"It's hard to trust an individual, it's easier to trust an image": patients with low back pain want imaging as a means of coping with uncertainty

Key points

1. 01Patients linked imaging to certainty in diagnosis and confidence in treatment, often saying they wanted to 'see what was going on'
2. 02The desire for imaging was strongest as a coping strategy against fear of missing something serious, with fear of uncertainty outweighing concerns about radiation or other harms
3. 03At intake, 78.6% of participants were neutral or disagreed that imaging was necessary for the best care, yet in later interviews many expressed strong desire for imaging, showing belief instability over time
4. 04Clinicians who clearly explained examination findings and reasons for not imaging appeared to reduce patients' demand, at least temporarily
5. 05Patients who felt unheard or whose imaging was refused without explanation expressed frustration and retained beliefs that imaging was essential

How it was conducted

Design

Qualitative study using semi-structured telephone or video interviews, analyzed with thematic analysis guided by the Common-Sense Self-Regulation Model (CSSRM)

Participants

28 patients with low back pain recruited by community-based family physicians (n=8), chiropractors (n=10), and physiotherapists (n=10) in Ontario, Canada

Recruitment period

October 2019 to February 2020 and June 2020 to January 2021; interviews conducted February to May 2021

Interview timing

Median 7 months (range 2 to 17 months) after last clinician visit; interview duration ranged from 13 to 73 minutes (mean 42 minutes)

Prior questionnaire

Participants completed intake questionnaires including the Roland-Morris Disability Questionnaire, STarT Back tool, and imaging belief items months before the interview

Analysis framework

CSSRM three domains: Stimuli and Illness Representations, Coping Procedures, and Appraisal of Outcomes

What they found

• 28 of 46 invited patients agreed to participate (7 did not respond, 11 declined)
• 53.6% of participants were female; 82.1% had at least one prior episode of low back pain; 46.4% rated pain intensity at least 7 out of 10 at intake
• At intake, 78.6% were neutral or disagreed that imaging was necessary to get the best medical care, and 71.4% were neutral or disagreed that everyone with low back pain should have imaging
• In later interviews, many of these same participants expressed strong beliefs that imaging would have been valuable, indicating belief change over time
• Most discourse in Coping Procedures was linked to Cognitive Reappraisal, where five themes emerged: imaging reveals needed information, imaging boosts confidence in diagnosis, imaging boosts confidence in treatment, fear of uncertainty trumps fear of harm, and recollections of clinician discussions about imaging
• Illness Outcomes discourse reflected the generally self-limiting nature of low back pain; emotional outcome discourse was limited and linked mainly to frustration and fear about not having had imaging

Limitations

• Small purposive sample of 28 participants limits generalizability; sample may be biased toward patients dissatisfied with imaging decisions
• Time gap of 2 to 17 months between clinical encounter and interview introduced recall bias and confounded belief stability assessment
• Interview guide focused strongly on imaging, which may have over-represented patients with strong imaging-related views
• CSSRM was applied retrospectively to interviews not fully structured to address all model constructs; fewer patients were recruited by family physicians than other provider types

Why it matters

For patients

Patients who feel their pain is not being taken seriously without imaging may find it helpful when their clinician clearly explains what the physical examination found and why imaging is not needed right now.

For clinicians

Consistent, contextualised education at every visit can reduce patients' desire for unwarranted imaging, but the effect may be transient and needs to be reinforced because patients' beliefs shift between episodes and encounters.

For readers

This study maps patient imaging beliefs onto a well-established illness cognition model, providing a useful framework for designing communication interventions to reduce low-value imaging in primary care.