Gatekeepers in primary care – a qualitative study on manual therapists’ role in triaging patients with back and neck pain | BMC Health Services Research

This study contributes to a deep and nuanced understanding of the perspective of various professionals at the PHC involved in delivering care to individuals with back and neck pain. It explores the perspectives of physicians, physiotherapists, nurses, and management. Specifically, if the current management of patients with back and neck pain at these PHCs needed improvement, and perceptions towards the potential role of licensed chiropractors and naprapaths in triaging patients with back and neck pain at PHCs. Staff at three PHCs in Stockholm described the current management of patients with back and neck pain in terms of navigating patients’ expectations: an expectation and overreliance from patients concerning seeing a physician and receiving imaging, not other healthcare professionals, resulting in long waiting times for physicians. When asked about assigning licensed chiropractors and naprapaths to triage these patients at the PHC, participants expressed that this would mean reconfiguring the care process, and that poor knowledge and concerns about the competence of manual therapists would challenge the boundaries of professional identity.

Navigating the weight of expectations

Participants expressed that they believed that patients with back and neck pain often expected to see their physician, not other healthcare professionals, resulting in long waiting times for all patients to see a physician. An explanation could be their trust in physicians’ competence, but also that physicians represent the top of the health care hierarchy, which may help patients in their search for quick fixes. This search for the silver bullet may lead to resistance from patients towards other options, including consulting manual therapists, who may be viewed as less authoritative figures in the health care space.

Our findings underscore the pivotal role of trust in shaping the dynamics within the healthcare community. Patients’ perceived trust in physicians influences their expectations and preferences, reinforcing the established hierarchy and shared practices. In the context of Lave and Wenger’s theory of CoP [16], this trust is essential for mutual engagement, joint enterprise, and the development of a shared repertoire. The issue of trust has previously been identified as a barrier in incorporating chiropractors into interprofessional practice [25]. By understanding and addressing the trust dynamics, healthcare providers can work towards a more inclusive community of practice that values and integrates diverse expertise. Additionally, the concept of social learning, central to CoP, is relevant to “Navigating the weight of expectations,” as patients’ trust and preferences are shaped through their interactions and experiences within the healthcare community.

Reconfiguring the care process

Participants related the introduction of licensed chiropractors and naprapaths as potentially changing the care process, leading to less use of low value care: reducing imaging, the number of sick leave notes and medical pain prescriptions, and more efficient care. In the US, such a change was tested as a standardized pathway for triaging patients with low back pain among members of the multidisciplinary team, resulting in good clinical outcomes at a low cost with high levels of patient satisfaction [26]. Although it was recognized that patients should self-manage to a higher degree, participants also acknowledged the need for guidance in this process.

The introduction of licensed chiropractors and naprapaths can reconfigure the care process through enhanced collaboration. Examining our results through the lens of CoP [16], collaboration is crucial for fostering mutual engagement and developing a cohesive approach to patient care. By promoting collaboration between licensed chiropractors, naprapaths and physicians, the healthcare community can reduce low-value care and support patients in self-management, leading to more efficient and effective care. Furthermore, the concept of identity, central to CoP [16], is also pertinent, as manual therapists and physicians develop their professional identities through their collaborative practices and interactions within the community.

Challenging boundaries of professional identity

Participants expressed poor knowledge about licensed chiropractors and naprapaths competence and confusion concerning differences between them. Licensed manual therapists in Sweden (chiropractors and naprapaths) have been part of Swedish Health and Welfare system for more than 30 years, with a four- to five-year full-time evidence-based education aiming to educate health care providers with expertise in the management of persons with musculoskeletal problems and injuries. This includes differential diagnosis, advice, reassurance, treatment, rehabilitation, health promotion and disease prevention. However, this uncertainty may reflect a threat to professional identity, described for physicians as that of medical expert and care coordinator [27]. Adding manual therapists, not only as part of the team, but also as first contact for these patients, may challenge the boundaries of professional identity. In a recent study of physicians’ attitudes towards collaboration with pharmacists, they made it clear that professional boundaries should not be crossed [28]. However, ten years after the introduction of chiropractors in the US as Primary Spine Care Providers, a positive shift has been noticed in other professionals’ attitudes toward this role [29].

Concerns were raised regarding potentially missing serious pathology, as the triaging role involves handing over the gatekeeping responsibilities for patients with back and neck pain. This lack of trust is found in previous research of interprofessional collaboration in different settings [27, 28, 30].

These findings illustrate the challenges and opportunities in negotiating professional identities within the healthcare community. Drawing on Lave and Wenger’s work and scrutinizing our results through the perspective of CoP [16], integration, trust, and collaboration are crucial for fostering mutual understanding and effective healthcare delivery. Additionally, the concept of identity is significant here, as licensed chiropractors and naprapaths negotiate their professional identities and establish their roles within the healthcare community through ongoing participation and interaction. By promoting these elements, the healthcare community can better understand and utilize the competencies of licensed manual therapists, ensuring that patients receive comprehensive and effective care. Legitimate Peripheral Participation (LPP), a central tenet of CoP [16], is particularly relevant here. LPP describes the process by which newcomers, such as licensed chiropractors and naprapaths, gradually become full participants in the community. Through LPP, manual therapists initially engage in peripheral activities, gaining experience and building trust. Over time, as they demonstrate their competence and contribute to the community, they transition from the periphery to more central roles, becoming recognized and trusted healthcare team members.

Relation to existing literature

A Canadian study [31] also investigated clinicians’ perspectives on the current management of patients with back and neck pain at PHCs. Like our participants, the Canadians knew that imaging is considered low-value care and results in high health system costs but also voiced that patients want validation from imaging.

We found that PHC staff expressed poor knowledge about licensed chiropractors and naprapaths’ competence. This is similar to another study from Sweden [32], where general practitioners reported having inadequate knowledge and minimal experience with chiropractic. This, together with an uncertainty regarding treatment effectiveness, led to a hesitancy towards recommending chiropractic to their patients.

In interviews concerning the use of manual therapies in the US, physicians expressed concerns such as limited patient awareness and practice autonomy [33]. The comment regarding physical space is also found in a previous study on professional boundaries among manual therapists [27]. It is worth noting that the concerns raised in our study may be those found when aiming for interprofessional collaboration in general. In an Australian study of attempting to integrate different health services, structural barriers and territorialism were mentioned [30].

Participants in a Swedish study [32] expressed uncertainty about manual therapists missing serious illnesses. A Norwegian study reported that general practitioners wanted information on examination findings, diagnosis, treatment, and advice given, when communicating with chiropractors about patients [34]. This could possibly be one way of mitigating this fear as expressed by the physicians.

Methodological considerations

A purposeful sampling strategy was employed, which took various professional experiences into consideration. The participants had a variety of professions, ages, and working experiences. Further, the three PHCs had different locations, organizations, and exposure to manual therapists to produce experiences from a rich and representative sample.

Throughout the analytical process, and primarily due to the senior investigator’s prior understanding of the empirical context, continuous scrutiny of codes, categories, themes, and the original data transcripts was conducted to ensure a robust alignment between the data and the findings. We thus gave careful consideration to Patton’s dual criteria of internal homogeneity and external heterogeneity [35].

Selection of participants was left to the discretion of the PHC managers, and we only asked for a diversity of professions managing back and neck pain patients, which was achieved. However, we do not know if the included participants were selected based on other factors, such as experience (the range of experiences of our participants suggests that this is not the case), or if they were simply available at the time of the interview. It is difficult to judge the impact of this selection.

Another possible limitation of the study is that no repeat interviews were conducted, which was due to logistical constraints at the participating healthcare centers. This may have restricted opportunities for follow-up clarification and cross-case comparison.

The nature of small-scale qualitative research inherently limits the interpretation of our findings. Qualitative studies, which focus on detailed and in-depth analyses within the constructivist paradigm, differ significantly from large-scale population-based studies that operate within the post-positivistic paradigm. Consequently, generalizing the findings from qualitative research is neither feasible nor desirable. However, by providing a detailed description of the contextual setting, the participants involved, and the analytical process, along with drawing connections between our findings and relevant theories and existing literature, we aim to enable readers to assess the applicability and relevance of our findings to their contexts.

While focus groups provide a valuable forum for in-depth analysis of topics, particular sensitivity surrounding the management of patients with back and neck pain at PHCs may have impeded this approach. Some aspects of the phenomenon may be sensitive, making participants reluctant to share personal experiences in a group setting. Although semi-structured interviews might have been a more suitable alternative method, logistical constraints prevented their implementation.

In this study, member checking, such as giving feedback on transcripts and findings, was not utilized, aligning with the cautionary stance of several methodologists [36, 37]. The decision was based on three primary considerations. Firstly, member checking assumes a fixed truth or reality, which may not align with the interpretive nature of qualitative research. This assumption can be problematic as qualitative research often seeks to explore multiple perspectives and understandings. Secondly, individual participants might struggle to grasp the broader context derived from data collected from multiple sources, potentially limiting their ability to provide meaningful feedback. Lastly, the process of member checking requires significant time and logistical resources, which can be challenging to manage effectively. These factors collectively informed our decision to employ alternative methods to ensure the credibility and reliability of our findings.

Existing literature suggests that patient satisfaction tends to be lower in gatekeeping systems compared to direct-access systems [38]. It is imperative to understand patients’ perceptions of licensed chiropractors and naprapaths in this gatekeeping role, as well as their willingness to accept manual therapists as primary contact providers. Addressing this knowledge gap is essential if licensed chiropractors and naprapaths are to be successfully implemented in PHCs. Future research should focus on incorporating qualitative data to explore patient experiences and satisfaction with manual therapists functioning as gatekeepers.

Perspectives on licensed chiropractors and naprapaths as gatekeepers in phcs

We are currently planning a study in Stockholm of licensed chiropractors and naprapaths as “gatekeepers” at PHCs to explore patient outcomes, use of low-value care, and PHC workload, since there is a scarcity of empirical evidence or detailed studies on the effectiveness of manual therapists as gatekeepers in PHC. The literature suggests that gatekeeping can positively impact the quality of care, health outcomes, and healthcare utilization [39]. Insights into the perceptions of PHC staff towards manual therapists in a triaging role for patients with back and neck pain within the PHC team are crucial for conducting such a study. We learned that PHC staff must be thoroughly educated about licensed chiropractors’ and naprapaths’ competence prior to introduction in a PHC. This would also mitigate the concern that manual therapists would miss severe pathology. Among the incentives for licensed chiropractors and naprapaths to have a triaging role, decreased physician workload and more patient choice were mentioned. The concerns included practical issues (time and space).