Exploring shared decision-making in prescribing analgesia for musculoskeletal pain in primary care consultations.

The problem

One in seven consultations in UK primary care is due to musculoskeletal symptoms. Many people with musculoskeletal pain take less than the therapeutic or prescribed dose of their analgesia or have inadequate pain relief. Shared decision-making, a process which occurs when a doctor and patient share information, and where the patient is supported to consider options, may enable patients to have a greater role in decisions about analgesia. It is unknown how these decisions are shared in practice.

The approach

195 archived digitally recorded consultations from 15 GPs across 7 practices in the West Midlands were utilised for this study. All consultations including a discussion about a musculoskeletal condition were included in the analysis. A framework for analysis was developed from the findings of a systematic review, Elwyn's model of shared decision-making, input from a patient advisory group and review of a sub-sample of the video consultations. Detailed analysis drew on techniques of conversation analysis and salient features of non-verbal communication.

Findings

79 consultations contained discussion about a musculoskeletal condition and of these 51 discussed analgesia. Mean consultation time was 12 minutes, with the median number of issues discussed being 4 (range 1-9), including the musculoskeletal condition. In 3 consultations, decisions about prescribing were shared explicitly including the offer of different options. In one consultation, a decision made by the GP was actively resisted by the patient. Preliminary analysis suggests consultations demonstrated a spectrum of sharing decisions: the GP apparently making a decision based on the patient's presentation of their condition; the GP offering options in a step-wise manner, or the patient declining an initial offer of analgesia, with no further discussion. Sharing the decision seemed more likely when the only topic in the consultation was the musculoskeletal condition; when the patient appeared to have an established relationship with the GP; where there was agreement on the diagnosis; where the patient's experience of and preference for analgesia were explored, and when subtle cues about the patient's preferences were acknowledged by the GP.

Consequences

An explicit model of shared decision-making about prescribing analgesia for musculoskeletal pain was rare in primary care consultations. An explicit model does not take into account the multiple issues GPs and patients discuss within a time-limited consultation, or patients' longitudinal relationship with their GP. Sharing decisions may be encouraged by specific factors, such as GPs exploring a patient's previous experience of analgesia, and a more flexible approach to decision-making.

Credits

• Catherine Hyde
• Zoe Paskins
• Kate Dunn
• Carolyn Chew-Graham