The blindspot of clinical expertise: be wary of strong opinions

Clinical experts often hold strong opinions about the interventions they champion.  They have no doubt helped a lot of people and have also been involved in research that supports their opinions. I want to listen to these people and learn from them.

But, they have blind spot that they don’t recognize.  They will often hold negative opinions about some interventions that they are against and I think this is an area where we should listen to them less.

For example, I am an advocate of heavy resistance training for a number of conditions.  In years past I was strongly against stretching, low load exercises and some passive interventions.  And many experts would agree with me.  They (and me) would say things like stretching for tendons is useless and unhelpful, low load exercises for tendinopathy won’t increase its stiffness and won’t help with pain and recovery.

We have to ask why someone like me or a recognized expert in tendinopathy would hold strong negative opinions about stretching, manual therapy or low load exercises.  And this is where our clinical experience shows our blindspot.

Proponents of heavy load, progressive and comprehensive exercise will have seen countless patients that low load exercises and stretching did not help.  The patient feels let down by their treatment and then we implement our favoured treatment and these people recover.  Ya, heavy resistance training for the win, right? We then say “Aha, heavy resistance exercise works! Stretching and the things these people were doing before sucks!” The experts now go out and tell people not to stretch and that they must implement heavy load for the person to recover. This “underdosing” was useless in our/their “clinical experience”.

Can you see the flaw in their argument?

We only saw the people where stretching, low load or manual therapy didn’t help.  But, all the people with tendinopathy who responded to stretching or low load exercise didn’t come and see us.  They’ve already recovered.  We can’t make conclusions about certain interventions being subpar based on our clinical experience.  Because unless we are also doing stretching and low load exercises and have learned that they don’t help our own patients how can anyone make the conclusion that these interventions are unhelpful based on their personal clinical experience?

This is why we need research studies that specifically compare whatever our favourite intervention is with some other intervention.  

Clinical experience is not something that allows you to make judgements about what is not helpful if you aren’t actually trialing those interventions. We have to be more humble and reserved about denigrating other interventions. e.g. how can you say clamshells suck if you’ve never actually treated a huge number of people with the clamshell exercise?

The bottom line here is to be cautious in accepting strong clinical opinions especially in areas where people are telling you not to do something. They can make a case for what they do but arguing against something is higher bar to clear.