“Take me seriously and do something!” - a qualitative study exploring patients’ perceptions and expectations of an upcoming orthopaedic consultation

Patients referred for orthopaedic consultation (n = 13) were recruited from two health care centres in the region of Västra Götaland, Sweden, during February to August 2016. A purposeful sampling strategy was used [37], with the aim of obtaining a variation of gender, age and pain location for referral. Data collection was intended to continue until no new information seemed to be forthcoming in the interviews. Inclusion criteria were: patients of working age (18–67 years) with sub-acute (4 weeks–3 months) or persistent (>3 months) pain due to MSDs, who were referred for orthopaedic consultation, with the ability to understand and speak Swedish. The exclusion criteria were based on a previously published protocol for a randomised controlled trial (RCT) [6], and were chosen in collaboration with an orthopaedic surgeon. Patients were excluded if the stated diagnosis on the referral was hallux valgus, ganglion or trigger finger.

The semi-structured interviews were conducted by the first author (KSS) who had postgraduate training in qualitative research methods, previous experience of qualitative research and clinical experience from treating patients with MSDs. The participants chose the location for the interviews; nine were held at a healthcare center, and four were conducted via telephone. The interviews lasted between 19 and 41 min (average 27 min), were audio-recorded and transcribed verbatim.

An interview guide was developed and agreed by all authors, to ensure that topics of interest were covered (Table 1).

Qualitative content analysis with an inductive approach was used for analysis of the data, according to the procedure described by Graneheim and Lundman [38]. The interviews were thoroughly read several times to obtain a sense of the whole. A systematic data analysis directed by the study aims was then performed, where meaning units were extracted, condensed and coded, while preserving the core. In the analysis, the codes were sorted and sub-categories and categories were developed, as internally homogeneous and externally heterogeneous as possible. This part of the analysis was still close to the data and on a descriptive level (manifest content). In the last step of the analysis the underlying meaning (latent content) was interpreted, expanding across all categories, and a general theme was formulated. The computer software NVivo 10 (QSR International Pty Ltd) was used for the analysis.

Three researchers performed the analysis in order to provide analyst triangulation and to increase credibility [38]. The first author (KSS) was responsible for coding and categorising all interviews, as well as the preliminary formulation of a theme. To verify the coding, three of the interviews were also independently coded by the other two authors (SB and MEHL), and discussed to reach consensus on coding strategy. KSS and SB discussed the codes, sub-categories and categories until consensus was reached. MEHL verified content conformity of the categories. Organisation and labelling of the categories were continually checked and modified throughout the analytical process. Lastly, the theme was constructed.

The theme is based on the participants’ expressed wish to be taken seriously throughout the consultation and that the orthopaedic surgeon could do that through listening, respecting, as well as by providing information and enabling the patient to participate. Moreover, an expectation of something to happen, both during the consultation and as an outcome of it, was evident across the interviews.

In this category, a feeling of wanting and hoping for something to happen during, or after the consultation with the orthopaedic surgeon was described, sometimes expressed as hoping for some magic. The participants emphasised the desire for the orthopaedic surgeon to able to do something, either wishing for surgery, or wanting to avoid surgery, but still wanting something to change.

The perception of the orthopaedic surgeon as the expert was described in this category. The participants emphasised a great trust in the orthopaedic consultant, in his decisions and that he should perform his best. The orthopaedic surgeon was perceived to have a great responsibility, since the outcome of the consultation could be life changing. Also, a perception of the orthopaedic surgeon being in charge and a feeling that the patients just “had to go with it” was described.

In this category, the importance of a respectful meeting was stressed. The participants expressed that they wanted to be seen as a whole person and to be taken seriously, and how they wished to not become a problem. The attitude of the orthopaedic surgeon was of great importance.

In this category, a firm belief that the consultation was about ‘my body’ was described, and since it was ‘my body’, it was also ‘my decision’ to make regarding further actions. The orthopaedic surgeon was seen as a sounding board who was looked to for information to help with decision making. Having knowledge was expressed as a means for participation. A feeling of being responsible as a patient was emphasised, either felt as taken or assigned or forced.

This category describes how investigations such as x-rays or magnetic resonance imaging (MRI) were perceived to provide evidence for the experienced problem and, if anything could be seen on these investigations, it would help you get better health care. On the other hand, a lack of these hard facts was stated as a possible barrier for being understood and helped.

This study found that patients with MSD referred for orthopaedic consultation expressed a strong desire to be taken seriously during the consultation, and for something to happen during, and as a result of the consultation. Participants perceived the orthopaedic surgeon as an expert and were willing to place their trust in him and his decisions. However, a desire to be provided with information and options, and to participate in the consultation and in decision making was expressed. Participants also described the importance of having a good, respectful meeting with the orthopaedic surgeon. The findings are in concordance with identified core components of person-centred care, such as patient participation and involvement, and relationship between the patient and the healthcare professional [39, 40]. While all healthcare professionals provide care based on these elements, the degree to which this is done depends on the interest and priority given to these elements by the professional group [40]. The context of care for this study was the orthopaedic consultation, and recent literature has suggested that in the management of ‘preference-sensitive conditions’ such as many musculoskeletal disorders, where there is no single treatment option which clearly stands out, shared medical decision making would be especially relevant [41]. The main categories of the results in this study show similarities with previous research on perceptions and expectations for consultations or management in other settings for various MSDs [25, 26, 42‐45], further elaborated on below.

The finding in this study that patients wanted something to happen, has been previously reported in a study on patients’ expectations of general practitioners management of back pain, where patients wished for more than just education and reassurance [26]. Verbeek et al. [25] showed in their systematic review of patients expectations of treatment for low back pain, that the patients expect more diagnostic tests as well as other therapy or referrals to specialists.

The perception described in this study of the orthopaedic surgeon as the expert, based on the surgeon’s experience and knowledge, is consistent with earlier studies. The expectation of proper qualifications, i.e. knowledge and skills, of the clinician has been reported both in patients seeking health care in general [44] and in patients seeing an extended scope physiotherapist [43]. The willingness of participants to place their trust in the orthopaedic surgeon, based on the view of them being the expert, as expressed in this study, is in line with the findings of Bernhardsson et al. [46] who reported a similar trust placed by patients with MSDs in the physiotherapist’s professional competence in choosing and guiding treatment. As expressed by the participants in our study, a lack of knowledge made them trust the orthopaedic surgeon with the decision making; findings that are in line with patients’ perceptions of an extended scope physiotherapist screening service [45]. This trust places a great responsibility on the orthopaedic surgeon, since the patients described a feeling of putting their life in the surgeons’ hands. It has been suggested that if patients are provided with the best available evidence regarding their disorder, as well as options for treatment, they are more likely to actively participate in their care [47], and patients in this study stated that knowledge could improve participation.

Patients in this study emphasised a desire to participate, both in the consultation as well as in decision making, and that to be able to participate they looked to the orthopaedic surgeon for information, viewing him as a sounding board. This is in line with the literature where shared decision making has been defined as an approach for clinician–patient collaboration; sharing the best available evidence to achieve informed patient preferences and reaching agreement on appropriate treatment [39, 48, 49]. Chewning et al. [50] have presented the desire for participating in decision making as a continuum, where different types can be defined; the ‘autonomist’ who wants to make decision themselves, the ‘collaborist’ who want to share decisions equally, and the ‘delegator’ who prefers leaving decisions with their healthcare practitioner. Previous studies have reported that the majority of patients want to discuss options and receive information from physicians, even though they may not wish to make the final decision [51, 52]. Patients in this study said that they wanted to participate in decision making, that it was their body, and that they wanted to participate to a high extent. This attitude seems to be in the ‘autonomist’ cluster; however, some participants assumed more of a ‘collaborator’ role, stating a preference for ‘informed consent’, and some seemed to be ‘delegators’, preferring to leave (by choice or a perception of not being able to participate) all the decision making to the orthopaedic surgeon. The participants in this study described that they were looking to the orthopaedic surgeon for information about options, management and procedure, which is supported by previous studies [43, 53]. This is in line with existing research, where shared decision-making has been defined as an approach where clinicians and patients share the best available evidence when making decisions, and where patients are supported to consider options, in order to achieve informed preferences [49]. It involves not only collaborating in making decisions about treatment, but also sharing information, building consensus about the preferred treatment, and reaching agreement on appropriate treatment [48].

The participants in our study stated taking a responsibility for their disorder; by preparing for consultation and taking an active role during the consultation. These findings are corroborated by Larsson et al. [54], who found that many patients with musculoskeletal conditions are prepared to take responsibility, both in seeking help and adhering to treatment, but that some are more inclined to share the responsibility and collaborate with the clinician.

The participants in this study emphasised that they wanted a respectful meeting and to be taken seriously. This finding is consistent with previous research on how communication is important, and how empathy and listening are closely associated with patient satisfaction and autonomy [55]. Similar to our study, it has been previously reported how patients want to be trusted and believed [42] or “being heard” [56]. Additionally, findings from recent research suggest that patients perceive clinician empathy as important [45], and that the perception of surgeon empathy during a consultation with a hand surgeon was primary linked to patient satisfaction; more so than to visit duration or pre-visit expectations of visit duration [57].

The participants in this study considered ‘hard facts’, i.e. results from x-rays or MRI, as evidence, and that the findings on these would influence the management of their problem. This is in concordance with previous research showing that patients believed that x-rays were necessary to identify the “cause of the pain”, and that any (even incidental) findings on x-ray were thought to indicate the cause of the pain [26]. It has previously been suggested that patients overestimate the benefit of tests and investigations and that by giving extensive information, patients can develop realistic expectations and make informed decisions [58].

In the tradition of qualitative research, trustworthiness of findings should be discussed in terms of credibility, dependability and transferability [38]. Several types of triangulation were used in the analytical process. A continuous dialogue amongst the co-authors was strived for throughout the data collection and in the analytic process. Although a purposeful sample strategy was used, the included participants were quite homogeneous which might affect credibility. The relatively small sample might be a limitation of the study. However, after the first twelve interviews the number of new codes emerging was low and no new information seemed to be forthcoming, and the amount of data collected was therefore judged as sufficient to answer the research question in a credible way [37]. Since the results of qualitative research are context-dependent [38], transferability of the study findings might be affected. Nevertheless, the findings in this study might be transferable to similar settings in primary as well as in secondary care/hospital settings in Sweden and internationally.

The findings illuminate aspects that are important for patients in an orthopaedic consultation, which could enhance collaboration in consultation as well as in decision making. The descriptions of patients’ perceptions and expectations can serve to improve patient–clinician relationships and a further understanding of these aspects may improve the patient experience. Since alternative models of care, such as physiotherapist-led orthopaedic triage assessment, may be considered for implementation, the results from this study could serve to inform the development of such a model of care.