Study design

A qualitative research design. The Consolidated Criteria for Reporting Qualitative Studies (COREQ) to guide the conducting and reporting of this study (S1 File) [29]. Ethical approval for this study was received from Trinity College Dublin School of Medicine Research Ethics Committee (Reference number 3007). The study was orientated in an interpretative descriptive study design. An interpretative descriptive study design is aligned with a constructivist and naturalistic orientation to inquiry [30], seeks to describe and understand a process or phenomenon (in this case, experiences of GPs’ management of LBP in primary care) through the subjective perspectives of research participants and, importantly, seeks to use this information to inform practice [31].

Data collection

To be included in the study, participants had to be licensed members of the Irish College of General Practitioners in full- or part-time practice and who consult patients with LBP as part of their routine clinical practice. General Practitioners seeing on average fewer than two new LBP patients per week were excluded. We sought to ascertain the experiences of General Practitioners across a sociodemographic continuum in Ireland. Ireland operates a hybrid public–private healthcare system. Public services, delivered by the Health Service Executive (HSE), are primarily tax-funded and accessible at low or no cost. Due to long waiting times in the public system, a large proportion of the population hold private health insurance in 2023 to access faster care. General practitioners play a central role in the Irish healthcare system. They are typically the first point of contact for patients and act as gatekeepers to most publicly funded health services. Access to diagnostic imaging, physiotherapy, specialist consultation, and elective hospital care generally requires a GP referral. Most GPs work in community-based, privately owned practices, and are reimbursed through a mix of public funding (e.g., capitation and fee-for-service under the General Medical Services scheme) and private patient fees.

A purposive and structured variation approach was used to select the sample for this study. This method allowed us to select a sample of participants representing a wide range of expertise and experience. Depending on their geographical location, participants were offered their preferred method of performing the semi-structured interviews, either in person at their clinic or online via Zoom (Zoom Video Communications, San Jose, USA).

A member of the research team (SS), a member of the Irish College of General Practitioners, utilised her professional networks to circulate the details of the study to members. Interested GPs contacted the research team via email. In addition, snowball sampling was employed where recruited GPs were asked to forward study details to colleagues and purposive sampling were used in the later stages of recruitment to capture variation in demographic factors or key characteristics that could influence GP perspectives. Data collection period was from April – October 2024.

Qualitative data (interview)

A semi-structured interview guide was developed to capture participants’ experiences of GPs’ management of LBP in primary care. The four-phase Interview Protocol Refinement Framework was used to develop and refine the interview guide (Castillo-Montoya, 2016). The interview guide was developed, informed by the available literature on the topic and on the clinical experience of the research group. The interview guide was piloted, and revised before study commencement by the PI with a member of the research team.

The interviews began with an introductory question about the GPs’ experience of working in primary care and the types of LBP patients they typically see in general practice. Subsequent questions explored GPs’ experiences of managing LBP in primary care. The topic guide was organised around recommended behaviours of the latest international clinical guidelines for LBP, namely: (1) referral for imaging (2) medication prescription (3) providing recommended advice on activity, and (4) providing referrals aditional treatment (Physiotherapy, Consultant in secondary care) [4,14,26,32]. The interview also explored participants’ experiences of managing LBP within their sociodemographic area, taking into consideration current health system structures and the impact of wider social determinants of health (S2 File).

All interviews were conducted by the PI (SMcA), a male physiotherapist with experience in conducting qualitative research. Given the semi-structured nature of the interview guide, the interviews adopted a flexible conversational style to facilitate participants in discussing their perspectives freely and in-depth. The capacity to probe beyond the specific questions of the interview guide assisted the PI in further exploring participants’ unique personal experiences, practices, and preferences, which shaped their perspective on managing LBP as GPs in primary care. All participants provided verbal informed consent for the qualitative study immediately before the interview. Demographics , including gender, years of GP experience, and characteristics of their medical practice, were collected prior to the interview. Field notes were taken during interviews. Interviews were audio-recorded using a digital voice recording device (Sony IC Recorder ICD-UX300) and transcribed verbatim or by using Zoom transcription software, depending on whether the interview was online (using Zoom technology) or in-person. The decision to utilise a mixed data collection approach was a pragmatic decision made by the authors in an attempt to maximise diversity of GP recruitment from a geographical perspective. However, care was taken to ensure that a similar approach was taken regardless of the data collection method (face to face or online) in terms of protocol, introductory questions, responses etc.

At the conclusion of each interview, the interviewer debriefed the participant on the main content of the interview, and time was permitted for any additional commentary to facilitate the emergence of new unanticipated information [33]. Recruitment ceased when no new themes or variants on established themes occurred with two subsequent interviews.

Data analysis

Data analysis was iterative, whereby data were analysed as they were generated. The data were analysed using Braun and Clarke’s reflexive thematic analysis [34]. Initially, the researchers familiarised themselves with the data by listening to the interviews and reading the transcripts. Initial coding of the entire transcripts (both semantic and latent) was performed independently using a line-by-line coding approach (SMcA, RD, AM). Members of the research team met regularly to review ongoing analysis and examine overlapping codes and patterns in the data to identify tentative or emerging themes. Preliminary or emerging themes were then collapsed and refined into themes and final themes through discussions with the wider research team, whose contrasting views explicitly sought to challenge interpretations and ensure that the data were consistent with the codes and themes [35].

Research team and reflexivity

Reflexivity underpinned the research process to account for potential bias amongst the research team to account for how subjectivity shaped our inquiry [36,37]. Reflexivity involves recognising that researchers are part of the process of co-construction of the data.

The research team consisted of the following: SMcA, a physiotherapist/researcher specialising in LBP; SS, a general practitioner in primary care; FW, a physiotherapist/researcher specialising in LBP; GF, an expert qualitative researcher; KOS, a physiotherapist/researcher specialising in LBP; RD & AM, final year BSc Physiotherapy students. The research team’s diverse academic training and experiences set the foundations for interdisciplinary dialogue and helped to promote reflexivity throughout the project [38].

Member checking

Member checking (also termed respondent or participant validation), was undertaken by returning the data (interview transcripts) to participants before finalising the themes to ensure that the data were an accurate representation of their experiences and/or whether the findings accurately reflected their viewpoint.

Participant characteristics

We interviewed 12 Participants working in primary care in Ireland between May and September 2024. Interviews were between 30–45 minutes in duration. Most participants were males (9/12 75%). Most participants worked in suburban practices. The mean years working as a GP was 19 years. Eight of the interviews were conducted in person, and four online via Zoom. Characteristics of the included participants are described in Table 1.

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Table 1. Demographics of General practitioners’ experiences of managing low back pain in primary care.

https://doi.org/10.1371/journal.pone.0339053.t001

General practitioners on the current barriers and facilitators to managing LBP in primary care

We identified three key themes relating to Participants’ experiences of managing LBP in primary care in Ireland: 1) A common issue with increasing patient complexity, 2) Managing LBP in primary care; a delicate balancing act, and 3) A system in need of change (Fig 1).

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Fig 1. Key themes relating to general practitioners’ experiences of managing LBP.

https://doi.org/10.1371/journal.pone.0339053.g001

Summary of main findings

The qualitative approach applied yielded rich and diverse insights into GPs experiences of managing LBP in primary care in Ireland. The study explored GPs experiences across three broad themes. GPs highlighted that LBP is extremely common in everyday practice and is rarely isolated, often coexisting with obesity, depression, diabetes, etc., making management more difficult (Theme 1). Management of LBP in primary care varied, especially in the context of medication and the usefulness of imaging in the context of LBP. The majority of GPs encouraged active approaches to managing pain (walking, avoiding bed rest, etc), stressing the need for self-management. However, GPs reported challenges in shifting patient mindset away from passive care models (Theme 2). A lack of timely access to physiotherapy, compounded by the inequities of a two-tiered system often left GPs feeling burdened with repeated presentations and few effective supports or resources that could enhance care in primary settings (Theme 3).

“General practice is unbelievably complex. Patients generally have a myriad of things going on.”

Similar to many healthcare systems across Europe, GPs are the gatekeepers to healthcare services for individuals with LBP, especially those in receipt of publicly funded healthcare services. Consequently, the results of this study confirm that LBP is commonly seen in primary care across age groups in different countries [40].

An awareness of increasing patient complexity in the context of comorbidities was a strong discussion point expressed by GPs in managing people with LBP in primary care. LBP has traditionally been viewed as an independent disorder, seen as a purely anatomic-physiologic condition [41]. However, LBP is increasingly now seen as a chronic health condition, often co-existing with multiple long-term conditions or comorbidities (e.g., diabetes, hypertension, obesity) [42–44]. GPs in the study highlighted the fact that LBP commonly co-exists with a spectrum of chronic conditions, compounding the complexity of overall patient management. Evidence from both high- and low-income settings demonstrates a strong association between LBP and comorbidities such as cardiovascular disease, diabetes, hypertension, and mental health disorders [45–47]. A systematic review by Oliveira et al. [42] found that individuals with chronic musculoskeletal pain — including LBP — are nearly twice as likely to report cardiovascular conditions compared to those without such pain. Similarly, Ritzwoller et al. [44] reported that comorbidities, including depression, diabetes, and arthritis, significantly increased healthcare utilisation and costs among patients with LBP, particularly in those with repeated episodes. This concept of increasing patient complexity was also discussed by GPs in the context of patients’ social determinants, where such factors were associated with a higher prevalence of more persistent LBP which had a knock-on effect in the subsequent management of LBP in primary care. The increasing awareness of the impact of the social determinants of health on musculoskeletal conditions such as LBP was recently highlighted in a systematic review by Karran et al. [48]. The findings highlight strong evidence that social determinants of health, especially low education and low socioeconomic status are linked to worse outcomes in LBP.

“But there’s an expectation now they want to be imaged.”

Current evidence-based clinical practice guidelines for the management of LBP recommend against the routine use of imaging in patients presenting with LBP [14,15,32]. GPs in the current study appeared to be in broad agreement with these clinical guidelines, discussing that they try to ensure that a referral for imaging referral was not made on the first consultation. In contrast, some GPs interviewed reported that the presence of radicular symptoms or “sciatica” met the threshold for imaging referral, despite current guidelines recommending against the use of imaging for sciatica [32].

Similar to a review by Hall et al. [26], some GPs expressed a belief that an absence of serious pathology on imaging provides reassurance to some patients which was a justification to refer patients for imaging [26]. A common barrier around imaging cited by GPs was that of navigating patient expectations. GPs reported an increased demand or expectation from patients for imaging referral when managing LBP. These findings are not unique to an Irish setting. Previous research by Slade et al. [49] highlights the impact of perceived pressure from patients as a key driver of imaging for LBP in primary care. It is thought that patient beliefs and expectations around imaging may stem from a desire for pathoanatomical findings on diagnostic imaging to validate their pain experience [50–52]. Although GP in the current study discussed the potential positive benefits of imaging access in terms of providing reassurance, many GPs also spoke about the potential downstream effects of unintended consequences of imaging for LBP in primary care. Previous international research has highlighted that incidental findings on imaging may provoke worry or concern in patients from a labelling effect if they fail to understand that these anomalies are common and benign [53,54]. This viewpoint was highlighted by participants in this study, with GPs discussing how imaging referrals increased their workload by having to explain or discuss incidental findings with patients that have no bearing on their overall management.

“Our society now wants everything to be fixed straight away.”

While there were some discrepancies across the participants in terms of how they manage LBP in primary care, overall, GPs’ management strategies were consistent with current clinical practice guidelines [14,15]. Advice to avoid bed rest, stay active and maintain normal activities where possible, and reassurance or advice around prognosis were all commonly reported by GPs as part of their usual management of LBP in primary care. Exercise, particularly for those with more persistent LBP, was also commonly reported by GPs. Often, GPs believed there was a need for patients with LBP to adopt a self-management approach to their pain, often likening it to other areas of clinical practice in the management of chronic diseases. The National Institute for Clinical Excellence [32] (2017) and other clinical guidelines recognise the need for effective self-management for the life-long condition and highlight the role of healthcare providers. However, GPs also discussed how patient perceptions or expectations of what management for LBP involved often impacted their ability to engage in exercise or other self-management strategies. The viewpoint is not unique to an Irish setting, with research indicating that patients with LBP often hold strong beliefs favouring “quick fixes” or passive treatments—such as manual therapy, massage, and acupuncture, with these beliefs influenced by cultural norms, personal experiences, and interactions with healthcare providers [55,56].

“It’s like passing a tennis ball.”

GPs in Ireland face considerable challenges in meeting the growing demand for musculoskeletal care, including LBP. GPs frequently highlighted the lack of time and general burden of care and responsibility as a barrier to managing LBP in primary care. This is perhaps not surprising as previous research highlighted that Ireland has one of the lowest ratios of GPs per 10,000 population in Europe [57], with high levels of emotional exhaustion reported by GPs [58]. The complexities of the Irish healthcare system were also identified as a significant barrier by GPs. Ireland is one of the only Western European countries that does not offer universal coverage of primary care. The Irish healthcare system is a hybrid complex public-private mix where GPs are independent contractors and act as gatekeepers for most publicly funded primary and secondary care services. It is estimated that 43% of the population is entitled to free GP care funded by the Health Service Executive (Ireland’s public healthcare system), with fee-based GP care for the remainder in the form of private healthcare schemes or out-of-pocket payment [59]. GPs highlighted the fragmented nature of Ireland’s hybrid public/private health system, resulting in inequitable access to physiotherapy and other secondary care services. This results in private healthcare patients having quicker access to services to manage their LBP, with those without private insurance facing long waiting times for appropriate services. The findings are consistent with previous Irish research [60] demonstrating public physiotherapy services were characterised by a significantly higher percentage of patients with chronic LBP, significantly longer waiting times, and a higher number of treatments over a longer period for all LBP patients, in contrast to the private sector, where prompt management of acute LBP conditions over a relatively short period was the norm. This is compounded by geographical inequalities, with the Economic and Social Research Institute of Ireland highlighting substantial variations in primary, community and long-term care supply across regions in Ireland [61]. One of the most prominent themes of this study was GPs frustration at insufficient access to public physiotherapy services for people with LBP. Physiotherapy services in Ireland are indeed under-resourced relative to demand, with a national supply of physiotherapists 30% below the EU-28 average, with substantial inequalities in access across geographical regions [62]. Previous international research has demonstrated that physiotherapy delivered in primary care for musculoskeletal conditions is highly requested by patients and may result in health benefits and cost savings [63–66]. Given the central role of physiotherapy in evidence-based LBP management, this workforce shortage presents a major barrier to implementing guideline-recommended care and addressing the burden of care in primary care for GPs. This is further compounded by a projected rise in MSK-related disability in the future, which will place further pressure on physiotherapy and primary care services alike, highlighting the urgent need for investment in community-based capacity and workforce planning to support sustainable LBP care. An additional challenge in the context of managing LBP in primary care in Ireland relates to the absence of implementation of national LBP guidelines, which has a potential impact on GP decisions and patient outcomes. Currently, there are numerous international, national and local clinical practice guidelines for the diagnosis and management of low back pain [14]. These guidelines provide recommendations to guide clinical practice based upon the best available evidence about benefits and harms, combined with other relevant factors. Previous research has demonstrated that improved uptake of guidelines results in improved patient outcomes, such as recovery trajectory and need for ongoing care [67,68]. Although a National Integrated Low Back Pain Pathway has been approved in Ireland in recent years, its implementation and adoption in primary care have not been demonstrated, which may be impacting a coordinated approach to how GPs manage LBP.

Strengths and limitations

One of the limitations of the current study may relate to the generalisability of the findings in the context of the setting. All participants were GPs in the Republic of Ireland. In addition, the unique hybrid complex public-private mix of the Irish healthcare system in primary care may mean the generalisability of the findings is limited in other international health systems and settings. Despite this, the views expressed by many of the participants aligned with previous research on the challenges of managing LBP in primary care. The authors acknowledge the variability in data collection methods may be seen as a potential limitation. A combination of face to face interviews and online technology (e.g., Zoom) was utilised during the data collection. This was a pragmatic decision in an attempt to ensure that an appropriate geographical mix of GPs by location in Ireland. However, we acknowledge this may be seen as source of potential bias. Another limitation of the current study may relate to the fact that all of the interviews were undertaken and coded by the lead author (SMcA), a physiotherapist, who may have a certain bias towards the management of LBP and the role of physiotherapy. It is possible that GPs participating in the study were aware of the lead researcher’s professional background and felt the need to highlight the role of physiotherapy. A further limitation may relate to participant diversity within the study. The majority of participants were practising in a suburban setting. This reflects the nature of general practice in Ireland, where declining population levels in rural areas have also coincided with declining levels of GPs in rural areas. In addition, although every effort was made to include an equal sample of male and female participants, the majority of participants in the study were male (75%), which is a potential limitation of the current study that should be acknowledged.

The strength of the study is underpinned by the various strategies employed to ensure methodological rigour, including researcher responsiveness, verification of data, methodological coherence and member checking (S3 and S4 Files). The purposive sampling approach was also a strength, as it ensured that participants had a wide range of practice experience and cared for populations from varied socio-economic strata. Furthermore, the authorship team is diverse, including other health care professionals who provided insight and contributed to the study.