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Hunch, Evidence, Doubt (HED):
A Communication Model for Massage Therapists

In "The Talk Book," Gerald Goodman presents a model which I believe can help massage therapists communicate more effectively.

Goodman uses the acronym HED to describe a communication model for the tricky task of offering interpretations of others' behavior.

The H stands for hunch - present your observations as a hunch, a speculation on what you guess might be going on.

The E stands for evidence - this is "a reminder to explain how you arrived at the hunch. If the evidence is partial and you admit to your incomplete knowledge, it'll enhance trust."

The D stands for doubt - "You give the hunch, describe your evidence for it, then express doubt." That is, you admit up front that you may have misunderstood, overlooked, or otherwise missed another logical explanation for the behavior.

The exact order of the elements is unimportant as long as you include all three.

Goodman created this model, which he calls a "soft interpretation," to reduce "the explosive impact and dangerous aftereffects of interpretations" in close relationships. Massage therapists can apply this model to communicate more effectively with clients, patients, and other health care practitioners.

For example, here's a scenario that massage therapists see fairly often. A patient presents with a diagnosis from a physician of bursitis of the shoulder. In their initial evaluation, the therapist does some routine orthopedic tests and becomes convinced that it is more likely an injury to the biceps tendon. Here's how to apply the HED model to conversation with the patient and to correspondence with the doctor.

Patient Conversation

"I know your doctor says you have bursitis, but I suspect that you might have an injury to your biceps tendon [hunch]. Of all the tests I did on your shoulder, you experienced pain only when I resisted flexion of your biceps muscle [evidence]. I can palpate all areas of your shoulder without pain with the exception of the bicipetal groove, which the biceps tendon runs through [more evidence]. Also, you report that the main activity that causes pain in your shoulder is flexing your arm while rotating your hand upward, which is exactly the motion that your biceps muscle does [yet more evidence]. Of course, I don't have as much training or experience as your doctor, and it's possible that an injury to a bursa is part of what you're feeling [doubt]."

Doctor Correspondence

"Dear Doctor Jones:
    "Thank you for referring John Doe for massage therapy for his shoulder injury. I have completed my initial evaluation.
    "Mr. Doe presented reporting pain in his left shoulder which is aggravated by his work as a carpenter.
    "I conducted several standard orthopedic assessments of the shoulder. All tests were normal with the exception of resisted biceps flexion [evidence]. I also palpated the major structures of the shoulder and found tenderness only in the biceps tendon [more evidence].
    "I don't question that there is an injury to a shoulder bursa, as you have diagnosed [doubt], but my tests and observations lead me to believe that there may be an injury to the biceps tendon [hunch]. . ."

Admittedly, this scenario is a little contrived. In real life, 99% of massage therapists would just treat the biceps tendon injury and related compensation patterns and use the doctor's bursitis diagnosis code when submitting their HCFA. Still, this example shows how the HED model can guide sensitive health care communications.

Another Example

Here's another example, one which I use almost every day in my practice.

"I suspect that using a computer mouse all day is causing your shoulder to roll forward and your scapula to wing out, which is why you are feeling pain in your rhomboid muscle [hunch]. I observe that on your mouse-hand side your pectoralis minor muscle is tender, fibrotic, and shortened; that there is more distance between your scapula and your spine, and that there are numerous adhesions in the fascia around your pectoralis major and anterior deltoid muscles [evidence]. Granted, it might just be that you use your dominant hand for everything and what I'm observing is a lifetime of overuse [doubt], but I rarely see this pattern in folks who don't use a mouse [more evidence]. Now, here, bite this bullet so I can dig my elbow into that pesky pec minor."

Using the HED Model to Address Two Major Limitations of the Massage Field

Massage therapists can't diagnose, but we gather a lot of information and develop strong hunches about what might be going on with our clients and patients. The HED model gives us a safe, systematic way to share our hunches without stepping beyond our scope of practice.

Massage therapists can't prescribe, but we have well-informed ideas about how other types of care might help our patients. The HED model gives us a way to qualify our recommendations to keep us squeaky clean with the authorities while still sharing with our patients and clients ideas about other types of care which might be appropriate, as well as exercises and other types of self-care.

I've been using this model a lot, both in my practice and in my personal communication, lately, and it's working well for me. Give it a try and let me know how it works for you.

This is an early draft of a work in progress. If you have comments, criticisms, or suggestions please e-mail me.