. And for some, they might be turned off by physiotherapy as a result of it, and perhaps seek treatment or therapy from somewhere else. So, always important to remember this is a good one, Jarrod overconfidence bias. pretty obvious. I think this one, what what's over confidence bias
Jarrod Hall:
Well, I, I, I have a feeling, I, I don't know the exact definition, but I have a feeling that it's a bias in which you have a false assumption or a false sense of, uh, skill or expertise, or that maybe, you know, a little bit more or better than you possib than maybe you think that you're better than maybe you are. So you, you have a lot of overconfidence that leads to overstepping, or, uh, maybe putting your foot in your mouth or, or maybe, you know, not performing to the level that you think that you should probably goes a little bit hand in hand with the Dunn and Kruger effect.
Jared Powell:
Yeah. Spot on. Yeah. Effectively an inflated opinion of, of, of yourself. That's not just in personal life, that's in let's let's ed through our perhaps diagnostic abilities, right? So if somebody comes in and you have these hands, Jarrod, you have these hands and you can palpate the, my nature of dysfunctional joint movement in somebody's Lu spine. So you have an overinflated opinion of yourself, irrespective of whether it's right or wrong, that you're doing that. But you think that you can, you can diagnose that person's suffering. You can feel the actual root cause of their painful experience if that's even possible. And then you confidently say that to the person and then, and then you match an intervention to, to fix them. So there's a few biases baked probably within that whole clinical scenario. There, it comes back to that, that guru effect. And the funny thing is Jarrod, right, would that person, and this is playing the devil's advocate for us, critical thinking, rational people who, you know, we put ourselves on these pedestal, does that person have any worse outcomes, worse clinical outcomes than us by going down that pathway, if we looked at it from a pure objective effect size perspective, I wonder if we took a couple of groups with the same pathology someone saw you or me, we seem like we have similar clinical reasoning and somebody saw the guru followed them up at 12 weeks and then a year, how would the clinical outcomes be?
Jared Powell:
What do you think?
Jarrod Hall:
I think for the vast, well, you know, it, I think that research, our current evidence tells us that the outcomes would probably be relatively similar. We, we probably wouldn't get to a clinical difference, right. A clinically significant difference. We might be able to get some statistical difference that we PHA and, and argue with each other about. Um, but I think in the vast majority of patients, we probably wouldn't have a dramatically different, you know, outcome. However, this is where I'm going to openly recognize my bias. My bias is that, uh, you know, maybe certain narratives for certain people could be more or less harmful or helpful. So my, my personal bias that is not necessarily well confirmed, there are some smaller studies that maybe show that the narrative that we lead people with or whether it is, uh, something that is, uh, empowering or positive or something that maybe promotes, learned helplessness, or maybe reduces pain, self efficacy might lead to more disability or more, uh, utilization of medical care in the future.
Jarrod Hall:
And, and I'm, I've kinda moved away from trying to argue over 0.5 outta 10 on the, the pain rating scale. And I think my, my mind these days was more worried about, uh, population level health and medical fund utilization, insurance utilization, disability levels, uh, disability adjusted life years and qualities and that sort of stuff. I, I, I'm starting to think down those lines. And, and I guess you could say maybe more of a utilitarian viewpoint of how do we create the least amount of harm or the most amount of good for the most amount of people. And yeah, I want to practice in a way that minimizes, um, the harm that I may, uh, directly or indirectly caused to a person either now, or, or somewhere down the line. And that gets into a really, really difficult thing to study because, uh, the human life is complex and, and health is complex and injury is complex and medical utilization within different cultures. And societies is very complex. So I don't, I don't know that we have the answer, but I'm being very forthcoming with what my bias is.
Jared Powell:
Yeah. I think your bias is probably okay there, it's probably somewhat on the money and it's a, it's a noble bias, right? We're thinking about general health, as opposed to the primary outcome measure in these studies, which is usually pain of a VA score out of 10 and perhaps a, a patient reported outcome measure. And, you know, then we equate those two with, ah, look, there's no clinical difference between these two, just do whatever. It's not as simple as that. You do have to think about kind of what you are invoking there, value based care. And what, what does this do if we scale this at mass, are we just going to allow everybody to go and have, go to a spa three times a week and have some hot stones put on their back to, to manage back pain? Probably not. It's probably not going to be the best bang for your buck.
Jared Powell:
So no, you're right. But the thing is, if we kind of advocate science in some respects, right? We're like, you've gotta be science informed. And then we do the science and the randomized control trial might not show any difference, but then we do invoke some other things to try and make ourselves feel better. It is, it's a, it's a, it's a funny thing that we do to, um, it kind of comes back to the, oh, anyway, let's not get into the, the limitations of the, of the randomized control trial. um, uh, some Jarrod something, and this is really important. So communication is all the buzz in physiotherapy these days. I've never seen so many communication mentorships or, uh, what have you around these days? It's a great thing. Communication, I think is the next wave of strength and conditioning or manual therapy or pain education.
Jared Powell:
I think that's, that's the 2020 buzz. And it's good. So the framing effect, the framing effect is another bias where I think communication gets stuck in with. So the framing effect is I think in our communication, we can actually force a patient for example, to make a biased decision based on how we frame the message that we deliver to them. For example, if I tell you, Jarrod, you come in to see me, you have back pain. I say, Jarrod, if you do this, uh, exercise program that I prescribed to you, there's an 80% chance that you're going to get better in 12 weeks. Versus if I say to you, Jarrod, if you do this exercise program, there's a 20% chance that you won't get better in 12 weeks. Will that influence your decision to actually do that therapy?
Jarrod Hall:
I mean, absolutely you, I mean, you're telling me there's a one in five chance that I'm gonna, that I'm gonna fail, right. Not
Jared Powell:
Waste.
Jarrod Hall:
Yeah. Not a four in five chance that I'm gonna succeed. And this just popped into my head while you were talking about that. One of my, I, I don't wanna call it a pet peeve, but one of the ways that I see this used really frequently, that bothers me is people that misconstrue absolute versus re relative risk, right? So we'll talk about an intervention or we'll talk about something or we're selling a supplement, whatever it is on an infomercial. And they say, well, if you do this, then you're gonna have a 300% better outcome. And what they don't tell you is, well, that's, that is relative change. But absolute change is from a 0.3 likelihood to a 0.9 likelihood, uh, you know, or a less than from less than 1% to still less than 1%, but it's 300% more . So we can frame it to somebody as look how great this is. It's 300% better, but on an absolute scale, it's really a minuscule change. It's a non noticeable change. It's, it's almost zero, but the way that we frame it to them really sells that message and it gets people excited about it, or it, it causes them to buy our product or do whatever we want. How'd.
Jared Powell:
Yeah. So this is why I'm real big fan of this shared decision making, uh, momentum coming along in, in, in physiotherapy and, and healthcare generally, which is good because shared decision making by, by the, the definition or, or what comes with shared decision making is that you must to a patient to the best of your ability, say this, these are all the options available you to manage your shoulder pain. This is the chance of success. This is the chance of failure. You, as an individual are now free and I'm gonna give you space to select that intervention, knowing the pros and cons of each intervention. I don't do that enough in my clinical practice. I, I don't, I still don't sit down and I map out, okay, you have rotator cuff related shoulder pain. For example, this is the evidence you have injections, you have surgery, you have strength and conditioning.
Jared Powell:
You have manual therapy, you have doing nothing. You have weight and watch, I don't sit down enough because my bias is towards exercise therapy or, or something like that. And I will sell I'll. I'll still will sell that. I'll still frame exercise therapy as the best intervention. And look, it probably is when you actually look at the data given, if we, if we look at value based care, it probab probably is the most value for your money considering benefit and harm compared to all the other things that we can offer. But I don't really go down the pathway of telling the person the pros and cons of each other intervention, because if you actually look at value based care or, or what's value for money, wait, and watch, or natural history is always going to be the best value for money. Right. But that's not gonna be okay for everybody. So the framing effect is a, is a fascinating thing to consider.
Jarrod Hall:
Yeah. It's de it's definitely something that, you know, I don't, I don't know that I do well enough either. I think that I like to, I, I like to think that I share in this, um, decision making process with patients, but now that I reflect on it, it's probably a little bit, it's probably not as shared as I would like to. Yeah. Like to believe or, or, or like to tell myself, because I will lay out a plan and say, does this sound reasonable to you? Would you like to change anything about it? Is there anything that doesn't, you know, doesn't jive well with you? So in my mind, I'm providing them, you know, shared decision making and things that are part of their plan, but I'm not actually zooming it out that extra step and saying, well, I, you know, one of the pathways that you can choose, but you could also choose these other pathways as well.
Jarrod Hall:
And, and that's probably to some degree because of, I function in the United States where we don't have, and in Texas in particular, we don't have very good direct access. Um, so the vast majority of patients that I see, 98% of them, or 95% of them are referred to me. So they've, they've already been told that that's the path or, or they've already chosen that that's the path. So I probably falsely make that assumption sometimes, but it would be very much, it'd be very interesting, you know, in, in your setting where you're probably very much more direct access to patients and they're coming to you much more off the street to look at it from that level, that zoomed out one more level of, I am an option, or this is an option, but there are also these other options. And why don't you choose between those?
Jared Powell:
Yeah, it's so hard because people fundamentally want an answer. People when they're in pain, mostly they seek care when they're not coping and they need assistance, they need help. And so it's hard to say, to invoke shared decision making all the time, because that person is unclear on what they want or what they need. They want to be led to the right answer if it exists, right? Like as if there's ever one answer for every single individual, but that's what they want. And that's what I would want. If I was a lay person, I had no knowledge about the body and about pain. I, I would want an authority or an expert to tell me what to do. And then I would judiciously do it. I would probably do the same if I had an aneurysm in my brain, or if I had a blocked artery in my heart, I don't think, I don't think I would. I don't know how I would respond to a, to a brain surgeon or a neurosurgeon saying, these are the options here. You make your decision. I'd be like, doc, I trust you. Tell me what to do. Do you think that has some resonance in our practice?
Jarrod Hall:
Oh, I think it absolutely does. And you, you kind of got me a little bit off track because while you were speaking, I, I started imagining myself having that conversation with, with a doc and, and, and then it went back to the framing effect of, well, what if they said to me, uh, well, Jared, you have a 10% chance of dying of dying from this operation versus you have a 90% chance of surviving this operation. And I, I, I kind of got a little bit lost because I, I, I had almost like this out of body split second experience where I was in, I was in that brain surgeon's, uh, you know, office while you were talking. And it was a surreal and heavy feeling. Magic Apologize if I out there for a second, did it.
Jared Powell:
So what were you feeling in that position, Jarrod, when you were, when you were, when you traveled through time or through the ether to another dimension and you were in a hypothetical scenario and you were the patient in a doctor's office, and that, that doctor said to you, you have a 90% chance of survival. If you, if you undergo this surgical procedure to fix your aneurysm, or you have a 10% chance of death, what would you do?
Jarrod Hall:
I, I think that the framing effect really does work there because a 90% chance of survival does sound very, sounds a lot more positive than
Jared Powell:
Aing.
Jarrod Hall:
Yeah. But, but at the same time, I, I would, I would want that person to not just say, well, you know, you could wait it out and see what happens, or, you know, we could try this, uh, other medication. It doesn't really have great, you know, uh, it doesn't have great effects. You, you could, you could maybe go to a shaman or something like that.
Jared Powell:
Try the naturopath, try the homeopath.
Jarrod Hall:
No, you, you, you could, you could try a, a thousand times diluted solution in water and see if that makes you, it goes away from the naturopath or whatever. I didn't lay out all of these scenarios for me. They, they recognize that this is, this is one of the most evidence based paths that I, that I have here. And I'm offering you the information within this, you know, buffer zone. Right? And, and I think that I can't remember the name of this. It's not a bias, but it's, it's essentially a human concept that we so much so rely on the expertise of other people. Because as an individual, it's the kind of the, the collective knowledge of mankind, the collective knowledge of humans, we rely on that. And we make so many assumptions that when we go to the doctor, right, when we go to the neurosurgeon, this person is at the pinnacle of, of education and UN understanding in this realm.
Jarrod Hall:
And I'm going to trust what they say, because they know so much more than I do. And when we invite a plumber into our house to fix our pipes, well, they know so much more than I do, and I'm relying on their expertise. And, uh, when somebody is flying a plane, we don't ever even see the pilot. We're just sitting in the back of a plane and this guy's flying us through the air at 500 miles, an hour, 30,000 feet off the ground. We just say, yeah, you know, we're gonna get there. It's gonna land. He's not gonna crash. He, he knows what he is doing. So we have all of this, uh, trust in the knowledge and, and, and the combined expertise of humankind, even though individually, we, uh, on average are not all that talented or skilled. When you look at the vast amount of things that human beings can be talented or skilled at. And, um, that in particular reminds me of a book I read by Steven slow called the knowledge illusion. Uh, and it was all about this concept. And if you haven't read that book, I, I definitely recommend it.
Jared Powell:
The knowledge effect. Did you
Jarrod Hall:
Say the knowledge illusion by Steve,
Jared Powell:
The knowledge illusion? So, so Jarrod, this is why I've named this YouTube show on the shoulders of giants for that exact same spiel that you just delivered. The, so where we are, we are, where we are now, right. Is, is basically due to all the work that people have done before us. We are standing on the shoulders of giants. So we should respect that we should respect the work that's been done before us and not arrogantly look back and say, oh, I can't believe they did it like that, then blah, blah, blah, blah, blah. That's all the knowledge that they had at that time knowledge progresses science is about the progression of knowledge over time through, through hypothesis formation and then testing, and then falsification or verification, and then modification. So on and so forth. It's something that changes over time. It's, it's not something that's stagnant or static and, and you're right.
Jared Powell:
I think people actually fundamentally see this. If I go and see an orthopedic surgeon for help with my painful bone on bone knee, then that surgeon's been trained in a university institution. He's been practicing for 20 years. So he's got many cases under his belt. He's reading scientific literature, he's talking to colleagues, he's building knowledge over time, right. So then why wouldn't I, as a, whatever, I am a construction worker, lawyer, whatever, someone with no knowledge of medicine, why would I expect to not, not cHallenge that person's expert opinion, but be involved in the decision making process. It's a funny thing to consider shared decision making. I love the theory of it. I love the conception of it. I love the nobility of it, especially, you know, with like, you know, not everybody has access to healthcare and not everybody like the inequities of healthcare and everything are outta control and shared decision making can be helpful towards that. But, and this is what Chad cook told, told me recently in, in my conversation with him, is that when you actually look at the data of shared decision making, there's actually evidence that people who are involved in a shared decision making process have worse clinical outcomes than people who are not involved with a shared decision making process.
Jarrod Hall:
You know, I mean, that, that doesn't necessarily surprise me because when we think about, you know, when, when I think about the average patient that comes in to see me, they have a lot of preconceived ideas and they they've seen a lot of things on social media. They've had a lot of friends that did this, or they, you know, that used their copper fit band that fixed their knee, or they squirted WD 40 on their knee and it got better. Or they put, put lettuce and wrap on their knee. You know, all of these things that I've seen on, on different, uh, you know, funny news sites and, you know, you hear about anecdotes. We can't necessarily what we want to engage in shared decision making, but we can't necessarily just assume that, you know, a person's expectations or a person's desires is going to be in line with what we do know is at least current best evidence.
Jarrod Hall:
So it's not necessarily super surprising to me that if we engaged in shared decision making, in a way that allowed the confines of good current evidence to be violated, that we probably wouldn't have super awesome outcomes. And I don't know if this has ever been discussed, but it just dawned on me that, you know, if a patient just decides that they want to be guided, is, is that not a form of shared decision making that the patient has let you know that, Hey, you're the expert. I, I want you to take the reins on this. I I'm giving over the control to you. And that, that is my decision. And I want it to be that way. And that's not something that I had considered until just now that having somebody allow you to take the reins and practice to what they trust your expertise to be, can be a form of shared decision making.
Jared Powell:
Totally. If that person is volunteering that information to you and is not coerced, or doesn't feel pressured into saying that, then that's absolutely part of shared decision making. That's perhaps how it should be. I should clarify shared decision making. Shouldn't be just doing what the patient wants. It's a meeting in the middle, right? There's this meeting in the, I think Matthew locals are the intersubjective space between you as a clinician and that person as a person, as an individual, how are you gonna meet in the middle to achieve a common outcome? And I think that's what shared decision making is. And, but that's, that's an art form. That's hard to do. There's not a framework. There's not an algorithm that you can go through and say, okay, I'm doing shared decision making here, right? that's, I think that's the art of being a good clinician.
Jared Powell:
And then sometimes that, that gets lost in purely empirical pursuits. And this is why gurus and healers can do well. I think sometimes because they, they, they do listen. Some, they might, they might recommend some pretty interventions, but they're good listeners and they're available and they're supportive and they're empathetic and their clinic feels nice cuz there's candles and nice, nice artwork and they get a nice massage. Anyway, we're getting off track a bit like the thing that the finally Jarrod I wanna touch on is, okay, so we accept that cognitive biases are probably fundamental to the human condition. It's baked into being a human being and we can't negate them or we can't rid ourselves of them, but are there things that we can do to mitigate their negative effects?
Jarrod Hall:
I want to say yes. And, and I, I do think that there is some evidence maybe to say to some degree, yes. Will we ever get rid of them or get them completely under control? No, but one of the analogies that I read from Jonathan, Jonathan height, or hate, however you pronounce his last name, it really stuck out to me and it's become one of my best and most it it's my most favorite way to conceptualize this is that, you know, much like Danny conman and type one and type two thinking, uh, Jonathan height, he describes it as the writer and the elephant. We have, uh, the elephant, which is a big, huge, powerful animal that if it wanted to, it could absolutely take control. It could squash us. It, it, it is much more powerful than we are as the writer, but over time.
Jarrod Hall:
And the, the, the elephant is our subconscious, the elephant is our autonomic nervous system. The elephant is our type one, thinking it's our fast thinking, it's our reactionary thinking. It's, you know, what people would call our gut instinct or, you know, our, our reflexive, um, response, right? It's all of that stuff that happens in our, in our lizard brain, I guess you could say, whereas the writer, the writer is more like our cortex and the writer is conscious decision making the, the writer is metacognition. The writer is, um, this thoughtful, reflective, uh, you know, conscious cognitive agent that rides on top of the elephant. So that's, that's our cortex over our lizard brain, or that's our type two thinking over our type one, thinking that's our slow thinking over our fast thinking and, uh, elephants and writers, they do build a relationship with people over time.
Jarrod Hall:
And maybe when the elephant is young, maybe before the elephant has been trained, it gets off track a lot easier. It gets spooked. It gets, you know, and, and it runs off the trail. It, it gets upset. It, it deviates from the path and the rider has to pull very, very hard on the reins of the elephant to get it back on track. The rider has to use, you know, the whip in the back and, you know, that sort of thing, and really has to coerce the elephant to get back on track either through force or whatever it may be, but maybe over time as the writer and the elephant develop this relationship with each other, and there's this constant communication. And the writer learns to understand, uh, when the elephant reacts and why the elephant reacts and the writer can maybe, uh, put fail safes, uh, uh, ahead on the pathway to prevent the elephant from, you know, getting spooked or getting off track, or the elephant learns to respond to the writer a little bit more quickly, or a little bit less aggressively.
Jarrod Hall:
I think that that's the same thing as being, becoming aware of all of these cognitive biases and, and, and, uh, you know, fallacious thought processes that we have. And then gradually over time. And we're, we're talking months and years in a lifetime of building this relationship, uh, and training each other to, to work more synergistically in tandem, the writer and the elephant to keep everything on track, to have less aggressive, um, veering off the track to have less stampedes and all of that sort of stuff that, that lead to problems. So I do think that through purposeful metacognition and practice and learning, becoming aware of these biases, becoming aware of fallacies, actively engaging and reflecting on when you do commit them and, and being open to being exposed to them is a way to maybe over time, try train the elephant and maybe make the writer a, a, a better writer of the elephant. And I know that was a very long thought process and story, but when I read it, uh, I believe first in, um, the righteous mind by Jonathan, that it really stuck with me. And it's, it's just helped me conceptualize this so much. So I hope anybody listening that that actually made some sense.
Jared Powell:
That was very well said, Jarrod, Jarrod, that's a fabulous book, too. Everybody should read that book, uh, by Jonathan HT. And it it's actually it's that analogy is actually extended from originally Arthur sharpener, a philosopher German philosopher, who said originally, I think in the 18 hundreds about there's a blind man or woman, and you are riding on the shoulders of a blind man. You're kind of at the whim of where the, where the blind person wants to go, but you can end up seeing for the blind man with communication. Um, and it's kind of what you're saying with the rider on the elephant, where there's this deep seated will with, or our reptilian brain. The elephant's powerful. If the elephant wants to turn left, it will turn left. The rider can't do much, but through shared decision making Jarrod , uh, and some sort of synergy, then perhaps you can work together. And I think that's a, that's a wonderful place to, to finish this, this conversation, uh, before you go, I always ask everybody, what book are you reading right now? And what TV show are you watching? You gotta tell me what cheesy TV show that you're watching, Joe.
Jarrod Hall:
Okay. Well, I just mentioned earlier today, I finished up homo by Yuval Noah Harari, and a couple of weeks back, I finished up, um, exercise by Dan Daniel Lieberman. You and I had chatted briefly about that. There was some interesting, interesting concepts in there. Um,
Jared Powell:
Do you recommend that book?
Jarrod Hall:
I, I do believe that it's worth a read. I, I don't necessarily agree with everything that was proposed or, or, you know, written by Lieberman in the way that he went about it. I, I think that some of his biases definitely showed through in the writing of the book, but I do think that it's worth a read because it was, I think it can be really helpful for the average person to reconceptualize physical activity, exercise, and movement, and actually maybe take a lot of the stress off of performing physical activity because we've gone, we've become a society that is hyper hyper medicalized or, you know, hyper, you know, um, I, I don't, I don't know, mechanized almost exercised it's this just almost exercise is this just gym routine, just run on the pavement gym routine, lift weights, machines, et cetera, et cetera. And, and there are ways to be very healthy through physical activity that aren't necessarily this, uh, this mode of exercise that doesn't fit a lot of people's, you know, um, preferences or what they is something that they enjoy. So I think that it was a freeing read for conceptualizing physical activity and the health benefits of it without having to be boxed into the, the concept of modern day exercise. So in that, through that lens, I definitely think it's worth the read and then TV show. My, my wife and I, we just, uh, recently finished up binge watching all of the Outlander, uh, series. And yeah, I will shamelessly admit is one of my favorite shows that I've ever fantastic.
Jared Powell:
I watched one episode couple years ago, couldn't it. I have to go back and revisit it.
Jarrod Hall:
E everybody says this the first, you know, four or five episode, they're, they're really not good. It's slow. It's, it's very hard to get into, but by the second half of the first season, you're really starting to get hooked. And I, I agreed reluctantly to watch it because my wife she's like, we're gonna watch it. And I finally said, okay. And, uh, you know, about episode six or seven of the first season, I started saying, okay, all right. And then by the second season I was you .
Jared Powell:
I love it. Good. Okay. So Jarrod Hall is recommending Outlander and is recommending exercise. I assume you're going to recommend, uh, sapiens with SAPs or homo
Jarrod Hall:
Homo
Jared Powell:
SAPs,
Jarrod Hall:
But SAPs is great if somebody, the book that I finished before that if you really, really deep, difficult concept, not difficult, but conceptual, um, mind blowing read, it's called the idea of the brain by, um, Matthew Cobb. And it is a fantastic read that starts basically 4,000 years ago in history and, and goes through the whole conceptualization to modern day neuroscience of what we know about the human brain and nervous systems and AI, you know, neural networks and how little we actually know about the brain is very, very humbling and makes me laugh now when research studies making, uh, what we sort model that human human behavior.
Jared Powell:
Jarrod, thank you so much for, for joining me and chatting about these weird and wonderful things and going into, uh, other dimensions in our thought process and, and, and touching on things from politics to philosophy, to neuroscience, to sociology, to psychology, to physiotherapy. It's been a wild ride, mate. Thank you very much.
Jarrod Hall:
No, thank you. I appreciate, I appreciate you having me on
Jared Powell:
Cheer mate. Thank you for listening to this episode of the shoulder physio podcast with Jarrod Hall. If you want more information about today's episode, check out our show notes at www dot shoulder, physio.com. If you liked what you heard today, don't forget to follow and subscribe on your podcast player of choice and leave a rating or review really helps the show reach more people. Thanks for listening. I'll chat to you soon. The shoulder physio podcast would like to acknowledge that this episode was recorded from the lands of the Yu GABA people. I also acknowledge the traditional custodians of the lands on which each of you are living, learning and working from every day. I pay my respects tos past, present, and emerging and celebrate the diversity of Aboriginal and Torres stra Islander peoples and their ongoing cultures and connections to the lands and waters of Australia.
