published 2/04/09

Buyer (of Therapy) Beware

All other things being equal, always choose the cheapest and most comfortable therapeutic option for your pain problem

by Paul Ingraham, Vancouver, Canada MORE
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Credentials and qualifications

I am a writer and retired Registered Massage Therapist (unusually well-trained for a massage therapist, a 3000-hour program). I’m almost done with a Bachelor of Health Sciences degree. I am a peer reviewer for The Natural Standard, and a copyeditor for Science-Based Medicine. My most important qualification is more than a decade of workaholic post-graduate study, clinical experience, and constant conversations with readers from around the world, including many experts who have provided countless suggestions and criticisms.

For more information, see: Who Am I to Say? More information about my qualifications, credentials and professional experiences for my readers and customers.

If two therapies both have roughly the same chance of working, choose the cheaper one. It might seem obvious, but unfortunately it’s not: patients often choose more expensive therapy than they need to. Less obvious, they also often submit to more painful treatments than they need to. For example:

People often pay for a large course of treatment — a $1500 series of Rolfing treatments — with an alternative health care professional before determining whether or not the therapy is effective for them. There are therapeutic situations that require several appointments without progress before it starts to “work,” but that is truly rare. If a physical therapy of is ever going to be successful, there should be signs of it early on. Yet many people buy therapy without the benefit of those signs.

And another example:

In massage therapy, therapists often recommend painfully intense treatments before less painful treatments have been tried. I’m not saying that very strong massage is never appropriate — sometimes it is. But it is something to try later, when gentler treatments have failed, when clear reasons for greater intensity are emerging. It’s a decision that patient and therapist should make together, because it can be extremely unpleasant for some patients, and because painful treatment is definitely not safe — there are real risks.

Why isn't this as obvious as it should be?

Just yesterday I tested this tip out on someone who was trying to choose between two surgical options. A $1500 difference as at stake. There didn’t really seem to be any way to know which one would be safer and more effective.

“All other things being equal,” I said, “choose the cheaper one.” And she said (somewhat to my amazement):

“Why?”

And she meant it! She really didn’t know why.

In her case, she had been assuming that an expensive therapy “had to be” better. It was clear to me that price tag was no real indication of the quality of the therapy she was considering — that, in fact, there was no possible way to be confident that one was any better than the other, and therefore no reason to pay more for one of them. Your options are “equal” when their quality is unknowable — when you have no firm reason to believe that one is better than the other.

I’m sure it’s more or less completely shocking how often people judge the quality of therapy primarily by its price. “You get what you pay for” is a reliable principle for refrigerators … not health care.

People often say to me, “Wow, you’re busy and expensive: you must be good!”

“Maybe,” I say. “Then again, I might also just be charming and a good businessman. You really have no way of knowing.”

I like to get people thinking.

Informed consent

Most alternative health care professionals are unlikely to say, “You don’t need my services.” Few are good at offering candid or detailed risk/benefit analysis to patients. Many can barely even define “informed consent” — the art and ethical necessity of fully disclosing all risks, including financial risks, before proceeding with treatment.

When patients don’t hear their full range of options, they don’t know it. And by golly if they don’t end up paying more. Funny how that works.

This is one of the shames of alternative health care. Doctors are mostly much, much better at doing informed consent than therapists. They are pretty diligent about saying things like, “You could do this or that, but this is expensive, and that’s risky, so how about this?”

But therapists have this amazing way of always recommending their own services, with barely a nod to the “alternatives.” Ironic, isn’t it? “Alternative” therapy isn’t actually good at recommending alternatives!

It’s a serious ethical shortcoming.

One more good example:

Intramuscular stimulation (IMS) is an interesting dry-needling trigger point therapy available primarily in Western Canada. It something going for it, but it’s also quite expensive and often extremely painful. It is, in short, definitely overkill for a lot of patients. I think it’s a wonderful therapy to try for a certain category of patients who have failed to get results from less expensive and invasive methods. But for people new to muscle pain? People who might get relief from much cheaper, much easier therapy? Surely you’re joking, Mr. IMS!

But, of course, I routinely see people who started their therapy journey with IMS, because an IMS therapist couldn’t bring themselves to say:

“You know, this stuff costs and arm and a leg, and it hurts to boot. Why don’t you try a combination of heat, gentle stretch and self-massage on these three trigger points first? It’s free, easy and it might do the trick. If that doesn’t work, then you can come back and pay me almost $2/minute and we’ll see what we can do.”

Education as an antidote

All of this is why I write tutorials, of course — my own services were “overkill” for about 75% of new clients. The majority of people in pain can be helped substantially with cheap self-education. Most of them don’t need therapy — they just need a way to save themselves.

	An Interesting Tutorial	A Few Sessions of Therapy
Tutorial vs. Therapy
Effectiveness	might do the trick	might do the trick
Cost	$20	$500

Interesting equation!