Is it just me or is there a growing sense in the community that health care delivery is not meeting the perceived needs of its consumers – patients and their families? “Google doctor” situations, horror stories of friends and relatives, less than perfect outcomes….. Bad experiences become folklore and bad news travels way faster than good stories. I see it sometimes creating an “Us Vs Them” scenario in hospital and healthcare settings and I think it can tell us a lot about consumer expectations – they largely don’t seem to intersect with the realities of our health care systems.
So with this in mind, is what we are doing in delivering health care falling short of the mark, or is it just that our patient’s expectations are not realistic? The answer is: probably a touch of both.
Qualitative research by Slade et al in 2009, paints a picture that by and large, patients want to be heard and understood. They desired a therapeutic partnership that was neither clinician dominant nor patient driven – an equal working relationship. We also know that for patients with back pain, one of the most common complaints they have about practitioners is that they don’t listen ( Allegretti, Andrew, Borkan et al, 2010; Stenberg, Fjellman-Wiklund, & Ahlgren, 2012) and that when practitioners are trained in empathy techniques, patients tend to report that those practitioners are more caring. (Bonvicini, Perlin, Bylund….et al, 2009). So it would seem that if we were to do a customer service overhaul to improve patient satisfaction (and likely clinical outcomes), a great place to start would be to allow more time for each patient so that they have the chance to feel heard and understood.
Getting the listening bits right seems like an easy start – to me it is a bit like the low hanging fruit. But what happens when we have done all the listening and education that “best practice” tells us is the way forward, and the patient still wants “something to be done” – an MRI to rule out the disc bulge like Aunty Mary had, or the antibiotics for their viral URTI? Do our efforts need to be turned towards educating the doctor?
Well, maybe, but probably not …….. This study by French et al, published in 2013, looked to educate general practitioners in best practice guidelines in the management of acute low back pain. Largely, what they were looking for was: would educating doctors on this topic change their clinical behaviour in terms of reducing the use of imaging, keeping patients active, reassuring them and promoting self management? The answer: a big fat no! The doctor’s clinical behaviour did not change, despite their assurances after the training session that it would – months down the track their referral rates for imaging were just the same as prior to the training. Speak to doctors at the coal face and the answer as to why this is becomes clear very quickly – patients demand action! Doctors are not stupid – they know the deal with management of low back – but the realities of their practice is that sometimes the patient is so insistent that even the best educational tools and reassurance don’t cut it. They are on a tight schedule and are aware that the patient will go elsewhere anyway.
Soooooo…… Do we need to direct our attention to changing society’s understanding of conditions like back pain? How easy is it to do this? Do public education campaigns work? A Cochrane review done in 2009 by Grilli, Ramsey and Minozzi tells us that although the body of evidence is not particularly large or of a very high quality, there is evidence that using mass media campaigns can change population attitudes and behaviour on topics such as HIV education, immunization rates and back surgery rates. The study acknowledges a couple of important points. Firstly, that it is hard to tell if the effects of the campaigns are coming about because of exposure of the material to the general population or because health practitioners are also exposed to the campaign and adjust their behaviour. Also, it recognises that while mass media can be a powerful tool in reaching people with education material, it may also play a role in shaping the damaging views people hold, such as those quick fix, miracle stories on the news or the sad (and often extreme) stories of people going down a path of pain and disability.
In the case of back pain public health campaigns, the ‘Back Pain: Don’t take it lying down’ campaign, run by Victorian Workcover Authority (Australia) in 1997-1999 was hailed as being a small but successful public intervention. Over the three year period that the campaign was run, it was found that there were significant improvements in back pain beliefs in both the nearly 5000 people surveyed in the general public and 2500 general practitioners (Buchbinder, 2008). The flow on effects from these positive outcomes are hard to measure – but the campaign was prompted by high absenteeism in the workplace. It wouldn’t be hard to account for the dollars spent if the subsequent clinical outcomes included reduced absenteeism and reductions in healthcare visits.
In addressing “risk” in public healthcare settings, there is said to be what is called a “prevention paradox” – this is the idea that there is a more substantial public health benefit from a small shift in risk across a large population, than from a large shift in risk for a small subgroup (perhaps even a high risk group). This fits with the idea that the shift needs to be population wide, and that even a small shift is a good start.
So, if I won 10 million dollars, would I spend it on a public health campaign to reduce the burden of low back pain on society? Maybe….. as long as I could manage the campaign from here:
Allegretti, Andrew, Borkan, Jeffrey, Reis, Shmuel, & Griffiths, Frances. (2010). Paired interviews of shared experiences around chronic low back pain: Classic mismatch between patients and their doctors. Family Practice, 27(6), 676-683.
Bonvicini, K.A., Perlin, M.J., Bylund, C.L., Carroll, G., Rouse, R.A., & Goldstein, M.G. (2009). Impact of communication training on physician expression of empathy in patient encounters. Patient Education and Counseling, 75(1), 3-10.
Buchbinder, R. (2008). Self-management education en masse: effectiveness of the Back Pain: Don’t Take it Lying Down mass media campaign. Medical Journal of Australia, 17;189(10 Suppl), S29-32.
French, S., MckKenzie, J., O’Connor, D., Grimshaw, J., Mortimer, D……..et al. (2013). Evaluation of a theory-informed implementation intervention for the management of acute low back pain in general medical practice: the IMPLEMENT cluster randomized trial. Plos One, 13;8(6):e65471. doi: 10.1371/journal.pone.0065471.
Slade, S., Molloy, E., & Keating, J. (2009). ‘Listen to me, tell me’: a qualitative study of partnership in care for people with non-specific chronic low back pain. Clinical Rehabilitation, 23(3), 270-80.
Grilli, R., Ramsay, C., Minozzi, S. (2002). Mass media interventions: effects on health services utilization. Cochrane Database Systematic Reviews. CD000389
Stenberg, G., Fjellman-Wiklund, A., & Ahlgren, C. (2012). “Getting confirmation”: gender in expectations and experiences of healthcare for neck or back patients. Journal of Rehabilitation Medicine , 44(2), 163-171