This is the first study to address medical student attitudes towards patients with CLBP. The results show that after undergraduate training medical students develop more positive attitudes towards CLBP patients and their ability to function. Breakdown of the scores into different HC-PAIRS subscales shows that medical students undergo an improvement in both functional (patients' ability to undertake activities of normal daily living) and social (patients' ability to work and take on family responsibilities) expectations when considering patients with CLBP. Hence undergraduate medical students do develop the appropriate attitudes towards CLBP during training and this reaches equivalent levels to those attained by final year UK physiotherapy students [15
]. Extrapolating from the evidence for correlation of attitudes and management of CLBP patients by qualified medical practitioners, these results imply that medical students should be more likely to use an evidence-based approach with these patients after graduation. However, final year medical student scores are not as positive as values recorded for a cross section of practicing USA community health care providers [10
]. This indicates that there remains an important role for postgraduate medical education about CLBP in the United Kingdom. It would be interesting to follow these students during their postgraduate training to assess if attitudes continue to change and if this is indeed reflected in their practice.
Comparisons between the two student groups at the start of their courses shows that medical students have more positive attitudes to CLBP than controls. The reason for this difference remains to be established but may result from potential medical students having more positive attitudes and so "self-selecting" to enter medical degree courses. Equally, it could be that students with positive attitudes to illnesses in general are more likely to be successful in their application and interview prior to joining the University.
Interestingly, both student groups improved their attitudes to CLBP during their courses. The explanation for the small improvement in the total HC-PAIRS and functional expectations scores in the business studies students remains unclear as they receive no formal training about CLBP. Student age was not a significant covariant in the analysis and hence would be insufficient to explain this phenomenon but increased maturity and awareness of CLBP which could exert a small influence on both student groups might be a cause. Nevertheless, the alterations in final year medical student scores were larger and the unique improvement in social expectations subscale scores confirms that positive attitudes can be reinforced during appropriate training.
Scores on the projected cognition subscale (i.e. patients' ability to concentrate despite having low back pain) and the need for a cure subscale (i.e. patients' need for a cure before they can function well) were no different between first and final year medical students (data not shown). This indicates that training has no effect on medical student perceptions of CLBP patients' abilities in these two areas. It could be argued that if the present holistically based training module on CLBP addressed these details then these two parameters should also change. In previous studies of physiotherapy students these parameters were also unchanged after training [15
], raising some uncertainty about the validity of these two subscales of the HC-PAIRS questionnaire [10
]. Nevertheless, in order to be sure that there are no areas being neglected during student training about CLBP, these need to be reviewed to ensure adequate coverage.
The HC-PAIRS questionnaire has been shown to be one of the most valid and reliable measures with which to assess attitudes to CLBP [13
] and hence was used in this study. One limitation was the cross-sectional nature of the study comparing separate groups of first and final year students. Analysis of one medical student group over five years would establish whether changes occur gradually or subsequent to modules where back pain is studied in detail. Certainly, physiotherapy student attitudes improved after introduction of a specific back pain module into their training programmes [16
] suggesting that specific training can have a positive effect. Longitudinal studies would also allow investigation of the influence of clinical placements on student attitudes to CLBP. A second limitation is that this study only addresses responses in a single centre and results may not generalise to all medical schools. Nevertheless, these results do imply that the HC-PAIRS questionnaire can be successfully applied, and can therefore be used to objectively assess the impact of undergraduate medical training about CLBP.
Another limitation of the study is the poorer recruitment rate in final year (64%) compared to first year (84%) medical students. All students were invited to participate in the study at a weekly lecture during the first semester of the year. Hence, final year students were recruited a few weeks before their final written examinations and the poor response rate follows a general trend for poorer attendance at lectures around this time. It is therefore conceivable that some of the apparent improvement in scores is through self-selection - that those more likely to maintain good attendance at lectures are more likely to have more positive attitudes. Again this is an issue we hope to resolve with the paired data that will accrue during the annual follow-up of the students in this first year cohort.
A number of medical students reported experiencing current or previous low back pain. It might have been predicted that this could influence student responses. The results from medical students suggest that it is training which shapes the student attitudes rather than their personal experiences. This is in keeping with a similar assessment of physiotherapy students who similarly seemed to have the ability to remain objective about their own LBP when completing the HC-PAIRS questionnaire [18
It is important to ensure that medical practitioners have the appropriate attitudes about CLBP if patients are to be given appropriate treatment to reach their full potential. If present clinicians have poor compliance with guidelines for CLBP management [8
] then there is clearly a need for improved postgraduate training. It is recognised that clinicians with more positive attitudes are more likely to comply with CLBP treatment guidelines [10
]. Hence the fact that medical students graduate with positive attitudes implies that new generations of clinicians will enter postgraduate training with a background that should lead to evidence based practice with CLBP patients and in turn to improved patient outcomes [19