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Thursby S, Dismore L, Swainston K. Clinical skills development for healthcare practitioners working with patients with persistent physical symptoms (PPS) in healthcare settings: a systematic review and narrative synthesis. BMC MEDICAL EDUCATION 2024; 24:328. [PMID: 38519955 PMCID: PMC10960475 DOI: 10.1186/s12909-024-05306-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 03/13/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND The complexity and uncertainty around Persistent Physical Symptoms (PPS) make it difficult to diagnose and treat, particularly under time-constrained consultations and limited knowledge. Brief interventions that can be utilised in day-to-day practice are necessary to improve ways of managing PPS. This review aimed to establish (i) what training primary and secondary healthcare practitioners have undertaken to develop their clinical skills when working with PPS, (ii) what training techniques or theoretical models have been used within these interventions, and (iii) how effective was the training. METHOD A systematic literature search was undertaken on eight databases to identify professional development interventions for healthcare practitioners working with PPS, were of any study design, and at a minimum were single measure studies (i.e., training outcome alone). Studies were assessed using the Mixed Methods Appraisal Tool (MMAT) and narratively synthesised. RESULTS Despite high methodological heterogeneity across the six included studies, they all aimed to improve healthcare practitioners' communication skills through educational (theory, awareness, attitudes, assessment, treatment, and management of PPS) and experiential (role play) learning. CONCLUSIONS The review findings demonstrate that developing healthcare practitioners' communicative behaviours led to increased confidence and self-efficacy when working with PPS, which facilitated improved consultations and improvements on some patient outcomes. Barriers to the uptake of training programmes and implementation into daily clinical practice are discussed, including the need for PPS to be formally implemented into undergraduate teaching and post-qualification continuous professional development. TRIAL REGISTRATION This review was registered at PROSPERO [CRD42022315631] prior to the review starting.
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Affiliation(s)
- Stacie Thursby
- Northumbria Healthcare NHS Foundation Trust, North Tyneside General Hospital, North Shields, NE29 8NH, United Kingdom
| | - Lorelle Dismore
- Northumbria Healthcare NHS Foundation Trust, North Tyneside General Hospital, North Shields, NE29 8NH, United Kingdom
| | - Katherine Swainston
- Faculty of Medical Sciences, School of Psychology, Newcastle University, 4 Floor Dame Margaret Barbour Building, Wallace Street, Newcastle Upon Tyne, NE1 7RU, England.
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Pierson SR, Ngoue M, Lam R, Rajagopalan D, Ring D, Ramtin S. When Musculoskeletal Clinicians Respond to Empathetic Opportunities, do Patients Perceive Greater Empathy? Clin Orthop Relat Res 2023; 481:1771-1780. [PMID: 36853843 PMCID: PMC10427050 DOI: 10.1097/corr.0000000000002614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 01/05/2023] [Accepted: 02/06/2023] [Indexed: 03/01/2023]
Abstract
BACKGROUND Patient use of verbal and nonverbal communication to signal what is most important to them can be considered empathetic opportunities. Orthopaedic surgeons may have mixed feelings toward empathetic opportunities, on one hand wanting the patient to know that they care, and on the other hand fearing offense, prolonged visit duration, or discussions for which they feel ill prepared. Evidence that action about empathetic opportunities does not harm the patient's experience or appreciably prolong the visit could increase the use of these communication tactics with potential for improved experience and outcomes of care. QUESTIONS/PURPOSES Using transcripts from musculoskeletal specialty care visits in prior studies, we asked: (1) Are there factors, including clinician attentiveness to empathetic opportunities, associated with patient perception of clinician empathy? (2) Are there factors associated with the number of patient-initiated empathetic opportunities? (3) Are there factors associated with clinician acknowledgment of empathetic opportunities? (4) Are there factors associated with the frequency with which clinicians elicited empathetic opportunities? METHODS This study was a retrospective, secondary analysis of transcripts from prior studies of audio and video recordings of patient visits with musculoskeletal specialists. Three trained observers identified empathetic opportunities in 80% (209 of 261) of transcripts of adult patient musculoskeletal specialty care visits, with any uncertainties or disagreements resolved by discussion and a final decision by the senior author. Patient statements considered consistent with empathetic opportunities included relation of emotion, expression of worries or concerns, description of loss of valued activities or loss of important roles or identities, relation of a troubling psychologic or social event, and elaboration on daily life. Clinician-initiated empathetic opportunities were considered clinician inquiries about these factors. Clinician acknowledgment of empathetic opportunities included encouragement, affirmation or reassurance, or supportive statements. Participants completed post-visit surveys of perceived clinician empathy, symptoms of depression, and health anxiety. Factors associated with perceived clinician empathy, number of empathetic opportunities, clinician responses to these opportunities, and the frequency with which clinicians elicited empathetic opportunities were sought in bivariate and multivariable analyses. RESULTS After controlling for potentially confounding variables such as working status and pain self-efficacy scores in the multivariable analysis, no factors were associated with patient perception of clinician empathy, including attentiveness to empathetic opportunities. Patient-initiated empathetic opportunities were modestly associated with longer visit duration (correlation coefficient 0.037 [95% confidence interval 0.023 to 0.050]; p < 0.001). Clinician acknowledgment of empathetic opportunities was modestly associated with longer visit duration (correlation coefficient 0.06 [95% CI 0.03 to 0.09]; p < 0.001). Clinician-initiated empathetic opportunities were modestly associated with younger patient age (correlation coefficient -0.025 [95% CI -0.037 to -0.014]; p < 0.001) and strongly associated with one specific interviewing clinician as well as other clinicians (correlation coefficient -1.3 [95% CI -2.2 to -0.42]; p = 0.004 and -0.53 [95% CI -0.95 to -0.12]; p = 0.01). CONCLUSION Musculoskeletal specialists can respond to empathic opportunities without harming efficiency, throughput, or patient experience. CLINICAL RELEVANCE Given the evidence that patients prioritize feeling heard and understood, and evidence that a trusting patient-clinician relationship is protective and healthful, the results of this study can motivate specialists to train and practice effective communication tactics.
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Affiliation(s)
- S. Ryan Pierson
- The University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Marielle Ngoue
- The University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Ryan Lam
- The University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Dayal Rajagopalan
- The University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - David Ring
- The University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Sina Ramtin
- The University of Texas at Austin Dell Medical School, Austin, TX, USA
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Lesnewich LM, Hyde JK, McFarlin ML, Bolton RE, Bayley PJ, Chandler HK, Helmer DA, Phillips LA, Reinhard MJ, Santos SL, Stewart RS, McAndrew LM. 'She thought the same way I that I thought:' a qualitative study of patient-provider concordance among Gulf War Veterans with Gulf War Illness. Psychol Health 2023:1-19. [PMID: 37654203 DOI: 10.1080/08870446.2023.2248481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 07/15/2023] [Accepted: 08/10/2023] [Indexed: 09/02/2023]
Abstract
Objective: Medically unexplained symptoms (MUS), such as chronic fatigue syndrome, irritable bowel syndrome, and Gulf War Illness (GWI), are difficult to treat. Concordance-shared understanding between patient and provider about illness causes, course, and treatment-is an essential component of high-quality care for people with MUS. This qualitative paper focuses on the experiences of United States military Veterans living with GWI who have endured unique healthcare challenges. Methods & Measures: Qualitative interviews were conducted with 31 Veterans with GWI to explore factors that contribute to and detract from concordance with their Veteran Affairs (VA) healthcare providers. In addition to being seen by VA primary care, over half of participants also sought care at a War Related Illness and Injury Study Center, which specializes in post-deployment health. Deductive and inductive codes were used to organize the data, and themes were identified through iterative review of coded data. Results: Major themes associated with patient-provider concordance included validation of illness experiences, perceived provider expertise in GWI/MUS, and trust in providers. Invalidation, low provider expertise, and distrust detracted from concordance. Conclusion: These findings suggest providers can foster concordance with MUS patients by legitimizing patients' experiences, communicating knowledge about MUS, and establishing trust.
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Affiliation(s)
- Laura M Lesnewich
- War Related Illness and Injury Study Center (WRIISC), Veterans Affairs New Jersey Health Care System, East Orange, NJ, USA
| | - Justeen K Hyde
- Department of Medicine, Section General Internal Medicine, Boston University, Boston, MA, USA
- Center for Healthcare Organization and Implementation Research (CHOIR), Veterans Affairs Bedford Healthcare System, Bedford, MA, USA
| | | | - Rendelle E Bolton
- Center for Healthcare Organization and Implementation Research (CHOIR), Veterans Affairs Bedford Healthcare System, Bedford, MA, USA
- The Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - Peter J Bayley
- War Related Illness and Injury Study Center (WRIISC), Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Helena K Chandler
- War Related Illness and Injury Study Center (WRIISC), Veterans Affairs New Jersey Health Care System, East Orange, NJ, USA
| | - Drew A Helmer
- Center for Innovations in Quality, Effectiveness & Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - L Alison Phillips
- War Related Illness and Injury Study Center (WRIISC), Veterans Affairs New Jersey Health Care System, East Orange, NJ, USA
- Department of Psychology, Iowa State University, IA, USA
| | - Matthew J Reinhard
- War Related Illness and Injury Study Center (WRIISC), Washington DC Veterans Affairs Medical Center, Washington, DC, USA high-quality
| | - Susan L Santos
- War Related Illness and Injury Study Center (WRIISC), Veterans Affairs New Jersey Health Care System, East Orange, NJ, USA
| | - Rachel S Stewart
- War Related Illness and Injury Study Center (WRIISC), Washington DC Veterans Affairs Medical Center, Washington, DC, USA high-quality
| | - Lisa M McAndrew
- War Related Illness and Injury Study Center (WRIISC), Veterans Affairs New Jersey Health Care System, East Orange, NJ, USA
- University at Albany, State University of New York (SUNY), Albany, NY, USA
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Scott L, Dolan E, Baker N, Melia Y. Exploring attitudes of healthcare professionals towards those with fibromyalgia: A Q-methodological approach. Br J Pain 2023; 17:352-365. [PMID: 37538944 PMCID: PMC10395391 DOI: 10.1177/20494637231159502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023] Open
Abstract
Fibromyalgia remains a difficult condition to diagnose and treat. Research suggests that this leads to frustrating experiences for service users and healthcare professionals. This has led to negative healthcare professional attitudes towards working with those with fibromyalgia. The research to date reports negative attitudes and predominantly investigates attitudes of primary care physicians. This study explores the attitudes of a range of healthcare professionals towards those diagnosed with fibromyalgia. Using Q-methodology, 27 healthcare professionals completed a sorting task and questionnaire to prioritise statements relating to a range of different attitudes towards service users. All participants significantly loaded onto three factors that explained a total of 64% of the data variance. Factor 1 reflected the attitude 'Service users with fibromyalgia are no different to other service users and I enjoy working with them'. Factor 2 reflected the attitude 'Service users with fibromyalgia are inaccurate informants of their own condition due to lack of understanding of their condition and are not likely to engage in treatments'. Factor 3 reflected the attitude 'Service users with fibromyalgia are trustworthy with a lot of clinical problems [but I lack confidence in specialist skills to support them]'. Contrary to the current literature, there appears to be supportive attitudes from healthcare professionals towards service users diagnosed with fibromyalgia. Increased specialised training, clinical exposure to working with fibromyalgia and reflective practice spaces were identified as elements that could improve healthcare professional attitudes.
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Affiliation(s)
- Laura Scott
- Staffordshire University, Stoke-on-Trent, UK
| | - Eamon Dolan
- Tameside and Glossop Integrated Care NHS Foundation Trust, Ashton-under-Lyne, UK
| | - Nita Baker
- Midlands Partnership NHS Foundation Trust, Stafford, UK
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Mariman A, Vermeir P, Csabai M, Weiland A, Stegers-Jager K, Vermeir R, Vogelaers D. Education on medically unexplained symptoms: a systematic review with a focus on cultural diversity and migrants. Eur J Med Res 2023; 28:145. [PMID: 37013665 PMCID: PMC10069028 DOI: 10.1186/s40001-023-01105-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 03/20/2023] [Indexed: 04/05/2023] Open
Abstract
BACKGROUND Health care providers often struggle with the management of patients with medically unexplained symptoms (MUS), especially in case of a different ethnicity and/or cultural background. These challenges are insufficiently addressed in their training. OBJECTIVES A systematic review on education in the field of MUS in a diverse context to improve MUS healthcare provider-patient interaction focused on intercultural communication. METHODS Screening of PubMed, Web of Science, Cinahl and Cochrane Library on the keywords 'Medical unexplained (physical) symptoms (MUS)', 'Somatoform disorder', 'Functional syndrome', 'Diversity', 'Migrants', 'Ethnicity', 'Care models', 'Medical education', 'Communication skills', 'Health literacy'. RESULTS MUS patients, especially with a different ethnic background, often feel not understood or neglected. Health care providers experience feelings of helplessness, which may provoke medical shopping and resource consumption. Attitudes and perceptions from undergraduate trainees to senior physicians tend to be negative, impacting on the quality of the patient/health care provider relationship and subsequently on health outcomes, patient satisfaction and therapeutic adherence. Current undergraduate, graduate and postgraduate education and training does not prepare health care providers for diagnosing and managing MUS patients in a diverse context. A continuum of training is necessary to achieve a long term and lasting change in attitudes towards these patients and trainers play a key role in this process. Hence, education should pay attention to MUS, requiring a specific competency profile and training, taken into account the variety in patients' cultural backgrounds. CONCLUSIONS This systematic review identified significant gaps and shortcomings in education on MUS in a diverse context. These need to be addressed to improve outcomes.
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Affiliation(s)
- An Mariman
- Faculty of Medicine and Healthcare Sciences, Ghent University, Ghent, Belgium
- Centre for Integrative Medicine, Ghent University Hospital, Ghent, Belgium
| | - Peter Vermeir
- Faculty of Medicine and Healthcare Sciences, Ghent University, Ghent, Belgium.
- Dean's Office of the Faculty of Medicine and Healthcare Sciences, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium.
| | - Marta Csabai
- Institute of Psychology, Károli Gáspár University of the Reformed Church, Budapest, Hungary
| | - Anne Weiland
- Department of General Practice, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Karen Stegers-Jager
- Institute of Medical Education Research, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Ruben Vermeir
- Faculty of Medicine and Healthcare Sciences, Ghent University, Ghent, Belgium
| | - Dirk Vogelaers
- Faculty of Medicine and Healthcare Sciences, Ghent University, Ghent, Belgium
- Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent, Belgium
- Department of General Internal Medicine, AZ Delta, Roeselare, Belgium
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6
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Selinheimo S, Keinonen K, Vuokko A, Liesto S, Sainio M, Lappalainen R, Paunio T. A randomized controlled trial protocol for persistent physical symptoms associated with indoor environment or chronic fatigue: Effectiveness of video-based functional case conceptualization and web-program for improving quality of life. Front Psychol 2023; 13:923532. [PMID: 36687807 PMCID: PMC9853541 DOI: 10.3389/fpsyg.2022.923532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 12/15/2022] [Indexed: 01/07/2023] Open
Abstract
Introduction Persistent physical symptoms (PPS) refer to symptoms that cannot be fully explained by structural bodily pathology or by environmental factors. Their impact on daily functioning varies from mild to severe disability. So far, evidence-based treatments for PPS have resulted in only small to moderate effects. Treatment protocols with a stronger orientation toward personalized approaches are needed to improve the efficacy and applicability of treatment. In this study, we aim to assess the effect of an online individual case conceptualization with web-based program for PPS. This study is conducted among two focus groups: patients with indoor air-related symptoms and patients with chronic fatigue syndrome. Methods and analyses Using a randomized controlled design (RCT) with two parallel groups in a 1:1 ratio, we will compare individual video-based case conceptualization with a web-based program based on Acceptance and Commitment Therapy (ACT), combined with treatment as usual, with treatment as usual only. The web-based program consists of ten modules, each lasting 1 week and including training. The planned sample size is 124 eligible patients without attrition. The primary outcome will be the health-related quality of life as measured by the 15D questionnaire. The secondary outcome measures will include questionnaires on psychiatric and physical symptoms, illness perceptions, psychological flexibility, and work ability. We will also use national registers to obtain information on the use of healthcare and social benefits to complete patient-reported outcomes. Data collection began in August 2020 and will continue until 2023. Discussion This trial will provide information on the effects and usefulness of an online administrated individual case conceptualization and an ACT-based web-program on PPS. Ethics and dissemination The Ethics Committee of the Hospital District of Helsinki and Uusimaa, Finland, has granted approval for the study. The results will be published in peer-reviewed journals. Clinical Trial Registration Clinicaltrials.gov, identifier NCT04532827 preresults.
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Affiliation(s)
- Sanna Selinheimo
- Finnish Institute of Occupational Health, Helsinki, Finland,*Correspondence: Sanna Selinheimo,
| | | | - Aki Vuokko
- Finnish Institute of Occupational Health, Helsinki, Finland
| | - Sanna Liesto
- Outpatient Clinic for Functional Disorders, HUS Helsinki University Hospital, Helsinki, Finland
| | - Markku Sainio
- Finnish Institute of Occupational Health, Helsinki, Finland,Outpatient Clinic for Functional Disorders, HUS Helsinki University Hospital, Helsinki, Finland
| | - Raimo Lappalainen
- Department of Psychology, University of Jyväskylä, Jyväskylä, Finland
| | - Tiina Paunio
- Finnish Institute of Occupational Health, Helsinki, Finland,Department of Psychiatry and SleepWell Research Program, Faculty of Medicine, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland
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Mooney C, White DA, Dawson J, Deary V, Fryer K, Greco M, Horspool M, Neilson A, Rowlands G, Sanders T, Thomas RE, Thomas S, Waheed W, Burton CD. Study protocol for the Multiple Symptoms Study 3: a pragmatic, randomised controlled trial of a clinic for patients with persistent (medically unexplained) physical symptoms. BMJ Open 2022; 12:e066511. [PMID: 36379663 PMCID: PMC9668014 DOI: 10.1136/bmjopen-2022-066511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Persistent physical symptoms (which cannot be adequately attributed to physical disease) affect around 1 million people (2% of adults) in the UK. They affect patients' quality of life and account for at least one third of referrals from General Practitioners (GPs) to specialists. These referrals give patients little benefit but have a real cost to health services time and diagnostic resources. The symptoms clinic has been designed to help people make sense of persistent physical symptoms (especially if medical tests have been negative) and to reduce the impact of symptoms on daily life. METHODS AND ANALYSIS This pragmatic, multicentre, randomised controlled trial will assess the clinical and cost-effectiveness of the symptoms clinic intervention plus usual care compared with usual care alone. Patients were identified through GP searches and mail-outs and recruited by the central research team. 354 participants were recruited and individually randomised (1:1). The primary outcome is the self-reported Physical Health Questionnaire-15 at 52 weeks postrandomisation. Secondary outcome measures include the EuroQol 5 dimension 5 level and healthcare resource use. Outcome measures will also be collected at 13 and 26 weeks postrandomisation. A process evaluation will be conducted including consultation content analysis and interviews with participants and key stakeholders. ETHICS AND DISSEMINATION Ethics approval has been obtained via Greater Manchester Central Research Ethics Committee (Reference 18/NW/0422). The results of the trial will be submitted for publication in peer-reviewed journals, presented at relevant conferences and disseminated to trial participants and patient interest groups. TRIAL REGISTRATION NUMBER ISRCTN57050216.
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Affiliation(s)
- Cara Mooney
- Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - David Alexander White
- Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Jeremy Dawson
- Sheffield University Management School, University of Sheffield, Sheffield, UK
| | | | - Kate Fryer
- Academic Unit of Primary Medical Care, The University of Sheffield, Sheffield, UK
| | - Monica Greco
- Department of Sociology, Goldsmiths University of London, London, UK
| | | | - Aileen Neilson
- Usher Institute, University of Edinburgh Division of Medical and Radiological Sciences, Edinburgh, UK
| | - Gillian Rowlands
- Population Health Sciences Institute, Newcastle University Institute for Health and Society, Newcastle upon Tyne, UK
| | - Tom Sanders
- Social Work, Education and Community Wellbeing, Northumbria University, Newcastle upon Tyne, UK
| | - Ruth E Thomas
- Centre for Healthcare Randomised Trials (CHaRT) Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Steve Thomas
- NHS Sheffield Clinical Commissioning Group, Sheffield, UK
| | - Waquas Waheed
- Centre for Primary Care, University of Manchester, Manchester, UK
| | - Christopher D Burton
- Academic Unit of Primary Medical Care, The University of Sheffield, Sheffield, UK
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Plagg B, Engl A, Piccoliori G, Atz H, Becker U, Kiem J, Barbieri V, Eisendle K, Wiedermann CJ, Elsen SU, Lorenz WA. Mutual Role Expectations by Patients and General Practitioners-A Mixed Methods Study on Complementarity. Healthcare (Basel) 2022; 10:healthcare10102101. [PMID: 36292548 PMCID: PMC9602485 DOI: 10.3390/healthcare10102101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 10/15/2022] [Accepted: 10/17/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Changes in public attitudes toward “authorities” in general, as well as shifts in medical practice toward participative models of diagnosis and treatment, imply fundamental transformations in the patient−doctor relationship. However, consistency in reciprocal role expectations cannot be assumed, and this study reveals significant discrepancies in attitudes and behaviors in primary health consultations. Methods: We conducted a study in the tri-lingual northeastern Italian region of South Tyrol to determine whether perceptions of the patient’s role were congruent or differed. In a mixed method approach, the quantitative research part consisted of a survey with 34 identical questions for general practitioners (n = 109) and adult primary care patients (n = 506) on verbal communication, self-initiative and health literacy, interpersonal and social qualities of the patient−physician relationship, and formal aspects of the consultation. Patients were interviewed via telephone, and general practitioners responded online. In the qualitative part, 26 semi-structured in-depth interviews were conducted with the patients and analyzed. Results: General practitioners considered patients’ communicative efforts (p < 0.001), self-initiative (p < 0.001), compliance (p = 0.0026), and openness regarding psychosocial issues (p < 0.001) to be significantly more important, whereas patients showed a tendency to give increased importance to formal aspects such as politeness and hygiene (p < 0.001). Perception of the patient’s role differed significantly between the Italian and German linguistic groups. Conclusions: Patients and general practitioners differ in their understanding of patients’ roles. These data suggest that a considerable proportion of the population lacks a clear and tangible idea of the active role they could play in consultations. Targeted information on the identified aspects of patient−provider communication may facilitate participatory behavior and positively impact the longitudinal quality of the patient−general practitioner relationship.
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Affiliation(s)
- Barbara Plagg
- Institute of General Practice and Public Health, College for Health Care Professions—Claudiana, 39100 Bolzano, Italy
- Faculty of Education, Free University of Bolzano, 39100 Bolzano, Italy
- Correspondence:
| | - Adolf Engl
- Institute of General Practice and Public Health, College for Health Care Professions—Claudiana, 39100 Bolzano, Italy
| | - Giuliano Piccoliori
- Institute of General Practice and Public Health, College for Health Care Professions—Claudiana, 39100 Bolzano, Italy
| | - Hermann Atz
- Apollis—Institute for Social Research and Opinion Polling, 39100 Bolzano, Italy
| | - Ulrich Becker
- Apollis—Institute for Social Research and Opinion Polling, 39100 Bolzano, Italy
| | - Johann Kiem
- Faculty of Education, Free University of Bolzano, 39100 Bolzano, Italy
| | - Verena Barbieri
- Institute of General Practice and Public Health, College for Health Care Professions—Claudiana, 39100 Bolzano, Italy
| | - Klaus Eisendle
- Institute of General Practice and Public Health, College for Health Care Professions—Claudiana, 39100 Bolzano, Italy
| | - Christian Josef Wiedermann
- Institute of General Practice and Public Health, College for Health Care Professions—Claudiana, 39100 Bolzano, Italy
- Department of Public Health, Medical Decision Making and HTA, University of Health Sciences, Medical Informatics and Technology—Tyrol, 6060 Hall in Tyrol, Austria
| | | | - Walter August Lorenz
- Faculty of Education, Free University of Bolzano, 39100 Bolzano, Italy
- Department of Applied Social Sciences, Faculty of Humanities, Charles University, 18200 Prague, Czech Republic
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9
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Førde S, Herner LB, Helland IB, Diseth TH. The Biopsychosocial Model in Paediatric Clinical Practice; - a Multidisciplinary Approach to Somatic Symptom Disorders. Acta Paediatr 2022; 111:2115-2124. [PMID: 36000514 DOI: 10.1111/apa.16517] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 07/26/2022] [Accepted: 08/18/2022] [Indexed: 11/27/2022]
Abstract
AIM The paper aims to show how the biopsychosocial (BPS) model can be applied as a clinical method and guide the assessment and treatment of children and adolescents with Somatic Symptom Disorders (SSD). METHODS Based on relevant literature and our clinical work with children and adolescents with SSD we have developed a method to ensure a structured, interdisciplinary examination of biological, psychological and social factors, operationalising the BPS model into a clinical method. RESULTS The BPS model renders assessment and treatment of complex conditions as a basis for evaluating phenomena not confined by diagnostic tools, but still includes all information from these tools. It requires an interdisciplinary approach, giving individual patient and caregivers a central position. A thorough medical examination is required as a starting point for assessments. Good results rest upon a shared understanding between patient, caregivers and professionals. CONCLUSIONS "Biopsychosocial" is often claimed as a basis for clinical work with complex cases, medical, functional, and psychiatric, but scarcely with a corresponding BPS method or practice. The BPS method should guide further development of holistic, multidisciplinary health care on all levels, in order to assess and help children and adolescents with SSD.
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Affiliation(s)
- S Førde
- Department of Child and Adolescent Mental Health in Hospitals, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Norway
| | - L Breen Herner
- Department of Child and Adolescent Mental Health in Hospitals, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Norway
| | - I B Helland
- Department of Clinical Neuroscience for Children, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Norway
| | - T H Diseth
- Department of Child and Adolescent Mental Health in Hospitals, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Norway
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Houwen J, de Bont OA, Lucassen PL, Rosmalen JGM, Stappers HW, Olde Hartman TC, van Dulmen S. Development of a blended communication training program for managing medically unexplained symptoms in primary care using the intervention mapping approach. PATIENT EDUCATION AND COUNSELING 2022; 105:1305-1316. [PMID: 34561144 DOI: 10.1016/j.pec.2021.09.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 07/29/2021] [Accepted: 09/08/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND General practice (GP) training in how to communicate with patients with medically unexplained symptoms (MUS) is limited. OBJECTIVE Development, implementation and evaluation of an evidence-based communication training program for GP residents focused on patients with MUS in primary care. METHODS We used the intervention mapping (IM) framework to systematically develop the MUS training program. We conducted a needs assessment to formulate change objectives and identified teaching methods for a MUS communication training program. Next, we developed, implemented and evaluated the training program with 46 residents by assessing their self-efficacy and by exploring their experiences with the training. RESULTS The resulting program is a blended training with an online course and two training days. After attending the training program, GP residents reported significantly higher self-efficacy for communication with patients with MUS at four weeks follow up compared to baseline. Furthermore, GP residents experienced the training program as useful and valued the combination of the online course and training days. CONCLUSION AND PRACTICE IMPLICATIONS We developed an evidence-based communication training program for the management of patients with MUS in primary care. Future research should examine the effect of the training on GP residents' communication skills in MUS consultations in daily practice.
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Affiliation(s)
- Juul Houwen
- Radboud university medical center, Radboud Institute for Health Sciences, Department of Primary and Community Care, Nijmegen, The Netherlands.
| | - Olga A de Bont
- Radboud university medical center, Radboud Institute for Health Sciences, Department of Primary and Community Care, Nijmegen, The Netherlands
| | - Peter Lbj Lucassen
- Radboud university medical center, Radboud Institute for Health Sciences, Department of Primary and Community Care, Nijmegen, The Netherlands
| | - Judith G M Rosmalen
- University Medical Center Groningen, Interdisciplinary Center for Psychopathology and Emotion Regulation, Groningen, the Netherlands
| | - Hugo W Stappers
- Radboud university medical center, Radboud Institute for Health Sciences, Department of Primary and Community Care, Nijmegen, The Netherlands
| | - Tim C Olde Hartman
- Radboud university medical center, Radboud Institute for Health Sciences, Department of Primary and Community Care, Nijmegen, The Netherlands
| | - Sandra van Dulmen
- Radboud university medical center, Radboud Institute for Health Sciences, Department of Primary and Community Care, Nijmegen, The Netherlands; Nivel (Netherlands institute for health services research), Utrecht, The Netherlands
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11
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Stortenbeker I, Stommel W, Olde Hartman T, van Dulmen S, Das E. How General Practitioners Raise Psychosocial Concerns as a Potential Cause of Medically Unexplained Symptoms: A Conversation Analysis. HEALTH COMMUNICATION 2022; 37:696-707. [PMID: 33441007 DOI: 10.1080/10410236.2020.1864888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
A common explanation for medically unexplained symptoms (MUS) relates patients' psychosocial concerns to their physical ailments. The present study used conversation analysis to examine how general practitioners (GPs) ascribe psychosocial causes to patients' unexplained symptoms during medical consultations. Our data consisted of 36 recorded consultations from Dutch general practice. We found that GPs raise psychosocial concerns as a potential cause of MUS in 14 consultations, either captured in 1) history-taking questions, or 2) diagnostic explanations. Whereas questions invited patient ideas, explanations did not make relevant patient responses in adjacent turns and subordinated patients' knowledge in symptom experiences to the GP's medical expertise. By questioning patients whether their symptoms may have psychosocial causes GPs enabled symptom explanations to be constructed collaboratively. Furthermore, additional data exploration showed that GPs lay ground for psychosocial ascriptions by first introducing psychosocial concerns as a consequence rather than a cause of complaints. Such preliminary activities allowed GPs to initiate rather delicate psychosocial ascriptions later in the consultation.
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Affiliation(s)
| | | | - Tim Olde Hartman
- Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute for Health Sciences
| | - Sandra van Dulmen
- Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute for Health Sciences
- NIVEL (Netherlands Institute for Health Services Research)
- Faculty of Health and Social Sciences, University of South-Eastern Norway
| | - Enny Das
- Centre for Language Studies, Radboud University
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12
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Ali SA, Ansari WE. Is tele-diagnosis of dental conditions reliable during COVID-19 pandemic? Agreement between tentative diagnosis via synchronous audioconferencing and definitive clinical diagnosis. J Dent 2022; 122:104144. [PMID: 35487287 PMCID: PMC9040478 DOI: 10.1016/j.jdent.2022.104144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 03/23/2022] [Accepted: 04/21/2022] [Indexed: 11/28/2022] Open
Abstract
Objectives To assess the reliability of synchronous audioconferencing teledentistry (TD) in making tentative diagnosis compared to definitive clinical face-to-face (CFTF) diagnosis; and whether agreement was influenced by dentist's experience, caller-patient relationship, and time of call. Methods All patients calling the TD hotline during COVID-19 pandemic, triaged as emergency/ urgent and referred for CFTF care were included (N=191). Hotline dentists triaged the calls, made tentative audio-dentistry (AD) diagnosis, while dentists at point of referral made the definitive CFTF diagnosis. Cohen's weighted kappa (κ) assessed the extent of agreement between AD vs CFTF diagnosis. Results There was significantly very good pair-wise agreement (κ = 0.853, P < 0.0001) between AD and CFTF diagnosis. AD diagnosis of pulpitis and periodontitis exhibited the most frequent disagreements. Tele-dentists with ≥ 20 years’ experience exhibited the highest level of agreement (κ =0.872, P < 0.0001). There was perfect agreement when mothers mediated the call (κ = 1, P < 0.0001), and very good agreement for calls received between 7 am-2 pm (κ = 0.880, P < 0.0001) compared to calls received between 2-10 pm (κ = 0.793, P < 0.0001). Conclusions Remote tentative diagnosis using AD is safe and reliable. Reliability was generally very good but varied by dentist's experience, caller-patient relationship, and time of call. Clinical significance The findings suggest that using AD in the home environment is safe and reliable, deploying providers with variable years of experience. The findings have generalizability potential to a variety of similar circumstances, healthcare settings and epi/pandemic situations.
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Affiliation(s)
- Shaymaa Abdulreda Ali
- Unit of Orthodontics, Hamad Dental Center, Hamad Medical Corporation, Doha, Qatar; University of Aberdeen, King's College, Aberdeen, AB24 3FX, UK.
| | - Walid El Ansari
- Department of Surgery, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar; College of Medicine, Qatar University, Doha, Qatar; Weill Cornell Medicine, Qatar, Doha, Qatar; School of Health and Education, University of Skovde, Skovde, Sweden.
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13
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Le TL, Mylopoulos M, Bearss E, Geist R, Maunder R. Multiple symptoms and health anxiety in primary care: a qualitative study of tensions and collaboration between patients and family physicians. BMJ Open 2022; 12:e050716. [PMID: 35428616 PMCID: PMC9014049 DOI: 10.1136/bmjopen-2021-050716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Patients with multiple, persistent symptoms and health anxiety often report poor health outcomes. Patients who are difficult to reassure are challenging for family physicians. The therapeutic alliance between a physician and a patient can influence the prognosis of these patients. Optimising the quality of the physician-patient alliance may depend on a better understanding of the interpersonal processes that influence this relationship. OBJECTIVE The purpose of this study is to understand the experiences of patients who experience multiple persistent symptoms or high health anxiety and their physicians when they interact. DESIGN, PARTICIPANTS AND SETTING A qualitative study was conducted using grounded theory of 18 patients, purposively sampled to select patients who reported high physical symptom severity, high health anxiety or both, and 7 family physicians in the same clinic. This study was conducted at a family medicine clinic in a teaching hospital. RESULTS A model of interpersonal tension and collaboration for patients and physicians in primary care was developed. Helpful attitudes and actions as well as troublesome topics influence crucial dilemmas between patients and physicians. These dilemmas include if patients feel heard and validated and the alignment of goals and mutual respect of expertise and experience between patients and physicians. These experiences contribute to a constructive collaboration and in turn positive outcomes. CONCLUSIONS This model of patient-physician interaction may facilitate providers to turn their attention away from the contentious topics and towards actions and attitudes that promote beneficial outcomes.
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Affiliation(s)
- Thao Lan Le
- Department of Psychiatry, Sinai Health System, Toronto, Ontario, Canada
| | - Maria Mylopoulos
- Wilson Centre, HoPingKong Centre for Excellence in Education and Practice, University Health Network, Toronto, Ontario, Canada
| | - Erin Bearss
- Mount Sinai Academic Family Health Team, Sinai Health System, Toronto, Ontario, Canada
| | - Rose Geist
- Department of Psychiatry, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Robert Maunder
- Department of Psychiatry, Sinai Health System, Toronto, Ontario, Canada
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14
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Haun MW, Tönnies J, Graue L, Hartmann M, Wensing M, Szecsenyi J, Wild B, Friederich HC. Mental health specialist video consultations for patients with somatic symptom disorder in primary care: protocol for a randomised feasibility trial (the VISION trial). BMJ Open 2022; 12:e058150. [PMID: 35410935 PMCID: PMC9003599 DOI: 10.1136/bmjopen-2021-058150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION General practitioners (GP) report increasing difficulties in referring patients with somatic symptom disorder (SSD) in specialised psychosocial care. Barriers are structural conditions of the respective healthcare system and patients' reservations against receiving specialised psychosocial care. As patients with SSD often predominantly assume somatic influencing factors for the development and maintenance of their somatic complaints, close collaboration between the GP and mental health specialist (MHS) seems particularly important. Integrating internet-based video consultations by remotely located MHS and primary care can improve effective treatment of patients with SSD by overcoming structural barriers and provide low-threshold and timely care. The aim of this randomised controlled feasibility trial is to investigate the feasibility of implementing MHS video consultations in primary care practices. METHODS AND ANALYSIS Fifty primary care patients with SSD will be individually randomised in two groups receiving either enhanced treatment as usual as provided by their GP (control group) or two versus five video consultations conducted by an MHS additionally to enhanced treatment as usual. The video consultations focus on (a) diagnostic clarification, (b) the development of a biopsychosocial disorder model, and (c) development of a treatment plan against the background of a stepped-care algorithm based on clinical outcomes. We will investigate the following outcomes: effectiveness of the recruitment strategies, patient acceptance of randomisation, practicability of the technical and logistical processes related to implementing video consultations in the practices' workflows, feasibility of the data collection and clinical parameters. ETHICS AND DISSEMINATION This trial has undergone ethical scrutiny and has been approved by the Medical Faculty of the University of Heidelberg Ethics Committee (S-620/2021). The findings will be disseminated to the research community through presentations at conferences and publications in scientific journals. This feasibility trial will prepare the ground for a large-scale, fully powered randomised controlled trial. TRIAL REGISTRATION NUMBER DRKS00026075.
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Affiliation(s)
- Markus W Haun
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Heidelberg, Germany
| | - Justus Tönnies
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Heidelberg, Germany
| | - Leike Graue
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Heidelberg, Germany
| | - Mechthild Hartmann
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Heidelberg, Germany
| | - Michel Wensing
- Department of General Practice and Health Services Research, Heidelberg University, Heidelberg, Germany
| | - Joachim Szecsenyi
- Department of General Practice and Health Services Research, Heidelberg University, Heidelberg, Germany
| | - Beate Wild
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Heidelberg, Germany
| | - Hans-Christoph Friederich
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Heidelberg, Germany
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15
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Novais F, Ganança L, Barbosa M, Telles-Correia D. Communication skills in psychiatry for undergraduate students: A scoping review. Front Psychiatry 2022; 13:972703. [PMID: 36032255 PMCID: PMC9402997 DOI: 10.3389/fpsyt.2022.972703] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 07/21/2022] [Indexed: 11/25/2022] Open
Abstract
Communication skills are paramount in all areas of medicine but particularly in psychiatry due to the challenges posed by mental health patients and the essential role of communication from diagnosis to treatment. Despite the prevalence of psychiatric disorders in different medical specialties, particularly in primary care settings, communication skills in psychiatry and their training are not well studied and are often not included in the undergraduate medical curriculum. Our paper explores the relevance of teaching communication competencies in psychiatry for undergraduate medical students. Our work focused on reviewing the methods for teaching communication skills to undergraduate students in Psychiatry. Eleven studies were selected to be included in this review. We found considerable heterogeneity among methods for teaching communication skills but also some common elements such as the use of simulated patients and providing feedback. This review has identified two models: the Calgary-Cambridge interview model and the Kolb cycle-based model. However, most studies still lack a theoretical background model. We believe that the inclusion of communication skills training in medical curricula is fundamental to teaching medical students general communication skills but also specific training on establishing adequate communication with psychiatric patients. However, more research is needed to determine the best method for training but also regarding its translation to patient care and cost-effectiveness.
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Affiliation(s)
- Filipa Novais
- Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.,Centro Hospitalar Universitário Lisboa Norte, Santa Maria Hospital, Lisbon, Portugal.,ISAMB - Instituto de Saúde Ambiental - Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Licínia Ganança
- Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.,Centro Hospitalar Universitário Lisboa Norte, Santa Maria Hospital, Lisbon, Portugal
| | - Miguel Barbosa
- Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.,Faculdade de Psicologia, Universidade de Lisboa, Lisboa, Portugal
| | - Diogo Telles-Correia
- Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.,ISAMB - Instituto de Saúde Ambiental - Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
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16
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Vermeir P, Mariman A, Lucza L, Sallay V, Weiland A, Stegers‐Jager KM, Vogelaers D. Epidemiology and organisation of care in medically unexplained symptoms: A systematic review with a focus on cultural diversity and migrants. Int J Clin Pract 2021; 75:e14855. [PMID: 34516726 PMCID: PMC9285020 DOI: 10.1111/ijcp.14855] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 09/10/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Since the pathophysiology of medically unexplained symptoms (MUS) remains unclear, healthcare providers often struggle with these patients, especially with a different ethnic and/or cultural background. These challenges are insufficiently addressed in their training and in the organisation of care. AIM To improve healthcare provider-patient interaction focused on MUS patients in general and in ethnic minorities and refugees in particular through a systematic review of syndromal definitions and epidemiology and organisation of care of MUS patients. METHODS Screening of PubMed, Web of Science, Cinahl and Cochrane Library on the keywords 'Medical unexplained (physical) symptoms (MUPS)', 'Somatoform disorder', 'Functional syndrome', 'Diversity', 'Migrants', 'Ethnicity', 'Care models', 'Medical education', 'Communication skills', 'Health literacy'. RESULTS Different case definitions result in markedly different epidemiological estimates for MUS patients. Nevertheless, they are prevalent in a wide range of healthcare settings. Literature offers evidence of the effectiveness of structural frameworks in approaching MUS patients. Organisation of MUS care needs to transcend different levels of care: specialist tertiary and secondary care and primary care involving different qualifications of caregivers need to be aligned. CONCLUSION The systematic review identified significant gaps and shortcomings in organisation of care. These need to be addressed in order to improve outcomes.
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Affiliation(s)
- Peter Vermeir
- Ghent University/Ghent University HospitalGentBelgium
| | - An Mariman
- Ghent University/Ghent University HospitalGentBelgium
| | - Lilla Lucza
- Doctoral School of EducationUniversity of SzegedSzegedHungary
| | - Viola Sallay
- Institute of PsychologyUniversity of SzegedSzegedHungary
| | - Anne Weiland
- Erasmus MC University Medical CenterRotterdamThe Netherlands
| | | | - Dirk Vogelaers
- Ghent University/Ghent University HospitalGentBelgium
- AZ Delta RoeselareRoeselareBelgium
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17
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Barriers and facilitators to implementing interventions for medically unexplained symptoms in primary and secondary care: A systematic review. Gen Hosp Psychiatry 2021; 73:101-113. [PMID: 34763113 DOI: 10.1016/j.genhosppsych.2021.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/20/2021] [Accepted: 10/26/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To integrate existing literature on barriers and facilitators to implementing interventions for Medically Unexplained Symptoms (MUS) in primary and secondary care. METHOD Systematic review following PRISMA guidelines. A search of PsychINFO/Pubmed/Web of Science was performed to select studies focusing on MUS-interventions and implementation. All included papers were checked for quality and bias. A narrative synthesis approach was used to describe the included papers by implementation level, ranging from the specific intervention to the broader economic/political context. RESULTS 20 (quantitative/qualitative/mixed design) papers were included, but the quantitative studies especially, lacked methodological quality, with possible publication bias as a result. Results showed that the intervention needs to be acceptable and in line with daily practice routines. The professional's attitude and skills are important for implementation success, as well as for overcoming problems in the professional-patient interaction. If patients stick to finding a somatic cause, this hampers implementation. A lack of time is a frequently mentioned barrier at the organizational level. Barriers/facilitators at the social context level and at the economic/political level were barely reported on in the included papers. CONCLUSION Results were integrated into an existing implementation model, as an example of how MUS-interventions can be successfully implemented in practice.
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18
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Bloeser K, McCarron KK, Merker VL, Hyde J, Bolton RE, Anastasides N, Petrakis BA, Helmer DA, Santos S, Litke D, Pigeon WR, McAndrew LM. "Because the country, it seems though, has turned their back on me": Experiences of institutional betrayal among veterans living with Gulf War Illness. Soc Sci Med 2021; 284:114211. [PMID: 34271400 DOI: 10.1016/j.socscimed.2021.114211] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 05/24/2021] [Accepted: 07/03/2021] [Indexed: 10/20/2022]
Abstract
People living with medically unexplained symptoms (MUS) often have poor quality of life and health outcomes. Many struggle to engage with and trust in healthcare systems. This qualitative study examined how experiences with institutions influence perceptions of medical care for MUS by applying the theoretical framework of institutional betrayal to narratives of U.S. military Veterans living with Gulf War Illness (GWI). Institutional betrayal refers to situations in which the institutions people depend upon for safety and well-being cause them harm. Experiences of institutional betrayal both during active military service and when first seeking treatment appeared to shape perceptions of healthcare in this sample. Veterans expressed the belief that the military failed to protect them from environmental exposures. Veterans' concerns regarding subsequent quality of healthcare were intrinsically linked to a belief that, despite official documentation to the contrary, the predominant paradigm of both the U.S. Department of Defense and the U.S. Department of Veterans Affairs (VA) is that GWI does not exist. Veterans reported that providers are not adequately trained on treatment of GWI and do not believe Veterans' descriptions of their illness. Veterans reported taking up self-advocacy, doing their own research on their condition, and resigning themselves to decrease engagement with VA healthcare or seek non-VA care. The study's findings suggest institutional level factors have a profound impact on perceptions of care and the patient-provider relationship. Future research and policy aimed at improving healthcare for people living with MUS should consider the concept of institutional betrayal.
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Affiliation(s)
- Katharine Bloeser
- The War Related Illness and Injury Study Center, The VA New Jersey Health Care System, 385 Tremont Ave. Mail Stop 129, 11th Floor, East Orange, NJ, 07018, USA; Silberman School of Social Work at Hunter College, The City University of New York, NY, USA.
| | - Kelly K McCarron
- The War Related Illness and Injury Study Center, The VA New Jersey Health Care System, 385 Tremont Ave. Mail Stop 129, 11th Floor, East Orange, NJ, 07018, USA
| | - Vanessa L Merker
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, MA, USA
| | - Justeen Hyde
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, MA, USA; Boston University, Department of Medicine, Section General Internal Medicine, Boston, MA, USA
| | - Rendelle E Bolton
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, MA, USA; Brandeis University, Heller School for Social Policy and Management, MA, USA
| | - Nicole Anastasides
- The War Related Illness and Injury Study Center, The VA New Jersey Health Care System, 385 Tremont Ave. Mail Stop 129, 11th Floor, East Orange, NJ, 07018, USA
| | - Beth Ann Petrakis
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, MA, USA
| | - Drew A Helmer
- VA Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Houston, TX, USA
| | - Susan Santos
- The War Related Illness and Injury Study Center, The VA New Jersey Health Care System, 385 Tremont Ave. Mail Stop 129, 11th Floor, East Orange, NJ, 07018, USA
| | - David Litke
- The War Related Illness and Injury Study Center, The VA New Jersey Health Care System, 385 Tremont Ave. Mail Stop 129, 11th Floor, East Orange, NJ, 07018, USA
| | - Wilfred R Pigeon
- VA Center of Excellence for Suicide Prevention, Canandaigua, NY, USA; Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA
| | - Lisa M McAndrew
- The War Related Illness and Injury Study Center, The VA New Jersey Health Care System, 385 Tremont Ave. Mail Stop 129, 11th Floor, East Orange, NJ, 07018, USA; Department of Educational and Counseling Psychology, University at Albany, State University of New York, NY, USA
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19
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Kealy D, Rice SM, Chartier GB, Cox DW. Investigating Attachment Insecurity and Somatosensory Amplification, and the Mediating Role of Interpersonal Problems. EUROPEAN JOURNAL OF HEALTH PSYCHOLOGY 2021. [DOI: 10.1027/2512-8442/a000078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Abstract. Background: Somatosensory amplification involves perceptual sensitivity to and cognitive-affective interpretation of bodily sensations and external stimuli, contributing to heightened experiences of somatic symptoms. However, little is known about somatosensory amplification in relation to vulnerabilities such as attachment insecurity. Aims: The present study investigated the link between attachment insecurity and somatosensory amplification, including the mediating role of dysfunctional interpersonal behaviors. Method: A sample of 245 adult community members completed the Somatosensory Amplification Scale, Generalized Anxiety Disorder Scale, and abbreviated versions of the Experiences in Close Relationships scale and Inventory of Interpersonal Problems. Correlational and regression analyses were used to examine relations among study variables, including a hypothesized parallel mediation model. Results: Somatosensory amplification was significantly associated with attachment anxiety, but not attachment avoidance. Regression analyses, controlling for general anxiety symptoms and gender, found that interpersonal sensitivity (but not aggression or ambivalence) mediated the link between attachment anxiety and somatosensory amplification. Limitations: Study limitations include the use of cross-sectional data and a non-clinical sample. Conclusion: The findings indicate that somatosensory amplification may be related to individuals’ attachment anxiety, through the mediating effect of interpersonal sensitivity problems.
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Affiliation(s)
- David Kealy
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Simon M. Rice
- Orygen, Parkville, Melbourne, Australia
- Centre for Youth Mental Health, University of Melbourne, Australia
| | | | - Daniel W. Cox
- Counselling Psychology Program, University of British Columbia, Vancouver, BC, Canada
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20
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Polakovská L, Řiháček T. What is it like to live with medically unexplained physical symptoms? A qualitative meta-summary. Psychol Health 2021; 37:580-596. [PMID: 33872098 DOI: 10.1080/08870446.2021.1901900] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Medically unexplained physical symptoms (MUPS) are a frequent phenomenon. Understanding adults and adolescents' lived experience with MUPS is essential for providing adequate care, yet a rigorous synthesis of existing studies is missing. Objective: This study aimed to summarize findings from primary qualitative studies focused on adults' and adolescents' experience of living with MUPS. Design: Qualitative studies were searched in the PsycINFO, PsycARTICLES, and Medline databases and manually. A total of 23 resources met the inclusion criteria and were subjected to a qualitative meta-summary. Results: Eight themes were found across the set of primary studies, namely, the need to feel understood, struggling with isolation, 'sense of self' in strain, facing uncertainty, searching for explanations, ambivalence about diagnosis, disappointed by healthcare, and active coping. Conclusion: The eight themes represent the core struggles adults' and adolescents' with MUPS face in their lives, psychologically and socially. Although these themes appear to be universal, the analysis also revealed considerable variability of experience in terms of expectations from healthcare professionals, attitude towards formal diagnoses, ability to cope with the illness, or potential to transform the illness experience into personal growth. Addressing this diversity of needs represents a significant challenge for the healthcare system.
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Affiliation(s)
- Lucia Polakovská
- Faculty of Social Studies, Department of Psychology, Masaryk University, Brno, Czech Republic
| | - Tomáš Řiháček
- Faculty of Social Studies, Department of Psychology, Masaryk University, Brno, Czech Republic
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21
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Scope A, Leaviss J, Booth A, Sutton A, Parry G, Buszewicz M, Moss-Morris R. The acceptability of primary care or community-based behavioural interventions for persistent physical symptoms: Qualitative systematic review. Br J Health Psychol 2021; 26:1069-1094. [PMID: 33797174 DOI: 10.1111/bjhp.12521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 03/09/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE Persistent physical symptoms (PPS) are often associated with profound physical disability and psychological distress. Interventions for PPS that promote behavioural change aim to reduce levels of symptoms and improve overall functioning in patients. The evidence for these interventions is mixed, with effective relationships between patients and health practitioners (HPs) reported as the key to the success of primary care interventions. The objectives of this systematic review were to synthesize the qualitative evidence and to evaluate the acceptability of behavioural interventions for PPS in primary care, from the perspective of both patients and HPs. METHODS A comprehensive literature search was conducted in seven major electronic bibliographic databases, to February 2019. The aim was to identify a broad range of literature including, qualitative research, mixed methods research, and qualitative data embedded in trial reports or process evaluations. Fifty-eight full papers were screened against the inclusion criteria. Nine studies were included and quality-assessed. A qualitative evidence synthesis was conducted using thematic synthesis. RESULTS Some patients and HPs reported positive gains from taking part in or delivering interventions, with appropriate support and explanation of their symptoms important for patients. Barriers appeared to be underpinned by the relationship between the patients and HPs, and by beliefs and attitudes held by both parties. CONCLUSIONS Patients should be provided with adequate information to make an informed decision about whether an intervention is appropriate for them, and interventions should not end suddenly or without adequate follow-up. HPs should receive training and supervision to address their lack of confidence, and improve their knowledge of PPS.
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Affiliation(s)
- Alison Scope
- School of Health and Related Research (ScHARR), The University of Sheffield, UK
| | - Joanna Leaviss
- School of Health and Related Research (ScHARR), The University of Sheffield, UK
| | - Andrew Booth
- School of Health and Related Research (ScHARR), The University of Sheffield, UK
| | - Anthea Sutton
- School of Health and Related Research (ScHARR), The University of Sheffield, UK
| | - Glenys Parry
- School of Health and Related Research (ScHARR), The University of Sheffield, UK
| | - Marta Buszewicz
- Research Department of Primary Care and Population Health, University College London, UK
| | - Rona Moss-Morris
- Psychological Medicine and Integrated Care Clinical Academic Group, Department of Psychology, Kings College London, UK
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Modgill O, Patel G, Akintola D, Obisesan O, Tagar H. AAA: a rock and a hard place. Br Dent J 2021:10.1038/s41415-020-2594-3. [PMID: 33479516 PMCID: PMC7819621 DOI: 10.1038/s41415-020-2594-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 11/26/2020] [Indexed: 11/09/2022]
Abstract
Introduction This retrospective analysis sought to ascertain the effect of the advice, analgesia and antibiotics (AAA) regimen upon the appropriateness of antibiotic prescribing for those patients attending for emergency dental extraction at the Department of Oral Surgery, King's College Dental Hospital (KCDH), London. This has subsequently been used as a foundation upon which to discuss the potential factors that are likely to have had an effect upon the prescribing patterns of general dental practitioners (GDPs) throughout the United Kingdom (UK) at this time and possible future implications should the UK experience a second mandatory closure of primary care dental settings.Materials and methods Retrospective data collection for patients attending for emergency dental extractions was performed at the Department of Oral Surgery, KCDH. Data were collected between March-June 2020 during KCDH's designation as an urgent dental care hub.Results In total, 1,414 patients attended for emergency dental extraction. Four hundred and seventy-one (33.3%) patients sought advice from their GDP before contacting KCDH's emergency dental triage service. Prior to attending KCDH for emergency dental extraction, 665 (47%) patients were prescribed antibiotics by a primary care health provider.Conclusion Our findings suggest that the AAA regimen may have inadvertently contributed to inappropriate prescription of systemic antibiotics by GDPs.
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Affiliation(s)
- Omesh Modgill
- Specialist Oral Surgeon, King´s College Dental Hospital, SE5 9RS, London, UK.
| | - Ginal Patel
- Dental Core Trainee Year 1, King´s College Dental Hospital, SE5 9RS, London, UK
| | - Dapo Akintola
- Consultant Oral Surgeon, King´s College Dental Hospital, SE5 9RS, London, UK
| | - Olamide Obisesan
- Consultant Oral Surgeon and Departmental Lead, King´s College Dental Hospital, SE5 9RS, London, UK
| | - Harjit Tagar
- Consultant Oral Surgeon, King´s College Dental Hospital, SE5 9RS, London, UK
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Stain N, Cheshire A, Ross C, Ridge D. An Exploration of the help-seeking experiences of patients in an allied professions-led rapid access chest pain pathway: a qualitative study. BMJ Open 2020; 10:e040468. [PMID: 33444203 PMCID: PMC7678391 DOI: 10.1136/bmjopen-2020-040468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE A number of studies have explored delayed help-seeking practices for acute coronary syndrome (ACS) and have indentified multiple intersecting factors which may play a role, for example, attributing symptoms, age, gender, ethnicity and contextual influences. However, the pathway to diagnosis for suspected coronary heart disease (CHD) symptoms in a rapid access chest pain clinic (RACPC) context is underexplored. The objective of this study was to examine patients' help-seeking experiences of accessing RACPC services, from the point at which they notice and interpret symptoms, to their decision to seek help from their general practitioner. DESIGN Qualitative study. SETTING Interviews were conducted in the RACPC at Queen Mary's Roehampton Hospital, London, UK. PARTICIPANTS Maximum variation sampling was used to recruit 30 participants (15 men and 15 women) referred to a RACPC, using sampling dimensions of age, ethnicity and occupation. METHODS Semi-structured interviews focussed on the patient experience of their pathway to the RACPC. Thematic analysis was used to analyse the interview data. RESULTS Participant interpretation of symptoms was shaped by multiple influences; reluctance to seek help contributed to delay; various factors acted as drivers as well as barriers to help-seeking; and GP referrals to RACPC were based on symptoms as well as patients' need for reassurance. CONCLUSION We found complex issues shaped the patient's decision-making when accessing the RACPC, including making sense of symptoms and help-seeking practices. These findings can be used to develop health promotion literature to encourage early help-seeking and improve RACPC services.
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Affiliation(s)
- Nolan Stain
- Cardiac Physiology, Barts Health NHS Trust, London, UK
| | - Anna Cheshire
- College of Liberal Arts and Sciences, University of Westminster, London, UK
| | - Catherine Ross
- The Office of Chief Scientific Officer, NHS England, London, UK
| | - Damien Ridge
- College of Liberal Arts and Sciences, University of Westminster, London, UK
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Murphy M, Salisbury C. Relational continuity and patients' perception of GP trust and respect: a qualitative study. Br J Gen Pract 2020; 70:e676-e683. [PMID: 32784221 PMCID: PMC7425201 DOI: 10.3399/bjgp20x712349] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 02/16/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Despite the benefits of relational continuity of care, particularly for patients with multimorbidity, the traditional model of continuity is changing. Revisiting what patients with ongoing problems want from relational continuity could encourage initiatives to achieve these within a modern healthcare system. AIM To examine the attributes of GPs that patients with long-term conditions value most, and which attributes patients believe are facilitated by relational continuity. DESIGN AND SETTING Qualitative study in UK general practice. METHOD A thematic analysis was carried out, based on secondary analysis of interviews with 25 patients with long-term conditions that were originally conducted to inform a patient-reported outcome measure for primary care. RESULTS Patients with long-term conditions wanted their GPs to be clinically competent, to examine, listen to, care for, and take time with them, irrespective of whether they have seen them before. They believed that relational continuity facilitates a GP knowing their history, giving consistent advice, taking responsibility and action, and trusting and respecting them. Patients acknowledged practical difficulties and safety issues in achieving the first three of these without relational continuity. However, patients felt that GPs should trust and respect them even when continuity was not possible. CONCLUSION Policy initiatives promoting continuity with a GP or healthcare team should continue. Many patients see continuity as a safety issue. When patients experience relationship discontinuity, they often feel that they are not taken seriously or believed by their GP. GPs should therefore consistently seek to visibly demonstrate trust in their patients, particularly when they have not seen them before.
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Affiliation(s)
- Mairead Murphy
- Centre for Academic Primary Care, University of Bristol, Bristol Medical School, Bristol
| | - Chris Salisbury
- Centre for Academic Primary Care, University of Bristol, Bristol Medical School, Bristol
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Leaviss J, Davis S, Ren S, Hamilton J, Scope A, Booth A, Sutton A, Parry G, Buszewicz M, Moss-Morris R, White P. Behavioural modification interventions for medically unexplained symptoms in primary care: systematic reviews and economic evaluation. Health Technol Assess 2020; 24:1-490. [PMID: 32975190 PMCID: PMC7548871 DOI: 10.3310/hta24460] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The term 'medically unexplained symptoms' is used to cover a wide range of persistent bodily complaints for which adequate examination and appropriate investigations do not reveal sufficiently explanatory structural or other specified pathologies. A wide range of interventions may be delivered to patients presenting with medically unexplained symptoms in primary care. Many of these therapies aim to change the behaviours of the individual who may have worsening symptoms. OBJECTIVES An evidence synthesis to determine the clinical effectiveness and cost-effectiveness of behavioural modification interventions for medically unexplained symptoms delivered in primary care settings was undertaken. Barriers to and facilitators of the effectiveness and acceptability of these interventions from the perspective of patients and service providers were evaluated through qualitative review and realist synthesis. DATA SOURCES Full search strategies were developed to identify relevant literature. Eleven electronic sources were searched. Eligibility criteria - for the review of clinical effectiveness, randomised controlled trials were sought. For the qualitative review, UK studies of any design were included. For the cost-effectiveness review, papers were restricted to UK studies reporting outcomes as quality-adjusted life-year gains. Clinical searches were conducted in November 2015 and December 2015, qualitative searches were conducted in July 2016 and economic searches were conducted in August 2016. The databases searched included MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO and EMBASE. Updated searches were conducted in February 2019 and March 2019. PARTICIPANTS Adult participants meeting the criteria for medically unexplained symptoms, including somatoform disorders, chronic unexplained pain and functional somatic syndromes. INTERVENTIONS Behavioural interventions were categorised into types. These included psychotherapies, exercise-based interventions, multimodal therapies (consisting of more than one intervention type), relaxation/stretching/social support/emotional support, guided self-help and general practitioner interventions, such as reattribution. Evidence synthesis: a network meta-analysis was conducted to allow a simultaneous comparison of all evaluated interventions in a single coherent analysis. Separate network meta-analyses were performed at three time points: end of treatment, short-term follow-up (< 6 months since the end of treatment) and long-term follow-up (≥ 6 months after the end of treatment). Outcomes included physical and psychological symptoms, physical functioning and impact of the illness on daily activities. Economic evaluation: within-trial estimates of cost-effectiveness were generated for the subset of studies where utility values (or quality-adjusted life-years) were reported or where these could be estimated by mapping from Short Form questionnaire-36 items or Short Form questionnaire-12 items outcomes. RESULTS Fifty-nine studies involving 9077 patients were included in the clinical effectiveness review. There was a large degree of heterogeneity both between and within intervention types, and the networks were sparse across all outcomes. At the end of treatment, behavioural interventions showed some beneficial effects when compared with usual care, in particular for improvement of specific physical symptoms [(1) pain: high-intensity cognitive-behavioural therapy (CBTHI) standardised mean difference (SMD) 0.54 [95% credible interval (CrI) 0.28 to 0.84], multimodal SMD 0.52 (95% CrI 0.19 to 0.89); and (2) fatigue: low-intensity cognitive-behavioural therapy (CBTLI) SMD 0.72 (95% CrI 0.27 to 1.21), relaxation/stretching/social support/emotional support SMD 0.87 (95% CrI 0.20 to 1.55), graded activity SMD 0.51 (95% CrI 0.14 to 0.93), multimodal SMD 0.52 (95% CrI 0.14 to 0.92)] and psychological outcomes [(1) anxiety CBTHI SMD 0.52 (95% CrI 0.06 to 0.96); (2) depression CBTHI SMD 0.80 (95% CrI 0.26 to 1.38); and (3) emotional distress other psychotherapy SMD 0.58 (95% CrI 0.05 to 1.13), relaxation/stretching/social support/emotional support SMD 0.66 (95% CrI 0.18 to 1.28) and sport/exercise SMD 0.49 (95% CrI 0.03 to 1.01)]. At short-term follow-up, behavioural interventions showed some beneficial effects for specific physical symptoms [(1) pain: CBTHI SMD 0.73 (95% CrI 0.10 to 1.39); (2) fatigue: CBTLI SMD 0.62 (95% CrI 0.11 to 1.14), relaxation/stretching/social support/emotional support SMD 0.51 (95% CrI 0.06 to 1.00)] and psychological outcomes [(1) anxiety: CBTHI SMD 0.74 (95% CrI 0.14 to 1.34); (2) depression: CBTHI SMD 0.93 (95% CrI 0.37 to 1.52); and (3) emotional distress: relaxation/stretching/social support/emotional support SMD 0.82 (95% CrI 0.02 to 1.65), multimodal SMD 0.43 (95% CrI 0.04 to 0.91)]. For physical functioning, only multimodal therapy showed beneficial effects: end-of-treatment SMD 0.33 (95% CrI 0.09 to 0.59); and short-term follow-up SMD 0.78 (95% CrI 0.23 to 1.40). For impact on daily activities, CBTHI was the only behavioural intervention to show beneficial effects [end-of-treatment SMD 1.30 (95% CrI 0.59 to 2.00); and short-term follow-up SMD 2.25 (95% CrI 1.34 to 3.16)]. Few effects remained at long-term follow-up. General practitioner interventions showed no significant beneficial effects for any outcome. No intervention group showed conclusive beneficial effects for measures of symptom load (somatisation). A large degree of heterogeneity was found across individual studies in the assessment of cost-effectiveness. Several studies suggested that the interventions produce fewer quality-adjusted life-years than usual care. For those interventions that generated quality-adjusted life-year gains, the mid-point incremental cost-effectiveness ratios (ICERs) ranged from £1397 to £129,267, but, where the mid-point ICER fell below £30,000, the exploratory assessment of uncertainty suggested that it may be above £30,000. LIMITATIONS Sparse networks meant that it was not possible to conduct a metaregression to explain between-study differences in effects. Results were not consistent within intervention type, and there were considerable differences in characteristics between studies of the same type. There were moderate to high levels of statistical heterogeneity. Separate analyses were conducted for three time points and, therefore, analyses are not repeated-measures analyses and do not account for correlations between time points. CONCLUSIONS Behavioural interventions showed some beneficial effects for specific medically unexplained symptoms, but no one behavioural intervention was effective across all medically unexplained symptoms. There was little evidence that these interventions are effective for measures of symptom load (somatisation). General practitioner-led interventions were not shown to be effective. Considerable heterogeneity in interventions, populations and sparse networks mean that results should be interpreted with caution. The relationship between patient and service provider is perceived to play a key role in facilitating a successful intervention. Future research should focus on testing the therapeutic effects of the general practitioner-patient relationship within trials of behavioural interventions, and explaining the observed between-study differences in effects within the same intervention type (e.g. with more detailed reporting of defined mechanisms of the interventions under study). STUDY REGISTRATION This study is registered as PROSPERO CRD42015025520. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 46. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Joanna Leaviss
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Sarah Davis
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Shijie Ren
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jean Hamilton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Alison Scope
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Andrew Booth
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anthea Sutton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Glenys Parry
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Marta Buszewicz
- Department of Primary Care and Population Health, University College London Medical School, London, UK
| | | | - Peter White
- Barts and The London School of Medicine and Dentistry, London, UK
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Geraghty K. The negative impact of the psychiatric model of chronic fatigue syndrome on doctors’ understanding and management of the illness. FATIGUE: BIOMEDICINE, HEALTH & BEHAVIOR 2020. [DOI: 10.1080/21641846.2020.1834295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Keith Geraghty
- Centre for Primary Care, The University of Manchester, Manchester, UK
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Patients' descriptions of the relation between physical symptoms and negative emotions: a qualitative analysis of primary care consultations. Br J Gen Pract 2020; 70:e78-e85. [PMID: 31848200 DOI: 10.3399/bjgp19x707369] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 06/03/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Primary care guidelines for the management of persistent, often 'medically unexplained', physical symptoms encourage GPs to discuss with patients how these symptoms relate to negative emotions. However, many GPs experience difficulties in reaching a shared understanding with patients. AIM To explore how patients with persistent symptoms describe their negative emotions in relation to their physical symptoms in primary care consultations, in order to help GPs recognise the patient's starting points in such discussions. DESIGN AND SETTING A qualitative analysis of 47 audiorecorded extended primary care consultations with 15 patients with persistent physical symptoms. METHOD The types of relationships patients described between their physical symptoms and their negative emotions were categorised using content analysis. In a secondary analysis, the study explored whether patients made transitions between the types of relations they described through the course of the consultations. RESULTS All patients talked spontaneously about their negative emotions. Three main categories of relations between these emotions and physical symptoms were identified: separated (negation of a link between the two); connected (symptom and emotion are distinct entities that are connected); and inseparable (symptom and emotion are combined within a single entity). Some patients showed a transition between categories of relations during the intervention. CONCLUSION Patients describe different types of relations between physical symptoms and negative emotions in consultations. Physical symptoms can be attributed to emotions when patients introduce this link themselves, but this link tends to be denied when introduced by the GP. Awareness of the ways patients discuss these relations could help GPs to better understand the patient's view and, in this way, collaboratively move towards constructive explanations and symptom management strategies.
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O'Connell N, Jones A, Chalder T, David AS. Experiences and Illness Perceptions of Patients with Functional Symptoms Admitted to Hyperacute Stroke Wards: A Mixed-Method Study. Neuropsychiatr Dis Treat 2020; 16:1795-1805. [PMID: 32801714 PMCID: PMC7399446 DOI: 10.2147/ndt.s251328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 07/07/2020] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION A proportion of patients admitted to acute-stroke settings have not had a stroke, but have conditions mimicking a stroke. Approximately 25% of suspected stroke cases are "stroke mimics" and 2% are patients with functional symptoms - "functional stroke mimics". This study aimed to explore experiences and illness perceptions of patients with functional symptoms admitted to hyperacute stroke wards. METHODS This study used mixed methods. Patients with functional stroke symptoms participated in semistructured qualitative interviews immediately after admission to one of two acute-stroke units in London and again 2 months after hospital discharge. Qualitative data were assessed using thematic analysis. The Brief Illness Perception Questionnaire (Brief-IPQ) measured illness perceptions at admission and at 2-month follow-up. RESULTS A total of 36 participants completed baseline interviews and 25 completed follow-up. Six themes emerged: physical symptom experience, emotional and coping responses, symptom causes, hospital experiences, views on the future, and uncertainty after hospital discharge. Mean Brief-IPQ score at admission was 49.3 (SD: 9.9), indicating a moderate-high level of perceived illness threat. Participants presented with a range of functional symptoms. At baseline, participants were highly concerned about their symptoms, but this had decreased at 2-month follow-up. Two months later, many were confused as to the cause of their admission. CONCLUSION This is the first study to examine functional stroke patients' experiences of acute-stroke admission. At admission, patients expressed confusion regarding their diagnosis, experienced high levels of emotional distress, and were concerned they were perceived as time wasting by stroke clinicians. While most participants experienced symptom recovery, there was a significant subgroup for whom symptoms persisted or worsened. A lack of care guidelines on the management of functional stroke patients may perpetuate functional symptoms.
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Affiliation(s)
- Nicola O'Connell
- Department of Public Health and Primary Care, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Abbeygail Jones
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Trudie Chalder
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Anthony S David
- UCL Institute of Mental Health, University College London, London, UK
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Houwen J, Lucassen PLBJ, Verwiel A, Stappers HW, Assendelft WJJ, Olde Hartman TC, van Dulmen S. Which difficulties do GPs experience in consultations with patients with unexplained symptoms: a qualitative study. BMC FAMILY PRACTICE 2019; 20:180. [PMID: 31884966 PMCID: PMC6935475 DOI: 10.1186/s12875-019-1049-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 11/12/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Many general practitioners (GPs) struggle with the communication with patients with medically unexplained symptoms (MUS). This study aims to identify GPs' difficulties in communication during MUS consultations. METHODS We video-recorded consultations and asked GPs immediately after the consultation whether MUS were presented. GPs and patients were then asked to reflect separately on the consultation in a semi-structured interview while watching the consultation. We selected the comments where GPs experienced difficulties or indicated they should have done something else and analysed these qualitatively according to the principles of constant comparative analysis. Next, we selected those video-recorded transcripts in which the patient also experienced difficulties; we analysed these to identify problems in the physician-patient communication. RESULTS Twenty GPs participated, of whom two did not identify any MUS consultations. Eighteen GPs commented on 39 MUS consultations. In 11 consultations, GPs did not experience any difficulties. In the remaining 28 consultations, GPs provided 84 comments on 60 fragments where they experienced difficulties. We identified three issues for improvement in the GPs' communication: psychosocial exploration, structure of the consultation (more attention to summaries, shared agenda setting) and person-centredness (more attention to the reason for the appointment, the patient's story, the quality of the contact and sharing decisions). Analysis of the patients' views on the fragments where the GP experienced difficulties showed that in the majority of these fragments (n = 42) the patients' comments were positive. The video-recorded transcripts (n = 9) where the patient experienced problems too were characterised by the absence of a dialogue (the GP being engaged in exploring his/her own concepts, asking closed questions and interrupting the patient). CONCLUSION GPs were aware of the importance of good communication. According to them, they could improve their communication further by paying more attention to psychosocial exploration, the structure of the consultation and communicating in a more person-centred way. The transcripts where the patient experienced problems too, were characterised by an absence of dialogue (focussing on his/her own concept, asking closed questions and frequently interrupting the patient).
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Affiliation(s)
- Juul Houwen
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Geert Grooteplein 21, 6525 EZ, Nijmegen, The Netherlands.
| | - Peter L B J Lucassen
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Geert Grooteplein 21, 6525 EZ, Nijmegen, The Netherlands
| | - Anna Verwiel
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Geert Grooteplein 21, 6525 EZ, Nijmegen, The Netherlands
| | - Hugo W Stappers
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Geert Grooteplein 21, 6525 EZ, Nijmegen, The Netherlands
| | - Willem J J Assendelft
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Geert Grooteplein 21, 6525 EZ, Nijmegen, The Netherlands
| | - Tim C Olde Hartman
- Department of Primary and Community care, Donders Institute for Brain, Cognition and Behaviour, Radboud university medical center, Nijmegen, The Netherlands
| | - Sandra van Dulmen
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Geert Grooteplein 21, 6525 EZ, Nijmegen, The Netherlands
- Faculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway
- NIVEL (Netherlands institute for health services research), Utrecht, The Netherlands
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McAndrew LM, Friedlander ML, Litke D, Phillips LA, Kimber J, Helmer DA. Medically Unexplained Physical Symptoms: What They Are and Why Counseling Psychologists Should Care about Them. COUNSELING PSYCHOLOGIST 2019; 47:741-769. [PMID: 32015568 PMCID: PMC6996203 DOI: 10.1177/0011000019888874] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Medically unexplained symptoms and syndromes (MUS) affect the health of 20%-30% of patients seen in primary care. Optimally, treatment for these patients requires an interdisciplinary team consisting of both primary care and mental health providers. By developing an expertise in MUS, counseling psychologists can improve the care of patients with MUS who are already in their practice, expand the number of patients they help, and enhance the integration of counseling psychology into the broader medical community. Additionally, counseling psychologists' expertise in culture, attunement to therapeutic processes, and our focus on prioritizing patients' perspectives and quality of life can fill the gap in research on MUS and bringing increased attention to counseling psychologists' unique contributions to health service delivery.
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Affiliation(s)
- Lisa M McAndrew
- Veterans Affairs New Jersey Health Care System University at Albany
| | | | - David Litke
- Veterans Affairs New Jersey Health Care System
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Claréus B, Renström EA. Physicians' gender bias in the diagnostic assessment of medically unexplained symptoms and its effect on patient-physician relations. Scand J Psychol 2019; 60:338-347. [PMID: 31124165 PMCID: PMC6851885 DOI: 10.1111/sjop.12545] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 04/02/2019] [Indexed: 12/24/2022]
Abstract
Nonspecific, functional, and somatoform (NFS) syndromes is an umbrella term for various diagnoses with medically unexplained symptoms. These syndromes are more prevalent among women than among men, and associated with negative preconceptions that can impede rehabilitation. In two studies, we quantitatively assess how patients’ gender affects the diagnostic assessment of NFS syndromes, as well as the healthcare experiences of individuals diagnosed with NFS syndromes. In the first study, our vignette‐based experiment showed that Swedish general practitioners (N = 90) were gender biased in their diagnostic assessment of NFS syndromes, such that a female patient with back pain was more likely to be assigned a NFS syndrome compared to an otherwise identical male patient. In the second study, a large community sample of Swedish individuals with medically explained (n = 432) and unexplained pain (n = 521) evaluated their treating physician's relational conduct. Even after accounting for a variety of sociodemographic variables and other pain characteristics, women with at least one NFS syndrome percieved their physician's relational conduct as significantly poorer than other women as well as men with and without NFS syndromes. When women's pain is more likely than men's to be assessed as NFS, their rehabilitation could be prolonged as pertient alternative diagnoses and treatments are omittied and their negative healthcare experiences lower their volition to partake and persevere in treatment.
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Affiliation(s)
| | - Emma A Renström
- Department of psychology, Gothenburg University, Gothenburg, Sweden
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Anastasides N, Chiusano C, Gonzalez C, Graff F, Litke DR, McDonald E, Presnall-Shvorin J, Sullivan N, Quigley KS, Pigeon WR, Helmer DA, Santos SL, McAndrew LM. Helpful ways providers can communicate about persistent medically unexplained physical symptoms. BMC FAMILY PRACTICE 2019; 20:13. [PMID: 30651073 PMCID: PMC6334465 DOI: 10.1186/s12875-018-0881-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 11/23/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Communication between patients and providers about persistent "medically unexplained" physical symptoms (MUS) is characterized by discordance. While the difficulties are well documented, few studies have examined effective communication. We sought to determine what veterans with Gulf War Illness (GWI) perceive as the most helpful communication from their providers. Veterans with GWI, a type of MUS, have historically had complex relationships with medical providers. Determining effective communication for patients with particularly complex relationships may help identify the most critical communication elements for all patients with MUS. METHODS Two hundred and-ten veterans with GWI were asked, in a written questionnaire, what was the most useful thing a medical provider had told them about their GWI. Responses were coded into three categories with 10 codes. RESULTS The most prevalent helpful communication reported by patients was when the provider offered acknowledgement and validation (N = 70). Specific recommendations for managing GWI or its symptoms (N = 48) were also commonly reported to be helpful. In contrast, about a third of the responses indicated that nothing about the communication was helpful (N = 63). There were not differences in severity of symptoms, disability or healthcare utilization between patients who found acknowledgement and validation, specific recommendations or nothing helpful. CONCLUSIONS Previous research has documented the discord between patients and providers regarding MUS. This study suggests that most patients are able to identify something helpful a provider has said, particularly acknowledgement and validation and specific treatment recommendations. The findings also highlight missed communication opportunities with a third of patients not finding anything helpful.
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Affiliation(s)
- Nicole Anastasides
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA
| | - Carmelen Chiusano
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA
| | - Christina Gonzalez
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA
| | - Fiona Graff
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA
| | - David R Litke
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA
- Department of Rehabilitation Medicine, New York University School of Medicine, New York, NY, USA
| | - Erica McDonald
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA
| | - Jennifer Presnall-Shvorin
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA
| | - Nicole Sullivan
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA
| | - Karen S Quigley
- Edith Nourse Rogers Memorial VA Hospital, Bedford, 01730, MA, USA
- Department of Psychology, Northeastern University, Boston, 02115, MA, USA
| | - Wilfred R Pigeon
- Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY, USA
| | - Drew A Helmer
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA
| | - Susan L Santos
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA
| | - Lisa M McAndrew
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA.
- Department of Educational and Counseling Psychology, University at Albany, 1400 Washington Ave Ext, Albany, NY, 12222, USA.
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Houwen J, Moorthaemer BJE, Lucassen PLBJ, Akkermans RP, Assendelft WJJ, Olde Hartman TC, van Dulmen S. The association between patients' expectations and experiences of task-, affect- and therapy-oriented communication and their anxiety in medically unexplained symptoms consultations. Health Expect 2018; 22:338-347. [PMID: 30597697 PMCID: PMC6543164 DOI: 10.1111/hex.12854] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 07/18/2018] [Accepted: 11/14/2018] [Indexed: 11/30/2022] Open
Abstract
Background It is unknown whether patients with medically unexplained symptoms (MUS) differ from patients with medically explained symptoms (MES) regarding their expectations and experiences on task‐oriented communication (ie, communication in which the primary focus is on exchanging medical content), affect‐oriented communication (ie, communication in which the primary focus is on the emotional aspects of the interaction) and therapy‐oriented communication (ie, communication in which the primary focus is on therapeutic aspects) of the consultation and the extent to which GPs meet their expectations. Objective This study aims to explore (a) differences in patients’ expectations and experiences in consultations with MUS patients and patients with MES and (b) the influence of patients’ experiences in these consultations on their post‐visit anxiety level. Study design Prospective cohort. Setting Eleven Dutch general practices. Measurements Patients completed the QUOTE‐COMM (Quality Of communication Through the patients’ Eyes) questionnaire before and after the consultation to assess their expectations and experiences and these were related to changes in patients’ state anxiety (abbreviated State‐Trait Anxiety Inventory; STAI). Results Expectations did not differ between patients with MUS and MES. Patients presenting with either MUS or MES rated their experiences for task‐related and affect‐oriented communication of their GP higher than their expectations. GPs met patients’ expectations less often on task‐oriented communication in MUS patients compared to MES patients (70.2% vs 80.9%; P = ˂0.001). Affect‐oriented communication seems to be most important in reducing the anxiety level of MUS patients (β −0.63, 95% Cl = −1.07 to −0.19). Discussion Although the expectations of MUS patients are less often met compared to those of MES patients, GPs often communicate according to patients’ expectations. Experiencing affect‐oriented communication is associated with a stronger reduction in anxiety in patients with MUS than in those with MES. Conclusion GPs communicate according to patients’ expectations. However, GPs met patients’ expectations on task‐oriented communication less often in patients with MUS compared to patients with MES. Experiencing affect‐oriented communication had a stronger association with the post‐consultation anxiety for patients with MUS than MES.
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Affiliation(s)
- Juul Houwen
- Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Bas J E Moorthaemer
- Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Peter L B J Lucassen
- Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Reinier P Akkermans
- Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.,Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Willem J J Assendelft
- Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Tim C Olde Hartman
- Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Sandra van Dulmen
- Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.,NIVEL (Netherlands Institute for Health Services Research), Utrecht, The Netherlands.,Faculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway
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Náfrádi L, Kostova Z, Nakamoto K, Schulz PJ. The doctor-patient relationship and patient resilience in chronic pain: A qualitative approach to patients' perspectives. Chronic Illn 2018; 14:256-270. [PMID: 29096534 DOI: 10.1177/1742395317739961] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To study patients' perspectives about the role of the doctor-patient relationship in promoting the resilience process. METHODS We conducted in-depth interviews with 20 chronic pain patients. Using open-ended questions, the interviews explored aspects of the doctor-patient relationship that impacted the patients' perceptions of their resilience. Thematic analysis built on an inductive, adaptive approach to data coding was employed to organize a representation of key factors affecting resilience. RESULTS The themes emerging from the interviews inform us about how the different aspects of the doctor-patient relationship can promote patient resilience in chronic pain. Three main themes emerged: the doctor providing psychological support, promoting patients' health literacy related to chronic pain and its treatment, and empowering the patients to cooperate in finding the right treatment. This fosters patients' direct outcomes (feeling validated, health literate, and empowered), which, in turn, lead to adaptive coping responses and day-to-day disease management. These direct outcomes are crucial for patients to maintain socially and personally meaningful activities and their functional (physical) capacity. DISCUSSION A doctor-patient relationship following the precepts of the patient-centered care is a significant resource that can lead to increased patient resilience. Thus, future interventions promoting patient resilience might consider addressing the doctor-patient relationship.
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Affiliation(s)
- Lilla Náfrádi
- 1 Institute of Communication and Health, Universita della Svizzera Italiana, Università della Svizzera Italiana, Lugano, Switzerland
| | - Zlatina Kostova
- 2 Department of Psychiatry, University of Massachusetts Medical School, Worcester, USA
| | - Kent Nakamoto
- 1 Institute of Communication and Health, Universita della Svizzera Italiana, Università della Svizzera Italiana, Lugano, Switzerland
| | - Peter J Schulz
- 1 Institute of Communication and Health, Universita della Svizzera Italiana, Università della Svizzera Italiana, Lugano, Switzerland
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Østbye SV, Wang CEA, Granheim IPH, Kristensen KE, Risør MB. Epistemological and methodological paradoxes: secondary care specialists and their challenges working with adolescents with medically unexplained symptoms. Int J Ment Health Syst 2018; 12:52. [PMID: 30258491 PMCID: PMC6151926 DOI: 10.1186/s13033-018-0232-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 09/19/2018] [Indexed: 12/03/2022] Open
Abstract
Background Early adolescence is considered a critical period for the development of chronic and recurrent medically unexplained symptoms (MUS), and referrals and system-initiated patient trajectories often lead to an excess of examinations and hospitalizations in the cross-section between mental and somatic specialist care for this group of patients. Dimensions of the relationship and communication between clinician and patient are shown in primary care studies to be decisive for subsequent illness pathways, often creating adverse effects, but knowledge on clinical communication in specialist care is still scarce. Methods This study explores communicative challenges specific to clinical encounters between health professionals and adolescent patients in specialist care, as presented through interviews and focus group data with highly experienced specialists working in adolescent and child services at a Norwegian university hospital. Results The results are presented in a conceptual model describing the epistemological and methodological paradoxes inherent in the clinical uncertainty of MUS. Within these paradoxes, the professionals try to solve the dilemmas by being creative in their communication strategies; applying metaphors and other rhetorical devices to explain complex ideas; creating clinical prototypes as a way to explain symptoms and guide them in clinical action; relying on principles from patient-centered care involving empathy; and trying to balance expertise and humility. Conclusion The challenges in communication arise as a result of opposing discourses on biomedicine, family, health and adolescence that create dilemmas in everyday clinical work. By moving away from a positivist and biomedical framework towards an interpretive paradigm, where culturally derived and historically situated interpretations are used to understand the social life-world of the patient, one can create a more humane health service in accordance with ideals of patient-centered care.
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Affiliation(s)
- Silje Vagli Østbye
- 1Department of Psychology, Faculty of Health, UiT-Arctic University of Norway, Tromsø, Norway
| | | | | | | | - Mette Bech Risør
- 4Department of Community Medicine, General Practice Research Unit, Faculty of Health, UiT-Arctic University of Norway, Tromsø, Norway
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Sun KS, Lam TP, Wu D. Chinese perspectives on primary care for common mental disorders: Barriers and policy implications. Int J Soc Psychiatry 2018; 64:417-426. [PMID: 29781372 DOI: 10.1177/0020764018776347] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND The World Health Organization (WHO) has called for integration of mental health into primary care for a decade. In Western countries, around 15% to 25% of patients with common mental disorders including mood and anxiety disorders seek help from primary care physicians (PCPs). The rate is only about 5% in China. AIMS This article reviews the Chinese findings on the barriers to primary care for common mental disorders and how they compared with Western findings. METHODS A narrative literature review was conducted, focusing on literature published from mid-1990s in English or Chinese. Patient, PCP and health system factors were reviewed. RESULTS Although Chinese and Western findings show similar themes of barriers, the Chinese have stronger barriers in most aspects, including under-recognition of the need for treatment, stigma on mental illness, somatization, worries about taking psychiatric drugs, uncertainties in the role, competency and legitimacy of PCPs in mental health care and short consultation time. CONCLUSION Current policies in China emphasize enhancement of mental health facilities and workforce in the community. Our review suggests that patients' intention to seek help and PCPs' competency in mental health care are other fundamental factors to be addressed.
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Affiliation(s)
- Kai Sing Sun
- 1 Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong
| | - Tai Pong Lam
- 1 Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong
| | - Dan Wu
- 2 University of North Carolina at Chapel Hill Project-China, Guangzhou, China
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Sun KS, Lam TP, Lam KF, Lo TL, Chao DVK, Lam EWW. Enablers to seeking professional help for psychological distress-a study on Chinese primary care attenders. Psychiatry Res 2018; 264:9-14. [PMID: 29626833 DOI: 10.1016/j.psychres.2018.03.056] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 03/16/2018] [Accepted: 03/22/2018] [Indexed: 11/30/2022]
Abstract
This study investigated enablers to seeking professional help for psychological distress among Chinese primary care attenders in Hong Kong. Nine focus groups and six individual interviews were conducted among adult patients with/without known distress, significant others of the distressed, and the general public. The identified potential enablers were further investigated in a questionnaire survey with data from 1626 patients. Survey respondents who had sought professional help for distress (n = 231) and those without this experience (n = 1395) showed similar attitudes to the enabler items. However, the first group had more "strongly agree" responses and their top five enablers were: crisis caused by distress, distress affecting daily life, wanting to treat associated physical symptoms, having trust in doctor, and encouragement by family/friends to seek help. Qualitative interviews found that the patients often somatised distress and they felt comfortable to consult for somatic symptoms. There was strong family involvement in help-seeking whereas the doctors were the authoritative figures to convince the patients for treatment. The findings, in line with Western literature, indicate that crisis and interference in daily life due to distress are the top enablers to seeking professional help. The other three key enablers are likely to be influenced by Chinese culture.
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Affiliation(s)
- Kai Sing Sun
- Department of Family Medicine and Primary Care, The University of Hong Kong, 3/F, Ap Lei Chau Clinic, 161 Main Street, Ap Lei Chau, Hong Kong, China
| | - Tai Pong Lam
- Department of Family Medicine and Primary Care, The University of Hong Kong, 3/F, Ap Lei Chau Clinic, 161 Main Street, Ap Lei Chau, Hong Kong, China.
| | - Kwok Fai Lam
- Department of Statistics and Actuarial Science, The University of Hong Kong, Hong Kong, China
| | - Tak Lam Lo
- Department of Family Medicine and Primary Care, The University of Hong Kong, 3/F, Ap Lei Chau Clinic, 161 Main Street, Ap Lei Chau, Hong Kong, China; Kwai Chung Hospital, Hong Kong, China
| | - David Vai Kiong Chao
- Department of Family Medicine and Primary Care, The University of Hong Kong, 3/F, Ap Lei Chau Clinic, 161 Main Street, Ap Lei Chau, Hong Kong, China; Department of Family Medicine and Primary Health Care, United Christian Hospital and Tseung Kwan O Hospital, Hong Kong, China
| | - Edmund Wing Wo Lam
- Department of Family Medicine and Primary Care, The University of Hong Kong, 3/F, Ap Lei Chau Clinic, 161 Main Street, Ap Lei Chau, Hong Kong, China
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Joyce E, Cowing J, Lazarus C, Smith C, Zenzuck V, Peters S. Training tomorrow's doctors to explain 'medically unexplained' physical symptoms: An examination of UK medical educators' views of barriers and solutions. PATIENT EDUCATION AND COUNSELING 2018; 101:878-884. [PMID: 29203082 DOI: 10.1016/j.pec.2017.11.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 11/07/2017] [Accepted: 11/27/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE Co-occuring physical symptoms, unexplained by organic pathology (known as Functional Syndromes, FS), are common and disabling presentations. However, FS is absent or inconsistently taught within undergraduate medical training. This study investigates the reasons for this and identifies potential solutions to improved implementation. METHODS Twenty-eight medical educators from thirteen different UK medical schools participated in semi-structured interviews. Thematic analysis proceeded iteratively, and in parallel with data production. RESULTS Barriers to implementing FS training are beliefs about the complexity of FS, tutors' negative attitudes towards FS, and FS being perceived as a low priority for the curriculum. In parallel participants recognised FS as ubiquitous within medical practice and erroneously assumed it must be taught by someone. They recommended that students should learn about FS through managed exposure, but only if tutors' negative attitudes and behaviour are also addressed. CONCLUSION Negative attitudes towards FS by educators prevents designing and delivering effective education on this common medical presentation. Whilst there is recognition of the need to implement FS training, recommendations are multifaceted. PRACTICE IMPLICATIONS Increased liaison between students, patients and educators is necessary to develop more informed and effective teaching methods for trainee doctors about FS and in order to minimise the impact of the hidden curriculum.
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Affiliation(s)
- Emmeline Joyce
- Manchester Centre of Health Psychology, School of Health Sciences, University of Manchester, Greater Manchester, UK; The Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Greater Manchester, UK
| | - Jennifer Cowing
- Manchester Centre of Health Psychology, School of Health Sciences, University of Manchester, Greater Manchester, UK
| | - Candice Lazarus
- Manchester Centre of Health Psychology, School of Health Sciences, University of Manchester, Greater Manchester, UK
| | - Charlotte Smith
- Manchester Centre of Health Psychology, School of Health Sciences, University of Manchester, Greater Manchester, UK
| | - Victoria Zenzuck
- Manchester Centre of Health Psychology, School of Health Sciences, University of Manchester, Greater Manchester, UK
| | - Sarah Peters
- Manchester Centre of Health Psychology, School of Health Sciences, University of Manchester, Greater Manchester, UK.
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Duration of untreated illness in patients with somatoform disorders. J Psychosom Res 2018; 107:1-6. [PMID: 29502757 DOI: 10.1016/j.jpsychores.2018.01.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 12/20/2017] [Accepted: 01/18/2018] [Indexed: 01/23/2023]
Abstract
OBJECTIVE A long duration of untreated mental illness (DUI) has been found to be associated with negative long-term outcomes. Although somatic symptom and related disorders are frequent in the general population and in primary care, data regarding the DUI of these disorders is scarce. The aim of this study was to investigate the DUI in patients with somatoform disorders. METHODS In a cross-sectional study, primary care patients at high risk of having a somatoform disorder were identified using the Patient Health Questionnaire (PHQ). In a second step, life-time somatoform disorder diagnosis was established using the Composite International Diagnostic Interview (CIDI). Additionally, DUI was retrospectively assessed via self-reporting and sociodemographic information was collected. Survival analysis was used to estimate the DUI and to identify patient-related predictors of DUI. RESULTS A total of 139 patients with somatoform disorders were included in the analyses. The mean DUI in these patients was 25.2years (median 23.1years). Higher education significantly predicted shorter DUI, whereas gender and age of onset were unrelated to DUI. CONCLUSIONS The results reveal a substantial delay in adequate treatment of patients with somatoform disorders. The reported DUI emphasizes the importance of improvements in the management of patients with these disorders.
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Twist K, Ablett J, Wearden A, Paine P, Vasant D, Lal S, Peters S. Gastrointestinal dysmotility: A qualitative exploration of the journey from symptom onset to diagnosis. Neurogastroenterol Motil 2018; 30:e13339. [PMID: 29575415 DOI: 10.1111/nmo.13339] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 02/15/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Gastrointestinal dysmotility (GID) covers a spectrum of disorders disrupting enteric neuromuscular co-ordination which, when severe, causes intractable gastrointestinal symptoms and malnutrition and is a recognized cause of chronic intestinal failure. To date, no study has provided an in-depth account of the experiences of patients with severe GID and their psychosocial needs. This study aimed to explore patients' experiences from symptom onset and the process of seeking and receiving a diagnosis. It specifically explored the psychological effect of this process and the effect on relationships. METHODS Participants (n = 20, mean age = 47.9, female n = 16, parenteral nutrition = 13) were recruited from a UK center with tertiary Neurogastroenterology and Intestinal Failure services. A qualitative exploratory design with semi-structured in-depth interviews was used. Data were analyzed using thematic analysis. KEY RESULTS Significant delays were experienced in obtaining a diagnosis. Participants reported having their mental health questioned and felt that they had to fight to prove their symptoms had a physical basis to access appropriate treatment. Although a diagnosis helped legitimize symptoms, the condition remained poorly understood by participants themselves, relatives, and health professionals. Participants discussed the impact that "feeling delegitimized" and the "lack of coherent understanding of GID" had on their relationships and mental health. CONCLUSIONS & INFERENCES The distressing experience of GID symptoms are compounded by a delay in validating symptoms and lack of coherent understanding. More knowledge of GID is needed by health professionals to speed up diagnosis and offer more coherent information. The psychological impact of a GID diagnosis should be acknowledged early to help facilitate adjustment.
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Affiliation(s)
- K Twist
- University of Manchester, Manchester, UK
| | - J Ablett
- Salford Royal NHS Foundation Trust, Manchester, UK
| | - A Wearden
- University of Manchester, Manchester, UK
| | - P Paine
- Salford Royal NHS Foundation Trust, Manchester, UK
| | - D Vasant
- Salford Royal NHS Foundation Trust, Manchester, UK
| | - S Lal
- Salford Royal NHS Foundation Trust, Manchester, UK
| | - S Peters
- University of Manchester, Manchester, UK
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Cooper A, Abbass A, Town J. Implementing a Psychotherapy Service for Medically Unexplained Symptoms in a Primary Care Setting. J Clin Med 2017; 6:jcm6120109. [PMID: 29186054 PMCID: PMC5742798 DOI: 10.3390/jcm6120109] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 11/13/2017] [Accepted: 11/16/2017] [Indexed: 12/24/2022] Open
Abstract
Medically unexplained symptoms (MUS) are known to be costly, complex to manage and inadequately addressed in primary care settings. In many cases, there are unresolved psychological and emotional processes underlying these symptoms, leaving traditional medical approaches insufficient. This paper details the implementation of an evidence-based, emotion-focused psychotherapy service for MUS across two family medicine clinics. The theory and evidence-base for using Intensive Short-Term Dynamic Psychotherapy (ISTDP) with MUS is presented along with the key service components of assessment, treatment, education and research. Preliminary outcome indicators showed diverse benefits. Patients reported significantly decreased somatic symptoms in the Patient Health Questionnaire-15 (d = 0.4). A statistically significant (23%) decrease in family physicians’ visits was found in the 6 months after attending the MUS service compared to the 6 months prior. Both patients and primary care clinicians reported a high degree of satisfaction with the service. Whilst further research is needed, these findings suggest that a direct psychology service maintained within the family practice clinic may assist patient and clinician function while reducing healthcare utilization. Challenges and further service developments are discussed, including the potential benefits of re-branding the service to become a ‘Primary Care Psychological Consultation and Treatment Service’.
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Affiliation(s)
- Angela Cooper
- Centre for Emotions & Health, Departments of Psychiatry & Family Medicine, Dalhousie University, Halifax, NS B3H 2E2, Canada.
| | - Allan Abbass
- Centre for Emotions & Health, Department of Psychiatry, Dalhousie University, Halifax, NS B3H 2E2, Canada.
| | - Joel Town
- Centre for Emotions & Health, Department of Psychiatry, Dalhousie University, Halifax, NS B3H 2E2, Canada.
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Rossen CB, Buus N, Stenager E, Stenager E. Identity work and illness careers of patients with medically unexplained symptoms. Health (London) 2017; 23:551-567. [PMID: 29160105 DOI: 10.1177/1363459317739440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This article reports a case study of the illness career and identity work of patients who have had medically unexplained symptoms for many years with a particular emphasis on their interactions with a specialized and standardized health care system. Patients with medically unexplained symptoms often experience being met with mistrust and feel their identity threatened as a consequence of being illegitimately ill. There is a strong tendency in health care towards assessment thorough standardized so-called assessment packages. The study used a case study approach. Ethnographic fieldwork was carried out and several types of data were sampled through theoretical sampling, resulting in data from and about a sample of 13 patients, from which two patients were selected as cases. The study showed that a standardized health care system characterized by a tendency towards narrow diagnostic assessment with limited time can lead to a diagnostic limbo and that patients and health care professionals keep on searching for legitimate explanations for the patients' still unexplained symptoms. Consequently the patients were left in a constant identity negotiation.
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Affiliation(s)
- Camilla Blach Rossen
- Research Unit of Mental Health, Odense, Institute of Regional Health Services, University of Southern Denmark & Neurological Research Unit, Sønderborg, DenmarkElective Surgery Center, Silkeborg Regional Hospital, Denmark
| | - Niels Buus
- The University of Sydney, Australia; University of Southern Denmark, Denmark
| | - Elsebeth Stenager
- Institute of Regional Health Research, University of Southern Denmark, Denmark; Focused research Unit in Psychiatry, Åbenrå and Department of Psychiatry, Odense, Denmark
| | - Egon Stenager
- Institute of Regional Health Research, University of Southern Denmark, Denmark; MS-clinic of Southern Jutland and Focused research Unit in Neurology, Hospital of Southern Jutland, Sønderborg, Denmark
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Robson C, Lian OS. " Blaming, shaming, humiliation": Stigmatising medical interactions among people with non-epileptic seizures. Wellcome Open Res 2017; 2:55. [PMID: 29152594 PMCID: PMC5664997 DOI: 10.12688/wellcomeopenres.12133.2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2017] [Indexed: 11/20/2022] Open
Abstract
Background: People with non-epileptic seizures (NES) describe challenging relationships with health professionals, and explain negative interactions as common and expected. Despite these difficulties, little is known about how people with NES experience difficult healthcare encounters. Methods: Using a thematic discourse analysis approach, we analysed the free-text survey responses of 135 people with NES and asked: what kind of challenges do people living with this condition encounter when interacting with health professionals, and how do they experience the consequences of difficult interactions? We explore their experiences by interpreting the latent meaning of participants' texts from a social-constructionist perspective on health and illness. Results: The overarching narrative depicts a fundamental breakdown in patient-provider relationships. According to our data, the negative experiences of study participants emerge from more than practitioners' lack of awareness of NES and access to information about the condition - to the extent that it is available. In examining the challenges people with NES encounter when interacting with health professionals, their main experiences centre on blame and humiliation. When exploring their experiences, theories of stigma serve as a useful theoretical framework. Conclusions: Normative judgements arising from psychogenic understandings of NES are stigmatising and restrict professional displays of respectful (patient-centred) care. Those with the condition depict being negatively stereotyped, illegitimated and held morally culpable by health professionals. Perceived to lack medical, moral and credible status, participants describe practitioners who treat them with disrespect, and some recount conduct that defies all ethical and professional obligations and standards. These encounters can have wide-ranging adverse consequences for patients: emotionally, physically, and for their future healthcare. The quality of healthcare interactions for people with NES requires urgent improvements. In addition to increased awareness of the condition, practitioners need to be conscious of making and acting on adverse moral appraisals when interacting with this patient group.
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Affiliation(s)
- Catherine Robson
- Department of Research Capacity Development, Nelson Mandela University, Port Elizabeth, South Africa.,Department of Community Medicine, Faculty of Health Sciences, University of Tromsø - The Arctic University of Norway, Tromsø, Norway
| | - Olaug S Lian
- Department of Community Medicine, Faculty of Health Sciences, University of Tromsø - The Arctic University of Norway, Tromsø, Norway
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Robson C, Lian OS. " Blaming, shaming, humiliation": Stigmatising medical interactions among people with non-epileptic seizures. Wellcome Open Res 2017. [PMID: 29152594 DOI: 10.12688/wellcomeopenres.12133.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: People with non-epileptic seizures (NES) describe challenging relationships with health professionals, and explain negative interactions as common and expected. Despite these difficulties, little is known about how people with NES experience difficult healthcare encounters. Methods: Using a thematic discourse analysis approach, we analysed the free-text survey responses of 135 people with NES and asked: what kind of challenges do people living with this condition encounter when interacting with health professionals, and how do they experience the consequences of difficult interactions? We explore their experiences by interpreting the latent meaning of participants' texts from a social-constructionist perspective on health and illness. Results: The overarching narrative depicts a fundamental breakdown in patient-provider relationships. According to our data, the negative experiences of study participants emerge from more than practitioners' lack of awareness of NES and access to information about the condition - to the extent that it is available. In examining the challenges people with NES encounter when interacting with health professionals, their main experiences centre on blame and humiliation. When exploring their experiences, theories of stigma serve as a useful theoretical framework. Conclusions: Normative judgements arising from psychogenic understandings of NES are stigmatising and restrict professional displays of respectful (patient-centred) care. Those with the condition depict being negatively stereotyped, illegitimated and held morally culpable by health professionals. Perceived to lack medical, moral and credible status, participants describe practitioners who treat them with disrespect, and some recount conduct that defies all ethical and professional obligations and standards. These encounters can have wide-ranging adverse consequences for patients: emotionally, physically, and for their future healthcare. The quality of healthcare interactions for people with NES requires urgent improvements. In addition to increased awareness of the condition, practitioners need to be conscious of making and acting on adverse moral appraisals when interacting with this patient group.
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Affiliation(s)
- Catherine Robson
- Department of Research Capacity Development, Nelson Mandela University, Port Elizabeth, South Africa.,Department of Community Medicine, Faculty of Health Sciences, University of Tromsø - The Arctic University of Norway, Tromsø, Norway
| | - Olaug S Lian
- Department of Community Medicine, Faculty of Health Sciences, University of Tromsø - The Arctic University of Norway, Tromsø, Norway
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Polk S, Horwitz R, Longway S, Bonilla A, Fothergill K, Karver M, Salmon P, Wissow L. Surveillance or Engagement: Children's Conflicts During Health Maintenance Visits. Acad Pediatr 2017; 17:739-746. [PMID: 28213132 DOI: 10.1016/j.acap.2017.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 02/01/2017] [Accepted: 02/08/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVE School-aged health maintenance visits seek to prevent or intervene early with health issues of lifelong importance. Little is known about what children expect to happen in these visits or how they experience them, factors related to their engagement as active collaborators in care. METHODS Thirty children (53% Latino, 27% African-American, and 20% white) ages 7 to 11 years were video recorded during a health maintenance visit and then interviewed while reviewing the videos. Interview transcripts were analyzed for understanding the purpose of the visit, feelings of comfort and discomfort, and decisions about how much to participate. RESULTS Children expected doctors to be helpful, caring, and a source of important information. They anticipated visits to include immunizations, a physical examination, and praise for accomplishments, but could be surprised by questions about behavior, family function, and lifestyle. During visits, feelings varied from warmth toward providers to embarrassment, wariness, irritation, and boredom. Even when bored or irritated, children hesitated to interrupt parent-provider conversations or correct perceived provider misunderstandings, not wanting to be seen as inappropriate or rude. When asked questions they considered off topic, likely to reveal sensitive information, or that could lead to changes in their lifestyle, some were silent or answered evasively. Some said they would have spoken more freely without their parent present but valued parental support and wanted parents to make important decisions. CONCLUSIONS School-aged children's limited knowledge of what to expect in health maintenance visits, uncertainty about conversational norms with adults, and desire to assert control over their lives compete with their desire to access expert advice and form bonds with providers. Engaging children in health maintenance visits might require more relationship-building and education about the visit's goals.
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Affiliation(s)
- Sarah Polk
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Md; Department of Pediatrics, Johns Hopkins Bayview Medical Center, Baltimore, Md.
| | - Russell Horwitz
- Department of Psychiatry, Johns Hopkins School of Medicine, Baltimore, Md; The Johns Hopkins Hospital, Baltimore, Md
| | - Shaina Longway
- Center for Mental Health and Pediatric Primary Care, Johns Hopkins School of Public Health, Baltimore, Md
| | - Alfonso Bonilla
- Center for Mental Health and Pediatric Primary Care, Johns Hopkins School of Public Health, Baltimore, Md
| | - Kate Fothergill
- Center for Mental Health and Pediatric Primary Care, Johns Hopkins School of Public Health, Baltimore, Md
| | - Marc Karver
- Department of Psychology, University of South Florida, Tampa
| | - Peter Salmon
- Department of Clinical Psychology, University of Liverpool, Liverpool, United Kingdom
| | - Lawrence Wissow
- Center for Mental Health and Pediatric Primary Care, Johns Hopkins School of Public Health, Baltimore, Md
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Mitchell MM, Nguyen TQ, Maragh-Bass AC, Isenberg SR, Beach MC, Knowlton AR. Patient-Provider Engagement and Chronic Pain in Drug-Using, Primarily African American Persons Living with HIV/AIDS. AIDS Behav 2017; 21:1768-1774. [PMID: 27787673 DOI: 10.1007/s10461-016-1592-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Among disadvantaged persons living with HIV/AIDS (PLHIV), patient-provider engagement, which has been defined as patient-provider relationships that promote the use of health care services and are characterized by active listening and supportive decision making, has been associated with antiretroviral therapy (ART) maintenance and viral suppression. However, chronic pain, depression, and substance use, all of which are prevalent in this population, can reduce the quality of patient-provider engagement. We hypothesized a model in which chronic pain, depression, and substance use would be associated with poorer patient-provider engagement, which would be positively associated with adherence, with the latter associated positively with viral suppression. We analyzed data from the BEACON study, which included surveys from 383 PLHIV who were primarily African American, on ART, and had histories of drug use. Due to six missing cases on the chronic pain variable, we used data from 377 respondents in a structural equation model. Chronic pain and depressive symptoms were significantly associated with poorer patient-provider engagement, while substance use was associated with better engagement. Patient-provider engagement in turn was associated with better ART adherence, which was associated with higher viral suppression. Results suggest the role of chronic pain in poor patient-physician engagement in this population, which has potential implications for quality of HIV patient care and health outcomes. Findings suggest the need for attention to patient-provider engagement in PLHIV.
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Affiliation(s)
- Mary M Mitchell
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 2213 McElderry St., 2nd Floor, Baltimore, MD, 21205, USA.
| | - Trang Q Nguyen
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Allysha C Maragh-Bass
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 2213 McElderry St., 2nd Floor, Baltimore, MD, 21205, USA
| | - Sarina R Isenberg
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 2213 McElderry St., 2nd Floor, Baltimore, MD, 21205, USA
| | | | - Amy R Knowlton
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Room 745, Baltimore, MD, 21205, USA
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Yon K, Habermann S, Rosenthal J, Walters KR, Nettleton S, Warner A, Lamahewa K, Buszewicz M. Improving teaching about medically unexplained symptoms for newly qualified doctors in the UK: findings from a questionnaire survey and expert workshop. BMJ Open 2017; 7:e014720. [PMID: 28450466 PMCID: PMC5719648 DOI: 10.1136/bmjopen-2016-014720] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Medically unexplained symptoms (MUS) present frequently in healthcare, can be complex and frustrating for clinicians and patients and are often associated with overinvestigation and significant costs. Doctors need to be aware of appropriate management strategies for such patients early in their training. A previous qualitative study with foundation year doctors (junior doctors in their first 2 years postqualification) indicated significant lack of knowledge about this topic and appropriate management strategies. This study reviewed whether, and in what format, UK foundation training programmes for newly qualified doctors include any teaching about MUS and sought recommendations for further development of such training. DESIGN Mixed-methods design comprising a web-based questionnaire survey and an expert consultation workshop. SETTING Nineteen foundation schools in England, Wales and Northern Ireland PARTICIPANTS: Questionnaire administered via email to 155 foundation training programme directors (FTPDs) attached to the 19 foundation schools, followed by an expert consultation workshop attended by 13 medical educationalists, FTPDs and junior doctors. RESULTS The 53/155 (34.2%) FTPDs responding to the questionnaire represented 15 of the 19 foundation schools, but only 6/53 (11%) reported any current formal teaching about MUS within their programmes. However, most recognised the importance of providing such teaching, suggesting 2-3 hours per year. All those attending the expert consultation workshop recommended case-based discussions, role-play and the use of videos to illustrate positive and negative examples of doctor-patient interactions as educational methods of choice. Educational sessions should cover the skills needed to provide appropriate explanations for patients' symptoms as well as avoid unnecessary investigations, and providing information about suitable treatment options. CONCLUSIONS There is an urgent need to improve foundation level training about MUS, as current provision is very limited. An interactive approach covering a range of topics is recommended, but must be delivered within a realistic time frame for the curriculum.
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Affiliation(s)
- Katherine Yon
- Research Department of Primary Care and Population Health, UCL, London, UK
| | | | - Joe Rosenthal
- Research Department of Primary Care and Population Health, UCL, London, UK
| | - Kate R Walters
- Research Department of Primary Care and Population Health, UCL, London, UK
| | | | - Alex Warner
- Research Department of Primary Care and Population Health, UCL, London, UK
| | - Kethakie Lamahewa
- Research Department of Primary Care and Population Health, UCL, London, UK
| | - Marta Buszewicz
- Research Department of Primary Care and Population Health, UCL, London, UK
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Houwen J, Lucassen PLBJ, Stappers HW, Assendelft PJJ, van Dulmen S, Olde Hartman TC. Medically unexplained symptoms: the person, the symptoms and the dialogue. Fam Pract 2017; 34:245-251. [PMID: 28122842 DOI: 10.1093/fampra/cmw132] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Many general practitioners (GPs) find the care for patients with medically unexplained symptoms (MUS) challenging. The patients themselves are often not satisfied with the care they receive. OBJECTIVES The aim of this study is to explore what patients with MUS expect from their GP by looking at relevant communication elements in consultations as identified by patients. METHODS We video-recorded everyday consultations with GPs and asked the GPs immediately after the consultation whether MUS were presented. The patients in these MUS consultations were asked to reflect on the consultation during a semi-structured interview while watching a recording of their own MUS consultation. The interviews were analysed qualitatively according to the principles of constant comparative analysis. RESULTS Of the 393 video-recorded consultations, 43 concerned MUS. All MUS patients said that they wanted to be taken seriously. According to the patients, their feeling of being taken seriously is enhanced when the GP: (i) pays empathic attention to them as individuals, meaning that the GP knows their personal circumstances and has an open and empathic approach, (ii) ensures a good conversation by treating the patient as an equal partner and (iii) is attentive to their symptoms by exploring these symptoms in depth and by acting on them. CONCLUSION Like chronic patients, patients with MUS value a personalised approach in which GPs pay attention to patients' personal circumstances, to proper somatic management of their symptoms and to a proper conversation in which they are treated as equal partners. Use of these basic consultation skills may greatly improve care of MUS patients.
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Affiliation(s)
- Juul Houwen
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Peter L B J Lucassen
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Hugo W Stappers
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Pim J J Assendelft
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Sandra van Dulmen
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.,NIVEL (Netherlands institute for health services research), Utrecht, The Netherlands.,Faculty of Health Sciences, University College of Southeast Norway, Drammen, Norway
| | - Tim C Olde Hartman
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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Town JM, Lomax V, Abbass AA, Hardy G. The role of emotion in psychotherapeutic change for medically unexplained symptoms. Psychother Res 2017; 29:86-98. [PMID: 28287345 DOI: 10.1080/10503307.2017.1300353] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES Evidence of the contribution of emotional processes to the emergence, maintenance, and experience of medically unexplained symptoms (MUS) suggests that clinical approaches which target these processes could be beneficial. In this study, qualitative methods were used to examine patients' perspectives and subjective experiences of emotional processes in the context of a psychotherapy assessment and treatment service for MUS provided in a hospital emergency department (ED). METHODS Seven semi-structured interviews were conducted with ED patients presenting with MUS who received a course of intensive short-term dynamic psychotherapy treatment. RESULTS Interpretative phenomenological analysis was employed with three superordinate themes emerging: Barriers to examining emotional processes; reflections on the therapeutic process; psychological change; and improved well-being. Obstacles to clinical engagement in treatment for MUS were described in relation to patients' and therapists' ability to identify, address, and utilize emotion processes. Specific elements of this work were identified as integral components of the psychotherapy change process for MUS. CONCLUSIONS Directly observing the physical effects of emotional experiencing in MUS provides sensory evidence that can enable patients to make mind-body connections. Psycho-emotional processes warrant further study to explore the applicability to other conceptual models for assessing and treating MUS. Clinical and methodological significance: In this article, we highlight that Medically Unexplained Symptoms (MUS) are a priority area for both physical and mental health care services. We present findings relevant to the effectiveness of a novel psychotherapy innovation within a hospital emergency department (ED). The use of interpretative phenomenological analysis to study the experiences of ED clients with MUS offers an established qualitative method for exploring the processes underlying therapeutic change. The results provide new insights around obstacles to engagement alongside potential solutions when addressing the psychological needs of clients with MUS. Although emotion processes have been described as a potentially important change process for MUS and in psychotherapy more generally, little empirical research has studied these two areas collectively.
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Affiliation(s)
- Joel M Town
- a Centre for Emotions & Health, Department of Psychiatry , Dalhousie University , Halifax , Canada.,b Clinical Trials and Population Studies , Plymouth University Peninsula Schools of Medicine and Dentistry , Plymouth , UK
| | - Victoria Lomax
- c Department of Psychology , University of Sheffield , Sheffield , UK
| | - Allan A Abbass
- a Centre for Emotions & Health, Department of Psychiatry , Dalhousie University , Halifax , Canada
| | - Gillian Hardy
- c Department of Psychology , University of Sheffield , Sheffield , UK
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