Are
they thinking alike? Back pain patients and doctors
expectations: A feasibility study
.........................................................................................................................
Ehab
E Georgy (a),
Eloise CJ Carr (a)
Alan C Breen (b)
(a) School of Health and Social Care, Bournemouth
University (UK)
(b) Institute for Musculoskeletal Research and
Clinical Implementation, Anglo-European College
of Chiropractic (UK)
Correspondence:
Ehab Georgy
Bournemouth University,
School of Health & Social Care
Royal London House,
Christchurch Road,
Bournemouth,
Dorset, BH1 3LT,
United Kingdom
Tel: +44 (0)1202 537141; Fax: +44 (0)1202 962194
Email: egeorgy@bournemouth.ac.uk
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ABSTRACT
Background and objectives: Patient-doctor
agreement is believed to promote the quality
of interaction and satisfaction; yet,
up to date, no study has attempted to
investigate the matching of back pain
patients' and doctors' expectations, nor
is there a valid measurement tool. This
study aims to explore the feasibility
of using a newly designed questionnaire
for investigating the congruence of patients'
and doctors' expectations in relation
to back pain consultation.
Methods: A
26-item questionnaire was developed and
was given to 20 patients and 11 doctors
to rank their objective of the encounter
and report their agreement with the expectation
statements. Responses were compared to
investigate the matching of patients'
and doctors' expectations.
Findings: Diagnosis,
explanation of the problem, and referrals
were the most important aspects for patients;
explanation, effective pain relief, and
information were common expectations for
doctors. Patients agreed with doctors
about most aspects of the consultation
except for referrals, ability of doctor
to help without referrals, as well as
items related to sharing the reason for
the encounter.
Conclusion:
The study reveals some areas of mismatch
that might adversely affect the consultation.
Further research is needed to consolidate
these results and to establish the significance
of matched expectations.
Keywords: back pain, expectations,
matching, congruence, primary care
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Affecting up to 2 in 3 of
the adult population during the course of a
year, back pain (BP) is a very common disorder,
with an estimated fifth of the patients consulting
their doctor about their condition (1, 2). Back
pain is cited as one of the most common reasons
for consulting a doctor (3). Biopsychosocial
management of BP in primary care has been problematical
(4), with many doctors seeing it as one of the
difficult and unrewarding conditions to deal
with in primary care (5). Over the last few
decades, research in primary care has focused
on understanding factors influencing the quality
of healthcare, as well as ways to optimize expectations
and enhance satisfaction with BP consultations.
Although it may seem that patients' met expectations
and satisfaction may be the key ingredients
for a successful consultation,, and in addition
to other clinical measures, might be important
measures of the quality of the healthcare services;
however, doctors' expectations may also be a
strong contributing factor to a more successful
consultation, as the clinicians' practice style
and views are thought to affect outcome in BP
care (6). Patient-doctor agreement is thought
to promote higher satisfaction (7, 8), better
general health outcomes (9, 10), as well as
greater adherence to treatment (11). Most previous
research suggested a negative impact of patient-doctor
disagreement on the consultation outcome; yet,
only few studies have addressed this issue (12).
Moreover, literature pertaining to patient-doctor
agreement is particularly scarce in the area
of BP (12, 13). Previous studies focused on
patients' general expectations rather than condition-specific
ones and, to date, none was done to explore
the congruency of BP patients' and doctors'
expectations, nor is there a valid measurement
tool (13-15). The aim of the paper is to present
the results of a pilot study exploring the feasibility
of using a newly designed questionnaire for
measuring the congruence of BP patients' and
doctors' expectations as well as to investigate
the range and matching of patients' and doctors'
expectations related to BP consultations in
primary care.
Questionnaire development
A literature review was carried out to produce
a preliminary list of patients' and doctors' expectations
related to aspects of the clinical encounter,
doctors' characteristics, management strategies,
attitudes and beliefs. Both qualitative and quantitative
studies that investigated patients' and doctors'
expectations related to BP management in primary
care settings were reviewed; detailed characteristics
and results of the literature review can be reviewed
elsewhere (13). Collected data from the literature
was used to produce a draft 36-item questionnaire
consisting of two matched parts: one for patients'
expectations and another, similar, but adapted
for doctors' expectations. For the purpose of
the questionnaire, expectations were defined as
anticipations formulated by patients and doctors
about specific actions, attitudes, or interventions
that are likely to happen during the consultation.
Subsequently, the questionnaire went through several
revisions for clarity and wording as well as relevance
of questions through a series of discussions with
patients, doctors, and researchers during a series
of eight collaborative learning workshops within
the LIMBIC project (Learning to Improve Management
of Back Pain in Community; A 3-year quality improvement
project). Several versions of the revised questionnaire
were produced until version IV (26 items) was
ready for the pilot study. The questionnaire was
designed to be self-administered, brief, understandable,
and easy to complete for adults aged over 18 years.
The questionnaire consisted of four different
sections: the first asked about age, gender, occupation
and duration of BP; the second required the subjects
to rank different purposes of the encounter according
to its importance as well the doctors' consultation
objectives; the third section included the 26
expectation items derived from the literature,
with a five-point Likert type scale asking for
agreement or disagreement with the statement;
and the last section was an open question asking
the subject about any other expectations not reported
in the questionnaire.
Patients' and doctors' expectations
The newly designed questionnaire was used to investigate
the range and matching of BP patients' and doctors'
expectations related to primary care consultation.
Thirty-one subjects (20 BP patients and 11 doctors)
participated in the study, recruited from The
LIMBIC project and drawn from nine primary care
practices in the South of England. Each subject
completed the expectations questionnaire and sent
it back in the provided pre-paid envelope. All
participating doctors were involved in direct
patient care for at least 20 hours per week in
general practice. All recruited patients have
had a recent consultation for their BP with their
doctor. The study was granted ethical approval
from the local research ethics committee.
Data Collection and statistical analysis
The study outcome measures were the ranking of
the reasons for the encounter as well as the agreement
scores for each expectations statement. Descriptive
statistics were used to present the distribution
and ranking of the reasons for encounter and doctors'
objectives; each stated reason or objective was
given a number from one to 10, equivalent to its
ranking by the subject, and the total ranks were
summed to calculate the overall ranking of each
stated purpose. Patients' and doctors' responses
to the questionnaire statements were reduced to
disagree (1/2), unsure (3), and agree (4/5). Descriptive
statistics were used to present the range of patients'
and doctors' expectations. The data from the full
5-point scale were then analysed to examine differences
between doctors and patients using Mann Whitney's
U test. Statistical Package for Social Science
(SPSS) version 13 was used to carry out the statistical
analysis.
Subjects' characteristics: Table 1 shows
the demographic data of the participants. Thirty
patients and 16 doctors were invited to participate
in the pilot study; 20 patients and 11 doctors
agreed to participate and completed the expectations
questionnaire with response rates of 67% and
69% respectively.
Table 1: Demographic data of the subjects
Reason for the encounter: The ranking
of the consultation objectives or reasons according
to its importance as perceived by patients and
doctors' is shown in Table 2. Diagnosis, explanation
of the problem, and referrals had the highest
ranks respectively for the patients group, while
explanation of the problem, effective pain relief,
and information provision were more prevalent
according to doctors. Effective pain relief,
sick certificate, education and medication were
the least reported by patients; while, on the
other hand, X-rays, referrals, reassurance and
prescriptions were less common reasons stated
by doctors. About two thirds of the patients
did not report education, reassurance, information,
pain relief, medication, or X-rays as a possible
reason for the encounter at all. Likewise, more
than three quarters of the doctors reported
that X-rays and referrals are not among the
common objectives of the consultation for BP.
(Click
for Table)
Table 2: The ranking of the reason for encounter
according to patients and doctor
Comparison of patients' and doctors' expectations:
In general, patients seemed to agree with doctors
in most aspects of the expectations questionnaire
(Table 3 and Figure 1) except for the items
related to sharing the reason for the encounter
(Q1; U=60, P<0.05), patients' expression
of their expectations (Q3; U=58.5, P<0.05),
doctors' enquiry about the impact of BP on social
life (Q9; U=63, P<0.05), referrals (Q12;
U=40, P<0.05), beliefs about the ability
of doctors to help patients with their pain
(Q24; U=52, P<0.05), and the ability to manage
the problem without need for referral (Q25;
U=28, P<0.05). Descriptive analysis of the
responses reveals that the majority of patients
and doctors agree that doctors showing interest
and listening (Q7), as well as being warm and
friendly (Q5) are common expectations for patients
(90% and 90%) and doctors (100% and 82%) respectively.
About three quarters of patients (75% and 85%)
and doctors (82% and 73%) agreed that history
taking (Q10) and physical examination (Q11)
should be expected during the consultation.
Patients and doctors shared their concerns about
the ability of the doctor to identify the cause
of the problem (Q15); yet, more than three quarters
of the patients and doctors (80% and 82% respectively)
expected an adequate explanation of the problem
to be given during the consultation (Q16). All
doctors (100%) and the majority of patients
(80-85%) expected information (Q17) and education
(Q18) to be essential components of the consultation
and they both agreed (90%) that patients should
be involved in decision-making (Q22). About
half of the patients and doctors (45% and 55%
respectively) revealed their perception of the
time constraints during BP consultations (Q23),
with more patients and doctors (65% and 55%
respectively) acknowledging the privilege other
healthcare professionals might have over doctors
in managing BP in primary care settings (Q26).
(Click
for Table)
Table 3: The results of the patients' and
doctors' expectations questionnaire
(Click
for Figure)
Figure 1: The results of the patients' and
doctors' expectations questionnaire
The patient-doctor relationship is of paramount
importance to a successful consultation. Very
few studies have investigated BP patients' and
doctors' expectations regarding the consultation
and the matching of such expectations (13);
however, the general literature on patient-doctor
relationships and meeting patients' expectations
reveals that a higher patient-doctor agreement
regarding diagnosis, nature of the problem,
diagnostic and treatment plans are associated
with higher satisfaction, better outcome, and
greater adherence to treatment (7-11). Patients
have a wide variety of specific expectations
for care that extend to both technical and interpersonal
management (16). Such expectations are measurable,
and can have potentially important clinical
consequences (17). On the other hand, despite
the suggested importance of a state of matched
(and not just fulfilled) patients' and doctors'
expectations for better BP management in primary
care (13), little is known about doctors' expectations
related to the consultation. The current pilot
study aimed at exploring the feasibility of
using the newly designed patients' and doctors'
expectations questionnaire for capturing the
range of expectations related to BP consultations
in an attempt to explore the matching of patients'
and doctors' expectations. Within the limitations
of this pilot study, and in terms of non-random,
purposive recruitment and small sample size,
the results of the pilot study showed that diagnosis
and explanation of the problem are the most
valued expectations by all patients; this finding
was also the same for doctors as to explanation
of the problem, but not the diagnosis (rated
fifth), which might constitute a major area
of mismatch that can adversely affect the patient-doctor
relationship. This is in line with previous
research suggesting the importance of diagnosis
as the most valued expectation by patients (18,
19). Interestingly, and in accordance with previous
studies (20, 21), both patients and doctors
agreed that knowing the cause of the problem
(Q15) is not a high priority compared to provision
of adequate explanation of the problem. This
contradicts a previous study (22), which stated
'knowing the cause of the pain' as a principal
expectation for BP patients; however, reviewing
the study showed that diagnosis and cause of
the problem were overlapping and were used interchangeably,
therefore, the results of the study actually
suggest both diagnosis and cause as principal
expectations for BP patients. Another area of
mismatch would be inferred by combining the
results of the ranking and questions sections
of the questionnaire; effective pain relief
was ranked as third important for doctors, while
referrals was ranked as third for patients.
Comparing patients' and doctors' expectations
reveals that patients were less likely to expect
their doctors to help with their pain (Q24),
expected the need for referral to address the
problem (Q25), and indeed expected more referrals
during the consultation than doctors did (Q12).
This emphasizes the fact that despite the doctors'
attempts to challenge their clinical frustration
with BP management by trying to provide effective
pain management without the need to refer patients,
still, patients do not think doctors would be
capable of helping without referrals (23), and
about half of them would expect to be referred
to a specialist (18). Nevertheless, expectations
for medications and tests are met more frequently
than expectations for referrals (24), and some
doctors do not consider referring to physical
therapy to be beneficial at all for BP management
(25), which affected their referral behaviour,
and caused unmatched expectation with their
prospective patients, who expected to be referred.
The mismatch in the ranking of the reasons and
objectives of the consultation, is consistent
with previous research suggesting a mismatch
between patients' and doctors' beliefs about
the role of doctors in general practice as well
as patients' reasons for visiting the doctor
(26), and can be explained in light of the significant
differences found between patients and doctors
in regards to expectations of sharing the reason
for the encounter (Q1; U=60, P<0.05), and
patients' expression of their expectations (Q3;
U=58.5, P<0.05). As suggested in the literature,
exploring and understanding patients' expectations
and encouraging patients to voice them during
the consultation might improve the clinical
process of care, in terms of satisfaction (22),
as well as patient-doctor interaction and concordance
(14, 27). It is alleged that doctor's recognition
of patients' expectations would improve doctor's
satisfaction with the consultation (28).
Patients and doctors agreed about different
aspects of the bio- and psycho- but not the
social aspect of the doctors' management, where
patients were less likely to expect the doctor
to explore the impact of BP on their social
life (Q9). In regards to the expectations questionnaire,
preliminary use of the tool suggests it to be
simple, appropriate and acceptable by users
as reflected by the good response rate. Some
potential problems for the use of the tool might
be the overlapping of some expectations items,
which prompts the need for a study to investigate
the content and construct validity of the questionnaire
to address any clarity and repetitiveness issues.
While no generalization can be made from the
study results; however, the results of the study
underpin important issues that need to be addressed
in order to achieve better patient-doctor relationship
and consultation outcome. This study would form
a good foundation for future research investigating
the matching of patients' and doctors' expectations
and the significance of such congruence, using
proper sample size and more rigour sampling
techniques.
Within the limitations of the study, the findings
showed that diagnosis, explanation of the problem,
and referrals are the most valued expectations
by patients; while explanation of the problem,
effective pain relief, and information provision
were the most common expectations reported by
doctors. Patients' and doctors' expectations
were in agreement for most aspects of the consultation
except in relation to referrals, ability of
doctor to help without the need for referrals,
as well as items related to sharing the reason
for the encounter and expression of expectations.
Patients and doctors agreed that doctors' interpersonal
and communication skills are very important
and that explanation of the problem is more
important than identifying the cause. The study
reveals some areas of mismatch that might adversely
affect the outcome of the consultation. Further
research is needed to explore the matching of
patients' and doctors' expectations using bigger
sample size as well as to investigate the significance
of matched expectations for more successful
BP consultations. The expectations questionnaire
seemed to be an appropriate and acceptable tool;
further research is needed to test its validity
and reliability for measuring BP patients' and
doctors' expectations in primary care settings.
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