Doctors' attachment style and their inclination to propose somatic interventions for medically unexplained symptoms

Attachment styles and healthcare utilization: exploring the role of the patient-doctor relationship

BACKGROUND

With the purpose of improving healthcare, past research has examined the link between healthcare utilization and attachment. It is suggested that an individual's attachment style influences both the quality of their patient-physician relationship and healthcare utilization patterns. Nevertheless, most studies concentrate on the individual aspect, overlooking the dyadic dimension; specifically, the investigation of how insecure attachment relates to health behavior within patient-physician relationships. This gap leaves the role of the patient-doctor relationship in this process unclear. Therefore, to elucidate this complex interplay, we hypothesized that the correlation between attachment and healthcare utilization is mediated by the quality of the patient-physician-relationship.

METHOD

Participant selection was based on electoral districts, a random-route procedure, and the Kish selection grid. The participants were visited by a trained interviewer who collected psychometric and sociodemographic information. Participants answered the Experiences in Close Relationships-Revised questionnaire (ECR-RD8) and the Patient-Doctor Relationship Questionnaire (PDRQ-9). Additionally, participants were asked about their healthcare utilization. The final sample consisted of N = 2.275 participants.

RESULTS

In average the participants reported consulting their primary health care practitioner M(SD) = 4.44 (4.76) times in the past 12 months. Generally, the participants rated the quality of the relationship with their primary health care practitioner close to "totally appropriate" (M = 4.12 ± .69). The degree of insecure attachment manifested towards the lower extremity of the scale. The total effect of the mediation analyses was significant. Regardless, the indirect effect indicated a trend result with minimal effect sizes.

CONCLUSION

The findings of the current study bridged the gap between attachment styles and healthcare utilization. Nonetheless, our results suggested insufficient support for the mediating role of the primary care physician in the relationship between attachment style and healthcare utilization. Considering the characteristics of the sample, this outcome may not apply in a clinical context. However, further research is needed to shed light in the revealed trends and indicate implications.

[Attachment Characteristics and Speciality Choice among Medical Students]

OBJECTIVES

Based upon a study by Ciechanowski et al. [27], a parallel survey was performed at the medical school of the University of Jena with the goal to determine a relationship between specialty choice and attachment characteristics among medical students.

METHOD

A sample of 411 medical students from different phases of the medical training (73,2% females, mean age: 22.7 yrs.) were asked about their current specialty choice and invited to describe themselves in three different attachment questionnaires. These were the Relationship Style Questionnaire (RSQ), the Bielefeld Partnership Expectation Questionnaire and the Relationship-specific Attachment Scales for adults in the versions related to the mother and the partner. In comparing subgroups, we first used Ciechanowski et al.'s [27] differentiation of specialty contrasting primary and non-primary care specialties. In addition, a categorization of Buddeberg-Fischer et al. [29] differentiating a total of 7 subgroups was used (general medicine, internal medicine, surgery, anesthesiology/emergency medicine, pediatrics, psychiatry/neurology and obstetrics/gynecology).

RESULTS

Comparing the groups according to Ciechanowski et al.'s categorization, differences occurred that were not replicating the original study: Students of the first subgroup (primary care) appeared to be more insecurely attached (according to the RSQ) and showed higher scores in subscales indicating dependency and preoccupation (e. g. fear of separation, dependently related to mother and partner). Similar as in Ciechanowski's study, the second group (non-primary care) revealed more individuals categorized as avoidant (or self-reliant). To differentiate the picture, the 7 categories according to Buddeberg-Fischer et al. [27] were compared. This comparison indicated that future pediatricians were classified as more insecure and ambivalent, whereas anesthesiologists more commonly were avoidant and dismissing. This picture was confirmed using comparisons of the questionnaire subscales. Since gender differences occurred both, related to specialty choice as well as attachment, gender was considered as a covariate in the analyses.

CONLUSIONS

In contrast to the study of Ciechanowski et al. [27], future pediatricians as part of the primary care group were characterized by a tendency to be dependent and preoccupied in all attachment measures, whereas the result of a tendency to be more avoidant and self-reliant among anesthesiologists and students choosing emergency medicine was more in line with the US-American study. Future research dealing with the motivation to choose specific fields of action in medicine should consider other psychological characteristics as well as biographical aspects.

Behavioural modification interventions for medically unexplained symptoms in primary care: systematic reviews and economic evaluation

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.

Development of the concept of patient-centredness - A systematic review

OBJECTIVE

Patient-centredness is often linked to high-quality patient care, but the concept is not well-defined. This study aims to provide an overview of how patient-centredness has been defined in the literature since Mead and Bower's review in 2000, and to provide an updated definition of the concept.

METHOD & DESIGN

We performed a systematic literature search in PubMed to identify original articles with a sufficient definition of patient-centredness. We analysed extracted data defining patient-centredness.

RESULTS

Eighty articles were included. The dimensions "biopsychosocial", "patient-as-person", "sharing power and responsibility" and "therapeutic alliance" corresponded to four of five dimensions described by Mead and Bower. "Coordinated care" was a new dimension.

CONCLUSION

The identified dimensions are encompassed by three elements: the patient, the doctor-patient relationship and the framework of care i.e. the health care system. The additional focus on coordinated care could reflect increasing complexity of the health care system.

PRACTICE IMPLICATIONS

Narrowing down the understanding of patient-centredness to these three focus areas, viz. 1) understanding of the patients' experience of the illness in their life situation, 2) the professional's relationship with the patient, and 3) coordination of care in the system, could make the operationalisation and implementation of a patient-centred approach more manageable.

Epistemological and methodological paradoxes: secondary care specialists and their challenges working with adolescents with medically unexplained symptoms

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.

Do doctors' attachment styles and emotional intelligence influence patients' emotional expressions in primary care consultations? An exploratory study using multilevel analysis

OBJECTIVE

To investigate whether and how doctors' attachment styles and emotional intelligence (EI) might influence patients' emotional expressions in general practice consultations.

METHODS

Video recordings of 26 junior doctors consulting with 173 patients were coded using the Verona Coding Definition of Emotional Sequences (VR-CoDES). Doctors' attachment style was scored across two dimensions, avoidance and anxiety, using the Experiences in Close Relationships: Short Form questionnaire. EI was assessed with the Mayer-Salovey-Caruso Emotional Intelligence Test. Multilevel Poisson regressions modelled the probability of patients' expressing emotional distress, considering doctors' attachment styles and EI and demographic and contextual factors.

RESULTS

Both attachment styles and EI were significantly associated with frequency of patients' cues, with patient- and doctor-level explanatory variables accounting for 42% of the variance in patients' cues. The relative contribution of attachment styles and EI varied depending on whether patients' presenting complaints were physical or psychosocial in nature.

CONCLUSION

Doctors' attachment styles and levels of EI are associated with patients' emotional expressions in primary care consultations. Further research is needed to investigate how these two variables interact and influence provider responses and patient outcomes.

PRACTICE IMPLICATIONS

Understanding how doctors' psychological characteristics influence PPC may help to optimise undergraduate and postgraduate medical education.

The role of attachment in medically unexplained symptoms and long-term illness

In this article, we explore the role of attachment in the development of medically unexplained symptoms (MUS) and response to physical illness. We review the evidence that attachment insecurity is common in people with different forms of MUS and certain long-term physical conditions. We discuss a possible developmental model for understanding how MUS develop. We conclude with discussion of potential therapies and implications for services.

Data quality and factor analysis of the Danish version of the Relationship Scale Questionnaire

Background

The Relationship Scale Questionnaire (RSQ) is a widely-used measure of adult attachment, but whether the results obtained by the RSQ fit the attachment construct has only been examined to a limited extent.

Objective

The objectives of this study were to investigate the psychometric properties of the Danish translation of the RSQ and to test whether the results are consistent with the hypothesized model of attachment.

Methods

The study included two samples: 602 general practitioners and 611 cancer patients. The two samples were analyzed separately. Data quality was assessed by mean, median and missing values for each item, floor and ceiling effects, average inter-item correlations and Cronbach’s α for each subscale. Test-retest was assessed by intra-class correlations among 76 general practitioners. A confirmatory factor analysis was conducted to establish evidence of the four proposed subscales. Due to an inadequate fit of the model, data was randomly split into two equally sized subsamples and an exploratory factor analysis was conducted for all 30 items in the first subsample comprised of 286 cancer patients and 285 general practitioners. The EFA yielded a three-factor structure which was validated through a confirmatory factor analyses in a second subsample comprised of 278 cancer patients and 289 general practitioners.

Results

The data quality of the RSQ was generally good, except low internal consistency and low to moderate test-retest reliability. The four subscales of the RSQ were not confirmed by the confirmatory factor analysis. An exploratory factor analysis suggested a three-factor solution for both general practitioners and patients, which accounted for 61.1% of the variance among general practitioners and 62.5% among patients. The new three-factor solution was verified in a confirmatory factor analyses.

Conclusion

The proposed four-factor model of the RSQ could not be confirmed in this study. Similar challenges have been found by other studies validating the RSQ. An alternative three-factor structure was found for the RSQ.

Attachment styles and clinical communication performance in trainee doctors

OBJECTIVE

To investigate the relationship between trainee doctors' attachment style and their performance in qualifying clinical and communication skills assessments.

METHODS

Participants were 190 undergraduate medical students whose performance was assessed by examiners across two areas (communication and clinical skills) during their qualifying Objective Structured Clinical Examination (OSCE). Simulated patients also rated communication skills. Participants' attachment style was rated across two dimensions, avoidance and anxiety, using the Relationship Questionnaire (RQ).

RESULTS

Lower levels of attachment avoidance and anxiety significantly predicted higher performance in both communication and clinical skills.

CONCLUSION

Trainee doctors' attachment styles are associated with patient communication and clinical performance. Further research is needed to investigate the impact of attachment on consultations between doctors and patients within clinical settings.

PRACTICE IMPLICATION

Attachment theory can inform our understanding why, for some student doctors, interacting with patients may be particularly challenging and require additional support by medical educators.

Managing Medically Unexplained Symptoms in Primary Care: A Narrative Review and Treatment Recommendations

Medically unexplained symptoms (MUS) are persistent physical symptoms in the absence of identifiable disease. MUS present a major challenge for primary care providers (PCPs) because complex symptom presentations, strained patient-physician relationships, and treatment-resistant symptoms can challenge a PCP's sense of competency. This review is intended to help PCPs understand the burden and theoretical context of MUS and to provide concise recommendations for managing MUS within primary care settings. Based on a narrative review of the literature, these recommendations emphasize in particular the importance of co-creating plausible explanations for MUS, understanding the pitfalls of consultations involving MUS, and developing multimodal treatment plans.

Validating relationships among attachment, emotional intelligence and clinical communication

CONTEXT

In a previous study, we found that emotional intelligence (EI) mediates the negative influences of Year 1 medical students' attachment styles on their provider-patient communication (PPC). However, in that study, students were examined on a relatively straightforward PPC skill set and were not assessed on their abilities to elicit relevant clinical information from standardised patients. The influence of these psychological variables in more demanding and realistic clinical scenarios warrants investigation.

OBJECTIVES

This study aimed to validate previous research findings by exploring the mediating effect of EI on the relationship between medical students' attachment styles and their PPC across an ecologically valid PPC objective structured clinical examination (OSCE).

METHODS

Year 2 medical students completed measures of attachment (the Experiences in Close Relationships-Short Form [ECR-SF], a 12-item measure which provides attachment avoidance and attachment anxiety dimensional scores) and EI (the Mayer-Salovey-Caruso Emotional Intelligence Test [MSCEIT], a 141-item measure on the perception, use, understanding and management of emotions), prior to their summative PPC OSCE. Provider-patient communication was assessed using OSCE scores. Structural equation modelling (SEM) was used to validate our earlier model of the relationships between attachment style, EI and PPC.

RESULTS

A total of 296 of 382 (77.5%) students participated. Attachment avoidance was significantly negatively correlated with total EI scores (r = -0.23, p < 0.01); total EI was significantly positively correlated with OSCE scores (r = 0.32, p < 0.01). Parsimonious SEM confirmed that EI mediated the negative influence of attachment avoidance on OSCE scores. It significantly predicted 14% of the variance in OSCE scores, twice as much as the 7% observed in the previous study.

CONCLUSIONS

In more demanding and realistic clinical scenarios, EI makes a greater contribution towards effective PPC. Attachment is perceived to be stable from early adulthood, whereas EI can be developed using targeted educational interventions. The validation of this theoretical model of PPC in Year 2 medical students strengthens the potential educational implications of EI.

What is called symptom?

There is one concept in medicine which is prominent, the symptom. The omnipresence of the symptom seems, however, not to be reflected by an equally prominent curiosity aimed at investigating this concept as a phenomenon. In classic, traditional or conventional medical diagnostics and treatment, the lack of distinction with respect to the symptom represents a minor problem. Faced with enigmatic conditions and their accompanying labels such as chronic fatigue syndrome, fibromyalgia, medically unexplained symptoms, and functional somatic syndromes, the contestation of the symptom and its origin is immediate and obvious and calls for further exploration. Based on a description of the diagnostic framework encompassing medically unexplained conditions and a brief introduction to how such symptoms are managed both within and outside of the medical clinic, we argue on one hand how unexplained conditions invite us to reconsider and re-think the concept we call a "symptom" and on the other hand how the concept "symptom" is no longer an adequate and necessary fulcrum and must be enriched by socio-cultural, phenomenological and existential dimensions. Consequently, our main aim is to expand both our interpretative horizon and the linguistic repertoire in the face of those appearances we label medically unexplained symptoms.

Medically unexplained symptoms: the need for effective communication and an integrated care strategy

Much is already known about medically unexplained symptoms (MUS) in terms of incidence, presentation and current treatment. What needs to be urgently addressed is a strategy for dealing with patients and their conditions, particularly when they do not fall neatly into medical frameworks or pathologies where the syndrome can be easily explained. This article will consider the provision of health and social care support for patients with MUS within an interprofessional education context. The author will contend that a sensitive and valued service for this large client group is dependent upon services without professional boundaries and practitioners with a clinical interest that can work together and agree an appropriate way forward in terms of care, support and strategic service provision. The article will support the idea that clear guidelines through the National Institute for Health and Care Excellence can offer clear clinical direction for practitioners working in primary and secondary care settings to work together interprofessionally to ensure a seamless and sensitive service for people with this condition.

The influence of medical students' and doctors' attachment style and emotional intelligence on their patient-provider communication

OBJECTIVE

Attachment style and emotional intelligence (EI) have been highlighted as potential factors influencing the variation in medical students' and doctors' patient-provider communication (PPC), particularly in relation to emotive issues. The objective of this review is to systematically review and synthesise the published literature relating to the influence of medical students' and/or doctors' attachment style and EI on their PPC.

METHODS

Electronic and hand searches were conducted to identify all published literature relating to the aim of the review. Data were narratively synthesised.

RESULTS

1597 studies were identified. 14 were included in the review, of which 5 assessed the influence of attachment style and 9 assessed the influence of EI on PPC. No studies assessed the impact of both attachment style and EI on PPC.

CONCLUSION

Whilst tentative links were found between both PPC and both attachment style and EI, heterogeneity in study design, predictor variables and outcome measures made drawing conclusions difficult.

PRACTICE IMPLICATIONS

More research is needed to assess the influence of both attachment style and EI on PPC.

What do medical trainees think is so difficult about communicating with patients?

OBJECTIVE

To identify the communication skills medical trainees perceive themselves to avoid or use during initial clinical encounters and the areas of communication learning need they identify.

METHODS

446 2nd year undergraduate medical students were invited to take part in the study. Details of four encounters with patients were entered into a web-based electronic logbook by the student. Details included perception of use, success and requests for further training from a list of communication process skills.

RESULTS

395 (89%) students took part. Factor analysis yielded three types of skills: those used to manage the flow of interaction; the emotional content of the interaction; and structuring the interaction. Skills perceived as being used least often and least successfully and identified by the students as requiring further training were primarily those that involved managing the emotional aspects of interactions with patients rather than managing the flow of information.

CONCLUSION

Communication training should focus further on the emotional aspects of patient interactions in order to support students during early clinical encounters.

PRACTICE IMPLICATIONS

Skills required to manage emotional encounters need to be made more explicit to students. Opportunities to obtain feedback and develop competency should be offered as part of the core curriculum.

Reattribution reconsidered: narrative review and reflections on an educational intervention for medically unexplained symptoms in primary care settings

OBJECTIVE

Medically unexplained symptoms (MUS) refer to bodily symptoms without a physical health explanation. In the context of MUS, reattribution is a process of attributing physical symptoms to a psychological cause. We review the use of a consultation model which employs reattribution, and which has been extensively utilised in teaching and research in primary care.

METHODS

Literature search for studies utilising the reattribution model. Narrative review of the results.

RESULTS

Data was extracted from 25 publications from 13 studies. The model has been modified over time and comparison between studies is limited by differences in methodology. The skills of the model can be acquired by training, which also improves practitioners' attitudes to MUS. However impact on clinical outcomes has been mixed and this can be explained in part from the findings of nested qualitative studies.

CONCLUSIONS

The reattribution model is too simplistic in its current form to address the needs of many people presenting with MUS in primary care. Reattribution of physical symptoms to psychological causes is often unnecessary. Further research is required into the effectiveness of stepped and collaborative care models in which education of primary care practitioners forms one part of a complex intervention. The consultation process is best seen as both a conversation and ongoing negotiation between doctor and patient in which there are no certainties about the presence or absence of organic pathology.

Noninvasive radioelectric asymmetric brain stimulation in the treatment of stress-related pain and physical problems: psychometric evaluation in a randomized, single-blind placebo-controlled, naturalistic study

Background

The aim of this study was to investigate the effects of noninvasive radioelectric asymmetric conveyer brain stimulation (REAC-BS) on pain and physical problems, a measurement cluster of the Psychological Stress Measure (PSM) test. When the symptoms of pain and physical problems do not respond to various therapeutic approaches such as medication, physiotherapy, and psychotherapy, they are often called medically unexplained symptoms. As such, these symptoms are reported to be a response to stressful situations or emotional states, often unknown to patients themselves. To explore the effectiveness of noninvasive radioelectric brain stimulation in the amelioration of symptoms of pain and physical problems, we administered a neuropsychophysical optimization protocol using a REAC device.

Methods

The PSM, a self-administered questionnaire, was used to measure psychological stress and pain and physical problems in a group of 888 subjects. Data were collected immediately prior to and following a 4-week REAC treatment cycle.

Results

There was a significant reduction in scores measuring subjective perceptions of stress for subjects treated with one cycle of neuropsychophysical optimization REAC-BS. At the end of the study, the number of treated subjects reporting symptoms of stress-related pain and physical problems on the PSM test was significantly reduced, whereas there was no difference in placebo-treated subjects.

Conclusion

One cycle of neuropsychophysical optimization REAC-BS appears to reduce subjective perceptions of stress as measured by the PSM, particularly on the pain and physical problems cluster.

Effect of attachment styles of individuals discharged from an intensive care unit on intensive care experience

INTRODUCTION

The present study was conducted as a cross-sectional type to examine the effect of attachment styles of individuals discharged from an intensive care unit (ICU) on intensive care experience and health status.

METHODS

The population of the study included patients discharged from the ICU in a university hospital. The sample included 108 patients who were selected via simple random sampling method. Data were collected using a Demographic Information Questionnaire, Intensive Care Experience Questionnaire, the Relationship Scales Questionnaire, and Acute Physiology and Chronic Health Evaluation II system. In the analysis of data, frequency, percentage, mean, standard deviation, minimum and maximum values, and Mann-Whitney U, Kruskal-Wallis, Bonferroni-adjusted Mann-Whitney, and Spearman ρ correlation tests were used.

RESULTS

A significant difference in the awareness of surroundings subscale for attachment styles was noted (χ(2) = 10.820, P ≤ .01). Moreover, participants' attachment styles (fearful, preoccupied, and dismissing) and intensive care experience were significantly correlated. A significant correlation was found between participants' secure attachment style points and Acute Physiology and Chronic Health Evaluation II score during discharge from the ICU (r = 0.322, P = .001).

CONCLUSION

Individuals' attachment styles should be taken into consideration when planning and implementing the nursing care and treatment of individuals hospitalized in an ICU.

Attachment in the doctor-patient relationship in general practice: a qualitative study

OBJECTIVE

To explore why interpersonal continuity with a regular doctor is valuable to patients.

DESIGN, SETTING, AND SUBJECTS

A qualitative study based on 22 interviews with patients, 12 who saw their regular general practitioner (GP) and 10 who saw an unfamiliar GP. The patients were selected after an observed consultation and sampled purposively according to reason for encounter, age, and sex. The research question was answered by means of psychological theory.

RESULTS

A need for attachment was a central issue for the understanding of the value of interpersonal continuity for patients. The patients explained that they preferred to create a personal relationship with their GP and the majority expressed a degree of vulnerability in the doctor-patient relationship. The more sick or worried they were the more vulnerable and the more in need of a regular GP. Furthermore, patients stated that it was difficult for them to change GP even if they had a poor relationship.

CONCLUSION

Attachment theory may provide an explanation for patients' need to see a regular GP. The vulnerability of being a patient creates a need for attachment to a caregiver. This need is fundamental and is activated in adults when they are sick or scared.

In their own words: qualitative study of high-utilising primary care patients with medically unexplained symptoms

BACKGROUND

High utilising primary care patients with medically unexplained symptoms (MUS) often frustrate their primary care providers. Studies that elucidate the attitudes of these patients may help to increase understanding and improve confidence of clinicians who care for them. The objective of this study was to describe and analyze perceptions and lived experiences of high utilising primary care patients with MUS.

METHODS

A purposive sample of 19 high utilising primary care patients for whom at least 50% (69.6% in this sample) of visits for two years could not be explained medically, were encouraged to talk spontaneously about themselves and answer semi-structured questions. Verbatim transcripts of interviews were analyzed using an iterative consensus building process.

RESULTS

Patients with MUS almost universally described current and/or past family dysfunction and were subjected to excessive testing and ineffective empirical treatments. Three distinct groups emerged from the data. 1) Some patients, who had achieved a significant degree of psychological insight and had success in life, primarily sought explanations for their symptoms. 2) Patients who had less psychological insight were more disabled by their symptoms and felt strongly entitled to be excused from normal social obligations. Typically, these patients primarily sought symptom relief, legitimization, and support. 3) Patients who expressed worry about missed diagnoses demanded excessive care and complained when their demands were resisted.

CONCLUSION

High utilising primary care patients are a heterogeneous group with similar experiences and different perceptions, behaviours and needs. Recognizing these differences may be critical to effective treatment and reduction in utilisation.

The analysis of verbal interaction sequences in dyadic clinical communication: a review of methods

OBJECTIVE

To identify methods available for sequential analysis of dyadic verbal clinical communication and to review their methodological and conceptual differences.

METHODS

Critical review, based on literature describing sequential analyses of clinical and other relevant social interaction.

RESULTS

Dominant approaches are based on analysis of communication according to its precise position in the series of utterances that constitute event-coded dialogue. For practical reasons, methods focus on very short-term processes, typically the influence of one party's speech on what the other says next. Studies of longer-term influences are rare. Some analyses have statistical limitations, particularly in disregarding heterogeneity between consultations, patients or practitioners. Additional techniques, including ones that can use information about timing and duration of speech from interval-coding are becoming available.

CONCLUSION

There is a danger that constraints of commonly used methods shape research questions and divert researchers from potentially important communication processes including ones that operate over a longer-term than one or two speech turns. Given that no one method can model the complexity of clinical communication, multiple methods, both quantitative and qualitative, are necessary.

PRACTICE IMPLICATIONS

Broadening the range of methods will allow the current emphasis on exploratory studies to be balanced by tests of hypotheses about clinically important communication processes.

Dependence and caring in clinical communication: the relevance of attachment and other theories

OBJECTIVE

Clinical relationships are usually asymmetric, being defined by patients' dependence and practitioners' care. Our aims are to: (i) identify literature that can contribute to theory for researching and teaching clinical communication from this perspective; (ii) highlight where theoretical development is needed; and (iii) test the utility of the emerging theory by identifying whether it leads to implications for educational practice.

METHODS

Selective and critical review of research concerned with dependence and caring in clinical and non-clinical relationships.

RESULTS

Attachment theory helps to understand patients' need to seek safety in relationships with expert and authoritative practitioners but is of limited help in understanding practitioners' caring. Different theories that formulate practitioners' care as altruistic, rewarded by personal connection or as a contract indicate the potential importance of practitioners' emotions, values and sense of role in understanding their clinical communication.

CONCLUSION

Extending the theoretical grounding of clinical communication can accommodate patients' dependence and practitioners' caring without return to medical paternalism.

PRACTICE IMPLICATIONS

A broader theoretical base will help educators to address the inherent subjectivity of clinical relationships, and researchers to distinguish scientific questions about how patients and clinicians are from normative questions about how they should be.

From consultation-liaison psychiatry to integrated care for multiple and complex needs

The aim of the present study was to review the ways in which contemporary medicine addresses physical/psychiatric multimorbidity, to review the underlying concepts and methodologies used, and to propose a novel approach that may help consultation-liaison psychiatry (CLP) position itself better in the health-care field. A Medline search of the terms 'consultation-liaison psychiatry', 'integrated care', 'quality assurance' and 'qualitative methodology', was complemented by study of the literature on complexity theory and by discussions with colleagues in both the health science and sociology fields. There is a growing realization that presentation with multimorbidity of both physical and psychiatric disorders is the norm. Other health-care disciplines have responded quickly to meeting the multiple and complex needs of such patients, attracting funding to an extent that CLP has been unable to achieve. Uncritical application, however, of integrated care technology based on evidence from randomized controlled trials has produced disappointing results. There is a growing realization that such quantitative methods need to be complemented by in-depth exploration using non-traditional methods including qualitative ones, and drawing on complexity theory. The Cochrane Collaboration is exploring this. As CLP and other medical and health-care disciplines face the challenge of patients with multimorbidity, they need to find acceptable answers to the question of what works for whom in what context for patients with multiple and complex needs. CLP can contribute its rich experience in the qualitative approaches that will be needed in research addressing this question, but needs help from other disciplines to refine its techniques so that its contributions are considered valid. The context for implementing effective interventions derived from such studies will in future be that of transdisciplinary teams whose mode of working is empirically based and transparent. CLP is well placed by dint of its psychodynamic and systems theory roots to provide leadership in this transformation in health-care delivery.

General practitioners' responses to the initial presentation of medically unexplained symptoms: a quantitative analysis

BACKGROUND

Physicians in primary and secondary care are frequently confronted with patients with medically unexplained symptoms (MUS). In order to solve their patients' problems and out of a fear of overlooking a serious disease, many physicians give their patients full physical examinations and interventions, thereby incorrectly confirming the somatic nature of their condition. Preventing somatization could be achieved by examining the patient's symptom presentation for clues to underlying psychosocial issues and by an appropriate physician response.

METHODS

Ninety-seven videotaped medical visits from primary care patients presenting MUS for the first time were analyzed. Patients' presentations were categorized in: (1) symptoms only; (2) symptoms with a clue to an underlying concern; or (3) symptoms with an explicit concern. General practitioners' (GPs') responses to patients' presentation were classified into ignoring or more or less exploring responses. Exploring responses were further subdivided in non-directional explorations, clue explorations and medical explorations.

RESULTS

Results show that most patients presented their symptoms together with a reference to an underlying concern. Yet, most of them did so in an implicit way. GPs usually explored the concern presented by the patients, but most often in a medical way only.

CONCLUSION

To address the potential psychological basis of patients' medically unexplained symptoms, GPs should pay more attention to the specific clues patients present to them. Likewise, in order to receive full attention, patients should try to present their concerns more explicitly.