‘Psychosocial’ – is it Pandora’s box?

I’ve been reading a paper written by Cam Crawford about GP’s use of the ‘Yellow Flags’, or psychosocial risk factors for identifying ‘at risk’ patients. It seems clear from his sample of GP’s that few of them are comfortable with the Guidelines as they are presented – and that their discomfort arises for quite a few reasons.
Crawford identifies that many GP’s don’t have time (or inclination) to read guidelines that pass across their desks. Some don’t like the rehabilitation model that ACC works from, and the ‘Yellow Flags’ Acute Low Back Pain guideline is strongly identified with ACC’s model. Some GP’s don’t identify themselves as working within a biopsychosocial model and firmly believe they must attend to the biomedical factors first – and consider psychosocial factors only after progress is slow.

Many of those in this study thought that their professional perspective and ‘gut feeling’ was sufficient to enable them to identify ‘at risk’ patients, and thought that using an ‘artificial’ structure such as the algorithm presented in the Acute Low Back Pain Guidelines was an attempt to place people into boxes – and people are too complex for this. Finally, most GP’s found that time constraints limited both their initial reading of the ‘Yellow Flags’ and their comfort and confidence in identifying and discussing psychosocial risk factors with their patients.

Unfortunately, I don’t believe the findings of Crawford and colleagues is very different from those we would find amongst physiotherapists, chiropracters, osteopaths or occupational health nurses – all of whom work with people who have acute low back pain. Somehow the confidence and comfort people have with the idea of nonmedical factors influencing recovery from acute low back pain is very very low.

I’ve heard people talk of the fear of ‘opening Pandora’s box’ if they ask about family relationships, mood, beliefs about the problem, work and so on. Fear that the problems may just be too big to fit into a brief clinical encounter. Fear that the person might need more clinical skill to unpack the person’s concerns…

I wonder how true this is? Yes, it does take a little time to ask about some of these things – but is it really a time factor, or could there be something more fundamental making it something to be wary of? Could it be that when we’re busy, it’s easier to disengage our emotions, to restrict our listening to things that are clear-cut and non-emotive? Do we fear hearing about someone else’s concerns because it might mean we are prone to them too?

I don’t know the answers – and over the next few days I want to explore this because if we are to reduce the number of people progressing to chronic disability, the risk factors that are well-known need to be identified and effectively managed. Now we might not have great management of them yet, but we do know how to identify them. And that’s a start.

Cameron Crawford, Kathleen Ryan, Edward Shipton (2007). Exploring general practitioner identification and management of psychosocial Yellow Flags in acute low back pain The New Zealand Medical Journal, 120 (1254), 1-13


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