Discharged and dismissed: A qualitative study with back pain patients discharged without treatment from orthopaedic consultations

Abstract

Background Consultation‐based reassurance for patients with low back pain (LBP) in primary care has been shown to be associated with patients' outcomes. Little is known about the role of reassurance in people with LBP consulting with orthopaedic spinal care teams. Reassurance may be important, especially in cases where surgery is not indicated and patients are discharged without treatment. Methods Semi‐structured interviews were conducted with 30 patients with chronic disabling musculoskeletal LBP who had recently consulted with spinal orthopaedic care teams. Interviews were audio recorded, transcribed, coded and analysed. Results Most patients reported feeling dismissed and discouraged. Patients perceived that they needed specific behaviours from practitioners in order to feel sufficiently reassured to commit to self‐management. These behaviours group into four domains: “Knowing my whole story” (evidence that practitioners read the case notes; were familiar with the patients' previous health care history; carried out tests and a physical examination and gathered information about the patients' lifestyle), “Seeing the right person” (showing empathy; listening; building rapport and demonstrating that they are qualified and experienced), “Nothing to worry about” (reducing generic reassuring statements but increasing validating statements recognizing suffering) and “Getting to grips with my problem” (providing explanations and a clear management plan). In the absence of these behaviours, patients rejected advice to self‐manage, reported distress, anger and intention to re‐consult. Conclusion Effective communication with patients attending spinal orthopaedic care settings is important, especially when no active treatment is being offered. Significance This study describes narratives from patients discharged without surgery following consultations with orthopaedic professionals for persistent and debilitating lower back pain. Findings suggest that these interactions are distressful to patients, and that patients require comprehensive and specific reassurance to promote self‐management. The findings contribute a unique insight into the special needs of people with complex pain problems and provide guidance to improve consultation‐based reassurance in orthopaedic spinal care settings.

'Reassurance and healthcare seeking in people with persistent musculoskeletal low back pain consulting orthopaedic spine practitioners: A prospective cohort study'

“…Communication between patients and community-practicing surgeons has shown that the majority of talking was conducted by surgeons, who typically used closed questions, and were limited and infrequent in their expression of empathy towards patients (Levinson & Chaumeton, 1999). In reference to providing explanations, orthopaedic surgeons have been shown to use a high level of jargon and offer explanations that patients find difficult to follow (Braeuninger-Weimer et al, 2019;Laerum et al, 2006). Other evidence suggests that orthopaedic surgeons show a tendency to focus mainly on technical aspects of care-giving, lack listening skills, are inconsistent in the terminology they use, frequently use medical jargon and express infrequent signs of empathy towards patients (Frymoyer & Frymoyer, 2002;Han & Pappas, 2018;Herndon & Pollick, 2002;Kampa et al, 2006;Kyle & Shaw, 2014;Levinson & Chaumeton, 1999;Levinson et al, 2013;Portalatín et al, 2018;Tongue et al, 2005).…”

“…There are no guidelines on what constitutes effective reassurance for such patients, or on how to deliver it (Oliveira et al., 2018), and it remains a neglected area of research (Linton et al., 2008). Reassurance is conceptualized as a set of practitioner's behaviours that aim to reduce patients concerns (Linton et al., 2008), and for back pain, research suggests that it includes components around data gathering and relationship building, but also clear explanations, a management plan, validation of the pain experience and where appropriate, positive messages aimed to increase self‐efficacy (Braeuninger‐Weimer et al., 2019; Pincus et al., 2013). Such reassuring behaviours may be particularly important when delivered by practitioners who believe they have no interventions left to try, often conceptualized as ‘end of the line’ consultations about possible spine surgery, because they aim to help empower patients towards self‐management.…”

“…Studies on consultation‐based reassurance in primary care have shown associations between specific components of reassuring behaviours and outcomes (Pincus et al., 2013), and in LBP specifically, there is evidence suggesting that these effects may differ for people with different psychological risk profiles (Holt et al., 2018). Findings from a qualitative study in orthopaedic settings suggest that these teams see some of the most challenging and complex patients with persisting and debilitating LBP, and that in the absence of a surgical option, these patients require comprehensive and specific reassurance (Braeuninger‐Weimer et al., 2019). For these patients, reassurance and good communication skills were perceived as pivotal to their willingness to engage with self‐management, their subsequent well‐being and their healthcare seeking behaviours.…”

Do not routinely offer imaging for uncomplicated low back pain

“…Communication style —Findings from a recent qualitative study suggests four key behaviours from clinicians that can help patients feel reassured 23…”

Taking patients to the ice cream shop but telling them that they cannot have ice cream: a qualitative study of orthopaedic spine clinicians’ perceptions of persistent low back pain consultations

“…5 Research suggests that these patients receive less reassurance and are less satisfied: instead of accepting the need to self-manage their problem, they feel dismissed, disbelieved and abandoned. 17 The findings from a prospective cohort study of 296 patients discharged from orthopaedic care without surgery suggest that better communication in consultations with orthopaedic spine clinicians might help reduce distress and unnecessary subsequent healthcare utilisation. 5 Effective reassurance necessitates engaging with patients and their concerns.…”