"We need to get you focused": general practitioners' representations of chronic low back pain patients

Situational analysis of general practitioners using a forecasting approach until 2025 and a multi-state Markov model: A retrospective longitudinal study

Introduction

Undesirable working conditions, insufficient professional development and other labour market pressures have significantly impacted the status of general practitioners (GPs). This study aimed to conduct a situational analysis of GPs in Iran using a forecasting approach until 2025.

Methods

Data were collected concurrently through direct contact, data matching among databases and tracking among graduates from four clusters of medical science universities over the past decade. This retrospective longitudinal study determined the status of GPs over consecutive years. Multi-state Markov and binary logistic regression analyses were performed using R and Stata 14.

Results

Of 430 graduates over the past decade, 94% were successfully identified. Only 20% of the graduates remained active as GPs. The greatest fluctuations in transfer occurred in the third year after graduation, with the remaining proportion of GPs dropping to less than 50%. The probability of remaining as GPs was 0.76 per year, while the highest transition was observed towards specialisation (0.12). Additionally, 2% of the GPs chose not to work, and less than 1% transitioned to a different specialty. Based on the transfer matrix for 2025, only 19% of the GPs were projected to remain, with the majority (59%) transitioning to specialisation.

Conclusion

The transfer probability varies across different years, indicating higher flow rates among GPs. However, only a limited number of GPs are projected to remain until 2025. A comprehensive set of interventions should be considered, spanning the pre-medical stage, during education and after graduation, to mitigate the factors contributing to GPs leaving their profession.

The Effect of a Brief Physician-Delivered Neurobiologically Oriented, Cognitive Behavioural Therapy (Brief-CBT) Intervention on Chronic Pain Acceptance in Youth with Chronic Pain-A Randomized Controlled Trial

At the Stollery Children’s Chronic Pain Clinic, new referrals are assessed by an interdisciplinary team. The final part of the intake assessment typically involves an explanation and compassionate validation of the etiology of chronic pain and an invitation to the youth to attend the group outpatient Cognitive Behavioural Therapy (CBT) program, called Pain 101, or to individual outpatient CBT. It was hypothesized that a brief physician-delivered CBT (brief-CBT) intervention at first point of contact improves subsequent pain acceptance. Using a randomized double blinded methodology, 26 participants received a standard intake assessment and 26 the standard assessment plus the brief-CBT intervention. Measures were taken at three points: pre and post-intake assessment and after Pain 101 or individual CBT (or day 30 post-assessment for those attending neither). The primary outcome measure was the Chronic Pain Acceptance Questionnaire—Adolescent version (CPAQ-A). Comparing pre and post-intake measures, there was a significant (p = 0.002) increase in the CPAQ-A scores—four-fold more in the brief-CBT intervention group (p = 0.045). Anxiety (RCADS-T Score) was significantly reduced post-intake and significantly more reduced in the intervention group compared to the control group (p = 0.024). CPAQ-A scores were significantly increased (p < 0.001) (N = 28) and anxiety (RCADs-T) was significantly reduced by the end of Pain 101 (p < 0.003) (N = 29) as was fear of pain as measured by the Tampa Scale for Kinesiophobia (p = 0.021). A physician-delivered brief-CBT intervention significantly and meaningfully increased CPAQ-A scores and reduced anxiety in youth with chronic pain. Furthermore, CBT through Pain 101 is effective at increasing acceptance, as well as reducing anxiety and fear of movement.

Barriers and enablers influencing healthcare professionals' adoption of a biopsychosocial approach to musculoskeletal pain: a systematic review and qualitative evidence synthesis

ABSTRACT

A substantial evidence-practice gap exists between healthcare professionals learning about the biopsychosocial model of pain and adopting this model in clinical practice. This review aimed to explore the barriers and enablers that influence the application of a biopsychosocial approach to musculoskeletal pain in practice, from the clinicians' perspective. Qualitative evidence synthesis was used. Four electronic databases (CINAHL, EMBASE, MEDLINE, and PsycINFO) were searched. Primary qualitative studies were included if they investigated the experiences of primary healthcare professionals using a biopsychosocial model of musculoskeletal pain care in outpatient settings or their perceptions towards biopsychosocial-oriented clinical practice guidelines. After screening 6571 abstracts, 77 full-text articles were retrieved. Twenty-five studies met the eligibility criteria, reporting the experiences of 413 healthcare professionals (including general practitioners, physiotherapists, and others) spanning 11 countries. Three metathemes were identified that impact the adoption of the biopsychosocial model across the whole of health: (1) at the microlevel, healthcare professionals' personal factors, knowledge and skills, and their misconceptions of clinical practice guidelines, perception of patients' factors, and time; (2) at the mesolevel, clinical practice guideline formulation, community factors, funding models, health service provision, resourcing issues, and workforce training issues; and (3) at the macrolevel, health policy, organizational, and social factors. Synthesized data revealed multilevel (whole-of-health) barriers and enablers to health professionals adopting a biopsychosocial model of pain into practice. Awareness of these multilevel factors may help inform preimplementation preparedness and support more effective implementation of the biopsychosocial model of musculoskeletal pain into clinical practice.

Clinician and patient beliefs about diagnostic imaging for low back pain: a systematic qualitative evidence synthesis

OBJECTIVE

Overuse of diagnostic imaging for patients with low back pain remains common. The underlying beliefs about diagnostic imaging that could drive overuse remain unclear. We synthesised qualitative research that has explored clinician, patient or general public beliefs about diagnostic imaging for low back pain.

DESIGN

A qualitative evidence synthesis using a thematic analysis.

METHODS

We searched MEDLINE, EMBASE, CINAHL, AMED and PsycINFO from inception to 17 June 2019. Qualitative studies that interviewed clinicians, patients and/or general public exploring beliefs about diagnostic imaging for low back pain were included. Four review authors independently extracted data and organised these according to themes and subthemes. We used the Critical Appraisal Skills Programme tool to critically appraise included studies. To assess confidence in review findings, we used the GRADE-Confidence in the Evidence from Reviews of Qualitative Research method.

RESULTS

We included 69 qualitative studies with 1747 participants. Key findings included: Patients and clinicians believe diagnostic imaging is an important test to locate the source of low back pain (33 studies, high confidence); patients with chronic low back pain believe pathological findings on diagnostic imaging provide evidence that pain is real (12 studies, moderate confidence); and clinicians ordered diagnostic imaging to reduce the risk of a missed diagnosis that could lead to litigation, and to manage patients' expectations (12 studies, moderate confidence).

CONCLUSION

Clinicians and patients can believe that diagnostic imaging is an important tool for locating the source of non-specific low back pain. Patients may underestimate the harms of unnecessary imaging tests. These beliefs could be important targets for intervention.

PROSPERO REGISTRATION NUMBER

CRD42017076047.

Effects of Biopsychosocial Education on the Clinical Judgments of Medical Students and GP Trainees Regarding Future Risk of Disability in Chronic Lower Back Pain: A Randomized Control Trial

Background

Chronic lower back pain (CLBP) is a major health care burden and often results in workplace absenteeism. It is a priority for appropriate management of CLBP to get individuals back to work as early as possible. Interventions informed by the flags approach, which integrates cognitive and behavioral approaches via identification of biopsychosocial barriers to recovery, have resulted in reduced pain-related work absences and increased return to work for individuals with CLBP. However, research indicates that physicians’ adherence to biopsychosocial guidelines is low.

Objective

The current study examined the effects of a flags approach–based educational intervention on clinical judgments of medical students and general practitioner (GP) trainees regarding the risk of future disability of CLBP patients.

Design

Randomized controlled trial (trial registration number: ISRCTN53670726).

Setting

University classroom.

Subjects

Medical students and GP trainees.

Methods

Using 40 fictional CLBP cases, differences in clinical judgment accuracy, weighting, and speed (experimental N = 32) were examined pre- and postintervention, as were flags approach knowledge, pain attitudes and beliefs, and empathy, in comparison with a no-intervention control group (control N = 31).

Results

Results revealed positive effects of the educational intervention on flags approach knowledge, pain-related attitudes and beliefs, and judgment weighting of psychologically based cues; results are discussed in light of existing theory and research.

Conclusions

Short flags approach–based educational video interventions on clinical judgment-making regarding the risk of future disability of CLBP patients may provide opportunities to gain biopsychosocial knowledge, overcome associated attitude barriers, and facilitate development of clinical judgment-making more aligned with psychological cues.

Key Push and Pull Factors Affecting Return to Work Identified by Patients With Long-Term Pain and General Practitioners in Sweden

Research shows that working is positive for people with long-term pain but that work-related support from health professionals is inadequate. One explanation for this inadequacy is that patients and providers differ in terms of perspectives on motivation to work. In this article, we compare factors that 31 patients and 15 general practitioners consider important to promote return to work for people with long-term pain. We analyzed the interviews with thematic analysis and a motivational push and pull framework to cover different motivational factors, societal and individual, that might push or pull patients from or toward work. Providers said that a difference between working and nonworking patients is their level of individual motivation, while the patients' stories showed that the main difference was the physical (non)ability to push themselves to work. We suggest that work-related support can be improved by addressing such differences in clinical practice.

The skills, knowledge and attributes needed as a first-contact physiotherapist in musculoskeletal healthcare

OBJECTIVES

The provision of musculoskeletal assessment and pathway management by physiotherapists in primary care is an expanding innovation within the UK National Health Service. This new model of care is challenging physiotherapists to work in new ways, and so an understanding of these roles is timely and wil contribute to the growing knowledge regarding these practitioners and their impact.

METHODS

This qualitative study aimed to improve the understanding of the clinical practice of first-contact clinicians in musculoskeletal healthcare. The study used a think-aloud method to explore eight clinicians' views via a stage 1 semi-structured interview process. This was followed by a stage 2 focus group involving physiotherapists and a general practitioner trainer. A thematic analysis then followed, which involved the researcher and a research colleague coding the data and subsequently developing themes.

RESULTS

The themes identified were: medical assessment and systems knowledge; speed of thought in an uncertain environment; breadth of knowledge; people and communication skills; common sense/simplify; and responsibility and experience.

CONCLUSIONS

The identified themes should help to underpin the competence, capability and training requirements for these new roles, and should be considered when developing new services utilizing first-contact primary care physiotherapy practice.

Inside the Mind of the Online Health Information Searcher using Think-Aloud Protocol

In this article we employ the think-aloud protocol to gain an in-depth look at how 23 individuals searched for online health information. Participants narrated their health searches as we audio and video recorded using screen-capture software. We transcribed the recordings verbatim and used axial and selective coding to inductively identify themes into two main search stages: online processing and consequences. A typology of online health searchers, including flounderer, skimmer, digester, aficionado and devourer, is used to guide the reader through our findings about individual's attitudes, cognitions, emotions, and behaviors. Finally, we discuss implications for online health literacy and provide suggestions for future research.

Unconventional Practitioners' Causal Beliefs and Treatment Strategies for Chronic Low Back Pain in Rural Nigeria

Chronic low back pain (CLBP) is highly prevalent and CLBP disability reinforces poverty and Nigerian rural-urban inequality. Most rural Nigerian dwellers with CLBP consult unconventional practitioners due to difficulty in accessing conventional health care. This interaction may influence back pain beliefs and behaviours, and health outcomes including disability. In line with the recent Lancet Low Back Pain series call to address widespread misconceptions in the population and among health practitioners about low back pain, this study explored the beliefs and management strategies of unconventional practitioners consulted by people living with CLBP in rural Nigeria. Qualitative semi-structured face-to-face individual interviews. Thematic analysis of transcripts was performed using the Framework approach. Nine unconventional practitioners consented to participate in this study. Patent medicine sellers and herbalists had biomedical beliefs about CLBP and encouraged passivity and drug dependence in patients. Pastors adopted spiritual or biopsychosocial-spiritual management models and either encouraged spiritual CLBP causal beliefs and spiritual healing expectations; or patients' resilience and acceptance, respectively. Unconventional practitioners' CLBP beliefs and management strategies aligned with the beliefs and coping strategies of patients who consulted them. Unconventional practitioners' beliefs and management strategies may therefore contribute to the adverse impact of CLBP in rural Nigeria.

A meta-ethnography of health-care professionals’ experience of treating adults with chronic non-malignant pain to improve the experience and quality of health care

Background

People with chronic pain do not always feel that they are being listened to or valued by health-care professionals (HCPs). We aimed to understand and improve this experience by finding out what HCPs feel about providing health care to people with chronic non-malignant pain. We did this by bringing together the published qualitative research.

Objectives

(1) To undertake a qualitative evidence synthesis (QES) to increase our understanding of what it is like for HCPs to provide health care to people with chronic non-malignant pain; (2) to make our findings easily available and accessible through a short film; and (3) to contribute to the development of methods for QESs.

Design

We used the methods of meta-ethnography, which involve identifying concepts and progressively abstracting these concepts into a line of argument.

Data sources

We searched five electronic bibliographic databases (MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and Allied and Complementary Medicine Database) from inception to November 2016. We included studies that explored HCPs’ experiences of providing health care to people with chronic non-malignant pain. We utilised the Grading of Recommendations Assessment, Development and Evaluation Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) framework to rate our confidence in the findings.

Results

We screened 954 abstracts and 184 full texts and included 77 studies reporting the experiences of > 1551 HCPs. We identified six themes: (1) a sceptical cultural lens and the siren song of diagnosis; (2) navigating juxtaposed models of medicine; (3) navigating the patient–clinician borderland; (4) the challenge of dual advocacy; (5) personal costs; and (6) the craft of pain management. We produced a short film, ‘Struggling to support people to live a valued life with chronic pain’, which presents these themes (seeReport Supplementary Material 1; URL:www.journalslibrary.nihr.ac.uk/programmes/hsdr/1419807/#/documentation; accessed 24 July 2017). We rated our confidence in the review findings using the GRADE-CERQual domains. We developed a conceptual model to explain the complexity of providing health care to people with chronic non-malignant pain. The innovation of this model is to propose a series of tensions that are integral to the experience: a dualistic biomedical model compared with an embodied psychosocial model; professional distance compared with proximity; professional expertise compared with patient empowerment; the need to make concessions to maintain therapeutic relationships compared with the need for evidence-based utility; and patient advocacy compared with health-care system advocacy.

Limitations

There are no agreed methods for determining confidence in QESs.

Conclusions

We highlight areas that help us to understand why the experience of health care can be difficult for patients and HCPs. Importantly, HCPs can find it challenging if they are unable to find a diagnosis and at times this can make them feel sceptical. The findings suggest that HCPs find it difficult to balance their dual role of maintaining a good relationship with the patient and representing the health-care system. The ability to support patients to live a valued life with pain is described as a craft learnt through experience. Finally, like their patients, HCPs can experience a sense of loss because they cannot solve the problem of pain.

Future work

Future work to explore the usefulness of the conceptual model and film in clinical education would add value to this study. There is limited primary research that explores HCPs’ experiences with chronic non-malignant pain in diverse ethnic groups, in gender-specific contexts and in older people living in the community.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Judgement analysis of case severity and future risk of disability regarding chronic low back pain by general practitioners in Ireland

Chronic low back pain is a major healthcare burden that has wide ranging effects on the individual, their family, society and the workplace. However, appropriate management and treatment is often difficult, as a majority of cases are non-specific in terms of underlying pathology. As a result, there are extensive differences in both individual patient preferences for treatment and treatment decisions amongst general practitioners. The current study examined the clinical judgements of GPs in Ireland, regarding fictional patients’ case severity and future risk of disability, through judgement analysis. Judgement analysis (JA) is an idiographic regression modelling technique that has been utilised in extant healthcare research for the purpose of allocating weighting to judgement criteria, or cues, observed by professionals in their clinical decision-making. The primary aim of the study was to model two critical information utilisation tasks performed by GPs with regard to CLBP–in combining information cues to form a judgement about current case severity and a judgement about the same patient’s risk of future disability. It was hypothesised that the judgement weighting would differ across the two judgements and that judgements regarding future risk of disability would be less consistent among GPs than judgements about case severity. Results from the regression-based judgement analysis and subsequent follow-up statistical analysis provided support for both study hypotheses. Study findings are discussed in light of theory and research on judgement, clinical decision-making and chronic low back pain.

Meta-ethnography to understand healthcare professionals' experience of treating adults with chronic non-malignant pain

OBJECTIVES

We aimed to explore healthcare professionals' experience of treating chronic non-malignant pain by conducting a qualitative evidence synthesis. Understanding this experience from the perspective of healthcare professionals will contribute to improvements in the provision of care.

DESIGN

Qualitative evidence synthesis using meta-ethnography. We searched five electronic bibliographic databases from inception to November 2016. We included studies that explore healthcare professionals' experience of treating adults with chronic non-malignant pain. We used the GRADE-CERQual framework to rate confidence in review findings.

RESULTS

We screened the 954 abstracts and 184 full texts and included 77 published studies reporting the experiences of over 1551 international healthcare professionals including doctors, nurses and other health professionals. We abstracted six themes: (1) a sceptical cultural lens, (2) navigating juxtaposed models of medicine, (3) navigating the geography between patient and clinician, (4) challenge of dual advocacy, (5) personal costs and (6) the craft of pain management. We rated confidence in review findings as moderate to high.

CONCLUSIONS

This is the first qualitative evidence synthesis of healthcare professionals' experiences of treating people with chronic non-malignant pain. We have presented a model that we developed to help healthcare professionals to understand, think about and modify their experiences of treating patients with chronic pain. Our findings highlight scepticism about chronic pain that might explain why patients feel they are not believed. Findings also indicate a dualism in the biopsychosocial model and the complexity of navigating therapeutic relationships. Our model may be transferable to other patient groups or situations.

What do patients value about spinal manipulation and home exercise for back-related leg pain? A qualitative study within a controlled clinical trial

BACKGROUND

Patient perceptions may influence the effectiveness and utilization of healthcare interventions, particularly for complex health conditions such as sciatica or back-related leg pain (BRLP).

OBJECTIVES

To explore BRLP patients' perceptions of spinal manipulative therapy (SMT) and home exercise with advice (HEA).

DESIGN

Qualitative study in a controlled clinical trial.

METHOD

Semi-structured interviews conducted after 12 weeks of treatment asked participants about satisfaction with care and whether treatment was worthwhile. An interdisciplinary research team conducted content analysis using qualitative data analysis software to identify and summarize themes.

RESULTS

Of 192 trial participants, 174 (91%) completed interviews (66% female, age 57.0 ± 11.5 years). Participants identified interactions with providers and staff, perceived treatment effects, and information as key contributors to both their satisfaction and the worthwhile nature of treatment. HEA was liked for its convenience and ability to foster an exercise habit. SMT was liked for specific aspects of the modality (e.g. manipulation, stretching) and provider competency. Most participants reported no dislikes for SMT or HEA, but some noted the dose/time commitment for SMT and discipline of HEA as least liked aspects of the interventions.

CONCLUSIONS

The quality of patient-provider interactions, perceived treatment effects, and information sharing influenced BRLP patients' satisfaction with care. Qualitative research describing patients' preferences can facilitate translation of study findings into practice and allow clinicians to tailor treatments to facilitate compliance and satisfaction with care.

Viewing Focus Groups Through a Critical Incident Lens

Scholars often do not describe in detail the complex process of conducting focus groups, including what happens when they take unexpected turns. A critical incident lens provides a framework for better analyzing and understanding what actually happens during focus group sessions. Using a critical incident approach, we examine our experiences of carrying out focus groups about the human papillomavirus (HPV) vaccine with vaccine-eligible adolescent girls and parents/caregivers of vaccine-eligible adolescent girls in New Mexico. The critical incident lens allowed us to productively explore the context and interactional dynamics of our focus groups and ultimately pushed us to talk through the challenges of conducting and analyzing them. We hope this serves as a call to qualitative researchers to be attentive to the critical incidents in your own research to enrich your analysis and contribute to a broader discussion of the realities of focus group conduct.

We need to talk about purpose: a critical interpretive synthesis of health and social care professionals' approaches to self-management support for people with long-term conditions

BACKGROUND

Health policies internationally advocate 'support for self-management', but it is not clear how the promise of the concept can be fulfilled.

OBJECTIVE

To synthesize research into professional practitioners' perspectives, practices and experiences to help inform a reconceptualization of support for self-management.

DESIGN

Critical interpretive synthesis using systematic searches of literature published 2000-2014.

FINDINGS

We summarized key insights from 164 relevant papers in an annotated bibliography. The literature illustrates striking variations in approaches to support for self-management and interpretations of associated concepts. We focused particularly on the somewhat neglected question of the purpose of support. We suggest that this can illuminate and explain important differences between narrower and broader approaches. Narrower approaches support people to manage their condition(s) well in terms of disease control. This purpose can underpin more hierarchical practitioner-patient communication and more limited views of patient empowerment. It is often associated with experiences of failure and frustration. Broader approaches support people to manage well with their condition(s). They can keep work on disease control in perspective as attention focuses on what matters to people and how they can be supported to shape their own lives. Broader approaches are currently less evident in practice.

DISCUSSION AND CONCLUSION

Broader approaches seem necessary to fulfil the promise of support for self-management, especially for patient empowerment. A commitment to enable people to live well with long-term conditions could provide a coherent basis for the forms and outcomes of support that policies aspire to. The implications of such a commitment need further attention.

Treating co-occurring chronic low back pain & generalized anxiety disorder

The complex, bidirectional correlation between chronic low back pain (CLBP) and generalized anxiety disorder (GAD), common ailments in primary care, can increase the risk of inadequate treatment. This article will review the relationship between CLBP and GAD and provide optimal management strategies for NPs caring for individuals with this dyad.