The Primary Care Osteoarthritis Consultation: Dissonance and Consonance

Background: OA is the commonest long-term condition in primary care. The NICE guidelines in the UK are clear that much can be done to improve patient outcomes but existing research suggests the guidelines are not widely implemented and general practitioners (GPs) and patients are pessimistic about OA treatment. The primary care consultation may be important in shaping and influencing this dichotomy. This study aimed to uncover what happens when patients with OA present to their GP, in order to identify possible areas for intervention to enhance patient care. Methods: With ethical approval, 15 GPs consented to have two half day surgeries video recorded. Patients aged 45 and over were approached prior to the consultation to consent to being video recorded. Consent was verified immediately after the consultation and 48 h later by phone. All videos were initially watched once, and consultations containing reference to OA selected. Patients and GPs were then invited to participate separately in post consultation individual interviews, during which the video recorded consultation was played back to them to stimulate recall. Analysis involved comparing and contrasting patient and GP interviews with the matched observed consultation findings, using thematic analysis. Results: 195 videos were collected, with a consent rate of 79.4%. 19 OA consultations were identified, the majority (15) of which were consultations where more than one symptom or problem was discussed. The over-arching theme emergent in the qualitative analysis was that of dissonance between the GP and patient and this was observed in three situations. First, dissonance occurred when patients’ and doctors’ agendas were not aligned; for example when patients were seeking information and/or reassurance and were given symptom management, or vice versa. Reassurance was described as important by GPs who were wary of provoking alarm in patients; this contributed to an avoidance of using the term OA. Secondly, dissonance resulted when doctor and patient agendas were aligned, but messages of reassurance (e.g. that OA is a normal part of ageing) failed to validate or lead to action on patients’ symptoms. Thirdly, GP’s use of standardized scripts in explanations and advice resulted in dissonance when patients perceived this as lacking relevance and meaning to their own individual and personal case. Conclusion: Eliciting the patient’s agenda is likely to be crucial in achieving consonance in the consultation; however patients often find it hard to articulate their agenda and the complexity of the consultation is a further practical barrier to identifying patient concerns. Future research could explore the usefulness of employing the term OA in primary care consultations with patients, consider patient-centred toolkits to help in identifying and communicating their agenda, and investigate whether improving concordance in consultations between GP and patient improves the quality of care