“How do I minimize confirmation bias?” was a question directed to me by my current doctoral intern.

The terminology was brought to his attention after I told him that a patient being seen for initial evaluation did not achieve the best treatment due to his preconceived confirmation bias.   What led to this conversation?

-He told me prior to seeing a patient, by just reading medical history report (specifically activities that are deemed difficult to the individual), that considering the individual had difficulty in sustained positions (such as sitting, standing and walking); that the patient would fit the bill for a stabilization program.  He just “knew” this would help her.

– Now, I am all about having an initial hypothesis just from medical history and body diagram, but the subjective history and objective findings should refute or confirm your hypothesis.

– Confirmation bias, even if findings refute your hypothesis, will deter the clinician from applying appropriate interventions based on preconceptions.

– Now granted, he was able to “back it up” per Delitto et al’s Clinical Practice Guidelines for Low Back Pain; but what does latest meta analysis say with strong concluding statement?  Plus, we need to be aware of all 3 pillars of EBP and don’t jump to conclusions too quickly.

In his case, his mind was on a railroad track to just stabilizing the patient without having options.  You know how much I am not on board with this anyway 🙂  Therefore, he did not perform the appropriate history taking and objective findings to refute his findings, just found what he wanted to confirm what he already thought.  Therefore, he fit the bill of a saying, “you will always find what you are looking for”.

So his question to me was, “how do I minimize confirmation bias”

My answers:

1. Firstly, you need to be aware of your confirmation bias.  You can’t change what you are not currently aware of.

2. You can’t avoid it, but you can minimize it.

3. You have to be exposed to multiple intervention disciplines and approaches.   My current intern was preached stabilization in school, past CIs did not teach him anything else but to “use what he knew”, so he is unaware of manipulation, dry needling, and directional preference.

4. Not only being exposed to different paradigms, you need to practice and create patterns within these paradigms.  In theory, this would create more confirmation biases, but then again, it will allow you build a strong foundation that holds up the 3 pillars of EBP.

This is a start.  What are your thoughts?  How do you minimize confirmation bias?





  1. I think you are spot on with this one. It is easy to assume things beforehand rather than attempting to confirm or deny your hypothesis. I find I have plenty of bias with assessing the immediate response to a technique done in the clinic (i.e. checking motion, endfeels, or gait after a mobilization). We try to regularly check each others work to make sure we agree with responses and effectiveness of treatment.

    p.s. I know you have mentioned some opposition to the stabilization approach to low back pain. Can you elaborate on your thoughts regarding this?

    1. Peter,
      Great points and agree all around. Reflection is a key component to being able to do this effectively.

      In regards to stabilization, yes, I have a bias against it. Meaning, I do not think you can isolate, nor should, any specific musculature in the low back. Also, I feel that core stabilization is the treatment that is normally fed to an individual after being taught of “instability” or something to that nature. I find that to be just as threatening to someone who make have fear avoidance or catastrophizing behaviors; just as bad as saying “you’re out of alignment”.
      With that said, I think general trunk and aerobic exercise is just as effective as specific TrA abdominal-hollowing-in maneuvers.
      What do you think?

  2. I agree with you for the most part. I don’t do any strengthening for the musculature of the low back as I don’t think it is very helpful or pertinent. I do do a fair amount of abdominal strengthening, though mainly functional weightbearing exercises. I do also try to encourage people to increase their activity/exercise levels as a whole as long as it is pain free (i.e. strengthening, cardio). I very much agree that it is easy to encourage the fear avoidance, catastrophizing, or sense that their condition is irreparable. I guess I tend to incorporate general abdominal and lower extermity strengthening, not under the guise of curing instability, but rather to improve neuromuscular control as an adjunct to other interventions we are doing. I hate how so many people say as an aside: ‘oh, I have a slipped disc at L4-5 from several years ago, so that is not going to get any better’. As if a finding on MRI is definitive and indicates a condition that is only fixable with surgery. It is easy to focus on the biomechanical approaches and ignore the psychosocial components that go on with most of our patients. Thanks for the response, I am always interested in others opinions and vantage points.

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