Improving general practice management of patients with chronic musculoskeletal pain: Interdisciplinarity, coherence, and concerns

1 Introduction

Chronic musculoskeletal pain (CMP) is a worldwide health problem and affects one in four individuals [1,2]. Chronic pain can be defined as a pain experience lasting for more than 3 months [3]. CMP is one of the main drivers of years lived with disability, and the overall cost for society is 2% of the gross national product [4]. Low back pain, neck pain, and shoulder pain are common pain sites, but patients often report multi-site pain [1,5,6]. Long-standing pain is often associated with significant concurrent psychological and social impact [7,8]. This is especially prevalent in a subgroup of complex patients with CMP. This subgroup is characterized by high healthcare utilization, with an average of 25 individual contacts per year [9,10]. They make up 8% of the total population of care-seeking patients with CMP [9].

In most healthcare systems, the general practitioner (GP) is the first point of contact for the patient experiencing CMP. The GP will oversee the management of the patient's CMP and will be able to refer the patient toward additional diagnostic examination or treatment in the specialized, secondary sector [11]. This traditional model of care may be challenged due to a lack of a specific pathoanatomical diagnosis in most patients with CMP [12]. This diagnostic uncertainty challenges the management of patients with complex CMP and frequently leads to time-consuming referrals back-and-forth between the GP and the specialized departments without the patient getting closer to a diagnosis or initiation of sufficient management of their CMP. This can leave the patients frustrated and discouraged [13,14].

Recent studies have shown that patients with CMP ask for an early interdisciplinary assessment, including a concrete plan with clear and uniform messages from all stakeholders [14,15]. However, GPs often feel ill-equipped to diagnose and manage patients with complex CMP [16,17]. This is evidenced by our recently conducted audit in Danish general practice (unpublished material). The audit showed that the GPs frequently referred patients to various specialized examinations and tried various treatments, including pain medication, and still, the GPs experienced diagnostic uncertainty in one-third of the patients.

The current unsatisfactory setup highlights the impending need to reframe our clinical management and care pathways for patients with complex CMP. It has been proposed that the management of patients with CMP should include interdisciplinary involvement [18]. However, before designing new care pathways, it is imperative to establish what the GPs consider crucial when developing examination and management options. Therefore, the objective of the study was to (1) investigate GP perspectives concerning challenges, needs, and solutions for the current management of patients with CMP and (2) provide feedback on the potential and concerns of developing an interdisciplinary unit to examine patients with complex CMP.

2 Methods

2.3 Future workshop

We used the future workshop approach as described by Apel [21] and Vidal [25] to design our data collection component. Future workshops use a three-step design, which focuses on critique, social fantasy, and implementation to support dialogue and co-construction of knowledge during workshop interventions (Figure 1). Overall, the methodology is based upon an initial critique of the present situation, expanding into a creative brainstorming phase where solutions are generated by the workshop participants, ending up in establishing the visions for the future. During this project, the critique phase was oriented toward critically reviewing the current care pathways for patients with CMP and establishing an understanding of the experienced issues and challenges. Next, the fantasy phase created a space for exploring future possibilities for solutions without restrictions or other barriers. This was done to stimulate “out-of-box thinking” and enhance the possibility of finding unconventional solutions. Finally, the implementation phase adopted a more realistic view of the proposed solutions from the fantasy phase, as participants' suggestions were evaluated, discussed, and modified into solutions that were novel, valuable, and implementable [25].

Figure 1

Overview of the phases, including the future workshop methodology (adapted from Vidal [25]).

Through these generative activities and plenary discussions, future workshops aim to produce general shared visions for resolving real-world problems, which are novel, implementable, and lead to desirable futures [21].

The theme of the future workshop was defined as exploring visions for optimizing the management for adults with CMP conditions. A case vignette and inspiration card exercises were included as workshop activities to encourage participant dialogues and guide their discussions through the three workshop phases [22,23].

2.3.1 Case vignette

The case vignette was designed by the members of the research group (JBL, SKJ, JLT, and MSR) and reflected our understanding of the biopsychosocial challenges that could be present for a patient with CMP (Appendix S1, case). The case was designed to be recognizable to GPs and included a background story, plus relevant and irrelevant information presented as a narrative [23]. The case vignette was tested for comprehension and relevancy with two GPs with experience in treating CMP in general practice.

2.3.2 Inspiration cards

The inspiration card game (Appendix S2, Inspiration cards) was developed to stimulate conversations during workshops and help participants progress through the three workshop phases [22]. The cards featured themes related to three conceptual domains, including (1) patient domains, e.g., the home, workplace, and municipality; (2) problems, e.g., pain, uncertainty, comorbidities; and (3) solutions, e.g., interdisciplinary, patient-centered approaches, communication, defined by the research group (JBL, SKJ, JLT, and MSR). The inspiration cards were developed based on previous findings from an audit held in general practice (unpublished material) and designed to illustrate the research group's understanding of management challenges experienced by patients and GPs when treating CMP. Finally, the case vignette and inspiration cards were tested for comprehension and relevancy with two GPs and two patients with CMP.

2.3.3 Procedure

The workshop was held in March 2022 at the facilities of the Center for General Practice in Aalborg East, Denmark. The workshop lasted approximately 3 h. Upon arrival, participants were divided into two workgroups of four people. The workshop activities were led by a workshop coordinator and external facilitator (SKJ), who presented the exercises, guided participants through the collaborative activities of the critique, fantasy, and implementation phases, and answered questions that arose during the workshop (Figure 1). During the first phase of critiquing, the facilitator presented the case and inspiration cards, which were available to assist the critique phase, and provided instructions on how to complete these workshop exercises. For the second phase of fantasying, the facilitator presented the inspiration cards available to assist this phase. During the third phase, participants were asked to continue to work with the available inspiration cards but change their focus to explore the implementation of their proposed solutions. Each workshop phase was concluded with a plenary discussion where the two groups would present the topics; they discussed with each other and received feedback. During the final phase of implementation, each group presented their visions for optimizing management for patients with CMP and received feedback from the facilitators and other participants.

2.3.4 Data collection

Participants' discussions were captured on audio recorders during the future workshop. The audio recordings from each workgroup were converted into two datasets using Express Scribe transcription software, while the NVivo 11 application was included to support the analysis of the data. The transcriptions were conducted with a focus on retaining the participants' meaning [26].

2.3.5 Data analysis

The data collected during the GP workshop were analyzed via Braun and Clarke’s [27] Reflective Thematic Analysis Approach by a research assistant (PB) as a lead analyzer in collaboration with two members of the research group (JBL and SKJ). The analysis followed a stepwise process, which included familiarization, coding, identification of semantic themes, generation of latent themes, and narrative production, guided by reflection and inductive reasoning [27]. The lead analyzer (PB) familiarized herself with the data during the transcription before briefing the other researchers (SKJ and JBL) on preliminary insights. The coding of the data was conducted using NVivo 11 coding software to organize the identified codes and relationships across datasets. A mind map and coding list were created and used to conduct stakeholder checks (SKJ) to ensure coding integrity through discussions of the generated codes. Semantic themes were developed iteratively through circles of coding, merging of codes, and inductive reasoning. Thematic overlaps and uncertainties were discussed between researchers (PB, JBL, and SKJ) in a collaborative and reflexive approach to ensure a nuanced interpretation of the data. The generated themes were organized, named, and renamed as the analysis progressed to generate latent themes. The analysis was finalized by the lead coder (PB), and the research group members identified four content summary themes that formed the narrative presented in Section 3.

3 Results

The future workshop consisted of eight participating GPs (five females). Four GPs worked in urban areas, and four GPs worked in rural areas. GPs have been working in general practice for an average of 16 years (individuals range from 1 to 32 years). The thematic analysis identified a system of four main themes titled: (1) challenges with current pain management, (2) barriers for pain management, (3) the need for a biopsychosocial perspective, and (4) solutions and visions, and 13 sub-themes concerning the challenges, needs, and possible solutions for optimizing the management of patients with CMP in general practice (Figure 2).

Figure 2

The themes and sub-themes identified during the analysis, and how these related to optimizing the care-pathway for CMP patients, which was a starting point for the thematic analysis.

4 Theme 1: Challenges with current pain management

The main theme 1 comprised of four sub-themes (Table 1). The GPs described the lack of time for a biopsychosocial approach and dialogue about the understanding and explanation of pain as a challenge. Still, the GPs agreed that receiving an understandable explanation for the pain was important to patients. All GPs described having experienced a need for assistance to support patients, regardless of whether they had a diagnosis or faced diagnostic uncertainty. Overall, diagnostic uncertainty was mentioned as a challenge and thought to reflect the complexity of the patients with CMP. Despite referrals to specialized departments, patients often return without a specific anatomical diagnosis. While several GPs described how they interpreted this as a sign that a shift toward a biopsychosocial approach was merited, patients would often keep asking for a biomedical reason for their pain, challenging the communication and support. Further, GPs generally agreed they lacked a “second opinion,” when specialized departments could not specify a diagnosis and diagnostic uncertainty arose. The GPs described having experienced patients being referred between specialists without regular GP follow-ups, leading to a lack of coherence in the examination of the patients. Consequently, several GPs highlighted how the patient and GP might not share the same understanding of the next steps necessary. This further challenged the support-based dialogue between the patient and the GP.

5 Theme 2: Barriers to pain management

The main theme 2 identified four sub-themes (Table 2). The GPs explained how the patients often anticipated the GP to provide a biomedical explanation for their pain and how these expectations acted as a barrier toward educating patients on the psychological and social aspects of CMP management. Based on this observation, some GPs expressed concerns about whether an increased focus on psychosocial factors would make patients feel that their pain condition was not taken seriously or that the GP was incapable of resolving the patients' issues.

The GPs agreed that the patients' working environment and stress-related pain could be a contextual barrier to the management of their CMP. The patient's perspective on their job situation was highlighted as a contributing factor in maintaining their CMP. If the patients' work-related challenges were not addressed and adjusted to their CMP, maintaining employment could become a barrier to their pain management. However, some GPs stated that it was difficult for them to influence the patients' working conditions, as some patients acted without consulting their GP, while others refrained from expressing their need for work adjustments with employers because of fear of being fired. The GPs highlighted that the fear of engaging in a workplace dialogue was a barrier, as patients, therefore, perceived sick leave as the only solution to overcoming their CMP.

Several GPs described being asked to estimate return-to-work time frames regardless of whether patients had a diagnosis or experienced diagnostic uncertainty. The GPs experienced that they often had to do so without support from the specialized departments. This was described as a challenge and a potential barrier for managing patient's chronic pain as the GPs felt caught in the middle of all stakeholders.

The GPs acknowledged how patients with diagnostic uncertainty had similar needs for support and treatment as patients with a specific diagnosis and a clear care pathway. However, some GPs highlighted how access to limited free-of-charge treatment options like physiotherapy- or municipality-based treatments was restricted for patients without a clear diagnosis. Some patients lacked the financial opportunities to prioritize physiotherapy, medicine, and, e.g., psychological treatment. Therefore, the financial burden was described as another potential barrier to adequate pain management.

6 Theme 3: The need for a biopsychosocial perspective

The main theme 3 comprised two sub-themes (Table 3). The GPs envisioned a need for an early focus on biopsychosocial factors. Since the GPs generally considered the patient's complex CMP as being influenced by psychosocial factors to some extent, they believed it would enhance the management to bring attention to such factors from an early point. However, several GPs underlined that they should continue to screen for somatic causes of pain. This could include a focus on the patient's domestic and family conditions as well as the situation at work.

The GPs highlighted how contextual circumstances in the patient's environment and life should be considered, e.g., how stress at home or work could influence patients' pain experience. The GPs described patients' fear of losing their work due to pain-related limitations or balancing family matters while managing their pain as sources of psychological stress experienced by patients with CMP. Furthermore, several GPs highlighted how they perceived the lack of understanding and acceptance of the patient's pain and limitations from their relatives as something that could influence pain management.

7 Theme 4: Solutions and visions

The main theme 4 identified three sub-themes (Table 4). The GPs agreed that there exists a need for an interdisciplinary approach when managing patients with complex CMP. They described that a more explicit collaboration between the GPs and an interdisciplinary unit could facilitate a cohesive examination and management. Additionally, GPs envisioned that an interdisciplinary unit should consist of specialists from both the biomedical and psychosocial fields, e.g., orthopedic surgeons, rheumatologists, occupational medicine, physiotherapists, psychologists, or social workers. This was stressed as important for targeting the individual needs and challenges of the patients.

The GPs emphasized how the interdisciplinary unit should focus on a biopsychosocial approach and make sure adequate time was allocated to consider these elements of the patient's pain. Further, they highlighted that an interdisciplinary unit could enhance the focus on pain management instead of the patients' focus on pain manifestations. The GPs suggested that improved coherence in the management of patients with CMP should be a priority. They believed that initiating several examinations at the same time could contribute to a more efficient process for this patient group, again highlighting the value of an interdisciplinary approach, where multiple examinations and factors could be considered simultaneously. The GPs stressed that they should still be coordinating the patients' treatments and pain management, thereby making coordination and communication between the GP and the specialized sector important. To improve and enhance coherence, the GPs suggested that teleconferences could be used to establish a dialogue between an interdisciplinary unit and the GP.

The GPs suggested that it could be of value to involve the municipality about possible assistance and treatment from, e.g., the rehabilitation centers, the center for mental health, or social workers. Thereby, the patient would be supported by their GP and other stakeholders.

Despite a general enthusiasm about the possible solutions, the GPs also voiced some concerns. The GPs were concerned that an interdisciplinary unit would include too much focus on pain medication and deprioritize other examinations or focus areas. The GPs agreed that it would be a barrier for them to refer patients to an interdisciplinary unit that focused on the patient's medication. Furthermore, GPs expressed that they should be coordinating the patient's medication, and an interdisciplinary unit should assist with a greater focus on biopsychosocial elements and other perspectives in the examination. A concern was raised regarding the need for a “second opinion” as a matter of routine. The GPs feared that their assessment, therefore, would not be considered sufficient by the patient and a need for a specialist team was required. Conversely, other GPs highlighted how it might be necessary to include a “second opinion” to meet the patients' expectation of a biomedical examination and ensure that possible diagnostic uncertainty is not because the patients have not been thoroughly examined.

8 Discussion

The study aimed to investigate GPs' perspectives on the challenges, needs, and solutions when managing patients with CMP to inform the improvement of the care pathway. The findings from the future workshop revealed that the diagnostic uncertainty related to this patient population was considered a challenge and frequently led to multiple referrals from the GP to the specialized secondary sector. The GPs perceived that the patients often sought a biomedical explanation for their CMP, which was considered a challenge for addressing the possible psychological and social factors related to managing the patients' CMP. The GPs highlighted how patients with CMP would ask specific questions on, e.g., return-to-work time frame, which they felt ill-equipped to answer, and how adapting an early focus on psychological and social factors contributing to the CMP experience could help address such issues during consultations. Finally, our participants envisioned how having the option of referring patients to an interdisciplinary unit, which could explore an interdisciplinary and biopsychosocial approach, provide GPs with a "second opinion" to alleviate diagnostic uncertainty and reduce unnecessary referrals back-and-forth.

Diagnostic uncertainty has been proposed as a challenge for providing adequate management and often results in delayed treatment of the patient's condition [16,28]. Similarly, our findings reflect that the GPs experience diagnostic uncertainty as a challenge for both the GP and the patient. The GPs request the possibility of getting a “second opinion” if in doubt about the diagnosis or when facing diagnostic uncertainty. First, such a setup could possibly diminish the diagnostic uncertainty and ensure that the patient feels adequately examined and that a correct diagnosis has been identified. Second, it could be part of the initial steps toward the patients’ recognizing that other factors besides the biomedical aspects are involved in the complex CMP experience. As such, research studies have recommended a biopsychosocial management approach to fully encompass the entire experience of CMP [18,29,30]. Our findings align with this and highlight that GPs consider an early focus on biopsychosocial factors important. However, the GPs refer to the challenge of patients often having a biomedical view of their CMP and expecting an anatomical explanation for their pain. This could create a mismatch between the patient's expectations and the GPs' broader insight that enables them to consider a biopsychosocial approach. The GPs mention that patients, apart from the biomedical view, can lack the understanding of how, e.g., their working conditions can influence their CMP. The GPs perceive that a thorough, interdisciplinary examination could be the turning point where the patient starts to feel adequately diagnosed to consider other contributing factors and engage in management options. Thereby, an interdisciplinary unit could become the catalyst for improved dialogue and support between the patient and the GP.

GPs state that an interdisciplinary unit should consist of orthopedic surgeons, rheumatologists, occupational medicine, physiotherapists, psychologists, and social workers. Their suggestions include healthcare practitioners who can consider the biomedical and psychological factors, as well as social workers, to assist with social factors. There are some discrepancies compared to suggestions from the literature that highlight the inclusion of a pain psychologist, pain physician, psychiatrist, nutritionist, physiotherapist, and pain nurse, enabling more focus on pain medication skills [30,31]. The discrepancy could be explained by the statements from the GPs, describing how they prefer to coordinate the patients' pain medication and using the interdisciplinary unit to focus on the psychosocial factors contributing to the complex CMP. Overall, both GPs in the present study and the literature underline that the interdisciplinary unit of healthcare practitioners should be specific to the individual patient's needs.

The challenges and gaps in the current care pathways for patients with CMP have been recognized, both nationally and internationally [11,12,18]. The current setup relies on the GPs singlehandedly managing the patients with complex CMP or referring the patients to different specialized departments in the quest for an anatomical cause for the pain. This leads to an overuse of imaging, usage of opioids and surgery, and a lack of patient education concerning the management of CMP [29,31]. This underlines the urgent need to revise the current setup, a statement that has been backed by patients [14]. The GPs suggest reframing the current setup and moving on to propose possible solutions. They want to be in charge of coordinating the management of the patients with complex CMP, but they request coherent inputs from the healthcare system to improve the management of this complex patient population. Therefore, the GPs envision an interdisciplinary unit that could fight the diagnostic uncertainty they face in general practice and simultaneously be a focal point for introducing a biopsychosocial approach for examination and management of the patient's pain. To bridge the knowledge between an interdisciplinary unit and the coordinating GP and enhance the care pathway for the patient, it is imperative to ensure coherence and communication between these sectors. The GPs propose teleconferences as a tool to enhance the communication between an interdisciplinary unit and the GP.

To fulfill the ambitions of providing an interdisciplinary unit of healthcare practitioners that will embark upon a biopsychosocial examination, several things need to be considered to provide a setup that will improve the management of patients with complex CMP. This includes deciding which healthcare practitioners should be included in an interdisciplinary unit so that the competencies match the patient's needs. It should also be considered how an interdisciplinary unit should implement the biopsychosocial approach, including how to prioritize psychosocial factors equally to the biomedical factors but still taking the patients' judgment of an anatomical structure as the explanation for their complex CMP into account.

The main solution derived from the workshop was the proposal of a multidisciplinary unit to examine patients with complex CMP. However, such a solution is not without challenges. A multidisciplinary unit would require that various specialized healthcare professionals (e.g., orthopedic surgeons, rheumatologists, and physiotherapists) would be interested in a mutual examination of the patient and merging the clinical findings into a conclusion. Given the high specialization of the individual healthcare professions, it could be challenging to combine these competencies into a comprehensive and inclusive setup. Yet, the possible benefits of establishing a coherent examination in one session compared to frequent referrals back-and-forth are appealing. Similarly, a multidisciplinary setup would come with increased costs compared to the patient seeing only one healthcare professional. However, compared to patients being referred to various healthcare professionals one at a time, the multidisciplinary setup could prove to be cost-effective. Initiation of a multidisciplinary unit would introduce the challenge of establishing which patients should be referred for a more comprehensive care pathway. Within low back pain, stratified care models have been used in general practice to guide treatment direction based on a prediction of which patients need a more comprehensive approach [32]. The stratified care approach to determine treatment decisions has been shown to provide improved treatment efficiency and patient satisfaction, and be cost-effective in patients with low back pain compared to a usual care approach [33]. However, when using a stratified care model for patients with common musculoskeletal (i.e., back, neck, knee, shoulder, and multi-site) pain, no differences in pain or function were observed between the stratified care and the usual care [34]. This could illustrate that it might be a challenge to be able to select patients with general musculoskeletal pain for the more comprehensive care pathway. However, it should be noted that the aforementioned studies focus on stratified treatment and not examination, as suggested by our workshop participants.

Several strengths and weaknesses were identified during this study, which should be considered when interpreting the results. One strength is related to the focus on GPs' experience of management of patients with CMP, rather than pain localized in specific bodily regions, e.g., low back pain or neck pain, resulting in a clearer picture of the challenges and barriers related to treating CMP in general practice. We included GPs working in clinical practice, and our findings are expected to be rooted in clinical practice and reflect the experiences of general practice in this region of Denmark. There may be different referral pathways in other countries, which limits the generalization of our findings to other healthcare systems than Denmark. We included GPs based on an open call. Thus, we anticipate that GPs who signed up for the workshop have a higher interest in CMP compared to other GPs [35], leading to more novel and relevant insights. Future workshops utilize participants' experiences and co-construction of knowledge as a driver for extracting future visions, which makes the workshop process vulnerable to say-do and social desirability bias [36]. Furthermore, by including insights gained during our previous audit and inspiration cards with themes identified by the author group, we risked imposing our ideas on participants, resulting in alternative topics that might have been missed during discussions. To address this limitation, special care was taken to ensure that inspiration card themes were open, participants were encouraged to add new cards, and workshop facilitators asked open questions during plenary discussions to alleviate this issue. Finally, since only one workshop was held, it remains unclear if all aspects of the topic have been uncovered, which should be viewed as a limitation when reviewing the findings.

9 Conclusions

Patients with complex CMP are a challenge for the current healthcare setup. GPs, frequently being the first point-of-contact for the patients, experience diagnostic uncertainty, and a patient preference for considering an anatomical explanation for their CMP remains a challenge in general practice. The GPs want to be the coordinators for this patient population but request a more coherent setup than the current possibilities of referring patients back-and-forth between specialized departments for examinations, often focusing on biomedical aspects of the CMP.

To improve the management of patients with complex CMP, the GPs recommend introducing an interdisciplinary unit to combat diagnostic uncertainty and to take the biopsychosocial factors into account. A thorough communication between the GP and an interdisciplinary unit should be enabled, possible by using teleconferences, to ensure coherence between sectors. Future studies should address the feasibility and effectiveness of an interdisciplinary unit and the coherent collaboration between the patient and the GP.