Dr. Nathan Kadlecek, PT
Is a physical therapist committed to providing high quality health information, largely focused on lower back pain and the gross overuse of diagnostic imaging, medication, surgery, low quality treatment methods, and the over-diagnosis of pain conditions. He's also a powerlifter, pain nerd, macro-scale thinker, and wants to help you think differently about pain, healthcare, and life.
"Uncertainty always creates doubt, and doubt creates fear."
Oscar Munoz — CEO, United Airlines
(personal opinions aside of this guy — I like the quote)
Uncertainty is a beast. “I’m really worried about this pain getting worse, I don’t know what to do. Will I need surgery?” he said. A past client of mine sent me a message on Instagram asking if I had some time to talk about a recent knee injury.
He ran. It popped. He got scared. What do you think happened?
Before I get into it, let’s talk about what he said first. “Will this get worse?” I think I get this question more than baristas at local coffee shops get the question “what’s the wifi password.” It’s a great question but it really is only a surface level question. Why are you worried the pain will get worse? Have you or a family member had previous experiences of something like this getting worse? Getting down to the root causes of the fear of this uncertainty is incredibly important.
To battle this uncertainty, people have tried many things… the “sure-thing principle,” was proposed by L. J Savage, an economist as a way to deal with uncertainty. Here is an excerpt from a great book “Made to Stick:”
"A businessman is thinking about buying a piece of property. There’s an election coming up soon, and he initially thinks that its outcome could be relevant to the attractiveness of the purchase. So, to clarify his decision, he thinks through both scenarios. If the Republican wins, he decides, he’ll buy. If the Democrat wins, he’ll do the same. Seeing that he’d buy in either scenario, he goes forward with the purchase, despite not knowing the outcome. This decision seems sensible—not many people would quibble with Savage’s logic.
After this initial stream of logic, two other psychologists, Amos Tversky, and Elder Shafir had a different idea. Their example is as follows: "For instance, imagine that you’re in college and you’ve just completed an important final exam a couple of weeks before the Christmas holidays. You’d been studying for this exam for weeks, because it’s in a subject that’s important to your future career. You’ve got to wait two days to get the exam results back.
Meanwhile, you see an opportunity to purchase a vacation during the holidays to Hawaii at a bargain-basement price. Here are your three options: You can buy the vacation today, pass on it today, or pay a five-dollar fee to lock in the price for two days, which would allow you to make your decision after you got your grade. What would you do? You may feel some desire to know the outcome of your exam before you decide, as did the students who faced this choice in the original experiment.
So Tversky and Shafir simply removed this uncertainty for two groups of participants. These groups were told up front how they did on the exam. Some students were told that they passed the exam, and 57 percent of them chose to go on the trip (after all, it makes for a good celebration). Other students were told that they failed the exam, and 54 percent of them chose to go on the trip (after all, it makes for good recuperation).
Both those who passed and those who failed wanted to go to Hawaii, pronto. Here’s the twist: The group of students who, like you, didn’t know their final exam results behaved completely differently. The majority of them (61 percent) paid five dollars to wait for two days.
Think about that! If you pass, you want to go to Hawaii. If you fail, you want to go to Hawaii. If you don’t know whether you passed or failed, you. . .wait and see? This is not the way the “sure-thing principle” is supposed to behave.
It’s as if our businessman had decided to wait until after the election to buy his property, despite being willing to make the purchase regardless of the outcome. Tversky and Shafir’s study shows us that uncertainty—even irrelevant uncertainty—can paralyze us."
Heath, Chip. Made to Stick (p. 36). Random House Publishing Group. Kindle Edition.
Isn’t that fascinating?? Due to uncertainty that was created, over an outcome they had literally 0 control over, they still wanted to wait until they had all the answers. And… once they did, they chose to go to Hawaii regardless of the outcome.
A similar study was done which posed two three scenarios, go to one of your favorite musicians, study for your test, or watch a new movie that’s out. The group that only had two choices, a larger percentage chose to go to the movies vs. study. BUT, when posed with two “fun” choices and studying, a much larger percentage chose to stay and study. This illustrates how sometimes when we have too many choices, even only three, it can be a bit overwhelming and we’ll choose something that we don’t really want.
I think these scenarios apply fairly well to the rehab process, too, specifically when dealing with the uncertainty of what might be ailing us? Is it a muscle, a ligament, a bone, a nerve, is something out of alignment (I don’t believe this BTW), or is it something else? There are so many competing theories as to WHAT is the cause, and how do we find the exact cause of my pain. The amount of options tend to paralyze us and we go with the choice that "comfortable," because at least we "know what we're getting."
If we only knew the exact cause in every case then we could be sure that the pain would not get worse, right? You’d think so but it’s not that simple… let’s talk about back pain for a second. Once cancer, inflammatory disorders, infection, fracture, and other red flags have been ruled out, it’s very unclear as to what specific structures are contributing MOST to the pain experience. This is largely in part to the complex nature of pain, meaning it is a combo of biological, psychological, sociological components which we simply aren’t able to measure down to a singular level of specificity (yet).
And finally, circling back to our friend with the knee that popped; he heard this pop while running, was fearful of what could have happened, and then the uncertainty, coupled with things he had read created more fear.
The conversation we had determined it wasn’t swollen, it hurt to extend it, and it had only been about 1 week since the incident. There was no instability whatsoever and the pain was tolerable. This definitely wasn’t an ACL tear (something this person was worried about), and also, even if it was a meniscal tear (also unlikely), it was way too early to even go down the route of talking injections or surgery.
When something happens that we don’t expect and aren’t experienced in dealing with, we often jump to conclusions and choose interventions that may not make the most sense. We jump to the craziest conclusions and often the worst case scenario. Next time something happens in your life that you don’t have much experience with, try to resist that urge to jump to the worst case scenario. Find someone who knows what they’re talking about and get their perspective!
It’s totally normal to find uncertainty unnerving — and sometimes clearing up uncertainty with “what it’s not” is the best thing we've got!
I’m curious… how do you deal with uncertainty? Do you fear it, or do you come up with solutions to address it?