Abstract
Background:
Chronic musculoskeletal pain (CMP) is a public health concern disproportionally affecting vulnerable populations. Outcomes for CMP are inequitable and are negatively influenced by health care providers’ (HCPs) implicit/explicit biases and unmet patient/HCP expectations. The clinical conversation, as experienced through the process of care, can improve outcomes in CMP when a therapeutic alliance is established and/or HCPs demonstrate empathy. However, vulnerable adult populations report discrimination and stigma during the clinical conversation. This thesis investigated if/how historical and contemporary sociopolitical factors influence the clinical conversation by/with vulnerable adult populations with CMP.
Methods:
This thesis involved four processes: research question development, supportive theoretical frameworks identification, multi-disciplinary systematic reviews of quantitative and qualitative studies, and two mixed method explanatory sequential studies. A preliminary review of the literature summarized the current theoretical frameworks related to CMP and the clinical conversation. A quantitative systematic review examined the state of knowledge of the clinical conversation in vulnerable patients; perspectives were primarily from HCPs. A second quantitative systematic review explored the clinical conversation in case vignettes used in CMP education/training. A subsequent meta-ethnography of qualitative/mixed method studies interpreted both HCPs and vulnerable populations experiences in CMP. Two mixed method sequential explanatory studies were completed. The first described the self-reported pain experiences of English-, Spanish-, and Arabic-speaking adults and interpreted vulnerable adults’ experiences. The second surveyed physical therapists (PTs) and physical therapist assistants (PTAs) regarding their perspectives of the influencing factors on the clinical conversation and interpreted their contemporary experiences with managing patients with CMP.
Results:
Several concepts or constructs identified in Chapters 1-2 reoccurred throughout the thesis. Although search strategies were similar for each literature review completed, Chapter 5’s meta-ethnography appeared to best capture the majority of themes relevant to both the patients and the HCPs. Empathy is often identified in the CMP; however, trust appeared to resonate more with stakeholders. There may be several reasons as to why trust may be more relevant. First, vulnerable adults have to seek candidacy to first enter a clinical conversation. Additionally, once that conversation had been entered the patients generally felt comfortable with, and trusted, their HCPs.
One key takeaway was that clinical conversation in CMP with vulnerable adults was that the clinical conversation was part of the process of care with the many health care workers that patients may encounter. This perception that the clinical conversation is bigger than just a discussion between the patient and provider was then supported by findings from both the patient and HCP participants. Another interesting finding was that Chapters 8-9 reflected HCPs’ apparently diametrically opposing viewpoints – that CMP has inherent invisible processes and their preferential reliance on biomedical imaging (i.e., visible evidence). Furthermore, constructs related to health insurance, vulnerable adults with CMP, and health inequities in CMP were not identified by HCPs, which may contribute to the dissonance reported. Finally, an emergent theme was that physical therapy is not conceptualized as a basic human right.
Conclusions:
This thesis produced a novel question that explored if/how sociopolitical and/or historical factors influenced the clinical conversation in CMP. Results of the extensive literature reviews and the mixed method studies indicates these factors are present and appear more salient to the patients than the HCPs. This work provides a step forward in an improved understanding of how the impact of clinical conversation in CMP does not seem to match HCPs’ intent or meet vulnerable adults’ expectations. This thesis underscored future educational/training and research that incorporates awareness of the broader sociopolitical/historical factors in teaching on CMP.