Healthcare Providers' Impact on the Care Experiences of Patients with Endometriosis: The Value of Trust

Survey of General Practitioner Perspectives on Endometriosis Diagnosis, Referrals, Management and Guidelines in New Zealand

INTRODUCTION

There is a growing body of literature concerning endometriosis patients' perspectives on the healthcare system and endometriosis care in New Zealand. However, there is little research available on the perspectives of general practitioners (GPs) internationally, and none currently in New Zealand. The purpose of this study is to address New Zealand GPs' understanding of and approach to endometriosis diagnosis, referrals, management and guidelines.

METHODS AND MATERIALS

An online, anonymous survey was shared with 869 GP clinics and completed by 185 New Zealand-based GPs regarding their awareness and application of the inaugural 2020 'Diagnosis and Management of Endometriosis in New Zealand' guidelines, their perception of their endometriosis knowledge, the diagnostic value they assign to symptoms, the treatments they recommend and the reasons they refer patients to specialist gynaecologists. Differences between groups were conducted using Chi-squared tests, and text answers were assessed thematically using inductive, semantic coding.

RESULTS

All 185 GPs had gynaecology consults, and 73% had gynaecology consults every week. Despite 65% being aware of the 2020 guidelines, only 35% overall had read them. Only 52% of GPs considered themselves to know enough about endometriosis for their routine practice. The most common treatment to be considered first line was intrauterine contraceptive devices (IUDs; 96%), whereas the most common alternative treatment recommended was exercise (69%). The most common reason for referral to specialist care was the failure of all attempted treatments (84%).

CONCLUSIONS

Many of the study's results align with current New Zealand and international endometriosis guidelines, particularly the prioritisation of progestin-only therapies, the reduced emphasis on surgical treatment as the first line and the low rates of alternative treatment recommendations. This study also highlights the need to improve awareness of inappropriate GP recommendations, including long-term treatment with prescription-only pain relief such as codeine and pregnancy for symptomatic relief.

PATIENT OR PUBLIC CONTRIBUTION

Two of the authors involved in the design and conduct of the study, data interpretation and manuscript preparation have sought care for endometriosis.

TRIAL REGISTRATION

NA.

Conceptualizing Symptom Invalidation as Experienced by Patients With Endometriosis

The aim of this paper is to provide foundational work to standardize the conceptual definition of what I refer to as symptom invalidation by using invalidating environments and illness representations as guiding conceptual frameworks. Mixed deductive-inductive thematic analysis was used to analyze survey responses to an open-ended question gauging an invalidating interaction patients experienced with a clinician among 1038 patients with endometriosis. Dissimilarity in illness representations between patients and clinicians, as perceived by patients, occurred with feelings of invalidation. Invalidation was experienced in relationship to all identified domains of illness representations including how clinicians communicated the diagnosis (identity label), the internal (internal cause) and/or external (external cause) nature of the cause, clinicians' understanding of the timeline (timeline) and consequences (consequences), and clinicians' understanding of control over the symptoms via the efficacy of patients (self-efficacy) and coping procedures (response efficacy). Inductive analysis revealed invalidation can also be related to how clinicians communicate judgments of whether patients are presenting with ulterior motives (secondary gains). Clinicians' actions appear to compound experiences of invalidation by not having symptoms investigated (investigative experiences). Invalidating environments and illness representations serve as effective conceptual frameworks for providing a conceptual definition of symptom invalidation.

Perceived challenges in treatment decision-making for endometriosis: healthcare professional perspectives

Background

Endometriosis, a systemic chronic inflammatory condition which has no cure, has a high symptom burden that can negatively impact every facet of life. Given the absence of a gold-standard treatment, the best symptom management regimen in endometriosis is heavily reliant on a patient's values and preferences, making shared decision-making (SDM) vital. However, a comprehensive patient decision aid (PtDA) intervention that could facilitate patient decision-making and promote SDM is lacking in endometriosis, and there is little research on the decisional support needs of individuals with this condition. This qualitative study aimed to explore healthcare professional (HP) perspectives of their clients' decisional support needs when choosing treatments to manage endometriosis symptoms, with a view to evaluating the need for a PtDA.

Methods

Australian HPs identified as specialising in endometriosis care (N = 13) were invited to participate in a short interview over the Internet by phone. Questions focussed on perceived facilitators and challenges of decision-making when choosing treatments for endometriosis. Transcribed qualitative data were thematically analysed and verified by multiple coders, using the template approach.

Results

Four themes were identified: (1) Identifying and setting priorities; (2) HPs' lack of time and perceived lack of knowledge; (3) Patient-centred care and SDM, including patient capacity; and (4) Decision-making blinded by hope. This is the first known study to explore HPs' perspectives on patient decision-making challenges in endometriosis.

Discussion

Findings draw attention to the difficulties people with endometriosis experience when assessing and choosing treatments, highlighting the need for a comprehensive PtDA intervention to support this decision-making.

Emotions of endometriosis in clinical encounters: An analysis of women's experiences of health care

BACKGROUND

A large number of illnesses that lack physical visibility are characterised by troubled clinical encounters. Endometriosis is one such condition with very real and often debilitating symptoms that remain invisible to the clinician's eye, but are experienced and lived by the patient.

METHOD

This paper probes into two first person accounts of endometriosis to find out how endometriosis patients experience health care. The Tiger and the Cage: A Memoir of a Body in Crisis (2022) by Emma Bolden and Vagina Problems: Endometriosis, Painful Sex, and Other Taboo Topics (2020) by Lara Parker are both memoirs that details on the trivialisation and delegitimization of the women's accounts of their own lived reality by a health care system that often privileges medical evidence over lived experiences of the patients. After giving a brief introduction on the condition, the paper goes on to detail on the method and conceptual frameworks chosen for analysis. This is followed by an in-depth analysis into the two texts using thematic analysis proposed by Virginia Braun and Victoria Clarke to identify shared patterns of meanings in the texts.

DISCUSSION

The identified themes take the form of emotions repeatedly narrated by the women. The findings indicate instances of disrespect, epistemic invalidation and compromised autonomy, due to which six shared categories of negative emotions are experienced by the patients: self-doubt, shame, fear, powerlessness, self-blame and anger.

CONCLUSION

The paper concludes by indicating the urgency of improved medical training, that better educates and facilitates health care professionals in dealing with conditions with complicated aetiology, difficult diagnosis and no cure.

Barriers to person-centered service design in pharmacy practice: examples, lessons, and potential solutions

Despite increased attention to, and frameworks conceptualizing person-centered care, systematic, organizational, and provider-level barriers continue to discourage the development and delivery of person-centered care (PCC) in pharmacy practice and beyond. This commentary describes existing pharmacy-specific literature related to PCC, barriers to PCC within the context of pharmacy practice, and potential solutions to increase person-centeredness in pharmacy services. Literature to substantiate and describe barriers and potential solutions was identified from 2008 to 2023, a period where the emphasis on PCC in pharmacy practice dramatically increased. Overall, pharmacy-specific literature was identified describing four key barriers to PCC. Several potential solutions were identified, including: using innovative and theory-informed approaches to collecting individual need and preference information, employing processes and equipping providers to facilitate trust, changing organizational culture, and aligning quality metrics and financial incentives with PCC. Identified solutions may be used to address individual, organizational, and systematic barriers to promote PCC.

A COM-B and Theoretical Domains Framework Mapping of the Barriers and Facilitators to Effective Communication and Help-Seeking Among People With, or Seeking a Diagnosis Of, Endometriosis

Endometriosis is a chronic condition in which tissue resembling the endometrium grows outside the womb, causing severe chronic pain. People with endometriosis report difficulty in help-seeking and communicating with healthcare professionals, contributing to diagnosis delays and ineffective management. The present study aimed to identify barriers and facilitators to effective communication using the Theoretical Domains Framework (TDF) and COM-B model to inform behavior change intervention development. This study was a qualitative semi-structured interview and open-ended survey design. Thematic Analysis was utilized to identify barriers and facilitators to effective communication which were mapped to the TDF and COM-B model. Four women aged 25 to 44 with a formal diagnosis of endometriosis participated in interviews. Thirty-three participants, aged 20-48 years, participated in the online survey, 21 of whom had a diagnosis of endometriosis (12 were currently seeking diagnosis). Five COM-B domains were identified: reflective motivation, social and physical opportunity, physical and psychological capability. Ten TDF domains were reflected in concerns surrounding dismissal, disempowerment, social norms, beliefs about consequences, cognitive resources, reinforcement, and environmental context and resources, among others. This is the first study to identify barriers and facilitators of effective communication and help-seeking in light of established behavioral change theory and frameworks for comprehensive intervention design. This provides a comprehensive explanation of challenges in help-seeking for endometriosis and represents the first step in the development of complex interventions to improve help-seeking and communication for people with endometriosis. Interventions targeting salient barriers will have greater potential to change behavior and improve outcomes.

Patient experiences of being advised by a healthcare professional to get pregnant to manage or treat endometriosis: a cross-sectional study

BACKGROUND

There is a lack of evidence that pregnancy reduces endometriotic lesions or symptoms, however studies indicate that people with endometriosis are commonly advised to get pregnant to manage or treat endometriosis. This study sought to examine the impact of this advice on patients with endometriosis when the advice was provided by healthcare professionals.

METHODS

The Endometriosis Patient Experience Survey was a self-reported, community-based, cross-sectional online survey of people who had been medically diagnosed with endometriosis. Descriptive statistics were used to analyse the quantitative survey data and thematic analysis was undertaken for the qualitative survey data.

RESULTS

1892 participants had received the advice to get pregnant or have a baby to manage or treat their endometriosis, with 89.4% of participants receiving this advice from healthcare professionals. In exploring the qualitative data, seven themes were contextualised relating to the impact of this advice in terms of health literacy, accepting the advice, rejecting the advice, major life decisions, healthcare interactions, mental health and relationships.

CONCLUSIONS

This study demonstrates profound and often negative patient impacts of the advice from healthcare professionals to get pregnant to manage or treat endometriosis. Impacts ranged from planning for pregnancy, hastening the making of major life decisions, eroding trust with healthcare professionals, worsening mental health and straining relationships. Providing evidence-based information on the treatment and management of endometriosis is essential. Pregnancy or having a baby should not be suggested as a treatment for endometriosis and the provision of this advice by healthcare professionals can have negative impacts on those who receive it.

Barriers to a Timely Diagnosis of Endometriosis: A Qualitative Systematic Review

OBJECTIVE

The diagnosis of endometriosis, a common gynecologic condition, is characterized by delays of up to 11 years. During this time, women may experience persistent symptoms that affect their quality of life, productivity, and relationships, and the disease may progress. It is therefore a priority to understand the factors that contribute to this delay to help improve the diagnostic pathway. Our objective was to describe the diagnosis barriers of endometriosis from the patient and health care professional perspectives using a qualitative evidence synthesis.

DATA SOURCES

We searched MEDLINE, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature using combinations of the synonyms of endometriosis, diagnosis, and qualitative research. The search was restricted to English-language articles from database creation until May 2022.

METHODS OF STUDY SELECTION

The initial search yielded 899 articles. Studies were included if they explored the experiences or views of affected women or health care professionals on the diagnosis of endometriosis and used qualitative methods for data collection and data analysis. Risk of bias was assessed with the Critical Appraisal Skills Programme checklist.

TABULATION, INTEGRATION, AND RESULTS

Thirty-seven articles were considered for full review, with 13 eligible articles identified for inclusion. Thematic synthesis was used to identify four key themes: 1) individual factors (n=6), 2) interpersonal influences (n=6), 3) health system factors (n=13), and 4) factors specific to endometriosis (n=13). These encompassed 12 subthemes that represented barriers to the diagnosis of endometriosis: 1) difficulty establishing pathologic symptoms from normal menstruation and the use of self-care techniques; 2) menstrual stigma and the normalization of menstrual pain; 3) attitudes and lack of training for health care professionals, delayed referrals to specialist services, and poor explanation of oral contraceptive pill use in the diagnostic process; and 4) variability in presenting symptoms, overlap with other conditions, lack of a noninvasive method of diagnosis, and concerns about the value of a diagnosis.

CONCLUSION

This review identified barriers to the timely diagnosis of endometriosis from the perspective of affected individuals and health care professionals. It highlights areas for improvement along the diagnostic pathway, which may guide future strategies to reduce delays.