Training in Back Care to Improve Outcome and Patient Satisfaction Teaching Old Docs New Tricks

,

Original Research

Training in Back Care to Improve Outcome and Patient Satisfaction Teaching Old Docs New Tricks

J Fam Pract. 2000 September;49(9):786-792

By

Peter Curtis, MD

Alternative or complementary approaches to medical care are gaining loyalty from patients and increasing interest from the allopathic health care community.

References

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6. American Association of Orthopaedic Medicine. Educational workshop: manipulation of the back. Colorado Springs, Colo, June 11-12, 1998.

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8. D, Deyo RA, Berg AO, Bergmann JJ, Lishner DM. Evaluation of a physician education intervention to improve primary care for low back pain: 1. Impact on physicians. Spine 1991;16:1168-72.

9. D, Deyo RA, Berg AO. Evaluation of a physician education intervention to improve primary care for low back pain: 2. Impact on patients. Spine 1991;16:1171-78.

10. T, Cherkin D, Barlow W. The impact of physician attitudes on patient satisfaction with care for low back pain. Arch Fam Med 1993;2:301-05.

11. TS, Garrett J, Jackman A, McLaughlin C, et al. The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors and orthopedic surgeons. N Engl J Med 1995;333:913-17.

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13. P, Evans P, Rowane M, Carey TS, Jackman A. Training generalist physicians in manual therapy for low back pain: development of a continuing education method. J Cont Ed Health Prof 1997;17:148-58.

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BACKGROUND: We examined clinical outcomes and patient perceptions of back care given by physicians before and after an intensive course of training in back care and limited manual therapy techniques.

METHODS: From a prospective observational cohort study of low back pain involving 208 physicians (115 primary care) and their patients and a subsequent clinical trial of treatment of low back pain given by 31 physicians specially trained in manual therapy and enhanced back care, outcome data from the patients of 13 physicians participating in both studies were compared. In the observational study, the 13 physicians cared for 120 patients. In the manual therapy trial (191 patients) a control group of 94 patients received enhanced back care and an intervention group of 97 patients received enhanced back care plus manual therapy. Pearson’s chi-square comparisons and linear and Cox proportional hazard modeling were used to examine effects of variables and recovery time.

RESULTS: Characteristics of the 13 physicians’ patients in the cohort group and the manual therapy trial showed some differences in income, workers’ compensation, previous employment, and baseline dysfunction. Both control and intervention patients in the manual therapy trial showed more rapid improvement in functional status over time and greater satisfaction with their care than those in the previous cohort study. However, there was no difference between the studies in patient-reported time to return to performing usual daily activities.

CONCLUSIONS: A structured clinical approach to low back care may bring modestly improved clinical outcomes and patient satisfaction.

Alternative or complementary approaches to medical care are gaining loyalty from patients and increasing interest from the allopathic health care community.^1-4 In particular, professional organizations in the areas of acupuncture and manual therapy are offering and expanding continuing medical education (CME) programs in these fields for allopathic physicians, though there are few published data on their effectiveness.^5,6

The direct impact of CME on patients and clinical practice has been little studied, particularly in relation to the treatment of low back pain.⁷ Cherkin and colleagues^8,9 undertook an evaluation of a didactic CME program on low back pain in 1991 by studying patient satisfaction and provider attitudes. It appeared that the patients of providers who professed greater confidence in managing low back pain were more satisfied with their care, though negative attitudes previously expressed by clinicians toward low back pain did not change significantly after CME. In a discussion of this study it was suggested that patients might be seeking information and practical guidance rather than a cure or empathy.¹⁰ However, the investigators did not study the effects of modifying physical examination and manual skills in the care of these patients, factors that might play an important role in outcomes.

Although greater patient satisfaction has been associated with chiropractic care (which emphasizes manual skills) than that given by primary care physicians, there appears to be no association of satisfaction with practitioner self-confidence or days to functional recovery of the patient.^11,12

We developed a workshop for generalist clinicians in the skills of assessment, limited manual therapy, and a graded exercise program, and in a randomized controlled trial evaluated clinician self-efficacy and patient outcomes for acute low back pain.^13,14 We demonstrated that allopathic generalist physicians could be effectively trained in limited manual therapy with self-reported increased competence in managing low back pain. The patients receiving therapy showed a trend toward feeling completely better more quickly but reported no greater satisfaction or objective functional improvement in terms of activities than patients in the control group who were receiving only high-quality conventional care through workshop training.¹⁴

Of 31 physicians recruited into the manual therapy trial, 13 had previously been involved in a cohort study of utilization and back care therapy given by 208 practitioners (115 primary care generalists) to 1633 patients (644 patients of primary care generalists).¹¹ We examined the outcomes of patients with low back pain from the practices of these 13 physicians before (data from the cohort study) and after an intensive hands-on training workshop (data from the manual therapy trial), using similar patient recruitment methods and evaluation instruments ([Figure 1]. Our hypothesis was that this training in manual and assessment skills would improve patient outcomes and satisfaction.

Methods

The initial cohort study was undertaken to examine the prevalence, care seeking, and outcomes of acute low back pain in the state of North Carolina. No interventions were undertaken in this study. Methods and measures used in its implementation have been described previously by Carey and coworkers.¹¹ Clinicians were randomly selected from medical and chiropractic licensure files (primary care generalists, chiropractic physicians, and orthopedic surgeons). To be included in the cohort study clinicians had to see ambulatory patients at least 50% of the time and provide first contact care for acute low back pain. Of the 208 clinicians from different disciplines recruited into the study, 115 were primary care physicians. During a 10-month period consecutive patients with acute or subacute low back pain (<10 weeks) were enrolled unless they had received previous care for the episode, had received previous back surgery, had a history of cancer, were pregnant, had no telephone, or were unable to speak English. Patients were contacted by telephone after the visit by staff members of the University of North Carolina Survey Research Unit, and interviews were undertaken at baseline, 2, 4, 8, 12, and 24 weeks.