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Met or Matched Expectations What accounts for a successful back pain consultation in Primary Care?. Ehab Georgy PG Researcher Bournemouth University United Kingdom Prof. Eloise Carr Deputy Dean, School of Health & Social Care Bournemouth University Prof. Alan Breen

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Met or Matched Expectations

What accounts for a successful back pain consultation in Primary Care?

Ehab Georgy

PG Researcher

Bournemouth University

United Kingdom

Prof. Eloise Carr

Deputy Dean, School of Health & Social Care Bournemouth University

Prof. Alan Breen

Professor, Musculoskeletal Health Care, Anglo-European College of Chiropractic

A presentation for the 3rd bi-annual conference of the European Forum for Primary Care - Pisa, Italy 2010

back pain bp
Affecting up to 2 in 3 of the adult population each year.
  • One of the most common reasons for consulting a doctor.
  • Main reason for hospitalisation and other care service utilisation.
  • Bio-psychosocial management has been problematic; many doctors see it as a difficult and unrewarding condition to deal with in Primary Care.

Back Pain (BP)

  • The essence of BP care in Primary Care is the consultation.
  • A process of negotiation between the patient and doctor.
  • Geared towards information, advice or specific care.
  • It serves three main functions: build a relationship, collect data and agree on a management plan.

Medical Consultation

Expectations

  • Prediction about specific events likely to happen during the consultation.
  • Patients & doctors seem to each have their own agenda of consultation.

(Malmivaara et al., 1995; Skelton et al., 1995; Maniadakis and Gray, 2000; Walker, 2000; Gask and Usherwood, 2002; Breen et al., 2007; Savigny et al., 2009).

expectations why complex
Expectations:why complex??
          • Defined and conceptualised in various ways.
          • No ideal method for measuring expectations.
  • Expectations are influenced by:
      • Culture and Background.
      • Past experiences.
      • Acquired knowledge.
      • Perceived vulnerability to illness.
  • (Thompson and Sunol, 1995; Kravitz, 2001)
slide4
Patients and doctors appear to have a specific agenda during the consultation;

These agendas seem to have different content and focus

and

there seems to be a mismatch between patients and doctors beliefs in regards to different aspects of the consultation

(Ogden et al., 1997; Georgy et al., 2009)

patients expectations doctors expectations
Patients’ expectationsDoctors’ expectations

GP showing

interest and

listening

Information

Accurate

diagnosis

Adequate

explanation

of the problem

Physical

examination

Education

and

stress

counselling

Information

Prescribing

effective

treatment

Priority

Sharing

problems and

doubts

Reassurance

and

advice

Education

Avoid

unnecessary

referrals

or tests

(Kravitz et al., 1994; Sanchez-Menegay and Stalder, 1994; Turner et al., 1998; Tomlin et al., 1999; Verbeek et al., 2004; Parsons et al., 2007; Ruiz-Moral et al., 2007).

matched patient doctor expectations why important
Patient-doctor agreement is of paramount importance and has the potential to affect the consultation outcome in various ways:

higher concordance

greater adherence to treatment

better communication

better general health outcomes

positive perception of improvement

higher satisfaction

Matched patient-doctor expectations:why important?

(Starfield et al., 1981; Williams et al., 1995; Cedraschi et al., 1996; Liaw, Young and Farish, 1996; Fagerberg et al., 1999; Maly et al., 2002; Kerse et al., 2004; Krupat et al., 2004; Azoulay et al., 2005; Staiger et al., 2005)

research aim and objectives
Research aim and Objectives

Main aim

  • to investigate the matching of patients’ and doctors’ expectations related to BP consultation in Primary Care.

objectives

  • To explore patients’ and doctors’ BP specific expectations using a structured questionnaire that was designed for the study.
  • To discern the matching of patients’ and doctors’ expectations related to BP consultation in Primary Care.
  • To explore the perceived importance of matched expectations for patients & doctors regarding specific aspects of consultation.
m ethods
A mixed methods sequential nested design.
  • 11 Doctors and 57 Back Pain Patients.
  • Two parts:
    • Quantitative part:
      • A cross-sectional correlation approach.
      • comparing each patient and his/her corresponding doctor.
      • Patients & doctors completed the expectations questionnaire; (a 21-item tool consisting of two matched parts: one for patients and another -similar but adapted- for doctors.
      • Main outcome measure was patients-doctor agreement.
    • Qualitative part:
      • Sub-sample of the same group (nested)- 6 patients & 6 doctors.
      • Recorded semi-structured telephone interviews.
      • to explore their perceptions of the significance of matched expectations for a successful BP consultation.
Methods
findings telephone interviews perceived importance of matched expectations
Findings- Telephone interviewsPerceived Importance of Matched Expectations

Better communication and interaction:

Mrs A (BP patient): “… obviously, if I feel I have agreed with my doctor about most aspects during the consultation, for example, explanation of the problem, the need for tests or referral and about the treatment plan that can fit my life style, then I feel I have had a positive experience and that I was able to share my doubts and concerns with my doctor much better”.

Dr B (GP): “... if the doctor is hopefully on the same wavelength of anticipation as the patient, the patient feels as if the doctor has been listening and the consultation would be much more valuable”.

findings telephone interviews perceived importance of matched expectations1
Findings- Telephone interviewsPerceived Importance of Matched Expectations

Better compliance and adherence to treatment:

Mr C (patient): “Patient-doctor agreement is very important, because if you feel that the doctor has been listening to you and isn’t just treating you as a number and does know your needs, then you are more likely to listen to what the doctor says and take his advice”.

Dr D (GP): “… if the patient’s agenda is not revealed and if the doctor is directing the consultation in a way that patient's expectations are not explored, most probably, this consultation will go wrong and the outcome will be compromised, and this obviously will affect the compliance and adherence to treatment and consequently the satisfaction and possibly the symptom improvement”.     

met or matched expectations
Met or Matched Expectations?

Met or Matched Model. Georgy EE, Carr ECJ and Breen AC (2010). In review; Health Expectations Journal

key message
Key message

It is proposed that, for more successful back pain consultation, it is important to:

  • Elicit patients’ expectations during the encounter.
  • Address unmet expectations with alternatives.
  • Manage and negotiate inappropriate expectations.
  • Educate patients for well-formulated future expectations.
  • Match rather than just meet patients’ and doctors’ expectations.
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References:
  • Skelton et al. (1995). General practitioner perceptions of low back pain patients. FamPract 12(1):44-48.
  • Walker (2000). The prevalence of low back pain: A systematic review of the literature from 1966 to 1998. J spin dis 13(3):205.
  • Maniadakis and Gray (2000). The economic burden of back pain in the UK. Pain 84(1):95-103.
  • Malmivaara et al. (1995). The treatment of acute low back pain: Bed rest, exercises, or ordinary activity? NEJM 332(6):351-355.
  • Gask and Usherwood (2002). ABC of psychological medicine: The consultation. BMJ 324(7353):1567-1569.
  • Geer (1991). Do open-ended questions measure "salient" issues? Public Opin Q 55(3):360-370.
  • Georgy et al. (2009). Back pain management in primary care: patients' and doctors' expectations. Qual Prim Care 17(6):405-413.
  • Azoulay et al. (2005). Effects of patient and clinician disagreement in occupational low back pain: A pilot study. Disab & Rehab 27(14):817-823.
  • Breen et al. (2007). "You feel so hopeless": a qualitative study of GP management of acute back pain. Europ j pain 11(1):21-29.
  • Savigny et al. (2009). Low back pain: Early management of persistent non-specific low back pain. London: NCCPC & RCGP.
  • Thompson and Sunol (1995). Expectations as determinants of patient satisfaction. Int J Qual Health Care 7(2):127-141.
  • Kravitz (2001). Measuring patients' expectations and requests. Ann int med134(9):881-888.
  • Ogden et al. (1997). To treat? to befriend? to prevent? Patients' and GPs' views of the doctor's role. Scan J Prim Health Care 15(3):114-117.
  • Kravitz et al. (1994). Internal medicine patients' expectations for care during office visits. J Gen Int Med 9(2):75-81.
  • Parsons et al. (2007). The influence of patients' and primary care practitioners' beliefs and expectations about chronic musculoskeletal pain on the process of care: a systematic review of qualitative studies. Clin J Pain 23(1):91-98.
  • Ruiz-Moral et al. (2007). The effect of patients' met expectations on consultation outcomes. J Gen Int Med 22(1):86-91.
  • Sanchez-Menegay and Stalder (1994). Do physicians take into account patients' expectations? J Gen Int Med 9(7):404-406.
  • Tomlin et al. (1999). General practitioners' perceptions of effective health care. BMJ 318(7197):1532-1535.
  • Turner et al. (1998). Back pain in primary care: Patient characteristics, content of initial visit, and short-term outcomes. Spine 23(4):463-469.
  • Verbeek et al. (2004). Patient expectations of treatment for back pain: a systematic review of qualitative and quantitative studies. Spine 29(20):2309-2318.
  • Williams et al. (1995). Patient expectations: what do primary care patients want from the GP and how far does meeting expectations affect patient satisfaction? J FamPract 12(2):193-201.
  • Staiger et al. (2005). Patient-physician agreement as a predictor of outcomes in patients with back pain. J Gen Int Med 20(10):935-937.
  • Starfield et al. (1981). The influence of patient-practitioner agreement on outcome of care. Am J Pub Health 71(2):127-131.
  • Maly et al. (2002). Implementation of consultative geriatric recommendations: The role of patient & primary care physician concordance. J Am Geriat Soc 50(8):1372-1380.
  • Liaw et al. (1996). Improving patient-doctor concordance: an intervention study in general practice. FamPract 13(5):427-431.
  • Krupat et al. (2004). Matching patients and practitioners based on beliefs about care. Am J Manag Care 10(11):814-822.
  • Kerse et al. (2004). Physician-patient relationship and medication compliance: A primary care investigation. Ann Fam Med 2(5):455-461.
  • Fagerberg et al. (1999). How well do patient and general practitioner agree about the content of consultations? Scan J Prim Health Care 17(3):149-152.
  • Cedraschi et al. (1996). The role of congruence between patient and therapist in chronic low back pain patients. J Man Phys Thera 19:244-9.
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