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| Journal of the New Zealand Medical Association,
18-May-2007, Vol 120 No 1254
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Exploring general practitioner identification and
management of psychosocial Yellow Flags in acute low back
pain
Cameron Crawford, Kathleen Ryan, Edward Shipton
The increasing prevalence of back pain has been described as
an epidemic.1–6 Most back pain becomes
manageable within a relatively short timeframe. Serious difficulties arise when
the pain persists. These consequences affect not only the person suffering from
the pain but their families and workplace as well. Pain impacts upon society in
terms of work loss and provision of welfare
benefits.7,8 Recently, psychological and social
factors have been recognised as playing a key part in the development of chronic
disability.9–13 This premise led to the
development of the New Zealand Acute Low Back Pain Guide (ALBPG) and
the Guide to Assessing Psychosocial Yellow Flags in Acute Low Back
Pain.
The Guide to Assessing Psychosocial Yellow Flags in
Acute Low Back Pain (‘Yellow Flags’ Guide) was
developed by the National Advisory Committee on Health and Disability of the
Ministry of Health together with the Accident Rehabilitation and Compensation
Insurance Corporation.14
The Yellow Flags Guide outlined the need for the
identification of the psychosocial risk factors by healthcare providers. The
Yellow Flags monograph comprised a clinical assessment, a screening
tool, and recommendations for early management.15
Linton and Hallden15 developed the
Acute Low Back Pain Screening Questionnaire (ALBPSQ). The Yellow
Flags Guide recommends use of the ALBPSQ after no progress 2 to 4 weeks
following initial presentation. This is to discriminate between ‘at
risk’ and ‘not at risk’ patients.
For those ‘at risk’ individuals identified, a
clinical assessment of psychological factors is advised. The healthcare provider
is asked to consider referral to a suitable clinician unless they themselves
have the skills and resources to develop and implement a management plan,
targeting specific issues to prevent long-term distress, reduced activity and
work loss. Appropriate early intervention could thus be provided resulting in
the prevention of persistent pain and
disability.16,17
Most New Zealand general practitioners (GPs) have been
repeatedly exposed to the Guide to Assessing Psychosocial Yellow Flags in
Acute Low Back Pain (‘Yellow Flags’ Guide). The screening
instrument is The Acute Low Back Pain Screening Questionnaire.
The aim of this study was to qualitatively explore (using a
social constructionist approach) the experiences of selected GPs in the
identification and management of the psychosocial risk factors (Yellow
Flags). This was performed with reference to the Guide to Assessing
Psychosocial Yellow Flags in Acute Low Back Pain as well as to the
theoretical underpinnings involved. Related features included: - What did the
GP’s make of these experiences? What were their beliefs or worldviews?
What were the consequences of the meanings that were constructed from the
experiences, for themselves, and for their patients?
There has been rapid international uptake of the construct
of Yellow Flags as being psychosocial factors that increase the risk of
long-term disability.18 The setting (the where
and how of the information gathering) needs to be described. In addition, the
screening instrument needs to be validated for each particular
context.18
MethodsThe qualitative paradigm was chosen as the most
appropriate means of exploring the experiences of GPs’ identification and
management of psychosocial Yellow Flags in sufferers of low back pain.
This due to the fact that it is concerned with describing patterns of behaviour
and processes of interaction as well as revealing the meanings, values and
intentions of a person’s life experience. The chosen perspective,
social constructionism, fits the aim of the study—to provide an
understanding (as experienced by physicians) of their reality in regard to the
use of Yellow Flags.
Purposeful sampling was employed to create depth to the
emerging knowledge. This allowed for (and permitted changes to) strategy and
adaptability of the researcher to the unique circumstances of the study. The
characteristics of the sampling process were viewed as follows—indigenous
to the study; not completely under control of a sampling design; and an ongoing
activity involving the interviewer and the participants. Participants were
selected for their relevance to the aim of the study, not for their
representativeness.
The interview was designed to incite narrative
production. GPs were selected, who (because of their experiences with Yellow
Flags) could provide eloquent and indepth insight into the research
question (so called ‘information-rich’ informants) as opposed to
representatives of populations.
The participants needed to be GPs who saw patients with
back pain and who (via the RNZCGP and ACC) had been exposed to guidelines. It
was calculated that 11 interviews were required to reach the point of variation
in data and diversity in participants for a study of this nature. The GPs were
informed that the study would explore their experiences regarding identification
and management of psychosocial risk factors in low back pain.
Semi-structured audiotaped telephone interviews were
conducted with 11 GPs. The basic structure of the interview is presented in
Table 1. Brief notes were made during the interviews to ensure that all topics
were discussed. Each GP was interviewed only once and interviews lasted between
25 and 45 minutes. The differences in time allowed provided space for open-ended
questions that interviewees answer differently, their varying experiences with
the guidelines, and their varying lengths of introspection and eloquence.
The audiotapes were transcribed and printed.
Interviewing took place over several months allowing the interviewer to develop
an understanding that enabled him to facilitate and permit the participants to
shift their perspectives during the interview process. Participants were offered
different ways of conceptualising an issue. The participants were made aware of
the interviewer’s background in pain medicine. The interviews were viewed
as an interpretive, active practice and process that examined the
how’s’ and what’s of the GPs experiences.
The GP’s constructions were explored with them at the time of the
interview as well as later by the researcher from the interview transcripts.
Table 1. The basic structure of the interview
process
The interview data was analysed to render recurring
themes and phrases, achieving primacy of the subjective data, and permitting
understanding of the GP’s construction of a worldview of their
experiences.
Inductive analysis was used to explore the details and
specifics of the emerging understanding. This was achieved by working from the
data of the specific cases towards a more general conclusion, while
simultaneously seeking to fashion a creative synthesis. The transcripts were
read and read again, examining them for broad themes and phrases. This initial
phase involved working with the more ‘concrete’ themes that came
directly from what the participants had constructed during the interview
process. These were coded from each interview.
An inductive and iterative process then followed in
which the information was grouped by the coding that had been developed.
Examining the issues identified in the way they related to the main focus
refined it further. These phases evolved over a period of several months. The
process was iterative and required consideration and repeated exposure to the
data in order to permit the recognition of the primary themes.
ResultsThe analysis of the data revealed three key themes: cultural
perspectives; orientation to guidelines; and orientation to ACC.
Cultural perspectives—The
relationship between the GP and their patient was described as being of key
importance to the identification and management of any symptoms, particularly if
psychosocial components were present.
We have a relationship with
them (from a GP in large group practice).
Knowing the person,
that’s probably the most important path
Here, the GPs take the initial position that what they are
told by their patient is real. The GPs described this as the most satisfactory
way of approaching any possible biopsychosocial issues. This gave them the
confidence to then start examining any Yellow Flags aspects. The
consultation follows the patient’s agenda and thereby maintains a
doctor-GP relationship.
The GP participants consistently stated that their initial
approach was biomedical. Some doctors felt that there could be repercussions if
they examined the patient from any other perspective than a biomedical one. The
GPs valued their relationships with other health professionals involved in their
patients’ care.
Time issues generated the greatest dialogue. Time was
considered a barrier to both the identification and management of Yellow
Flags. In every case, it was simply not possible to schedule any additional
patient time at the initial appointment.
It takes ages and then
you’re half an hour late sort of thing...I mean to do a really good
physical examination, to take a really good musculoskeletal history and then a
psychosocial history is a time-consuming process
The time required for identifying and managing any
presenting Yellow Flags impacts financially upon both the patient and
GP. The GPs consistently identified that a greater amount of time needs to be
devoted to patients who have biopsychosocial issues. Longer or earlier follow-up
appointments are booked by some physicians for patients with Yellow
Flags. Compounding the impact of time on the consultation dynamic is the
ever-present paperwork that comes with ACC claimants (GPs described the amount
of work that ACC represented in their businesses was between ten and fifteen
percent. A disproportionate amount of administration occurred with ACC-based
work). The limited availability of time became a barrier to GPs reading the
guideline in depth and in detail. GPs whose practices were orientated towards
the biopsychosocial model felt that education for GPs on the guideline was
lacking as well.
There’s probably a
lack of understanding with the recognition of the implications of Yellow
Flags amongst general practitioners
Physicians are obligated to examine and screen for
biophysical red flags before undertaking any other approach.
Many are very split...,
there’s mind things over there and physical things over here and
they’re not often thinking about the connections and doctors just simply
aren’t given the training to deal with it
Most GPs continued with the biomedical approach until there
was a lack of progress. Once past the biomedical parameters, strategies were
used by GPs to start exploring the possibilities of non-physical signs being a
component of their patient’s problems.
If it’s like a story
that just doesn’t fit or you know it’s like a very minor thing that
all of a sudden, you know
I’ve got stress mood
graphs and physical symptom graphs that I graph for
Showing the patient that their problems are not purely
biomedical may create the risk of losing that patient from their practice. To
identify Yellow Flags, and communicate this to the patient takes
understanding, trust, and time. Biopsychosocial model-orientated GPs felt that
patients needed to start to make the connections themselves. This required their
facilitation, a skill for which they felt under-trained in.
Doctors simply aren’t
given the training to deal with that
The personal orientation of the GP as well as their clinic
helped shape the patient’s attitude towards exploration of the
psychosocial aspects.
Cause that’s the way
they’re used to us operating really
Orientation to clinical
guidelines—Participants held definite views and feelings about
the character of the guidelines. The guidelines were seen as an artificial,
mechanistic approach to medicine. They were viewed as highly structured,
categorical, and prescriptive, subjugating clinical judgement by reducing
medicine to algorithms.
It’s pigeon-holing
patients in here, there and everywhere
Some of it is a wee bit
insulting...it reduces medicine to...all these algorithms
Too often it was almost too
prescriptive
I would have been incredibly
resistant to someone sort of pushing me through an algorithm.
In identifying and managing psychosocial problems in low
back pain, the GPs relied on past experience and clinical judgement over and
above the use of guidelines. An intuitive, experiential approach—with the
ability to contextualise the problems through the existing doctor-patient
relationship—was prized ahead of clinical guidelines.
They’re quite sort of
structured aren’t they, and I think that eighty percent is missing. Eighty
percent is your gut feeling
The idea of a guideline...it
just isn’t really useful
...I use those things that
make up Yellow Flags intuitively and from experience ‘cause I
know that those things influence what happens’.
Given the constraints of the
ten to fifteen minute appointment, I personally believe the issues are largely
ignored
I get the feeling that
they’re unhappy...and they would sort of flag things in my mind, but I
don’t sort of routinely go down the list and check them all out
I get the feeling in my gut
as soon as they come through the door
The usefulness of the guideline, and associated screening
questionnaire, was described as poor with limited clinical value. The advice
they provided was perceived as ineffective.
You know the guidelines from
ACC. I’m afraid I’m a little bit jaundiced
I can never put my hand on
it and people seem to fall outside algorithms
They’re not a lot of
use basically
By the time I need to look
out for the guidelines—where are they?
To be honest I don’t
even refer to them
The guideline presumed consultations to be always doctor
driven and operating in a linear fashion. Consultations were, however, described
as dynamic and did not necessarily follow the “ACC agenda”.
Some things that ACC might
like attended to end up being relegated further down the list...that’s
actually appropriate
The guidelines were not suitable to the ‘real’
patient situations with which GPs deal on a day-to-day basis. This contributed
to some GPs choosing not to use them.
A guideline tends to look at
the difficult patient or and the patients never quite fit
The guidelines are
constructed in a very mechanistic and objective way and what you’re doing
with your patient so often is a lot different from that
Available time to read them was limited.
To be honest I don’t
get the time to read them all
Reading the guideline was often the only educative method
used by GPs.
I read them when a new one
comes out but then I don’t pay much attention I must admit
The initial reading determined relevance to their clinical
practice.
I would cast my eye over a
guideline...and it might modify my behaviour
There was a general mistaken assumption that the ACC
guideline was evidence-based.
The guidelines are
evidenced-based aren’t they?’
The volume of all the guidelines with which GPs are faced
was overwhelming in terms of having time to read them and assimilate into their
clinical practice.
If everything that came
across our desks we were meant to read, we wouldn’t be doing any
work
If you put them all in a
pile it comes to about forty-five centimetres. It’s another nice glossy
document which goes more or less on the shelf...it very rarely comes down
The ACC-created paperwork and process barriers became
disincentives to guideline compliance.
You’ve got this great
big piece of paper and you’ve got to fill it out
Just paper work gone
mad
What was accepted practice amongst their peers superseded
any guideline recommendation.
The judges may look at your
peers more than they would the guidelines
GPs queried the clinical value of guidelines.
ACC rolls out these
guidelines with screening questionnaires but clinically they have little
value
The short-term benefits of guidelines were not readily
identifiable by most GPs. Guideline recommendations were seen primarily as a
system of ACC cost-saving.
This is just to save money
for ACC
Orientation to ACC—Three aspects from
the GP’s perspective affected their outlook on ACC and their guidelines,
namely: the process behind the model; funding; and the GP’s opinion of the
rehabilitation model of ACC. A disproportionate amount of paperwork and ongoing
administration was linked to ACC work.
At any time ACC ask things,
they want all the information again. So when you go back over a few years worth
and photocopy all these things
It was perceived that the quantitative values measured did
not necessarily reflect quality of care.
You and I both know that
(it) doesn’t always equate to quality just because someone’s off
their books
The identification of Yellow Flags might even work
against the patient and their rehabilitation.
It’s going to attract
the ACC Case Manager who may want a copy of my old notes...so I quite often
deliberately don’t write down those things
Participants argued that financial support was needed to
explore the psychosocial dimensions and assist with the dissemination of
effective implementation strategies.
There should be financial
drivers
ACC actually has to release
funding...because it takes time
Counteracting this was the opinion that the present system
(fee for service) gave the GP a financial incentive for medicalising the
treatment.
...an incentive to continue
to medicalise a problem by getting people back
It never fails to amaze
me...why do ACC fund, you know, all sorts of things when we think there is no
evidence that it actually works
Participants saw no self-directed incentive for patients to
return to independence. Patients are encouraged to demonstrate to ACC (in an
ongoing fashion) that they are unwell in order to obtain continued support.
For people to continue to
receive support they have to demonstrate they are sick. And what does that do
for rehabilitation?’
The attitudes of the GPs were partially related to personal
experience or practice experience with the local ACC branch.
Because too many patients
have been irritated by the ACC process. That gets in the way of the
rehabilitation
DiscussionLow back pain (LBP) is expensive for society and for the
individual affected. A small number (5–10%) of LBP sufferers are
responsible for the majority of costs
(70–90%).19–26 The total costs vary
from country to country, but are measured in billions of
dollars.2,20,22 Many of the costs are
medically-related costs, with surgery and clinical investigations being the most
expensive followed by physical therapy.
Approaching the treatment of back pain via the disease model
does not allow for the complex sensory and emotional human response to pain and
disability. The biopsychosocial model allows for the interaction between the
person, their social environment, and physical dysfunction and illness
behaviour, beliefs, and coping strategies. It represents the clinical
presentation of LBP at a point in time and recognises the behavioural and
psychological factors that could help explain a person’s levels of pain
and disability.2,14
The World Health Organization (WHO) has used this
biopsychosocial model as the basis for the international classification of
functioning, disability, and health.27 Most
risk factors in LBP that result in chronicity are psychological, behavioural,
environmental, or social in nature.28,29 The
relevance of these risk factors in acute and subacute LBP has been
demonstrated.14,30–39
Many clinical guidelines have been produced and promoted.
However, there is little evidence in the literature showing that using
guidelines results in better outcomes. For instance, in a case-controlled study,
547 patients with LBP from urban and rural clinics throughout Australia were
compared to groups that were subject to either usual medical care or
evidence-based care for LBP.39 The results
indicated that those who received the evidence-based care had significantly
better symptom relief, a significantly greater rate of full recovery,
experienced greater satisfaction regarding their care and outcome, and were
significantly less expensive to treat.
Sheehan40 looked at LBP in
countries where guidelines for LBP had been published and disseminated
nationally several years ago. The study found that there was in fact no overall
reduction in the number of back pain cases referred to healthcare providers.
The GP participants identified that their interpersonal
relationships with their patients allowed them to manage Yellow Flags
as they felt appropriate. A patient-centred approach facilitated the
patient’s involvement in the decision-making process. The GPs in this
study used a collaborative or partnership approach, where the doctor was the
service-provider. They described strategies that permitted them to work with
their patient to understand how psychosocial factors may form part of their
problem. In doing this, the GPs avoided an antagonistic “tug-of-war”
situation.
The doctor-patient relationship has been influenced by
several factors: group type practices; the establishment of after-hours clinics
where no appointment is required; and a redistribution of medical work to nurses
and non-medical staff. This often reduces the work of a GP to a set of
biomedical tasks. Yet failure to meet their patient’s expectations could
result in the patient changing to another GP.
Time is central to medicine. Longer waiting times heightened
anxiety and increased patient vigilance in monitoring their consultation
time.41 The GPs in this study all identified
time management to be challenging in patients that present with psychosocial
elements. The strategies used to manage in these situations included extending
the initial consultation time and/or scheduling subsequent appointments.
In the literature, the relationship between consultation
length and quality of care is
unclear.42–44 The GPs in this study had
appointment times of similar length to one another. They would schedule more
time if required. When there are psychosocial aspects to patient’s
problems, the consultation becomes more complex and takes more
time.45,46 The study demonstrated that
appropriate education relevant to identifying and managing Yellow Flags
in general practice is needed. Thoughts expressed on evidence-based medicine in
general and the ACC guidelines in acute low back pain in particular, confirmed
these added demands on GPs.
How do GPs use evidence-based medicine to attain ‘best
practice’ in a resource-constrained environment? Simply supplying
clinicians with information has not bridged the gap between evidence-based best
practice and actual clinical care. The Yellow Flags guideline is a
consensus document not directly supported by evidence. None of the GPs were
aware of this. They assumed that this guideline was supported by good evidence.
Participants expressed criticisms and concerns about these
Yellow Flags. A New Zealand study47
surveying 448 GPs concluded that low morale and high stress continue to affect
New Zealand general practice. Paperwork and bureaucracy scored as the highest
sources of stress. Indeed, a sense of frustration was detected in the GPs
interviewed. High demands and low locus of control affected their
work—data from this study confirms bureaucracy to be a stressor for New
Zealand GPs.
There are many theories and models relating to the
dissemination and implementation of clinical guidelines and the challenges that
they present.48–52 Grol and
Wensing52 found that knowledge relating to
barriers and incentives for change occurred at various levels (innovation,
individual professional, patient, social context, organisational context,
economic context, political context). No advantage to clinical practice by the
use of this guide was expressed by the GPs. There were mixed levels of
enthusiasm for guideline implementation. This was partially related to their
previous experience of clinical guidelines, the consultation dynamic and their
orientation towards ACC.
ACC’s primary dissemination strategy had been
mail-outs or secondary a ‘road show’ format. Selected clinicians
presented these ‘road shows’, to which GPs and other health
providers were invited. In addition to ACC-led initiatives regarding Yellow
Flag dissemination, contributions were made from the independent
practitioner organisations (IPOs), small group meetings, and a GP’s
individual worldview. There was a lack of evidence of any communication or
strategy operating between these different factions to coordinate the process of
guideline dissemination and implementation.
Arroll50 reported that in
New Zealand too little emphasis is placed on guideline implementation with the
bulk of resources being allocated to the development of the guidelines. This is
reinforced by the experiences of GPs in the study. None were aware of the level
of evidence used in developing the guidelines. All described a marked lack of
utility and saw the guidelines as mechanistic, prescriptive, and as having
little relevance to the context of their daily work.
A previous publication readily identifiable as being
evidence-based (the ALBPG) was merged with the Yellow Flags
Guideline, a guideline not subjected to the same level of development
and scrutiny. The New Zealand Guideline Group felt the “information in
the document was misleading, in that the Yellow Flags section of the Guideline
is a consensus document” (New Zealand Guidelines Group Information
Manager—personal communication, April 2005).
GPs are overwhelmed by information but are unable to find it
when they need it. Gray53 called this
information paradox the two laws of dissemination. Firstly
“... the probability that a disseminated document will arrive
on someone’s desk the moment it is needed is infinitesimally small, and
secondly the probability that the same document will be found three months later
when it is needed, is even smaller”. The GPs in this study
exemplified this statement with their comments on their difficulty in initially
reading the guidelines and then accurately locating them when they were
needed.
This study exposed the lack of usefulness of the guideline.
One participant described the stack of guidelines he was supposed to be aware
of, as “sitting over 6 inches in height on a desk”. None of the GPs
referred back to the Yellow Flags guidelines. GPs manage 90% of
presenting problems without referral
elsewhere.54 The challenge remains to
effectively disseminate and integrate guidelines to improve everyday clinical
behaviours yet without imposing a further burden. The participant GPs focus is
on providing the best possible care for their patients.
ConclusionThis qualitative study examined the experiences of a
selected group of New Zealand GPs in identifying and managing psychosocial risk
factors in their patients with acute LBP. The instrument published to assist GPs
with this task, the Guide to Assessing Psychosocial Yellow Flags in Acute
Low Back Pain, was evaluated. The criticisms and concerns articulated by
the participants of these Yellow Flags are expressed. In New Zealand
today, GPs are expected to follow guidelines, work within the biopsychosocial
model, and comply with paperwork from ACC. These factors result in a mismatch
between the availability of time, and the expectations of
care.55
The GPs stated that their existing relationship with their
patient allowed them to discuss psychosocial risk factors. Yet to first reach
that point a biophysical approach was needed. The identification and management
of psychosocial risk factors depended on the individual GP’s worldview and
culture of practice. The barrier of time was multifaceted and affected all GPs
alike. Constructions were drawn from their experiences with the ACC process, and
their lack of adequate training and funding. The GPs orientation to the
Yellow Flags guideline related to their experiences of guidelines in
general, and was not linked to methodological status. The GPs did not refer to
or make use of the guideline for identification or management of any
psychosocial risk factors in patients with acute LBP.
Identification of psychosocial risk factors requires a
combination of a suitably skilled clinician, adequate time, and a screening
system. Since 1997, the concept of Yellow Flags being indicators of
psychosocial risk for long-term disability has been rapidly adopted in the
medical literature. From a systems perspective, the publication of the
Yellow Flags Guideline aimed at secondary prevention has been
considered visionary.18
The guideline’s construction incorporated the belief
that the setting, timing, and screening were key elements. Most GPs chose not to
use it to acquire further knowledge. More prospective studies testing other
variables are unlikely to alter the GP’s choice. Does the situation need a
new perspective as has happened in other areas of healthcare? In the world of
back pain, there appears to be a need to invest resources at GP level, focus on
their needs, and then work towards evidence-based medicine and ‘best
practice’. In this way, engagement with change that is sustained and
progressive may be achieved.
Based on this study’s findings, for such an approach
to succeed, the emphasis would need to alter from the current orientation of
guideline dissemination and implementation, to one based around the GP, taking
cognisance of their organisational and behavioural mechanisms of change, as well
as their binding within a local context. GPs operate in a pressured environment.
With time, patients may shift from acute and sub-acute states towards persistent
(or chronic) status.
This study suggests that investment of resources in GPs is
needed to empower them to be effective gatekeepers guarding against chronicity.
This is particularly important if GPs are to be involved during the acute stage
and remain engaged as active participants throughout the entire course of their
patient’s rehabilitation.
Competing interests: None.
Author information: Cameron Crawford,
Postgraduate Student, Department of Rehabilitation, Wellington School of
Medicine, University of Otago, Wellington; Kathleen Ryan, Senior Research
Fellow, Institute of Health and Community Studies, Bournemouth University,
Bournemouth, UK; Edward A Shipton, Academic Head, Department of Anaesthesia,
Christchurch School of Medicine and Health Sciences, University of Otago,
Christchurch
Correspondence: Edward A Shipton,
Department of Anaesthesia, Christchurch School of Medicine and Health Sciences,
PO Box 4345, Christchurch. Fax: (03) 357 2594; Email: ted.shipton@cdhb.govt.nz
References:
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