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PAPERS:
Rachelle Buchbinder, Damien Jolley, and Mary Wyatt
Population based intervention to change back pain beliefs and disability: three part evaluation
BMJ 2001; 322: 1516-1520 [Abstract] [Full text]
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[Read Rapid Response] Time pressures erode action on "keep active" message
Douglas Carnall   (22 June 2001)

Time pressures erode action on "keep active" message 22 June 2001
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Douglas Carnall,
GP
Hackney, London

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Re: Time pressures erode action on "keep active" message

The authors of the paper are to be commended on the results of their programme: it is interesting to note how much more proactive things can be when private insurers are footing the bill for both sick pay and treatments, and explicitly cost action versus inaction.

Part of the validity of the paper rests on the efficacy of the booklet "The back book". You can order it--try a search on "Roland Back Book" (without the quotes) at http://www.the-stationery-office.co.uk/ (Note: this is not the same as http://www.hmso.gov.uk). As the book costs £1.25 and has 6 academic authors it was presumably no-one's prime focus in the enterprise of its publication to make money. It seems a false economy not to make it freely available on the internet; in fact, sales of its paper version would probably rise.

The Royal College of General Practitioners deserves credit for making their back pain guidelines freely available. There's also a nice summary on p11 of this PDF version I found kicking about.

It's worth considering how all this actually plays out in the British primary care consultation. The essence of the situation is trying to motivate someone in pain to keep active. One of my favourite lines is that "everyone I know who had back pain, and now does not found some form of exercise to keep their back supple and strong." My favourite example is a friend who used to suffer a lot with her back who is now a yoga teacher. Then we talk about what kind of exercise they would like to do.

A consultation that takes sufficient time to get a full history, do an appropriately focussed examination (no, I don't routinely attempt to elicit saddle anaesthesia), make appropriate referrals (physiotherapy), prescribe safely, and advise on activity in a way that connects with the reality of the patient's own life takes time. The average British GP has an 8.2 minute consultation; the easy place to economise on time is by not talking about physical activity. It's nice to see evidence suggesting that such shortcuts would be a false economy, though primary care in the NHS seems to be moving in the opposite direction. Demanding that all consultations take place within 48 hours inevitably implies shorter consultations, which will inevitably be of lower quality.