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

Abstract

ObjectiveThis study aimed to explore the perceptions of orthopaedic clinicians about consultations for people with persistent musculoskeletal low back pain (PMLBP) in which surgery is not recommended. Surgery is not recommended for the majority of PMLBP consulting in secondary care settings.SettingSecondary care sector in the UK.ParticipantsSemi-structured qualitative interviews were conducted with 24 orthopaedic team clinicians from 17 different hospitals in the UK and Ireland. Interviews explored clinicians’ perceptions of the challenges in consultations where surgery is not indicated. Interviews were transcribed verbatim and analysed using thematic analysis.ResultsTwo meta-themes, Difficulties and Enablers, each consisting of several subthemes were identified. Difficulties included challenges around the choice of appropriate terminology and labels for PMLBP, managing patients’ expectations, working with mentally vulnerable patients and explaining imaging findings. Enablers included early management of expectations, use of routine imaging, triaging, access to direct referral elsewhere, including other non-surgical practitioners in the team, training to improve communication skills and understanding of psychological issues.ConclusionThe findings highlight clinicians’ perceived need for concordance in messages delivered across the care pathway and training of orthopaedic clinicians to deliver effective reassurance and address patients’ needs in circumstances where surgery is not indicated.

Improving consultations for persistent musculoskeletal low back pain in orthopaedic spine settings: an intervention development

“…There is also a large body of evidence suggesting that communication skills, in general, could be improved in orthopaedic surgeons [ 27 – 34 ]. Within our study, spinal clinicians recognised that they do not have formal training or effective skills in assessing, screening, and discussing psychosocial factors with their patients, especially for those where surgery is not indicated, and thus identified it as a training need [ 17 ].…”

“…Stage three consisted of qualitative interviews with 24 spinal clinicians, including 16 surgeons, 3 registrars/fellows, and 5 APP’s working under NHS secondary care settings [ 17 ], aiming to explore their experience of consultations in which surgery was excluded, and their perceptions of the patients’ framework and the recommendations produced in the interactive workshop. Participants were recruited through a snowball sampling method and all worked in an orthopaedic outpatient setting as part of the National Health Service (NHS).…”

“…The interview content was divided into two parts. The first part is published in full elsewhere, and describes participant’s perceptions of their difficulties in communicating with patients when surgery is not an option [ 17 ]. In the second part of the interview, clinicians were presented with the findings from stage 1–2 of the intervention development and asked to discuss each item, in reference to whether they felt that the items make sense, would be useful, and feasible to implement.…”

“…This means that when spinal clinicians, such as spinal surgeons and advanced practice practitioners (APP’s), explain to patients that surgery is not indicated, they need to offer acceptable alternatives, and ensure that patients feel reassured, rather than dismissed [ 15 ]. This can present a challenge, as the majority of spinal surgeons are not trained to treat patients who do not require surgery [ 16 ], despite patients viewing them as the final authority for back pain [ 15 , 17 ]. Although reassurance is recommended by guidelines for PMLBP [ 18 ], it is a neglected area of research with limited advice on how to reassure patients [ 19 ].…”

“…Although reassurance is recommended by guidelines for PMLBP [ 18 ], it is a neglected area of research with limited advice on how to reassure patients [ 19 ]. There is emerging evidence [ 15 , 17 , 20 ] about the need to improve consultations between people with PMLBP and orthopaedic spine clinicians when surgery is excluded, to ensure that reassurance is effective and alternatives are discussed. Current practice does not offer optimal care to patients: recent evidence [ 15 , 20 ] indicate that poor communication and lack of education about self- management in these consultations are associated with increased distress and higher subsequent health care seeking.…”