INTRODUCTION
People seek musculoskeletal specialty care when a symptom becomes a concern, which is not alleviated in non-specialty care. Unhelpful thoughts regarding symptoms and feelings of worry, despair, or insecurity are common in association with musculoskeletal symptoms.1–4 People who are flexible in their thinking–ready to replace unhelpful thoughts with healthier narratives about their symptoms–experience less intense symptoms and are more capable.5,6
Patients can be coached to enter specialty care visits with an open and curious mind, prepared to move from how they currently regard their symptoms to a potentially healthier mindset.7 Previous studies found that greater patient activation (feeling agency to take action to maintain and improve one’s health)8 is correlated with greater capability, lower pain intensity, and greater satisfaction with treatment.9 A surgical question prompt list (a list of questions that patients can consider as they interact with a surgeon to consider surgery)10 has been used to help increase patient agency and increase participation in decision-making regarding discretionary surgery.11 A question list prompts patients to reflect on and ask about things that matter to them. We are interested in whether or not patients who review a question prompt list before the consultation feel greater comfort with decisions, have a greater health agency, regard their specialist as more empathetic, and are more satisfied with their care.
A Cochrane review identified 16 studies of the effectiveness of a question prompt list for an oncology consultation and found evidence that they enhance patient participation, reduce feelings of anxiety, and improve recall of information.10 One study of patients seeking specialty hand care compared a question prompt list with three simple questions and found comparable patient-perceived involvement in their care. However, it did not address whether either tool improved patient agency and experience or limited decision conflict beyond what patients experience without using either tool.12
We addressed this question: Do patients who receive a question prompt list before a musculoskeletal specialty care visit experience greater comfort with decisions, feel greater agency for their care, perceive their surgeon as more empathetic, and are they more satisfied with their care?
METHODS
Study design and setting
Our Institutional Review Board approved this study at the Office of Research at the University of Texas in Austin. New, English-literate adults (18 years or older) seeking care for musculoskeletal symptoms were invited to enroll from January 2018 to March 2020. The question prompt list was developed by surgeons and patients alike. Questions were considered important after reviewing. After verbal consent and reading a research letter, subjects were randomized 1:1 using a random number generator to be given or not given a question list before their visit.
Participants
Patients were asked by medical assistants throughout all clinical offices and voluntarily decided to participate. Participants were fluent and literate in English, and there was no concern about understanding the list of questions. Participants had an average of 5-10 minutes to review the list before the physician came in. We enrolled 146 adults (60% women) with an average age of 53 (SD=17) [Table 1]. Seventy participants (48%) received a question prompt list. More than half of the patients had non-trauma conditions (77%), and more than half had upper-extremity conditions (59%). Injuries and diagnosis include but are not limited to rotator cuff and labral tears, Dupuytren’s contracture, lumbar radiculopathy, total joint replacement, and pilon fractures.
Measurements
The list suggested questions about diagnosis, cause, treatment options, and recovery. For instance, “What is causing my symptoms?”, “Have I done anything to cause this problem?” “Are there treatments that can stop, slow, or reverse the problem?” finally, questions about the specific treatments offered, such as, “Does this treatment cure the disease?”
After the visit concluded, including a specific treatment plan, the physician left the room, and the research assistant administered the surveys. Patients in both groups completed a demographic survey (age, gender, ethnicity, etc.), the Decisional Conflict Scale (measures personal perceptions of uncertainty in choosing options; modifiable factors contributing to uncertainty and unsupported in decision making, and effective decision making), a measure of perceived clinician empathy (CARE measure), a measure of patient activation (PAM score: assesses an individual´s knowledge, skill and confidence for managing their health and health care), and an 11-point ordinal measure of satisfaction with the visit. The Decisional Conflict Scale was used as our primary outcome variable. It is a validated measure of patient uncertainty in making decisions about their care, the factors contributing to their uncertainty, and whether or not the patient felt involved in their care through shared decision-making.11,13
Statistical Analysis
Descriptive statistics were performed on all patients. Shapiro-Wilk tests were conducted to test the normality of continuous variables. The mean and standard deviation were reported for normally distributed variables; the median and interquartile range were reported for all nonparametric variables. To seek factors associated with receiving a QPL, we performed bivariate analyses using Mann-Whitney U tests for nonparametric response variables. Spearman rank-order correlations were calculated for all continuous explanatory variables. All variables with P < 0.10 were moved to multivariable analysis. Multivariable linear regression analysis was used to identify variables associated with CARE score. Alpha was set at 0.05.
A priori power analysis using G power determined that a sample size of 128 subjects would have 80 percent power to detect a difference of effect size 0.5 with alpha set at 0.05. Anticipating the potential for 10% incomplete surveys, we aimed to enroll more than 141 patients.
RESULTS
In bivariate analysis, there were no significant differences in (Median [IQR]) in decision comfort (4 [0-13], 5 [0-14]), agency (92.3 [80.8-100], 92.3 [83.7-100]), perceived clinician empathy, (31 [26-34], 31 [27.5-35]) and satisfaction with care (50 [48-50], 50 [46.5-50]) between two groups whether they received a question prompt list (QPL) prior to a visit or not [Tables 2-6].
DISCUSSION
Question lists encouraged discussion and improved patient knowledge in prior studies of people considering surgery.10,14 We tested the influence of a question list on patient experience after an initial musculoskeletal specialty care visit. We did not find a difference in comfort with decisions or other aspects of patient experience when people received a question list prior to their visit.
Our study has limitations. First, it was performed at several musculoskeletal specialty care offices in a relatively wealthy, educated, White urban center in the United States [Table 1]. There is evidence that Black patients generally have shorter visits, ask fewer questions, and participate less than their counterparts.14,15 Patients with lower incomes have been shown to ask fewer questions.11 Therefore, it is possible that these populations could benefit more from a question prompt list than the people in our sample. Although the question list was not reviewed by the physician prior to each interaction, nor were they made aware of who received the list, the questions asked by patients may have alerted clinicians to patients who received the prompt list. A study that intentionally made clinicians aware of whether or not patients received a question list might alter clinician behavior and result in different outcomes—a hypothesis that merits testing. The current study addressed how experience with specialty care might be altered when patients were more prepared and inquisitive.
The observation that there was no measured benefit to receiving a question list suggests that these tools may not be sufficient to improve patient-clinician communication and development of health strategies or that the tools we used to measure a difference were inadequate. A list that prompts patients to ask about things that matter to them may or may not improve their connection with the surgeon and their perception of the clinician’s empathy. Furthermore, experience measures (empathy and satisfaction) have known shortcomings as research tools, such as powerful ceiling effects and non-normal distributions.16 Other measures, such as anxiety regarding symptoms and trust in the clinician, might register a difference.14,16 A systematic review of studies of question prompt lists for patients receiving cancer care has demonstrated associations with increased question asking, decreased anxiety over time, and improved recall as subsequent visits,17 none of which were measured in this study. On the other hand, evidence suggests that a greater difference can be made by adjusting clinician tactics than by providing patients with tools. For instance, one trial in oncology randomized clinicians to train how to engage patients in care decisions or whether patients should receive a communication aid. They found that training clinicians had a large positive effect on independent observer ratings of the involvement of patients in decisions and a positive impact on patient’s perception of their involvement. The patient communication aid did not improve feelings of involvement. Neither intervention affected satisfaction with the consultation or decisional conflict.18 There are important differences between cancer care, where treatment is necessary, and the potential harms of treatment are greater, and upper extremity specialty care, where most treatments are discretionary, which makes even small potential harms potentially more influential.
We are interested in developing tools and interventions to help patients explore what matters most to them (their values), correct any misconceptions about what tests and treatments offer, and allow patients to choose treatment and testing options most consistent with their values and priorities. Clinician variation in biases and priorities with regard to tests and treatment can be tempered through shared decision-making with patient values. In future studies, we aim to target injuries based on acuity as we have acknowledged that patient preparation regarding questions they may ask and their anxiety around the clinical encounter will differ among patients. We found that—in a population of relatively socially advantaged people–a question list was not associated with lower decision conflict or greater perceived empathy, satisfaction, or agency. Future research can address the use of specific tools in less advantaged patients. Still, we think the current evidence may point to a need for tools and strategies that alter clinician behavior, perhaps by emphasizing guiding rather than directing patient approaches in a musculoskeletal specialty care visit.
Declaration of conflict of interest
The authors do not have any potential conflicts of interest pertinent to this manuscript.
Declaration of funding
The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.
Declaration of ethical approval for study
Approved by UT Austin IRB. IRB number: 2017-02-0122
Declaration of informed consent
There is no information (names, initials, hospital identification numbers, or photographs) in the submitted manuscript that can be used to identify patients.