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The elusive x-factor



The 2024 Global Year will examine what is known about sex and gender differences in pain perception and modulation and address sex-and gender-related disparities in both the research and treatment of pain.

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What is it about some clinicians? They just seem to get great results by doing almost nothing! Could that be true? What is that elusive x-factor? Well, fortunately for us, Laura von Bertouch has agreed to tell us about a paper she does read that covers exactly that. Here is what Laura had to say:

There is no doubt that sports and business are gradually merging – we seem to be hearing more and more about the  ‘franchise’ and less about the ‘team’.  Athletes are routinely sent off to draft camps where they are put through a series of rigorous scientific tests designed to measure physical prowess (vertical jump, vo2 max, strength, agility). Results from these tests are used to justify investment.  Ultimately however the critical question remains – can this person actually play? Will they respond in the right way, at the right time of the game?

If we look closely at the performance of health practitioners we can see there are a number of parallels that can be drawn.  No doubt many of these practitioners will have excellent knowledge and will be able to execute their skills perfectly when cued – but can they actually teach? Are they able to engage the patient and will this interaction result in the desired outcome (a change in behavior, disability and pain that is real and lasting)?

This so called ‘practitioner/therapist effect’ was examined by Lewis et al in a recently published article [1]. The authors examined results from three randomized trials of low back pain and neck pain interventions in primary care. They found a ‘small but identifiable practitioner effect’ with greater variability amongst biopsychosocial interventions. The existence of a practitioner effect has obvious implications for research particularly in regards to design and data analysis. Some of the issues discussed include cluster randomization across treatment arms, multilevel analysis and sample size.

Given the current movement toward biopsychosocially based treatment approaches there appears a need to examine the practitioner effect identified in more detail.  While the data from the studies included in this paper did not identify which practitioner factors influenced outcome, this was highlighted as a key area for investigation.  Current thinking in the fields of education and psychology identify a number of interacting variables that impact on deep learning and conceptual change [2].  Some of the features of the deliverer suggested as likely contributors include appearance, credibility, age and training [2].  Some of these factors seem to actually determine what type of clinician one becomes – male surgeons are taller and considered better looking than male physicians, although film stars who play doctors on screen are better looking than both.  Further work is needed to quantify practitioner effect in a way that is contextually relevant to ensure future treatments are based on sound evidence and outcomes are maximised.

About Laura

Laura von Bertouch is an OT in Adelaide, who works in rehabilitation and return to work services.  She is guest lecturer for NOI University and Professional Development pain science programmes, has established a community based chronic disease self-management programme and commenced some very interesting research into health literacy, conceptual change and the effect of the clinician on conceptual change.  Somehow, she finished school, got into OT, finished OT, developed a stellar clinical reputation, became a key player in important links between industry and research pushing for better outcomes for injured workers AND their employers AND their insurers, all the while being one of the best netballers on the entire planet (this is NOT an exaggeration – to our knowledge, Laura is the first BiM blogger to have also been a World Champion).


[1] Lewis, M., Morley, S., van der Windt, D., Hay, E., Jellema, P., Dziedzic, K., & Main, C. (2010). Measuring practitioner/therapist effects in randomised trials of low back pain and neck pain interventions in primary care settings European Journal of Pain DOI: 10.1016/j.ejpain.2010.04.002

[2] Dole JA, Sinatra GM (1998). Reconceptualising change in the cognitive construction of knowledge Educational Psychologist, 33, 109-128

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