Editorial

Stan Innes BAppSc(Chiro), BA(Hons), Mpsych.

I came across several articles over the summer, that when grouped together, gave cause for some reflection on the patient-practitioner dynamics.

The first that caught my eye was titled “The Good Back-Consultation”¹ which was intended to identify core elements of what patients with chronic low back pain perceive as good clinical communication and interaction with a specialist. It was a qualitative study including observation of consultations and a subsequent patient interview. Thirty-five consultations were observed with respect to history-taking, clinical examination and interaction between patient (n=35) and doctor (medical specialists, n=14). Patients were subsequently interviewed about how they perceived the consultation.

Not surprisingly the patients emphasized the importance of being given an explanation during the examination of what was being done and found, of receiving understandable information on the causes of the pain, of receiving reassurance, discussing psychosocial issues and discussing what can be done. The most important characteristic of “The Good Back-Consultation” was that the specialist took the patient seriously. They concluded that the findings may represent an important potential for enhancing clinical communication with patients. No surprises there.

The second was an editorial written by two eminent researchers in the field of chronic LBP, Steven Linton (noted for his Antipodean contribution, The NZ Guidelines for Acute LBP) and Johan Vlaeyen². Admittedly their research emphasis has been on Fear-Avoidance. The Fear-Avoidance model hypothesises that a person’s excessive fear of pain and subsequent avoidance of activity leads to physical deconditioning. This in turn results in central nervous system changes (e.g., allodynia), that lower the thresholds of pain for future activities. It is viewed as a cycle that leads to increasingly poor outcomes. I openly admit that this is an over simplistic summary, but it will suffice for the current article (feel free to drop me a note if you would like more information).

The excessive fear may lead to an interplay of cognitive-behavioural dynamics. For instance, catastrophic thinking/ interpretations that may lead to safety behaviours, such as hypervigilance of potential threat situations and overuse of escape/avoidance alternatives (any awareness of pain and these people tend to “rest or stop the activity straight away”). These choices augment disability levels.

By reviewing the available research they suggest that persistent pain patients with high levels of disability are prone to misinterpretation on two levels. First they may misinterpret their own environment as excessively threatening or holding the potential to cause reinjury or aggravation of persistent pain. Second the information provided by health care practitioners. Clinicians might inadvertently increase the threat value of pain by using diagnostic terms that may be interpreted by patients as evidence for serious pathology. They suggest that threatening diagnostic labels such as ruptured disc, back injury and degenerative changes (perhaps subluxation?) may activate the fear network.

Linton and Vlaeyen cite two studies. The first study revealed that general practitioners who report increased pain-related fear themselves are more likely to recommend bed rest or rest during sick leave for patients with acute low back and are less likely to advise maintaining physical activities in chronic low back pain. The second study suggests that patients’ fear-avoidance beliefs are strongly associated with their rheumatologists’ fear-avoidance beliefs (this begs the question are we similar in nature to rheumatologists). These studies add evidence to the existing literature already suggesting that ‘‘patients’ beliefs may be influenced by the projected beliefs of their health care providers’’. Some caution is needed however. The current studies are cross-sectional and basically descriptive, excluding the ability to make causal inferences. Consequently, more experimental research will be required. Nevertheless, the results are intriguing.

I was particularly intrigued by the notion of the role of ‘‘reassurance’’, a widely adopted management strategy for patients with so-called non-specific pain complaints. They suggest that reassurance in the absence of a credible rationale of the existing pain complaints is likely to have paradoxical fear strengthening effects, but the literature on this is surprisingly scarce. One study showed that providing an ostensibly ‘reassuring’ diagnostic MR test result in patients with low back pain did not affect outcome at all and suggests that it may even be counterproductive.

These two articles lead me reflect on the models of patient care that underlie day-to-day practice i.e., what informs and acts as a guide to the way I practice and will result in the best outcomes for all involved in health care delivery. The current state of the art model is “patient-centred collaborative care”. It is a health care model that is gathering momentum and garnering wider acceptance. What is this I hear you say? The term “patient-centred” care seems to have its origins as a reaction to paternalistic “doctor-centred” health services. “Collaborative care” results when doctors and members of the “health care team” actively engage patients in “evidence-based” decision-making and management based decisions on what matters to the patients. Here the aim is for patients to become better “self-care managers” as a result of collaborative care.

Collaborative care – almost synonymous with a “productive interaction” is associated with improved patient outcomes. Regardless of jargon, patients who experience the best health care possible, the best “patient-centred collaborative care” possible, should strongly agree that they are receiving “exactly the care they want and need, exactly when and how they want and need it”. Only about 25 percent of adult Americans strongly agree that they have received “patient-centred collaborative care” defined in this way (sorry I don’t know of any Australian studies to date).

Being patient-centred requires us to understand both, “what’s the matter with the patient” and “what matters to the patient,” as well. If we do that, then we’re on the same page with them. The collaborative side of it means that, once we are on the same page, we know how to give our patients the best information and support they need to both better manage what matters to them and what is the matter with them. Why is it important? Because the literature, and common sense, indicates that when patients attain patient-centred collaborative care their outcomes are much better than patients not receiving such care. It’s good for patients and good for physicians who are increasingly being asked, and paid, for improved outcomes.

Clearly, in an acute setting like an emergency room, the concept of patient-centred collaborative care is silly. If someone is having a CVA, we’re not going to sit there and ask them and ourselves what is it that might matter to the patient. But, as you move away from those acute situations and move to the real work of most practices, if you don’t engage the patient and help them in a collaborative way and you’re not on the same page with them, you’re just not going to have good results.

There is seldom a best scientifically validated approach for a patient because most patients seldom have just one thing wrong with them for which there is one perfectly validated treatment. Maximally effective treatment requires us to balance what we know scientifically, what we don’t know scientifically and what the informed patient would want and benefit from. To manage “what is the matter” it is important to know “what matters” to our patients.

We need to help patients become confident with self-management and problem solving. Patient confidence is an important “final common pathway,” COCA is currently exploring the possibility of presenting more information on this approach in the near future.

References:

1. Laerum E, Indahl A, Skouen JS. What is “the good back-consultation”? A combined qualitative and quantitative study of chronic low back pain patients’ interaction with and perceptions of consultations with specialists. J Rehabil Med. 2006 Jul; 38(4):255-62
2. Vlaeyen J, Linton S. Are we “fear-avoidant”? Editorial. J Behav Med. 2006 Dec 20.