Journal of the New Zealand Medical Association, 18-May-2007, Vol 120 No 1254
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
The 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.
The 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
Low 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.
This 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: firstname.lastname@example.org
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