Abstract
Background:
The study focused on perceptions of older adults toward the healthcare processes they experienced during a clinical trial for back pain that involved family medicine residents and licensed chiropractors.
Methods:
Individual semi-structured interviews were conducted with 115 older adults after a 12-week, 3-arm, randomized controlled trial. Two researchers conducted thematic analysis with inductive coding using qualitative software to identify participants’ salient experiences of the doctor–patient relationship, healthcare process, and collaboration between study providers. Investigators categorized thematic codes within an existing framework of clinical excellence in primary care.
Results:
Participants emphasized provider communication and interpersonal relationships, professionalism and passion for patient care, clinical and diagnostic acumen, and skillful negotiation of the health-care system. Older adults also described the importance of interdisciplinary collaboration and their preferences for receiving hands-on treatments for musculoskeletal conditions.
Conclusion:
These older adults valued doctors who communicated clearly and spent time listening to their concerns. Many participants appreciated clinicians who supported an active role for patients in their health-care and who provided touch-based care for musculoskeletal conditions.
Keywords
Introduction
Health-care providers, including family medicine doctors (MDs) and doctors of chiropractic (DCs), face special challenges when treating older adults with painful musculoskeletal conditions, such as low back pain (LBP). A National Institutes of Health Task Force of Research Standards for chronic LBP defined the condition as back pain that is an ongoing problem for the past 3 months (1). Among US adults, between one-quarter to one-third have experienced LBP during a 3-month period and the rates are similar in adults older than 65 (2,3). Low back pain symptoms may present in older adults as or along with other biomechanical and soft-tissue abnormalities (4), such as scoliosis, sacroiliac or hip pain, or myofascial pain. Without reliable evaluation, including a structured history and physical examination, such conditions might be missed (4), which can lead to overutilization of healthcare resources, such as inappropriate or unnecessary testing, imaging, and injection procedures (5). Low back pain is an important topic of interest because it is one of the most common reasons people seek health care (6). It is especially crucial to learn about LBP in older adults because it can interfere with activities of daily living and increase the risk of falling (7).
Health communication, one facet of the doctor–patient relationship, is an important component of chronic pain management. Problematically, doctors’ empathy may decrease for older patients and those with chronic pain (8), which may impact patient outcomes (9). This could be the result of a steady decline in empathy among younger people due to a decrease in face-to-face communication and also a decrease in medical student empathy (10,11). Additionally, patients who appear distressed or in pain appear to be harder to work with which could adversely affect provider–patient relationship and empathy (12).
Human interaction is a psychophysiological process, such that providers and patients who perceive empathy and mutuality during the clinical encounter both benefit (13). Differential communication and decreased empathy associated with chronic pain may negatively impact the doctor–patient relationship (14). Strong doctor–patient relationships may lead to better treatment adherence, higher patient satisfaction, and better health outcomes (15). Patients value respect as an important aspect of doctor–patient communication (16), with shared values and support considered essential for effective collaboration (17). Barriers to effective health communication include poor interpersonal skills on the part of the physician, overuse of medical terminology, and not listening thoroughly to the patient’s complaints (18).
Qualitative studies of patients living with LBP describe varied aspects of health communication, such as ageism and negative attitudes (19), professional and family support (20), and clinician feedback (21), as affecting patient perceptions of the doctor–patient relationships. Our previous work explored older adults’ opinions about the potential benefits of collaboration between MDs and DCs for managing LBP, with interprofessional communication a primary consideration (22). The purpose of this study was to explore older adults’ perceptions of the healthcare processes, including doctor–patient relationships and health communication, that they experienced during a clinical trial of interprofessional care for LBP.
Methods
This descriptive study was a secondary analysis of qualitative interviews from a prospective randomized controlled trial (RCT) (23 -25). Participants were randomized into 3 treatment groups and received 12 weeks of (a) primary medical care for LBP, (b) parallel primary medical and chiropractic care, or (c) collaborative primary medical and chiropractic care using a professional practice model to improve interdisciplinary communication. Trial participants (n = 131) were age 65 years or older and diagnosed with subacute or chronic LBP, with the current LBP episode lasting at least 1 month in duration and with an LBP severity rating ≥4 on the 11-point pain numerical rating scale (NRS) (25). Given the design of this pragmatic RCT, which was to evaluate 3 different professional practice models of conservative care for LBP, neither the patient participants nor their study clinicians were blinded to participant treatment group (23). Institutional review boards (IRB) at Genesis Health System and Palmer College of Chiropractic, Davenport, Iowa, approved the study protocol for the original trial, with the Palmer College IRB approving the secondary analysis. Participants provided written consent and gave verbal permission to audio-record (23).
The corresponding author (S.A.S) completed all interviews (n = 115) at the chiropractic research clinic after collection of the quantitative outcomes. The audio-recorded interviews followed a structured guide and lasted approximately 15 minutes (range 10-25 minutes) in duration. Recordings were transcribed verbatim by a professional service and reviewed for accuracy. For this secondary analysis, full transcripts were de-identified (names/titles removed) and shortened to include the sections which explored the older adults’ experiences of their doctor–patient relationships and perceptions of collaboration between MDs and DCs. The data analysts were also blinded to participants’ age, gender, and treatment group. Transcripts were imported into NVivo-9 software (QSR International, Doncaster, Victoria, Australia) for analysis.
Demographic statistics were calculated with SPSS version 22.0 (IBM SPSS Statistics, Chicago, Illinois). Measurement of clinical characteristics was described in detail in the published protocol (23) and reported in the primary results (25). Briefly, overall pain level in past 24 hours was recorded using an 11-point NRS where 0 was rated as “no pain” and 10 was rated as “worst possible pain.” Baseline LBP duration was categorized on a 7-point scale with 1 being pain onset of less than 1 week and 7 being pain onset 1 year or more, with clearly defined categories between these anchors. Baseline general health status was rated on a 5-point scale, with 1 = excellent, 2 = very good, 3 = good, 4 = fair, and 5 = poor.
Two researchers (B.W. and S.A.S.) conducted a thematic analysis to describe the experience of these health-care processes from participants’ perspectives (26). S.A.S. is a female, PhD-prepared, registered nurse with advanced training in geriatric nursing and extensive experience conducting qualitative research. S.A.S. served as the project manager for this RCT; her primary interaction with patient participants consisted of conducting these qualitative interviews. B.W. is a female doctor of chiropractic who was a student in a master of science in clinical research program who completed coursework and mentored experiences in qualitative research. She had no contact with the participants as this was a secondary data analysis which was completed after the original study. D.D., L.N., and D.L., faculty members at Palmer College of Chiropractic, served as graduate advisory committee members to B.W. during her degree program and had no interactions with patient or clinicians in this trial. C.G. was the principal investigator of the trial and had no interaction with patient participants. S.A.S. and C.G. were involved in clinician training for the RCT.
A random sample of 36 interviews, stratified by gender and treatment group, was analyzed to generate the initial codebook. The analytic team relied upon inductive coding, a process where researchers generate insights while reading the transcript, therefore developing the coding framework on an ongoing basis throughout analysis (26). Multiple rounds of coding took place in NVIVO. B.W. first coded 36 interviews, which S.A.S. then reviewed. The analysis team met to discuss the codebook and development of themes, with emerging themes disseminated to the graduate advisory committee at key points throughout the analysis. B.W. revised the coding based on these discussions, and then proceeded to code another round of interviews and meet again to discuss until all transcripts were complete. As more themes or codes were generated, previously coded interviews were recoded. After multiple coding rounds of all 115 transcripts, codes were organized into themes, or recurrent concepts summarizing the range of topics or experiences of participants (26). Themes then were categorized into the core domains of clinical excellence for primary care, including communication and interpersonal skills, professionalism and humanism, diagnostic acumen, skillful negotiation of health care systems, knowledge, scholarly approach to practice, and passion for patient care (27). Quotes are provided with a participant number, gender, and age.
Results
Table 1 shows participant demographics (25). Figure 1 provides the health-care processes identified by participants as important in LBP management. These older adults emphasized 4 themes consistent with the clinical excellence in primary care framework (27), including communication and interpersonal relationships, professionalism and passion for patient care, clinical and diagnostic acumen, and skillful negotiation of the health care system. Two additional themes also were important to participants, interdisciplinary collaboration and hands-on treatment approaches for musculoskeletal complaints.
Baseline Characteristics of 115 Older Adults With Low Back Pain.
Abbreviation: SD, standard deviation.
Older adults’ perceptions of key health-care processes for the treatment of low back pain.
Communication and Interpersonal Relationships
Participants reported generally favorable interpersonal relationships with study clinicians and remarked upon the caring bedside manner of both the MDs and DCs. Patients often mentioned their clinician was helpful, encouraging, and genuine. Patient-centered communication set the tone for positive relationships: She makes you feel at ease. You don’t hesitate to tell her anything and everything, and she works well with you. She’s a good conversationalist; explained everything…She’s very good. I enjoyed her company; enjoyed her work (P4, Female, Age 74). I think the communication process was important, the listening and the direction back and forth is probably the most important thing. I mean, the fact that I told her what my problem was, she said “okay.” And once we had addressed the treatment she said, “do this or do that”…it was just caring and information between the individuals (P54, Male, Age 66). (Doctor) would sit down and ask me what I was doing and listen to everything I had to say and answer all my questions…wonderful with teaching (P21, Female, Age 68). He listened to concerns. The neck cracking, kind of, freaked me a little bit. When I told him that, he concentrated on other things and we stayed away from that area (P32, Male, Age 65). None of them did anything anyway, they just asked questions and recommended Tylenol (P3, Male, Age 72).
Professionalism and Passion for Patient Care
Professionalism was a quality these older adults noticed, whether the attitude was demonstrated by their doctor or went lacking. Participants liked their doctor to be courteous, organized, and thorough in their treatment plan. He always was very cordial, always answered all my questions. We discussed things, and he was very, very thorough about explaining things to me (P69, Male, Age 72). She’s been fantastic, very patient-oriented, very caring, takes time to listen, to any questions or concerns you have, and address them, takes the time (P44, Female, Age 70). He explained different things and had plenty of time. I never felt rushed. I was totally relaxed. He was very professional (P113, Female, Age 77). (Doctor) seemed to care about me as a person, not just as a study object, but as a person and knew what I was going through (P84, Male, Age 67).
Clinical and Diagnostic Acumen
These older adults valued a doctor who knew how to manage their care; that is, possessed the clinical acumen to diagnose and treat LBP: If you had an ache or a pain, she straightened you out. She put you back on the right track (P4, Female, Age 74). I liked knowing what they found and why I was having pain (P115, Male, Age 66). I’ve had several back doctors…He is the first one who explained to me what’s wrong with me, why this hurt. I went home, and I was telling my family, “I now understand why my back hurts so much where it hurts, why it hurts there.” He did a great job. First of all, he told me, “this is what we’re looking at, and this is what we can do.” And then he did it (P52, Female, Age 65). He examined me and figured out the problem and gave me exercises to do and kept checking me. I mean it couldn’t have been any better, got down to the problem and we worked it out and solved it (P38, Male, Age 66). I felt she cared, but she didn’t do anything. She just asked me the same questions the receptionist or the other person did (P5, Female, Age 74).
Skillful Negotiation of the Health-Care System
Participants wanted doctors who know the local health-care system. Older adults appreciated doctors who knew when to refer them to another doctor and who had established relationships with professional colleagues who might better address their health concerns: Very informative as far as what he said to me and what he did in the referrals he made, but it was all the referrals that’s where I got my help (P7, Female, Age 77). He suggested physical therapy and the option of surgery. He never suggested that I should get chiropractic treatment (P100, Male, Age 65).
Interprofessional Collaboration
Participants considered interprofessional collaboration, the primary intervention tested in this RCT, as beneficial and essential for patient care: Collaboration between any providers is always necessary no matter what the subject matter. Proper communication makes for good performance. Improper communication makes for squat (P36, Male, Age 67). When I got over to the MD, he seemed to know what was going on with my problems that were being taken care of here [at the chiropractic clinic] (P4, Female, Age 74).
Hands-On Treatment Approach
Participants highly valued hands-on treatment approaches and specifically stated the words “hands-on,” “human contact,” or “touch” during their interviews. Clinicians offering manual therapies, such as chiropractors, physical therapists, and massage therapists were appreciated for their hands-on approach, with many of these older adults associating touch with treatment. MD was fine, but the physical therapist just had the hands on, like the DC had the hands on (P21, Female, Age 68). I’m sure he did his job and he was very pleasant, and he explained things and was informative, but as far as a hands-on thing…(P4, Female, Age 74). It was a hands-off arrangement over there, it was a hands-on arrangement over here (P90, Male, Age 78). (Doctor) did a few of the things—put me on the table and pulling my leg up. “Does this hurt? Does that hurt?” Just went through some of that routine and it was a good experience (P77, Male, Age 75).
Table 2 offers perceived strengths in patient-provider communications and areas for improvement. Each theme included positive and negative examples, for both MDs and DCs. Many participants (n = 53), when asked how doctor–patient interactions might improve, stated either no improvements were needed, or they were unqualified to make this determination, as they were not health care providers. Participants appreciated it when providers had a caring demeanor. Patient education was important as patients wanted to be able to discuss treatment options with their providers and have the providers listen to them with concern. Time was also valuable as patients wanted the doctors to spend time with them as well as frequent treatments.
Older Adults’ Perceptions of the Health-Care Processes in a Low Back Pain Clinical Trial.
Discussion
This secondary analysis of qualitative interviews highlighted important aspects of the health care processes experienced by older adults who completed a pragmatic RCT of 3 professional practice models of LBP care involving medical doctors and DCs. This RCT was conducted in 2 unique settings, a family medicine residency program that trained early career physicians and a chiropractic research center that employed DCs with at least 5 years clinical experience. With only one exception, the assigned clinicians were not the primary care provider or usual chiropractor of the participant. In addition, most patient participants received care from both MDs/DOs and DCs and also might have received care from other types of health professionals. Given this trial context, we primarily sought to understand the experiences of these older adults in receiving LBP care under these different practice models comprehensively across providers rather than comparatively between the professions or treatment groups.
Participants reflected extensively upon the doctor–patient relationships they had with the clinicians who treated them in this study. These older adults appreciate doctors who were effective communicators, skillful listeners, apt diagnosticians, and sound educators. Participants remarked negatively on the quality of their health-care when such communication was lacking. Similar to our findings, a recent scoping review of patients’ perceived needs of health-care providers for LBP management indicated a desire for good communication, shared decision-making, information that legitimized their symptoms, and individualized continuity of care (28).
We aligned our coding framework to a systematic review of 2000 studies that informed a model of clinical excellence in primary care that included 6 major themes: communication and interpersonal skills, professionalism and humanism, diagnostic acumen, skillful negotiation of the healthcare system, knowledge and a scholarly approach to clinical practice, and a passion for patient care (27). Our participants discussed these indicators of clinical excellence, except for the theme of the providers’ knowledge base and scholarly approach, which, along with professional orientation, may influence LBP outcomes (29). Interestingly, primary care providers and health professionals with a special interest in LBP may lack knowledge about appropriate treatments (30,31), demonstrate fear-avoidant behavior (21,32), or hold problematic attitudes about LBP (33,34) that may impact patient perceptions of health-care quality (35).
Our analysis introduces an additional theme to the concept of clinical excellence, the hands-on treatment approach (22), which may be an especially salient concern for patients with musculoskeletal complaints, such as LBP, or those who have had positive past experiences with manual therapies. Many of the older adults we interviewed praised providers who touched them during clinical exams or who treated their LBP with their hands, whether these providers were chiropractors, physical therapists, or osteopathic and medical physicians. In contrast, these elders spoke critically of clinicians whose approach used talk, medications, or referral with little physical touch. Human touch is beneficial for decreasing pain levels (36,37) which may explain why these patients appreciated the hands-on treatment approach (22). Clinicians untrained in the manual therapies might consider how to incorporate more hands-on approaches, such as physical examinations, when caring for patients with musculoskeletal conditions.
Communication was valuable to the patients. The older adults in this study did not like one-sided communication where the doctor was doing most of the talking. Although not specifically in this study, this harmonizes with previous literature examining barriers to effective doctor–patient communication, which may be attributed to a lack of communication skills on the doctor’s end, the use of medical terms, and not listening thoroughly to the patients’ complaints (18). Patients want open communication and a doctor who listens carefully and gives appropriate time and attention to their needs (38). A qualitative study of adults 50 years and above showed that doctors need to initiate conversations and help guide patients health-care management (39).
The combination of poor communication and decreased empathy associated with chronic pain may negatively impact the doctor–patient relationship. Doctor–patient communication may also differ based on the social class and education of the patient. Patients with more education and a higher social class tend to be more involved in their health care and may have better communication with their doctor (14). When patients have a good relationship and trust their doctor, this may allow for better communication.
These patients wanted doctors to offer LBP treatment options besides pain medicine or referrals to other providers, which is consistent with another study of older adult perspectives of medical care for back pain (40). Collaboration between MDs, DCs, and other healthcare professionals is a result of good communication, with the patient’s best interest in mind (14,41). Some studies of MDs, DCs, and DOs show that referral patterns among providers are low; thus, comanagement is minimal (42 -44). If comanagement occurs, usually the patient is the source of information between providers, not the providers themselves (16). Collaboration among providers can affect the quality and efficiency of the healthcare system (42). If doctors are aware patients desire collaborative care, doctors may want to start collaborating with the patient’s other healthcare providers. This may also change the doctor–patient relationship because if the patient knows that his or her doctor is trying to learn about their total healthcare picture, they may trust the doctor’s opinions and treatment options. Learning the importance of collaboration in the study also corresponds to the literature, which states that collaborating leads to better communication, more comprehensive services, and better health education (45).
Limitations
Nonresponse bias is a potential limitation given the number of participants who made no recommendations for improving trial processes or who reported they were unqualified to make such suggestions because they were not a doctor. Other studies have noted older adults’ reluctance to bother or burden doctors with pain-related complaints because of their previous interactions with providers (19,46). In addition, our participants were almost exclusively white, non-Hispanic older adults from the Midwestern United States, whose perceptions of LBP care may not reflect those of more racially, ethnically, geographically, or age diverse populations. Our study clinicians were not the usual primary care providers or chiropractors for these participants. These older adults might have offered different perspectives on the LBP care received from their own clinicians in their usual healthcare settings. As is the case for pragmatic RCTs that examine healthcare processes, including those using manual therapy techniques, blinding of patients and providers to the study interventions was not possible (47). Thus, we are not able to assure that the patients’ participation in a clinical trial did not somehow bias the clinicians’ communication patterns. We also cannot definitively state that the patients’ perceptions of these healthcare processes were not colored by other aspects of this RCT, such as dissatisfaction with treatment group assignment or perceived clinical outcomes. Future studies also may consider assessing patients’ perceptions of health communication with clinicians who are gender- or ethnicity-congruent with themselves (48,49) or between patients and doctors who had similar preferences for the amount and style of patient involvement in health-related collaboration (50,51). This may influence patient perceptions of care quality and clinical outcomes. Finally, this analysis sought to uncover how health professionals generally might improve healthcare processes and communication with older adults. We intentionally removed specific references to individual providers or professional groups from the transcripts prior to analysis. A strength of our study was that the analysis team was composed of a registered nurse (the mentor) and a doctor of chiropractor (the mentee), representing both the biomedical and complementary medicine perspectives, which allowed for fruitful conversations intended to minimize researcher reflexivity, or the potential effects of the researchers’ personal experiences, background, or beliefs on the analysis and enhance the trustworthiness of the findings (52). There may be, however, very real differences in the ways that DCs and medical physicians interact with their patients which should be explored in future studies.
Conclusion
Older adults in this trial identified healthcare processes that enhanced their experience with multidisciplinary care for back pain. Participants appreciated patient-centered communications in which doctors spent time listening to their concerns and used their clinical acumen to provide diagnostic explanations on back pain causation and self-care options. These older adults emphasized the importance of hands-on care for back pain, which included chiropractic treatments and medical examinations of musculoskeletal complaints. Interdisciplinary collaboration between providers also was viewed as beneficial. Future research might evaluate the effectiveness of communication and touch-based interventions for older patients with musculoskeletal pain.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The clinical trial from which this analysis was conducted was supported by the Health Resources and Services Administration (R18HP15126) and the National Institutes of Health National Center for Research Resources (C06-RR015433). Dr Wells was supported by a graduate research assistantship funded in part by the Palmer Center for Chiropractic Research.
