Journal de la colonne vertébrale

“Big Pros and Big Cons”: Factors Influencing Utilization of Shared Decision-Making in Low Back Pain from a Surgeon’s Perspective

Abstract

Reginald Q Knight, Anthony C Waddimba, Flannery Foster, Blake Alberts and Julie Sorensen

Abstract Study design: Qualitative study design, using semi-structured interviews. Objective: To characterize the shared decision-making (SDM) process from the perspective of orthopedic and neurosurgical physicians treating patients with low back pain (LBP). Summary of background data: Unwarranted variations in quality and cost of healthcare for LBP persist. SDM is a process of informed consent that could improve patient education and outcomes. Its success depends on the quality of patient-physician communication. Lack of monolithic, cross-specialty, clinical guidelines for physicians treating LBP makes SDM especially important for this preference-sensitive condition. Therefore, further study of physician perceptions of the SDM process is warranted. Methods: We conducted semi-structured, in-depth interviews in a sample of thirteen orthopedic and neurosurgeons that treated patients with LBP. Interviews were then transcribed, coded and qualitatively analyzed using a grounded theory approach. Results: Detailed narratives of surgeons’ experiences and perspectives revealed varying interpretations of SDM. Some limited it to the patient-physician dyad, describing it as a process of educating patients about their illness, treatment options and optimum treatment goals. Others included inter-practitioner and systemic dimensions, hospital environment, physician-patient characteristics, physician-patient relationships and financial considerations as influential in SDM. Although physicians indicated SDM as beneficial in theory, patient expectations, the experience and attitude of the physician, and time pressure influenced the actual practice of it. Conclusions: Patient-related barriers to SDM were unrealistic expectations, hidden motives, multiple morbid conditions and older age, while facilitators were fewer illnesses and younger age. Physician-level facilitators included younger age and SDM-related training or experience, while time constraints and specialty biases toward treatment options were barriers. The physician-patient relationship was deemed critical to SDM, but insurance coverage and treatment affordability limited the available choices.