Ehab GeorgyPG ResearcherBournemouth UniversityUnited Kingdom

Prof. Eloise CarrDeputy Dean, School of Health & Social Care Bournemouth University

Prof. Alan BreenProfessor, Musculoskeletal Health Care, Anglo-European College of Chiropractic

Met or Matched ExpectationsWhat accounts for a successful back pain consultation in Primary Care?

A presentation for the 3rd bi-annual conference of the European Forum for Primary Care - Pisa, Italy 2010

Back Pain (BP)

Medical Consultation

Expectations

Main reason for hospitalisation and other care service utilisation.

(Malmivaara et al., 1995; Skelton et al., 1995; Maniadakis and Gray, 2000; Walker, 2000; Gask and Usherwood, 2002; Breen et al., 2007; Savigny et al., 2009).

Affecting up to 2 in 3 of the adult population each year. One of the most common reasons for consulting a doctor.

Bio-psychosocial management has been problematic; many doctors see it as a difficult and unrewarding condition to deal with in Primary Care.

The essence of BP care in Primary Care is the consultation. A process of negotiation between the patient and doctor. Geared towards information, advice or specific care. It serves three main functions: build a relationship, collect data and agree on a management plan.

Prediction about specific events likely to happen during the consultation. Patients & doctors seem to each have their own agenda of consultation.

Expectations:why complex??

Defined and conceptualised in various ways.

No ideal method for measuring expectations.

Expectations are influenced by:

• Culture and Background.

• Past experiences.

• Acquired knowledge.

• Perceived vulnerability to illness.

(Thompson and Sunol, 1995; Kravitz, 2001)

Patients and doctors appear to have a specific agenda during

the consultation;

These agendas seem to have different content and focus

and

there seems to be a mismatch between patients and doctors beliefs in regards to different aspects of the consultation

(Ogden et al., 1997; Georgy et al., 2009)

Patients’ expectations Doctors’ expectations

Reassurance and

advice

Sharing problems and

doubts

Avoid unnecessary

referrals or tests

Education

Accurate diagnosis

GP showing interest and

listening

Adequate explanation

of the problemInformation

Information

Education and

stress counselling

Prescribing effective treatment

Physical examination

(Kravitz et al., 1994; Sanchez-Menegay and Stalder, 1994; Turner et al., 1998; Tomlin et al., 1999; Verbeek et al., 2004; Parsons et al., 2007; Ruiz-Moral et al., 2007).

Matched patient-doctor expectations: why important?Patient-doctor agreement is of paramount importance and has the potential to affect the consultation outcome in various ways:

higher satisfaction

better communicatio

n

greater adherence to treatment

better general health

outcomes

positive perception of improvement

higher concordance

(Starfield et al., 1981; Williams et al., 1995; Cedraschi et al., 1996; Liaw, Young and Farish, 1996; Fagerberg et al., 1999; Maly et al., 2002; Kerse et al., 2004; Krupat et al., 2004; Azoulay et al., 2005; Staiger et al., 2005)

Research aim and ObjectivesResearch aim and Objectives Main aimto investigate the matching of patients’ and doctors’ expectations related to BP consultation in Primary Care.

objectives

To explore patients’ and doctors’ BP specific expectations using a

structured questionnaire that was designed for the study.

To discern the matching of patients’ and doctors’ expectations

related to BP consultation in Primary Care.

To explore the perceived importance of matched expectations for

patients & doctors regarding specific aspects of consultation.

A mixed methods sequential nested design. 11 Doctors and 57 Back Pain Patients. Two parts:

1. Quantitative part: A cross-sectional correlation approach. comparing each patient and his/her corresponding doctor. Patients & doctors completed the expectations questionnaire;

(a 21-item tool consisting of two matched parts: one for patients and another -similar but adapted- for doctors.

Main outcome measure was patients-doctor agreement.2. Qualitative part:

Sub-sample of the same group (nested)- 6 patients & 6 doctors. Recorded semi-structured telephone interviews. to explore their perceptions of the significance of matched

expectations for a successful BP consultation.

Findings- Findings- Questionnaire analysisQuestionnaire analysisHighly expectedLess expected

Findings- Findings- Questionnaire analysisQuestionnaire analysis *Low agreement *Disagreement

*Moderate agreement

*High agreement

Findings- Telephone interviewsPerceived Importance of Matched Expectations

Better communication and interaction:Mrs A (BP patient): “… obviously, if I feel I have agreed with my doctor about most aspects during the consultation, for example, explanation of the problem, the need for tests or referral and about the treatment plan that can fit my life style, then I feel I have had a positive experience and that I was able to share my doubts and concerns with my doctor much better”.

Dr B (GP): “... if the doctor is hopefully on the same wavelength of anticipation as the patient, the patient feels as if the doctor has been listening and the consultation would be much more valuable”.

Findings- Telephone interviewsPerceived Importance of Matched Expectations

Better compliance and adherence to treatment:Mr C (patient): “Patient-doctor agreement is very important, because if you feel that the doctor has been listening to you and isn’t just treating you as a number and does know your needs, then you are more likely to listen to what the doctor says and take his advice”.

Dr D (GP): “… if the patient’s agenda is not revealed and if the doctor is directing the consultation in a way that patient's expectations are not explored, most probably, this consultation will go wrong and the outcome will be compromised, and this obviously will affect the compliance and adherence to treatment and consequently the satisfaction and possibly the symptom improvement”.

Met or Matched Expectations?

Met or Matched Model. Georgy EE, Carr ECJ and Breen AC (2010). In review; Health Expectations Journal

Key messageIt is proposed that, for more successful back pain consultation, it is important to:o Elicit patients’ expectations during the

encounter.o Address unmet expectations with

alternatives.o Manage and negotiate inappropriate

expectations.o Educate patients for well-formulated future

expectations.o Match rather than just meet patients’

and doctors’ expectations.

Have a very enjoyable and fruitful time in

Pisa

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