This study makes it clear that persons who repeatedly seek medical care for chronic back pain bring more than pain and impaired physical functioning to their physician visit. Many have back problems complicated by emotional, family, and social difficulties. As 81% of participants in this study described their health as good, very good, or excellent as compared with others their age, it is possible that chronic back pain patients do not recognize the connection between their overall health and emotional, family, and social difficulties. It is not surprising that many providers find such patients difficult and frustrating to deal with. Such patients are unlikely to feel much benefit from brief visits with their family doctor or from prescriptions of medications or exercise.
The reasons patients give for seeking care provide some useful insights. In this study, increased pain and inability to function were both viewed by a large majority of participants as important motivations for seeking care and are probably highly interconnected. Because of pain or the fear of pain, individuals may avoid certain activities. It is noteworthy that, despite years of experience with pain, remarkably large percentages of participants were still looking for the cause of their pain and for a more effective treatment. Specifically, most still wanted a diagnostic test, a new treatment, or a referral to a specialist. Many reasons for repeated medical visits (i.e., looking for the cause of pain, seeking a diagnostic test or referral to a specialist) may be associated with the patients' need to validate their suffering.
What are the implications of all this for the development of clinical strategies for improving outcomes of care or decreasing costs? Treating these patients with the standard primary care approach used for most patients with low back pain (e.g., brief visits, medications, exercise, physical therapy) is likely to continue to fail. Patients who have long-term back pain problems that have had a major impact on their lives need something different. Although the available research provides little guidance in this area, the results of this study suggest that clinicians should consider certain actions that might lead to improvements in patient outcomes.
First, it is important for clinicians to recognize that patients who visit for recurrent episodes of low back pain may require more time for their underlying needs to be made clear. Eliciting the patients' views about the underlying causes of their pain and of possible solutions might help the clinician focus on the patients' primary concerns, thereby increasing the chances that these patients will leave the visit feeling that their concerns were heard and needs met. Careful inquiry into patients' expectations of a diagnosis or a diagnostic test may help clarify misconceptions about the value of tests. Laying out several of the numerous reasonable (though mostly unproven) options for treatment and letting the patient choose which one to try may help dissipate a sense that nothing can be done and make the patient feel more control. There is empirical evidence that these approaches can have beneficial effects. Although it may be difficult to do, studies have found that providing patients with a clear and confident diagnosis and treatment plan improves patient outcomes.13
Similarly, agreement between the patient and provider about the nature of the problem is a stronger predictor of outcomes than are clinical measures.14
The results reported here are not without potential weaknesses and limitations. Although several members of the research team independently coded a sample of transcripts and then met to generate the coding guidelines, only one researcher coded all the transcripts, and no further efforts were made to assess coding reliability. In addition, the majority of participants in this study were employed, homemakers, or students, and therefore our findings may not be generalizable to chronic back pain patients who are disabled or receiving worker's compensation. Because this study was undertaken to better understand patients' reasons for repeated medical visits to traditional (i.e., medical) care settings, patients who primarily sought chiropractic care were excluded from the analyses, and therefore our results are not generalizable to chiropractic patients. Although the sample size was not large (N= 54), the generalizability of this study was enhanced by its respectable participation rate (64%) and by its inclusion of randomly selected samples of clearly defined groups of recurrent users of medical care for low back pain from three separate geographic regions of the country.
In summary, this study found that patients repeatedly seek care, not because past care was remembered as having been helpful, but because past care failed to answer fundamental questions about the cause of their pain, or the value of diagnostic tests or referrals to specialists. The needs of this subset of patients with chronic back pain are complex. This study provides initial insights into possible ways of better meeting the needs of this challenging group of patients. However, further research will be required to determine which approaches are in fact effective. We hope that studies such as this will encourage other researchers to recognize the legitimacy and value of combining the approaches, particularly in situations in which there is an incomplete understanding of the range of potentially important issues involved.