Nudging Our Patients

🎙️ Episode 64 – Nudging Our Patients

“She’s one fall away from paralysis.”
 “If it were my mom, I’d do the surgery.”
 “This is your window.”

These aren’t just medical phrases—they’re nudges: subtle but powerful cues that steer decision-making long before our patients say “yes” or “no.”

In this short solo episode, Dr. Fred Bagares unpacks five common types of clinical nudges we hear (and use) every day in musculoskeletal care:

• Fear-based nudges
• Authority-based nudges
• Urgency-based nudges
• Fix-it framing
• Hopelessness language

🎧 Learn how these shortcuts shape the way patients interpret risk, autonomy, and what's really “on the table”—and why reclaiming our language is a step toward better shared decision-making.

⏱️ Timestamps

Time Topic
| 00:00  | Welcome + Podcast Purpose
| 00:00:40  | “She’s one fall away…” – Language with weight
| 00:01:00  | What is a nudge, anyway?
| 00:03:00  | 1. Fear-Based Nudges
| 00:04:00  | 2. Authority-Based Nudges
| 00:05:00  | 3. Urgency-Based Nudges
| 00:06:00  | 4. Fix-It Framing
| 00:07:30  | 5. Hopelessness Nudges
| 00:10:00  | Reframing language: clear ≠ coercive
| 00:12:30  | Why I started MSK Direct
| 00:14:00  | Reflection Questions + Substack plug
| 00:15:00  | Final thoughts + Thanks

#TalkRehab #DirectCare #SharedDecisionMaking #MSKCare #PhysicianVoices #OutOfNetwork #RehabilitationMedicine #HealthcareCommunication #MusculoskeletalHealth #ClinicalLanguage #PatientCenteredCare #PhysicianLeadership

Transcript

0:00

What is rehab or rehabilitation? My name is Fred, be Garris, a board certified sports and spine medicine physician in Virginia Beach, Virginia. After 10 years of practice, I still find musculoskeletal medicine both fascinating and challenging. I. This podcast is about the lingering thoughts and questions I've had after residency and fellowship. My hope is to spark discussion, challenge, dogma, and share my experiences in musculoskeletal medicine. Welcome to The Talking Rehab Podcast. I. She is one fall away from paralysis. This is the gold standard. If it were my mom, I'd do the surgery. These aren't just clinical phrases. They're nudges. Carefully or carelessly crafted bits of language that can subtly steer our patients toward or away from a treatment decision. Some are meant to protect others to persuade, but all of them bypass the messy, uncertain middle of shared decision making in today's episode of Talking Rehab. We're diving into the psychology of nudges in clinical care. We'll break down the types of nudges clinicians often use, whether they realize it or not, and explore what it means to communicate without accidentally tipping the scales. Most of us are trained to diagnose patients, but more importantly, educate them, inform them, talk about the, pros and cons of each procedure, essentially, to inform them of what their options are. But in the fast paced, high stakes world of musculoskeletal care, our language has become essentially like a shortcut. and you have to ask yourself, do these shortcuts, are they shaping behavior? Not all nudges are created equal though. So let's get a little bit more specific, because understanding the type of nudge we use helps us get closer to the type of care we want to give. Let's break down five of the most common nudge subtypes, each with examples and their emotional or behavioral effect on the patient. The first one is the fear-based nudges. These type of nudges usually cause anxiety or dread, and the goal is to spark an immediate compliance or action. So as I mentioned in the beginning, you're one fall away from paralysis. I hear this very commonly with cervical stenosis when it's. and obviously with a severe spinal cord impingement, it frightens the patient. and even though the surgeon is trying to give them the specifics of their diagnosis, it does frighten them and potentially it gets them to agree to a surgery, Essentially quicker than normal right now. Not to say that cervical stenosis and a myelopathy isn't a surgical issue, but it is a choice of words. and I definitely have had patients. You don't wanna think about a surgery, even though the imaging looks really bad. and it's the right to think about it, I do find that we tend to nudge them with if you fall down, you could be paralyzed. And I've seen that happen. but it's a very powerful statement, it's also followed up with, if you don't act soon, this could become permanent, which again, is true. but again, it does cause an emotion into the patient, even though the physician is trying to do what they believe is right, for the patient. why it matters is that if, fear overrides, reflection. It doesn't allow them the opportunity to process things. It nears the focus. And in medicine, Not every problem needs, that, That's scared or anxiety response sometimes we have to sit with the options. I think that's part of good patient care. The second is authority based nudges. essentially this is a nudge where the emotion you're trying to trigger is trust or, or deference. a good example is if it were me, I'd do it. or most of my patients go this route. I couldn't recommend this if I didn't truly believe it was best for you. And these see are fairly innocent, nudges, but, it is a, paternalistic approach where, the decision isn't really shared. it's really mainly the clinician's decision, at that point and. why it does matter, is that it can have certain effects on the relationship and what the patient is going to respond. I. It's a little bit of a relational shortcut, because it does insert your own personal beliefs into someone else's life, even though that is sometimes what people want to hear is, what you would do. Because I think there's a belief that, if you would do it to yourself, then it must be good, or it must be relatively safe. but it can shut down dialogue, if you, Even though it is very effective, again, it doesn't allow the patients necessarily to, to process it with the clinician. So the third one is the urgency based nudges. This is the time pressure We need to get this scheduled before it gets worse. This is your window, Again, this is a little bit like the first one there where there is some anxiety, but it's mainly time-based. You know where even though it may be true, it, there is that time sensitive nature, to schedule the surgery because of the underlying pathology. You know that this is your window is a pretty good one because I, I think that patients also feel if they wait too long and they eventually have the surgery, that somehow their outcome is going to be different. And meaning that if they had waited. If they hadn't waited one one day longer, their outcome would've been tremendously better. And even though that's an extreme example, I do think that's how patients sometimes see it is it's a week too long. Is two weeks too long? Is one day too long? so that urgency nudge is fairly effective. the fourth one is. The fix it framing, the fix it type nudges where, you'll hear people say, we will go in and clean it up. we can fix this once and for all, after an injection, you should be good to go. And, these are all effective. it's really that kind of anatomic based, Approach where the pathology is going to be good is new, and you'll never have to think about it again. it's nice to hear that, and no one likes to hear that they're gonna get a surgery and we'll see how things go. the, even injections are quick and easy. sometimes you'll get a cortisone injection and you're just like, yeah, you should be fine. And we can always repeat it if necessary, So sometimes we as clinicians, have to, give patients that hope, that belief. but at the same time, it is, it's. it's a human response. we're trying to, we're trying to give people something, so that in, so that we're trying to give people, some hope and some relief, and fixing it, who doesn't like a problem that just will quote unquote go away? the last one I'll mention is the hopelessness. The hopelessness type of nudging. where the motion that's being drawn is despair or resignation. So you know that joint is completely shot. I. There's nothing else we can do. It's bone on bone. it's a damning type of language, where I've seen people, even in their twenties, have problems with knee pain and they have some advanced arthritis, and they get that in 20 years you're gonna have it replaced, I, I personally don't like that kind of language, even though it's true, because not only does it, it doesn't make the patient, necessarily feel better in the moment. It might make them. Have a decision sooner than later. But I often think about the people who aren't ready to make a decision because they're just essentially emotionally stunned by everything, and then they move on. They, and they kinda live their lives, with this, essentially this weight on their back, that their body is just falling apart. you know what, as clinicians, do, what do we do with these nudges? Do we keep'em? are we even aware of them? If we are aware of them, what do you do with them? So the first thing you have to do is you have to recognize that you're nudging somebody. I don't think it's impo, it's not realistic to, to expect a human to be completely unbiased. and, consciously or unconsciously. but. the first part is really understanding, your own personal language. what are your quote unquote catchphrases. Because if there are catchphrase, I bet you they fall into one of these categories. And so if you are sensitive to that, you have to practice re reframing a lot of these. a lot of these nudges elicit a negative emotion, anxiety, fear, despair, things like that. And instead of saying, telling someone like, one fall and you're paralyzed, you could try and say there is some narrowing. There is significant narrowing around your spinal cord and in rear cases it can lead to injury with a fall. And let's talk about, your activity level and how we can manage that risk. that might be something to, buffer it a little bit, maybe not have it land as hard. the authority type of nudge where, you know, what we say goes. We can sometimes lean a little bit more into what the evidence says, as opposed to saying, this is what I would do, or this is what everybody does. I think for some patients that's fine, but some people they need a different approach and maybe leaning on what the literature shows, and lead with that as opposed to, what you would do or what everybody else does. Now the urgency one. This one is a tough one because again, in the very, very busy clinics, it can be hard to, not, take a shortcut and just say, Hey, we gotta do this, or else, trying to change that language into, I'm telling the patient, maybe this condition can change over time, but right now we have some time and space to explore the other surgical and non-surgical options. Now this one, to me, unfortunately I just don't see physicians doing it. I'm sorry. I wish I could be a little bit more optimistic, I've done this long enough that I just know that, physicians really don't have time to have this kind of conversation. So I guess if I had to pick. One of'em, this is the one that I would focus on the most because, some of these surgeries you can't reverse. many of these surgeries can't be reversed. So if they make a hasty decision, that's it. the next one is the fix it, framework. Again, this is also a little bit, tied to the urgency. as opposed to saying Hey, this is just going to, be good as new, you won't have to think about this anymore. you could, be a little bit more realistic and say, this treatment may help reduce symptoms, but we'll still need a longer plan for mobility and strength. again, a little bit of my commentary. This is a tough one. I still just don't find that this is. a conversation that most physicians are going to have or trying to have because they're just trying to get in and out. again, that is why I started my own practices so I can structure my clinic and spend the time with my patients the way that I saw fit. but, I don't want to go too much in, on that tangent. But, the last one is the hopelessness. as opposed to. telling them that their knee is shot and there's no hope or you're gonna be in a wheelchair, you might at least start off with, yes, there's somewhere interior on the imaging, but your function and pain don't always match what it looks like. I think that's very important to point out and let's focus on what you want to do and build from there. I think that's a great way to talk to a patient. this was an, a fun episode to put together, that I've never really tried to put a framework around the nudges. It's something that, as humans, we all do. but it did allow me to dive in a little bit deeper. Into the type of language that we use in the clinic. I do believe it's a mirror of how we see health and risk and see our role in other people's lives. So these nudges are very powerful. But, when they're unconscious or sometimes conscious, we use these to persuade people, to do what we think is best or do what we think is convenient. I hate to say that, but it's true. I like to leave you guys with questions, what type of nudge shows up in your practice the most, and, what would you do to reframe it essentially? I think, not to say that you have to change it, but if you can at least acknowledge it, I think that's a great first step. Because when we become more precise with our words, we invite patients into the conversation. It's not just about getting them to agree, it's really about having the discussion and making sure we're on the same page with them the entire step of the way, versus just saying, Hey, come over here and waiting for them to step into our place. I just don't think that's the best way, to help people in the big picture of things. But, Anyhow. Hope you guys enjoyed this one. Thanks again for listening, to the podcast today. If you guys have any questions, you know where to find me. On another note, I am starting a, substack called Out of Network. it is a newsletter that I'm using to essentially help teach, physicians that are looking. How to get out of the insurance based model, while using ai. I'm hoping it's going to help inspire people to, to take the leap and create the practice that they've always wanted. But I think it's a pretty fun read. I also have some content on that's secure specifically to the patients. I think it does, it does give you a clue into the mindset of a lot of us that are practicing, on a day-to-day basis, but are wanting something different. But anyhow, thanks again for listening. Check out my substack. have a great one. I. Thank you for listening to The Talking Rehab podcast. I hope that this podcast stimulates you to question your own practice and how you approach rehabilitation. I truly appreciate your time and attention. If you enjoyed listening, make sure to like and subscribe to the podcast. I wish you a movement filled day. Take care.