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Nagel C, Queenan C, Burton C. What are medical students taught about persistent physical symptoms? A scoping review of the literature. BMC MEDICAL EDUCATION 2024; 24:618. [PMID: 38835003 DOI: 10.1186/s12909-024-05610-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 05/27/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Persistent Physical Symptoms (PPS) include symptoms such as chronic pain, and syndromes such as chronic fatigue. They are common, but are often inadequately managed, causing distress and higher costs for health care systems. A lack of teaching about PPS has been recognised as a contributing factor to poor management. METHODS The authors conducted a scoping review of the literature, including all studies published before 31 March 2023. Systematic methods were used to determine what teaching on PPS was taking place for medical undergraduates. Studies were restricted to publications in English and needed to include undergraduate medical students. Teaching about cancer pain was excluded. After descriptive data was extracted, a narrative synthesis was undertaken to analyse qualitative findings. RESULTS A total of 1116 studies were found, after exclusion, from 3 databases. A further 28 studies were found by searching the grey literature and by citation analysis. After screening for relevance, a total of 57 studies were included in the review. The most commonly taught condition was chronic non-cancer pain, but overall, there was a widespread lack of teaching and learning on PPS. Several factors contributed to this lack including: educators and learners viewing the topic as awkward, learners feeling that there was no science behind the symptoms, and the topic being overlooked in the taught curriculum. The gap between the taught curriculum and learners' experiences in practice was addressed through informal sources and this risked stigmatising attitudes towards sufferers of PPS. CONCLUSION Faculties need to find ways to integrate more teaching on PPS and address the barriers outlined above. Teaching on chronic non-cancer pain, which is built on a science of symptoms, can be used as an exemplar for teaching on PPS more widely. Any future teaching interventions should be robustly evaluated to ensure improvements for learners and patients.
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Affiliation(s)
- Catie Nagel
- Primary Care Research Group, Division of Population Health, School of Medicine, University of Sheffield, Regent Court, 30 Regent Street, S1 4DA, Sheffield, UK.
| | - Chloe Queenan
- Primary Care Research Group, Division of Population Health, School of Medicine, University of Sheffield, Regent Court, 30 Regent Street, S1 4DA, Sheffield, UK
| | - Chris Burton
- Primary Care Research Group, Division of Population Health, School of Medicine, University of Sheffield, Regent Court, 30 Regent Street, S1 4DA, Sheffield, UK
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McGhie-Fraser B, McLoughlin C, Lucassen P, Ballering A, van Dulmen S, Brouwers E, Stone J, Olde Hartman T. Measuring persistent somatic symptom related stigmatisation: Development of the Persistent Somatic Symptom Stigma scale for Healthcare Professionals (PSSS-HCP). J Psychosom Res 2024; 181:111689. [PMID: 38704347 DOI: 10.1016/j.jpsychores.2024.111689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 04/19/2024] [Accepted: 04/28/2024] [Indexed: 05/06/2024]
Abstract
OBJECTIVE Persistent somatic symptoms (PSS) describe recurrent or continuously occurring symptoms such as fatigue, dizziness, or pain that have persisted for at least several months. These include single symptoms such as chronic pain, combinations of symptoms, or functional disorders such as fibromyalgia or irritable bowel syndrome. While stigmatisation by healthcare professionals is regularly reported, there are limited measurement instruments demonstrating content validity. This study develops a new instrument to measure stigmatisation by healthcare professionals, the Persistent Somatic Symptom Stigma scale for Healthcare Professionals (PSSS-HCP). METHODS Development was an iterative process consisting of research team review, item generation and cognitive interviewing. We generated a longlist of 60 items from previous reviews and qualitative research. We conducted 18 cognitive interviews with healthcare professionals in the United Kingdom (UK). We analysed the relevance, comprehensibility and comprehensiveness of items, including the potential for social desirability bias. RESULTS After research team consensus and initial feedback, we retained 40 items for cognitive interviewing. After our first round of interviews (n = 11), we removed 20 items, added three items and amended five items. After our second round of interviews (n = 7), we removed four items and amended three items. No major problems with relevance, comprehensibility, comprehensiveness or social desirability were found in remaining items. CONCLUSIONS The provisional version of the PSSS-HCP contains 19 items across three domains (stereotypes, prejudice, discrimination), demonstrating sufficient content validity. Our next step will be to perform a validation study to finalise item selection and explore the structure of the PSSS-HCP.
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Affiliation(s)
- Brodie McGhie-Fraser
- Department of Primary and Community Care, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, Netherlands.
| | - Caoimhe McLoughlin
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom.
| | - Peter Lucassen
- Department of Primary and Community Care, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, Netherlands.
| | - Aranka Ballering
- Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
| | - Sandra van Dulmen
- Department of Primary and Community Care, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, Netherlands; Nivel (Netherlands Institute for Health Services Research), Utrecht, the Netherlands; Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Sweden.
| | - Evelien Brouwers
- Tranzo, Scientific Center for Care and Wellbeing, Tilburg University, Tilburg, the Netherlands.
| | - Jon Stone
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom.
| | - Tim Olde Hartman
- Department of Primary and Community Care, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, Netherlands.
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3
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Habermann-Horstmeier L, Horstmeier LM. [Systems thinking, subjective findings and diagnostic "pigeonholing" in ME/CFS: A mainly qualitative public health study from a patient perspective]. Dtsch Med Wochenschr 2024; 149:e19-e36. [PMID: 38096913 PMCID: PMC10824585 DOI: 10.1055/a-2197-6479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
BACKGROUND ME/CFS (Myalgic encephalomyelitis/chronic fatigue syndrome) is an illness that is predominantly viewed as a neuroimmunological multisystem disease, which is still unknown to many doctors in Germany or which they classify as a psychosomatic disease. From their perspective, ME/CFS patients report significant deficits in terms of medical treatment and a doctor-patient relationship (DP relationship) that is perceived as problematic. The aim of the present study is to more precisely analyse the process of finding a diagnosis as an influencing factor on the DP relationship in ME/CFS from the point of view of those affected. METHOD As part of an explorative qualitative survey, 544 ME/CFS patients (> 20 years; 455 ♀, 89 ♂) with a medical diagnosis of ME/CFS were asked in writing about their experiences with regard to the process of finding a diagnosis. The sampling was previously done by self-activation and via the snowball principle. The questionnaire to be answered was structured analogously to a focused, standardized guideline interview. The evaluation was carried out as part of a qualitative content analysis according to Mayring. Some of the results were subsequently quantified. RESULTS The participants described what they saw as the inadequate process of making a diagnosis as a central factor in a problematic DP relationship in ME/CFS. From their point of view, many doctors deny the existence of ME/CFS or classify it as a solely psychosomatic illness, insist on their level of knowledge, ignore patient knowledge and disregard scientific information provided. They follow the standard program, think in "pigeonholes" and are incapable of systemic thinking. This has a significant impact on the DP relationship. DISCUSSION From the point of view of ME/CFS patients, the process of making a diagnosis and the recognition of ME/CFS as a neuroimmunological multisystem disease are the central aspects of a DP relationship that they experience as problematic. In the past, findings classified as "subjective" and thus ignored, the pigeonholing that is characteristic of biomedically oriented medicine and a healthcare system that opposes systemic thinking when making a diagnosis have all been identified as factors that may have a significant impact on the DP relationship.
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Affiliation(s)
| | - Lukas Maximilian Horstmeier
- Sektion für Versorgungsforschung und Rehabilitationsforschung, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, GERMANY,
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4
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Bakken AK, Mengshoel AM, Synnes O, Strand EB. Acquiring a new understanding of illness and agency: a narrative study of recovering from chronic fatigue syndrome. Int J Qual Stud Health Well-being 2023; 18:2223420. [PMID: 37307500 DOI: 10.1080/17482631.2023.2223420] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 06/06/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND The condition known as chronic fatigue syndrome or myalgic encephalomyelitis (CFS/ME) is poorly understood. Simplified medical models tend to neglect the complexity of illness, contributing to a terrain of uncertainty, dilemmas and predicaments. However, despite pessimistic pictures of no cure and poor prognosis, some patients recover. PURPOSE This study's purpose is to provide insight into people's experiences of suffering and recovery from very severe CFS/ME and illuminate understanding of how and why changes became possible. METHODS Fourteen former patients were interviewed about their experiences of returning to health. A narrative analysis was undertaken to explore participants' experiences and understandings. We present the result through one participant's story. RESULTS The analysis yielded a common plotline with a distinct turning point. Participants went through a profound narrative shift, change in mindset and subsequent long-time work to actively pursue their own healing. Their narrative understandings of being helpless victims of disease were replaced by a more complex view of causality and illness and a new sense of self-agency developed. DISCUSSION We discuss the illness narratives in relation to the disease model and its shortcomings, the different voices dominating the stories at different times in a clinically, conceptually, and emotionally challenging area.
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Affiliation(s)
- Anne Karen Bakken
- Centre of Diaconia and Professional Practice, VID Specialized University, Oslo, Norway
| | - Anne Marit Mengshoel
- Department for Interdisciplinary Health Sciences, University of Oslo, Oslo, Norway
| | - Oddgeir Synnes
- Department for Interdisciplinary Health Sciences, University of Oslo, Oslo, Norway
| | - Elin Bolle Strand
- Centre of Diaconia and Professional Practice, VID Specialized University, Oslo, Norway
- Dep of Digital Health Research, Oslo University Hospital, Oslo, Norway
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5
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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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Thomas HR, Best M, Chua D, King D, Lynch J. Whole person assessment for family medicine: a systematic review. BMJ Open 2023; 13:e065961. [PMID: 37080631 PMCID: PMC10124221 DOI: 10.1136/bmjopen-2022-065961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/22/2023] Open
Abstract
OBJECTIVES To identify and evaluate clinical approaches to whole person assessment (WPA) that are translatable to family medicine regarding feasibility, quality and alignment with theoretical models of whole person care (WPC). DESIGN Systematic literature review. DATA SOURCES MEDLINE, CINAHL, PsycINFO and ATLA Religion databases were searched through 9 March 2020, with additional handsearches. ELIGIBILITY CRITERIA English language clinical assessments of multiple domains; which involve patient-clinician interaction and are translatable to general practice (GP); from the fields of medicine, allied health, nursing, mental health and pastoral care. Tools designed for single diseases or symptoms, for outcome rather than clinical assessment or with outdated classification systems were excluded. DATA EXTRACTION AND SYNTHESIS We appraised the quality of included papers using Johanna Briggs' Institute Checklists and Terwee's criteria for validation studies. Clinical assessments' alignment with theoretical WPC, feasibility for adaptation to GP and quality were examined. We analysed extracted data using framework synthesis. RESULTS Searches retrieved 7535 non-duplicate items. Fifty-nine were included after screening, describing 42 WPA methods and representing multiple disciplines, purposes and formats. All included assessments aligned partially with models of WPC, but most did not adequately encompass all aspects of WPC. Robustness varied significantly and was often inadequately described. We judged none of the identified assessments to be ideal as a multipurpose WPA in GP. Some could be used for specific purposes, such as elicitation of patient perspectives or complexity assessment. CONCLUSIONS While no WPAs were found that were sufficient for broad implementation in GP, some approaches may be suitable with adaptation and evaluation. Strengths of existing approaches could inform WPA development in future. PROSPERO REGISTRATION NUMBER CRD42020164417.
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Affiliation(s)
- Hayley Robyn Thomas
- General Practice Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Megan Best
- Institute for Ethics and Society, The University of Notre Dame Australia, Sydney, New South Wales, Australia
| | - David Chua
- General Practice Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - David King
- General Practice Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Johanna Lynch
- General Practice Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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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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Saunders C, Treufeldt H, Rask MT, Pedersen HF, Rask C, Burton C, Frostholm L. Explanations for functional somatic symptoms across European treatment settings: A mixed methods study. J Psychosom Res 2023; 166:111155. [PMID: 36680846 DOI: 10.1016/j.jpsychores.2023.111155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 01/06/2023] [Accepted: 01/07/2023] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Engaging patients in treatment for functional somatic symptoms (FSS) relies on a shared understanding of the mechanisms underlying the complaints. Despite this, little is known about the explanatory models used in daily clinical practice. We aim to examine the approaches healthcare professionals use to explain FSS across European healthcare settings. METHODS This is an exploratory mixed methods study, combining sequential qualitative and quantitative analyses. 3 types of data were collected: a survey of Health-Care Professionals (HCPs) with special interest in FSS from 16 European countries (n = 186), Patient Education Material collected systematically from survey respondents (n = 72) and semi-structured Interviews with HCPs (n = 14). Survey results are summarized descriptively. Qualitative data was thematically coded following template analysis methods. Findings were integrated through mixed-methods triangulation. RESULTS Five main explanatory models for FSS that are used across treatment settings and diagnostic constructs were represented in the data. The 'Multisystem Stress' Approach explains FSS through physiological stress responses within a bio-psycho-social paradigm. 'Sensitized Alarm' and 'Malfunctioning software' are both approaches derived from the neurosciences. Explanations related to 'Embodied Experience' are often used within integrated psychosomatic therapies. In the person-centred 'Symptoms' approach, HCPs aim for co-constructed, individualized explanations. These approaches, which rely on different models of mind-body-environment are complementary and are used flexibly by skilled HCPs. CONCLUSION Taken together the explanatory models described might form the basis of a curriculum of medical explanation with the potential to equip clinicians to form more collaborative relationships with patients across healthcare.
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Affiliation(s)
- Chloe Saunders
- Faculty of Health, Aarhus University Hospital, Denmark; Department for Functional Disorders and Psychosomatic Medicine, Aarhus University Hospital, Denmark.
| | - Hõbe Treufeldt
- Academic Unit of Primary Care, University of Sheffield, UK
| | - Mette Trøllund Rask
- Faculty of Health, Aarhus University Hospital, Denmark; Department for Functional Disorders and Psychosomatic Medicine, Aarhus University Hospital, Denmark
| | - Heidi Frølund Pedersen
- Faculty of Health, Aarhus University Hospital, Denmark; Department for Functional Disorders and Psychosomatic Medicine, Aarhus University Hospital, Denmark
| | - Charlotte Rask
- Faculty of Health, Aarhus University Hospital, Denmark; Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Denmark
| | - Chris Burton
- Academic Unit of Primary Care, University of Sheffield, UK
| | - Lisbeth Frostholm
- Faculty of Health, Aarhus University Hospital, Denmark; Department for Functional Disorders and Psychosomatic Medicine, Aarhus University Hospital, Denmark
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10
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McGhie-Fraser B, Lucassen P, Ballering A, Abma I, Brouwers E, van Dulmen S, Olde Hartman T. Persistent somatic symptom related stigmatisation by healthcare professionals: A systematic review of questionnaire measurement instruments. J Psychosom Res 2023; 166:111161. [PMID: 36753936 DOI: 10.1016/j.jpsychores.2023.111161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Patients with persistent somatic symptoms (PSS) experience stigmatising attitudes and behaviours by healthcare professionals. While previous research has focussed on individual manifestations of PSS related stigma, less is known about sound ways to measure stigmatisation by healthcare professionals towards patients with PSS. This review aims to assess the quality of questionnaire measurement instruments and make recommendations about their use. METHODS A systematic review using six databases (PubMed, Embase, CINAHL, PsycINFO, Open Grey and EThOS). The search strategy combined three search strings related to healthcare professionals, PSS and stigma. Additional publications were identified by searching bibliographies. Three authors independently extracted the data. Data analysis and synthesis followed COSMIN methodology for reviews of outcome measurement instruments. RESULTS We identified 90 publications that met the inclusion criteria using 62 questionnaire measurement instruments. Stereotypes were explored in 92% of instruments, prejudices in 52% of instruments, and discrimination in 19% of instruments. The development process of the instruments was not rated higher than doubtful. Construct validity, structural validity, internal consistency and reliability were the most commonly investigated measurement properties. Evidence around content validity was inconsistent or indeterminate. CONCLUSION No instrument provided acceptable evidence on all measurement properties. Many instruments were developed for use within a single publication, with little evidence of their development or establishment of content validity. This is problematic because stigma instruments should reflect the challenges that healthcare professionals face when working with patients with PSS. They should also reflect the experiences that patients with PSS have widely reported during clinical encounters.
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Affiliation(s)
- Brodie McGhie-Fraser
- Radboud University Medical Center, Radboud Institute for Health Services Research, Department of Primary and Community Care, Nijmegen, the Netherlands.
| | - Peter Lucassen
- Radboud University Medical Center, Radboud Institute for Health Services Research, Department of Primary and Community Care, Nijmegen, the Netherlands.
| | - Aranka Ballering
- University of Groningen, University Medical Center Groningen, Department of Psychiatry, Groningen, the Netherlands.
| | - Inger Abma
- Radboud University Medical Center, Radboud Institute of Health Sciences, IQ Healthcare, Nijmegen, the Netherlands.
| | - Evelien Brouwers
- Tranzo, Scientific Center for Care and Wellbeing, Tilburg University, Tilburg, the Netherlands.
| | - Sandra van Dulmen
- Radboud University Medical Center, Radboud Institute for Health Services Research, Department of Primary and Community Care, Nijmegen, the Netherlands; Nivel (Netherlands Institute for Health Services Research), Utrecht, the Netherlands; Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Sweden.
| | - Tim Olde Hartman
- Radboud University Medical Center, Radboud Institute for Health Services Research, Department of Primary and Community Care, Nijmegen, the Netherlands.
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11
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Lynch JM, van Driel M, Meredith P, Stange KC, Getz L, Reeve J, Miller WL, Dowrick C. The Craft of Generalism clinical skills and attitudes for whole person care. J Eval Clin Pract 2022; 28:1187-1194. [PMID: 34652051 DOI: 10.1111/jep.13624] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/16/2021] [Accepted: 09/12/2021] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Generalists manage a broad range of biomedical and biographical knowledge as part of each clinical encounter, often in multiple encounters over time. The sophistication of this broad integrative work is often misunderstood by those schooled in reductionist or constructivist approaches to evidence. There is a need to describe the practical and philosophically robust ways that understanding about the whole person is formed. In this paper we describe first principles of generalist approaches to knowledge formation in clinical practice. We name the Craft of Generalism. METHODS The newly described methodology of Transdisciplinary Generalism is examined by skilled generalist clinicians and translated into skills and attitudes useful for everyday generalist person-centred practice and research. RESULTS The Craft of Generalism defines the required scope, process, priorities, and knowledge management skills of all generalists seeking to care for the whole person. These principles are Whole Person Scope, Relational Process, Healing Orientation, and Integrative Wisdom. These skills and attitudes are required for whole person care. If any element of these first principles is left out, the resultant knowledge is incomplete and philosophically incoherent. CONCLUSIONS Naming the Craft of Generalism defines the generalist gaze and protects generalism from the colonization of a narrowed medical gaze that excludes all but reductionist evidence or constructivist experience. Defining the Craft of Generalism enables clear teaching of the sophisticated skills and attitudes of the generalist clinician. These philosophically robust principles encourage and defend the use of generalist approaches to knowledge in settings across the community - including health policy, education, and research.
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Affiliation(s)
- Johanna M Lynch
- Primary Care Clinical Unit, The University of Queensland, Brisbane, Queensland, Australia.,Integrate Place at Zest Infusion, Birkdale, Queensland, Australia
| | - Mieke van Driel
- Primary Care Clinical Unit, The University of Queensland, Brisbane, Queensland, Australia
| | - Pamela Meredith
- School of Health, Medical and Applied Sciences, Central Queensland University, Rockhampton, Queensland, Australia
| | - Kurt C Stange
- Center for Community Health Integration, Case Western Reserve University, Cleveland, Ohio, USA
| | - Linn Getz
- Department of Public Health and Nursing, NTNU: Norwegian University of Science and Technology, Trondheim, Norway
| | - Joanne Reeve
- Primary Care Research, Hull York Medical School, Hull, UK
| | - William L Miller
- Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania, USA.,Department of Family Medicine, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Christopher Dowrick
- Institute of Population Health Sciences, University of Liverpool, Liverpool, UK
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12
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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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13
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How persons with systemic mastocytosis describe the time between symptom onset and receiving diagnosis. Prim Health Care Res Dev 2022; 23:e54. [PMID: 36069067 PMCID: PMC9472238 DOI: 10.1017/s146342362200024x] [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] [Indexed: 11/05/2022] Open
Abstract
AIM The aim of the study was to explore how persons with systemic mastocytosis (SM) described the time between the onset of symptoms and signs and getting the diagnosis. BACKGROUND SM is a rare disease caused by the accumulation of clonal mast cells with abnormal function. The symptoms and signs of the disease are varied, often diffuse and affect individuals differently. Due to this complexity, a multi-disciplinary diagnostic approach is required, in which general practitioners play an important part in identifying and referring patients relevant for such investigations. METHODS Sixteen persons with SM were interviewed about their experiences of the time before the diagnosis was received. Systematic text condensation was used in the analysis process. FINDINGS The time between symptom and signs onset and diagnosis was perceived as difficult. SM often had a complex and unpredictable effect on a person's daily life, long before diagnosis. In the analysis, three themes were found. Having symptoms and signs with an unknown cause included the participants' descriptions of numerous symptoms and signs, often years before diagnosis. These could be severe and result in worries for both participants and their next-of-kin. Dealing with the symptoms and signs encompassed the different ways in which the participants coped with the symptoms and signs, and sought relief. Being a patient without a diagnosis underlined the lack of information and knowledge within healthcare, often resulting in a delayed or incorrect diagnosis. The study highlighted the importance of a person-centred approach and the need to increase knowledge of the disease within primary care, to shorten this stressful and vulnerable time.
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14
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Jøssang IH, Aamland A, Hjörleifsson S. Discovering strengths in patients with medically unexplained symptoms - a focus group study with general practitioners. Scand J Prim Health Care 2022; 40:405-413. [PMID: 36345858 PMCID: PMC9848323 DOI: 10.1080/02813432.2022.2139345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND When patients suffer medically unexplained symptoms, consultations can be difficult and frustrating for both patient and GP. Acknowledging the patient as a co-subject can be particularly important when the symptoms remain unexplained. One way of seeing the patient as a co-subject is by recognizing any among their strong sides. OBJECTIVES To explore GPs' experiences with discovering strengths in their patients with medically unexplained symptoms and elicit GPs' reflections on how this might be useful. METHODS Four focus-groups with 17 GPs in Norway. Verbatim transcripts from the interviews were analyzed by systematic text condensation. RESULTS Recollecting patients' strengths was quiet challenging to the GPs. Gradually they nevertheless shared a range of examples, and many participants had experienced that knowing patients' strong sides could make consultations less demanding, and sometimes enable the GP to provide better help. Identifying strengths in patients with unexplained symptoms required a deliberate effort on the GPs' behalf, and this seemed to be a result of a strong focus on biomedical disease and loss of function. CONCLUSIONS Acknowledging patients' strong sides can bolster GPs' ability to help patients with medically unexplained symptoms. However, the epistemic disadvantage of generalist expertise makes this hard to achieve. It is difficult for GPs to integrate person-centered perspectives with biomedical knowledge due to the privileged position of the latter. This seems to indicate a need for system-level innovations to increase the status of person-centered clinical work. Key pointsMUS is challenging for both patients and GPs mainly because of the incongruence between symptoms and the dominating biomedical model.GPs' focus on pathology and loss of function can prevent them from discovering patients' strengths.Awareness of patients' strengths can make consultations less demanding for GPs and enable them to provide better help.A conscious effort is needed to discover patients' strengths.
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Affiliation(s)
- Ingjerd Helene Jøssang
- Department of global public health and primary care, University of Bergen, Norway
- Research unit for general practice, NORCE Norwegian Research Centre, Bergen, Norway
- CONTACT Ingjerd Helene Jøssang Research unit for general practice, NORCE Norwegian Research Centre, Årstadveien 17, Bergen5016, Norway
| | - Aase Aamland
- Research unit for general practice, NORCE Norwegian Research Centre, Bergen, Norway
| | - Stefan Hjörleifsson
- Department of global public health and primary care, University of Bergen, Norway
- Research unit for general practice, NORCE Norwegian Research Centre, Bergen, Norway
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15
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den Boer C, Terluin B, van der Wouden JC, Blankenstein AH, van der Horst HE. Experiences of general practitioners explaining central sensitisation to patients with persistent physical symptoms: a focus group study. BMJ Open 2022; 12:e060063. [PMID: 35882464 PMCID: PMC9330311 DOI: 10.1136/bmjopen-2021-060063] [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: 11/16/2022] Open
Abstract
OBJECTIVE Patients with persistent physical symptoms (PPS) require an explanation that is acceptable and comprehensible to them. Central sensitisation (CS) is an explanatory model for PPS and chronic pain that has been broadly applied in the context of pain medicine, but, until recently, not by general practitioners (GPs). We explored how GPs used the CS model in their consultations with patients with PPS. DESIGN AND SETTING A qualitative focus group study among GPs in the Netherlands. METHODS We instructed 33 GPs on how to explain CS to patients with PPS. After 0.5-1.5 years of using the CS model, 26 GPs participated in focus groups and interviews to report and discuss their experiences with CS as an explanatory model. Audio recordings were transcribed and two researchers independently analysed the data. The text was coded, codes were organised into themes and discussed until consensus was reached. RESULTS We identified eleven themes and grouped these into four categories.The GPs regarded the CS model as evidence-based, credible and giving recognition to the patient. On the other hand, they found explaining the CS model difficult and time-consuming. They tailored the CS model to their patients' needs and used multiple consultations to explain the model. The GPs reported that the use of the CS model seemed to improve the understanding and acceptance of the symptoms by the patients and seemed to reduce their need for more diagnostic tests. Furthermore, patients seemed to become more motivated to accept appropriate therapy. CONCLUSION GPs reported that they were able to provide explanations with the CS model to their patients with PPS. They regarded the model as evidence-based, credible and giving recognition to the patient, but explaining it difficult and time-consuming.
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Affiliation(s)
- Carine den Boer
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of General Practice, Boelelaan 1117, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Berend Terluin
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of General Practice, Boelelaan 1117, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Johannes C van der Wouden
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of General Practice, Boelelaan 1117, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Annette H Blankenstein
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of General Practice, Boelelaan 1117, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Henriëtte E van der Horst
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of General Practice, Boelelaan 1117, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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16
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Hunt J. Making space for disability studies within a structurally competent medical curriculum: reflections on long Covid. MEDICAL HUMANITIES 2022; 49:medhum-2022-012415. [PMID: 35853689 DOI: 10.1136/medhum-2022-012415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/15/2022] [Indexed: 06/15/2023]
Abstract
While critically informed approaches to medical education are increasingly advocated in literature, discussion of the potential role of disability studies in informing pedagogy and practice is largely lacking. The emergence of long Covid, alongside the strong possibility of a wave of covid-related disability, underlines an urgent need for medicine to develop more contextualised, nuanced and structurally competent understandings of chronic illness and disability. This article argues that the integration of thinking from disability studies into medical curricula offers a pathway to such understanding, informing a more equitable, holistic and patient-centred approach to practice. Further, a structurally competent, antiableist approach positions clinicians and patients as allies, working together within a structural context that constrains both parties. Such positioning may mitigate tensions within the clinical encounter, tensions that are well documented in the realm of marginalised chronic illness and disability. While the possibilities arising from a partnership between disability studies and medicine are numerous, the foci here are the social relational model of disability and the concept of psycho-emotional disablism, within a broader framework of critical disability studies. It is argued that inadequate healthcare provision and policy in the realm of long Covid can be understood as a form of structural and psycho-emotional disablism, arising from and reinforcing an ableist psychosocial imaginary permeated with neoliberal assumptions, and carrying a risk of furthering both disability and impairment. After considering long Covid through these particular lenses, the article concludes with a discussion of how a partnership between disability studies and a structurally competent approach to medical education might translate into practice.
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Affiliation(s)
- Joanne Hunt
- Independent disabled researcher, Stroud, Gloucestershire, UK
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17
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Lost in fragmentation: exploring patients’ experiences with coordination of care when somatic symptoms persist, a qualitative study. Br J Gen Pract 2022; 72:e790-e798. [DOI: 10.3399/bjgp.2021.0566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 04/13/2022] [Indexed: 10/31/2022] Open
Abstract
Background: GPs can play a central role in the care for patients with persistent somatic symptoms (PSS). To date, little is known about patients’ experiences with the coordination of care. Aim: Exploring experiences of patients with PSS with the coordination of care -in particular by their GP- during their illness trajectory. Design and setting: Qualitative study, part of a multi-center prospective cohort study on the course of PSS (PROSPECTS). Method: Thematic content analysis of fifteen interviews. Results: We identified three themes: 1) care fragmentation during the diagnostic trajectory; 2) transition from the search for a cure to coping; and 3) reframing to coping: GP’s role in facilitating supportive care. Patients experienced misalignment between healthcare providers (HCPs) during the diagnostic trajectory and some ended up in a ‘collusion of anonymity’ (repeated cross-referrals between specialists). Guidance by their GP in a process of shared decision making was positively valued. Moving focus from searching for a cure to coping with symptoms was described as a personal endeavor, challenged by ongoing uncertainty. When reframing to coping, the extent to which patients were aligned with their GP played a role in whether their supportive care request was met. Conclusion: Patients experienced difficulties navigating the diagnostic trajectory and shifting to coping. Our findings underline the importance of collaboration and alignment between GPs and other HCPs during the diagnostic trajectory. We recommend that GPs provide pro-active guidance and are sensitive to patients who shift to coping by providing supportive care in a process of shared decision making.
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18
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van Wietmarschen HA, van Velthoven K, Hummelen HJ, Lamers H, Elens R, van Rooijen R, de Klyn B, Zeegers M, Barthels R, Jansen JP, Kocken J, Lugten R, de Rijk EJ, Hertog KD, Robinson A, de Sonnaville M, Kusse F. Dutch Integrative Medicine physicians can improve quality of life of patients with medically unexplained physical symptoms - a cross-sectional observational study. Eur J Integr Med 2022. [DOI: 10.1016/j.eujim.2022.102140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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19
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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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20
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Sallay V, Martos T, Lucza L, Weiland A, Stegers-Jager KM, Vermeir P, Mariman ANM, Csabai M. Medical educators' experiences on medically unexplained symptoms and intercultural communication-an expert focus group study. BMC MEDICAL EDUCATION 2022; 22:310. [PMID: 35461231 PMCID: PMC9034474 DOI: 10.1186/s12909-022-03275-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 03/17/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Medically unexplained symptoms (MUS) are highly prevalent and remain challenging in healthcare and medical education, along with the increase in the importance of intercultural issues regarding MUS. However, less is known about the challenges of professionally addressing patients with MUS in the interprofessional and intercultural contexts. Thus, the present study aims to provide the first exploration of the experiences of medical specialists regarding treating MUS in intercultural contexts and inputs for training development on the intercultural aspects of MUS. METHODS Three focus groups (total n = 13) consisting of medical specialists from a Hungarian university who were teaching at the medical faculty in intercultural settings and also worked for the university health services were interviewed. The topics covered the participants' personal experiences on addressing MUS and the challenges of intercultural communication and the intercultural educational context. Thematic analysis was used to yield a qualitative account of the interviews as guided by the research questions. RESULTS Representing the different aspects of medical specialists, the study identified three main themes in the experiences of medical specialists, namely, 1) the need to adapt to the personal world of patients and search for common frames to understand MUS, 2) the need to discover methods for adapting to cultural differences and 3) the need to enhance the interprofessional coordination of knowledge and practices. CONCLUSIONS The results are in line with the distinct conclusions of previous studies. Moreover, an integrated educational program on the intercultural aspects of MUS may address the main themes separately and, subsequently, support their integration. Therefore, the study discusses the manner in which an integrated educational program on the intercultural aspects of MUS may address the needs recognized in these aspects.
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Affiliation(s)
- Viola Sallay
- Institute of Psychology, University of Szeged, Egyetem u. 2, 6722, Szeged, Hungary
| | - Tamás Martos
- Institute of Psychology, University of Szeged, Egyetem u. 2, 6722, Szeged, Hungary.
| | - Lilla Lucza
- Doctoral School of Education, University of Szeged, Szeged, Hungary
| | - Anne Weiland
- Department for Internal Medicine & General Practice, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | | | - Peter Vermeir
- Faculty of Medicine and Healthcare sciences, Ghent University, Ghent, Belgium
- Ghent University Hospital, Ghent, Belgium
| | - An Noelle Margareta Mariman
- Faculty of Medicine and Healthcare sciences, Ghent University, Ghent, Belgium
- Ghent University Hospital, Center for Integrative Medicine, Ghent, Belgium
| | - Márta Csabai
- Institute of Psychology, University of Szeged, Egyetem u. 2, 6722, Szeged, Hungary
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21
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Nishiyama J, Abe T, Imaizumi S, Yamane A, Fukunaga M. Characteristics of outpatients with functional somatic syndromes at a university hospital's general medicine clinic. J Gen Fam Med 2022; 23:268-274. [PMID: 35800641 PMCID: PMC9249930 DOI: 10.1002/jgf2.543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 02/03/2022] [Accepted: 03/22/2022] [Indexed: 11/16/2022] Open
Abstract
Background The term medically unexplained symptoms (MUS) is unhelpful for both patients and physicians, and more acceptable illness categories are needed as substitutes for MUS. While some potential substitutes are characterized by excessive psychological burden related to somatic symptoms, “functional somatic syndromes” (FSS) is a category that focuses on physical dysfunction and emphasizes similarities among individual syndromes. Examples of FSS include irritable bowel syndrome, functional dyspepsia, and fibromyalgia syndrome. This study aimed to distinguish FSS from MUS and compare the somatic and psychobehavioral characteristics of FSS with those of other diseases. Methods This study included 1975 first‐visit outpatients at a Japanese university hospital's general medicine clinic. According to their first‐listed diagnosis, they were classified as having FSS, acute infection, organic disease (OD), psychiatric disorder, and unknown condition (UC). The somatic symptom burden and health‐related quality of life (HRQoL) were assessed using the Somatic Symptom Scale‐8 and EuroQol‐5 Dimension, respectively; the involvement of psychobehavioral factors affecting somatic symptoms was also evaluated. Results Overall, 33% of patients were included in the FSS category, and 93% of the supposed MUS (FSS and UC) were diagnosed with FSS. Compared with OD, FSS showed more severe somatic symptom burden, similar reduced HRQoL, and higher involvement of psychobehavioral factors. Conclusion It can be useful to improve FSS diagnostic skills for the reduction of MUS misdiagnosis. Psychobehavioral factors might be less associated with MUS (in the narrow sense of the term) than FSS. We classified 1975 first‐visit outpatients at a Japanese university hospital's general medicine clinic as having functional somatic syndrome (FSS), acute infection, organic disease, psychiatric disorder, and unknown condition (UC). FSS comprised one‐third of our study population, and almost all of the supposed medically unexplained symptoms (FSS and UC) were diagnosed with FSS. Compared with other organic diseases, FSS showed more severe somatic symptom burden, similar health‐related quality of life, and higher involvement of psychobehavioral factors.
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Affiliation(s)
- Junji Nishiyama
- Department of Psychosomatic and General Internal Medicine Kansai Medical University Hirakata Japan
- Clinic of General Medicine Kansai Medical University Hospital Hirakata Japan
| | - Tetsuya Abe
- Department of Psychosomatic and General Internal Medicine Kansai Medical University Hirakata Japan
| | - Sumito Imaizumi
- Department of Psychosomatic and General Internal Medicine Kansai Medical University Hirakata Japan
| | - Akira Yamane
- Department of Psychosomatic and General Internal Medicine Kansai Medical University Hirakata Japan
| | - Mikihiko Fukunaga
- Department of Psychosomatic and General Internal Medicine Kansai Medical University Hirakata Japan
- Clinic of General Medicine Kansai Medical University Hospital Hirakata Japan
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22
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Huang Y, Xu J, Liu Q, Zeng Z, Zhang Y. Stellate ganglion block successfully relieved medically unexplained chronic pain: a case report. J Int Med Res 2022; 50:3000605221086735. [PMID: 35301893 PMCID: PMC8935417 DOI: 10.1177/03000605221086735] [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] [Indexed: 11/28/2022] Open
Abstract
Medically unexplained symptoms refers to a clinical syndrome characterized by somatic symptoms that cannot be reasonably explained by any organic disease. Chronic pain can be a type of medically unexplained symptom. The current treatment modalities for chronic pain mainly include drugs and psychotherapy. The use of stellate ganglion block for treatment of chronic pain has rarely been reported. Herein, we report a patient whose chronic pain was completely relieved after receiving a stellate ganglion block.
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Affiliation(s)
- Yiting Huang
- Department of Surgery and Anesthesia, The Third Affiliated Hospital of Sun Yat-sen University Yuedong Hospital, Guangdong, China
| | - Jian Xu
- Department of Surgery and Anesthesia, The Third Affiliated Hospital of Sun Yat-sen University Yuedong Hospital, Guangdong, China
| | - Qingyan Liu
- Department of Surgery and Anesthesia, The Third Affiliated Hospital of Sun Yat-sen University Yuedong Hospital, Guangdong, China
| | - Zhimin Zeng
- Department of Surgery and Anesthesia, The Third Affiliated Hospital of Sun Yat-sen University Yuedong Hospital, Guangdong, China
| | - Yuenong Zhang
- Department of Surgery and Anesthesia, The Third Affiliated Hospital of Sun Yat-sen University Yuedong Hospital, Guangdong, China
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23
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Smith CF, Kristensen BM, Andersen RS, Ziebland S, Nicholson BD. Building the case for the use of gut feelings in cancer referrals: perspectives of patients referred to a non-specific symptoms pathway. Br J Gen Pract 2022; 72:e43-e50. [PMID: 34844921 PMCID: PMC8714524 DOI: 10.3399/bjgp.2021.0275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 08/02/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Gut feelings may be useful when dealing with uncertainty, which is ubiquitous in primary care. Both patients and GPs experience this uncertainty but patients' views on gut feelings in the consultation have not been explored. AIM To explore patients' perceptions of gut feelings in decision making, and to compare these perceptions with those of GPs. DESIGN AND SETTING Qualitative interviews with 21 patients in Oxfordshire, UK. METHOD Patients whose referral to a cancer pathway was based on their GP's gut feeling were invited to participate. Semi-structured interviews were conducted from November 2019 to January 2020, face to face or over the telephone. Data were analysed with a thematic analysis and mind-mapping approach. RESULTS Some patients described experiencing gut feelings about their own health but often their willingness to share this with their GP was dependent on an established doctor-patient relationship. Patients expressed similar perspectives on the use of gut feelings in consultations to those reported by GPs. Patients saw GPs' gut feelings as grounded in their experience and generalist expertise, and part of a process of evidence gathering. Patients suggested that GPs were justified in using gut feelings because of their role in arranging access to investigations, the difficult 'grey area' of presentations, and the time- and resource-limited nature of primary care. When GPs communicated that they had a gut feeling, some saw this as an indication that they were being taken seriously. CONCLUSION Patients accepted that GPs use gut feelings to guide decision making. Future research on this topic should include more diverse samples and address the areas of concern shared by patients and GPs.
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Affiliation(s)
| | | | - Rikke Sand Andersen
- Department of Public Health, Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
| | - Sue Ziebland
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Kane NS, Anastasides N, Litke DR, Helmer DA, Hunt SC, Quigley KS, Pigeon WR, McAndrew LM. Under-recognition of medically unexplained symptom conditions among US Veterans with Gulf War Illness. PLoS One 2021; 16:e0259341. [PMID: 34874939 PMCID: PMC8651123 DOI: 10.1371/journal.pone.0259341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 10/18/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Conditions defined by persistent "medically unexplained" physical symptoms and syndromes (MUS) are common and disabling. Veterans from the Gulf War (deployed 1990-1991) have notably high prevalence and disability from MUS conditions. Individuals with MUS report that providers do not recognize their MUS conditions. Our goal was to determine if Veterans with MUS receive an ICD-10 diagnosis for a MUS condition or receive disability benefits available to them for these conditions. METHODS A chart review was conducted with US Veterans who met case criteria for Gulf War Illness, a complex MUS condition (N = 204, M = 53 years-old, SD = 7). Three coders independently reviewed Veteran's medical records for MUS condition diagnosis or service-connection along with comorbid mental and physical health conditions. Service-connection refers to US Veterans Affairs disability benefits eligibility for conditions or injuries experienced during or exacerbated by military service. RESULTS Twenty-nine percent had a diagnosis of a MUS condition in their medical record, the most common were irritable colon/irritable bowel syndrome (16%) and fibromyalgia (11%). Slightly more Veterans were service-connected for a MUS condition (38%) as compared to diagnosed. There were high rates of diagnoses and service-connection for mental health (diagnoses 76% and service-connection 74%), musculoskeletal (diagnoses 86%, service-connection 79%), and illness-related conditions (diagnoses 98%, service-connection 49%). CONCLUSION Given that all participants were Gulf War Veterans who met criteria for a MUS condition, our results suggest that MUS conditions in Gulf War Veterans are under-recognized with regard to clinical diagnosis and service-connected disability. Veterans were more likely to be diagnosed and service-connected for musculoskeletal-related and mental health conditions than MUS conditions. Providers may need education and training to facilitate diagnosis of and service-connection for MUS conditions. We believe that greater acknowledgement and validation of MUS conditions would increase patient engagement with healthcare as well as provider and patient satisfaction with care.
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Affiliation(s)
- Naomi S. Kane
- VA New Jersey Health Care System, War Related Illness and Injury Study Center, East Orange, NJ, United States of America
| | - Nicole Anastasides
- VA New Jersey Health Care System, War Related Illness and Injury Study Center, East Orange, NJ, United States of America
| | - David R. Litke
- VA New Jersey Health Care System, War Related Illness and Injury Study Center, East Orange, NJ, United States of America
- Department of Rehabilitation Medicine, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Drew A. Helmer
- VA New Jersey Health Care System, War Related Illness and Injury Study Center, East Orange, NJ, United States of America
- Michael DeBakey VA Medical Center, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, TX, United States of America
| | - Stephen C. Hunt
- VA Puget Sound Health Care System, Seattle, WS, United States of America
- Department of Medicine, University of Washington, Seattle, WS, United States of America
| | - Karen S. Quigley
- VA Bedford Healthcare System, Center for Health Organization & Implementation Research (CHOIR), Bedford, MA, United States of America
- Department of Psychology, Northeastern University, Boston, MA, United States of America
| | - Wilfred R. Pigeon
- Finger Lakes Healthcare System/VISN 2 Center of Excellence for Suicide Prevention, Canandaigua, NY, United States of America
- Psychiatry Department, University of Rochester Medical Center, Rochester, NY, United States of America
| | - Lisa M. McAndrew
- VA New Jersey Health Care System, War Related Illness and Injury Study Center, East Orange, NJ, United States of America
- Department of Educational and Counseling Psychology, University at Albany, Albany, NY, United States of America
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Brodwall A, Brekke M. General practitioners' experiences with children and adolescents with functional gastro-intestinal disorders: a qualitative study in Norway. Scand J Prim Health Care 2021; 39:543-551. [PMID: 34930079 PMCID: PMC8725859 DOI: 10.1080/02813432.2021.2012347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Objective: Functional gastrointestinal disorders (FGIDs) are common in children and adolescents. During 2016 and 2019, we investigated the experiences among parents of children with FGIDs and interviewed their children and adolescents during 2020. The aim of the present study was to explore the experiences among general practitioners (GPs) who treat this patient group.Design: Individual interviews with open-ended questions were audio recorded and transcribed, and subsequently analysed using descriptive content analysis.Setting: Urban and rural areas in two municipalities in Southern Norway. Participants: Twelve GPs practicing in the region were interviewed.Results: GPs generally feel competent treating these patients without referring them to hospital or specialists. Having known the patients and their families over time is important. Providing psycho-educational resources to the patients and parents is essential for their understanding that the pain is not dangerous. The importance of attending school was emphasised.Conclusions: The GPs' biopsychosocial focus and long-term follow-up care are essential in treating children and adolescents with FGIDs and their parents.KEY POINTSCurrent awarenessAbdominal pain is a common symptom in children and adolescents, for which an organic cause is seldom found.Main statementsGPs feel competent to treat children and adolescents who have functional gastro-intestinal disorders (FGIDs) without referring them to hospital or specialists. • A main task for GPs is to inform children, adolescents, and their parents that FGIDs are not a serious organic disease and that everyday life should continue.
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Affiliation(s)
- Anne Brodwall
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of Child and Adolescent Psychiatry, Vestre Viken Trust, Baerum, Norway
- CONTACT Anne Brodwall Department of Child and Adolescent Psychiatry, Vestre Viken Trust, Drammen, 3004, Norway
| | - Mette Brekke
- General Practice Research Unit, Institute of Health and Society, University of Oslo, Oslo, Norway
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26
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McAndrew LM, Khatib LA, Sullivan NL, Winograd DM, Kolar SK, Santos SL. Healthcare providers' perceived learning needs and barriers to providing care for chronic multisymptom illness and environmental exposure concerns. Life Sci 2021; 284:119757. [PMID: 34425128 DOI: 10.1016/j.lfs.2021.119757] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 06/08/2021] [Accepted: 06/16/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Patient provider encounters for chronic multisympom illness (CMI) and/or environmental exposures are difficult often resulting in Veterans and providers having high levels of dissatisfaction. Patients attribute these difficulties to providers lacking knowledge about these health concerns. It is not known whether providers perceive themselves as lacking expertise in CMI and environmental exposure concerns. METHODS This needs assessment used a descriptive online survey design. A total of 3632 VA healthcare providers across disciplines were surveyed. RESULTS Healthcare providers reported speaking with Veterans about CMI and environmental exposures despite feeling they have minimal to no knowledge of these topics. At the same time, only half of the providers had taken an available training on CMI or environmental exposure within the last year. CONCLUSION Healthcare providers recognize a knowledge gap regarding CMI and environmental exposures, despite this, there is low uptake of provider education on these topics. PRACTICE IMPLICATIONS A better understanding of barriers to uptake of training on CMI and environmental exposures is needed to increase engagement with these important trainings.
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Affiliation(s)
- Lisa M McAndrew
- War Related Illness and Injury Study Center (WRIISC), Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ 07018, USA; Department of Educational and Counseling Psychology, University at Albany, Albany, NY 12222, USA.
| | - Linda A Khatib
- War Related Illness and Injury Study Center (WRIISC), Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ 07018, USA.
| | - Nicole L Sullivan
- War Related Illness and Injury Study Center (WRIISC), Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ 07018, USA.
| | - Darren M Winograd
- Department of Educational and Counseling Psychology, University at Albany, Albany, NY 12222, USA.
| | - Stephanie K Kolar
- Employee Education System, Veterans Health Administration Veterans Affairs, Long Beach Medical Facility, 901 East 7thStreet, Long Beach, CA 90822, USA.
| | - Susan L Santos
- War Related Illness and Injury Study Center (WRIISC), Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ 07018, USA.
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Goutte J, Cathébras P. Attitudes of internal medicine specialists and rheumatologists towards chronic pain complaints. Int J Clin Pract 2021; 75:e14463. [PMID: 34535053 DOI: 10.1111/ijcp.14463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 06/08/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Julie Goutte
- Internal Medicine Department & Jean-Monnet University, University Hospital (Hôpital Nord), Saint-Etienne, France
| | - Pascal Cathébras
- Internal Medicine Department & Jean-Monnet University, University Hospital (Hôpital Nord), Saint-Etienne, France
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28
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Hall KH, Amos C, Jaye C, Young J. Successful Psychological Strategies of Experienced Chronic Fatigue Patients: A Qualitative Study. J Patient Exp 2021; 8:23743735211034962. [PMID: 34395851 PMCID: PMC8358485 DOI: 10.1177/23743735211034962] [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] [Indexed: 11/30/2022] Open
Abstract
Trying to care for patients with medically unexplained symptoms (MUS) can lead to frustration and disappointment for both patients and health care professionals alike. Learning positive ways to assist patients avoids professionals collapsing into therapeutic nihilism. We sought to understand how people with such symptoms can live well despite (or even because of) their condition. Chronic fatigue was chosen as the exemplar symptom. Participants were invited to join the research if they, themselves, considered they were living well with this symptom. One-on-one interviews using an appreciative enquiry approach were performed and thematic analysis undertaken. Twelve participants were interviewed before data saturation occurred. The emotional stance or relationship a participant had with, and towards, their illness was the primary determinant underlying their interpretation of “living well.” Five major themes of this meta-theme were identified: (1) engaging with elusiveness, (2) befriending uncertainty, (3) reflecting on self, (4) living creatively, and (5) moving in stillness. Encouraging patients who are struggling with MUS to consider how they emotionally engage with their illness via these 5 positive dynamics may lead to better health outcomes for patients and happier, more fulfilled health care professionals.
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Affiliation(s)
- Katherine H Hall
- Department of General Practice and Rural Health, University of Otago, Dunedin, New Zealand
| | - Claire Amos
- Department of General Practice and Rural Health, University of Otago, Dunedin, New Zealand
| | - Chrystal Jaye
- Department of General Practice and Rural Health, University of Otago, Dunedin, New Zealand
| | - Jessica Young
- Department of General Practice and Rural Health, University of Otago, Dunedin, New Zealand
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Affiliation(s)
- Sean L Davidson
- University of Auckland, Waikato Hospital, Hamilton, New Zealand
| | - David B Menkes
- Waikato Clinical Campus, University of Auckland, Hamilton, New Zealand
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30
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Marcinow M, Sandercock J, D'Silva C, Daien D, Ellis C, Dias C, Mansfield E. Making sense of symptoms, clinicians and systems: a qualitative evaluation of a facilitated support group for patients with medically unexplained symptoms. BMC FAMILY PRACTICE 2021; 22:142. [PMID: 34210272 PMCID: PMC8252243 DOI: 10.1186/s12875-021-01495-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 06/17/2021] [Indexed: 11/23/2022]
Abstract
Objectives Health services to date have inadequately addressed the physical and mental health needs of patients with medically unexplained symptoms. This qualitative study evaluates a piloted facilitated support group (FSG) developed for patients with medically unexplained symptoms to inform recommendations and resources for this patient population. Methods Using a qualitative descriptive design, we conducted and thematically analyzed semi-structured interviews with participants (n = 8) and facilitators (n = 4) to explore their experiences of the facilitated support group. Common themes that captured strengths and challenges of the facilitated support group were identified. Results The following key themes were identified through analysis of the data: Participants described 1) feeling validated through sharing similar experiences with peers; 2) learning practical symptom management and coping strategies; and 3) gaining new perspectives for navigating conversations with PCPs. Conclusions Our findings show that a facilitated support group may provide additional forms of support and resources for patients with medically unexplained symptoms, filling a gap in currently available clinical care offered by health care professionals. Potential implications: This paper highlights lessons learned that can inform the design and delivery of future supports and resources directed toward optimizing patient care for this underserved patient population. Our findings are relevant to those who are involved in direct patient care or involved in designing and implementing self-management programs. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01495-9.
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Affiliation(s)
- Michelle Marcinow
- Institute for Better Health, Trillium Health Partners, Administrative Building - 6th Floor, 100 Queensway West, Mississauga, ON, L5B 1B8, Canada.
| | - Jane Sandercock
- Institute for Better Health, Trillium Health Partners, Administrative Building - 6th Floor, 100 Queensway West, Mississauga, ON, L5B 1B8, Canada
| | - Chelsea D'Silva
- Institute for Better Health, Trillium Health Partners, Administrative Building - 6th Floor, 100 Queensway West, Mississauga, ON, L5B 1B8, Canada
| | - David Daien
- Family Medicine, Institute for Better Health, Trillium Health Partners, 100 Queensway West, Mississauga, ON, L5B 1B8, Canada
| | - Carly Ellis
- Strategic Projects, Trillium Health Partners, 100 Queensway West, Mississauga, ON, L5B 1B8, Canada
| | - Christine Dias
- Medical Psychiatry Alliance, Trillium Health Partners, 100 Queensway West, Mississauga, ON, L5B 1B8, Canada
| | - Elizabeth Mansfield
- Institute for Better Health, Trillium Health Partners, Administrative Building - 6th Floor, 100 Queensway West, Mississauga, ON, L5B 1B8, Canada.,Department of Occupational Health, University of Toronto, 6 Queen's Park Crescent West, Toronto, ON, M5S 3H2, Canada
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31
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Lynch JM, Dowrick C, Meredith P, McGregor SLT, van Driel M. Transdisciplinary Generalism: Naming the epistemology and philosophy of the generalist. J Eval Clin Pract 2021; 27:638-647. [PMID: 32939937 DOI: 10.1111/jep.13446] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/25/2020] [Accepted: 06/28/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Transdisciplinary research and generalist practice both face the task of integrating and discerning the value of knowledge across disciplinary and sectoral knowledge cultures. Transdisciplinarity and generalism also both offer philosophical and practical insights into the epistemology, ontology, axiology, and logic of seeing the 'whole'. Although generalism is a skill that can be used in many settings from industry to education, the focus of this paper is the literature of the primary care setting (i.e., general practice or family medicine). Generalist philosophy and practice in the family medicine setting highly values whole person care that uses integrative and interpretive wisdom to include both biomedical and biographical forms of knowledge. Generalist researchers are often caught between reductionist (positivist) biomedical measures and social science (post-positivist) constructivist theories of knowing. Neither of these approaches, even when juxtaposed in mixed-methods research, approximate the complexity of the generalist clinical encounter. A theoretically robust research methodology is needed that acknowledges the complexity of interpreting these ways of knowing in research and clinical practice. METHODS A conceptual review of literature to define the alignment between (a) the philosophy and practice of generalism in primary care and (b) both the practical (Zurich) and philosophical or methodological (Nicolescuian) schools of transdisciplinarity. RESULTS The alignment between generalism and transdisciplinarity included their broad scope, relational process, complex knowledge management, humble attitude to knowing, and real-world outcome focus. CONCLUSION The concurrence between these approaches to knowing is offered here as Transdisciplinary Generalism - a coherent epistemology for both primary care researchers and generalist clinicians to understand, enact, and research their own sophisticated craft of managing diverse forms of knowledge.
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Affiliation(s)
- Johanna M Lynch
- Primary Care Clinical Unit, The University of Queensland, Brisbane, Queensland, Australia.,Integrate Place, Brisbane, Queensland, Australia
| | - Christopher Dowrick
- Institute of Population Health Sciences, University of Liverpool, Liverpool, UK
| | - Pamela Meredith
- School of Health, Medical and Applied Sciences, Central Queensland University, Rockhampton, Queensland, Australia
| | | | - Mieke van Driel
- Primary Care Clinical Unit, The University of Queensland, Brisbane, Queensland, Australia
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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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Ferguson C, Hickman LD, Turkmani S, Breen P, Gargiulo G, Inglis SC. “Wearables only work on patients that wear them”: Barriers and facilitators to the adoption of wearable cardiac monitoring technologies. CARDIOVASCULAR DIGITAL HEALTH JOURNAL 2021; 2:137-147. [PMID: 35265900 PMCID: PMC8890057 DOI: 10.1016/j.cvdhj.2021.02.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background Wearable technologies are increasingly popular. Yet their use remains low by older adults, who may stand the greatest benefit of use. While there is an abundance of research examining the performance, accuracy, specificity, and sensitivity of wearable devices, many barriers remain and need to be addressed to optimize uptake in clinical practice. There is a paucity of research exploring factors that help to understand barriers and facilitators to inform acceptance, adoption, wearability, and sustainability of use. Objectives (1) To explore the perceptions and experiences of older adults and health professionals about using wearable cardiac monitoring technologies, and (2) to identify barriers and facilitators of acceptance and uptake of these devices in clinical practice. Methods A systematic review with a qualitative meta-synthesis was undertaken. Results A total of 7 original research studies were included. Four interrelated themes emerged: (1) trust, including safety, and confidence; (2) functionality and affordability; (3) risks; and (4) assurance. Conclusion There are many barriers and facilitators to the adoption of wearable devices based on experiences of older adults, health professionals, and carers. Most significant factors related to the design aspects of the devices, appropriate and timely feedback, user-friendly technology, and issues related to affordability and cost.
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Affiliation(s)
- Caleb Ferguson
- Western Sydney Nursing & Midwifery Research Centre, Western Sydney Local Health District, and Western Sydney University, Sydney, Australia
- MARCS Institute for Brain, Behaviour & Development, Western Sydney University, Sydney, Australia
- Translational Health Research Institute, Western Sydney University, Sydney, Australia
- Address reprint requests and correspondence: Dr Caleb Ferguson, Senior Research Fellow, NHMRC Emerging Leadership Fellow & Heart Foundation Postdoctoral Fellow, Western Sydney Nursing & Midwifery Research Centre, Western Sydney University, & Western Sydney Local Health District, Blacktown Hospital, Marcel Crescent, Blacktown, NSW, 2148, Australia.
| | - Louise D. Hickman
- Faculty of Health, University of Technology Sydney, Sydney, Australia
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Sabera Turkmani
- Western Sydney Nursing & Midwifery Research Centre, Western Sydney Local Health District, and Western Sydney University, Sydney, Australia
- Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Paul Breen
- MARCS Institute for Brain, Behaviour & Development, Western Sydney University, Sydney, Australia
- Translational Health Research Institute, Western Sydney University, Sydney, Australia
| | - Gaetano Gargiulo
- MARCS Institute for Brain, Behaviour & Development, Western Sydney University, Sydney, Australia
| | - Sally C. Inglis
- Faculty of Health, University of Technology Sydney, Sydney, Australia
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, Australia
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34
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Houwen J, Lucassen PLBJ, Stappers HW, van Spaendonck K, van Duijnhoven A, Hartman TCO, van Dulmen S. How to learn skilled communication in primary care MUS consultations: a focus group study. Scand J Prim Health Care 2021; 39:101-110. [PMID: 33569982 PMCID: PMC7971340 DOI: 10.1080/02813432.2021.1882088] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Many general practitioners (GPs) experience communication problems in medically unexplained symptoms (MUS) consultations as they are insufficiently equipped with adequate communication skills or do not apply these in MUS consultations. OBJECTIVE To define the most important learnable communication elements during MUS consultations according to MUS patients, GPs, MUS experts and teachers and to explore how these elements should be taught to GPs and GP trainees. METHODS Five focus groups were conducted with homogeneous groups of MUS patients, GPs, MUS experts and teachers. MUS patients and GPs formulated a list of important communication elements. MUS experts identified from this list the most important communication elements. Teachers explored how these elements could be trained to GPs and GP trainees. Two researchers independently analysed the data applying the principles of constant comparative analysis. RESULTS MUS patients and GPs identified a list of important communication elements. From this list, MUS experts selected five important communication elements: (1) thorough somatic and psychosocial exploration, (2) communication with empathy, (3) creating a shared understanding of the problem, (4) providing a tangible explanation and (5) taking control. Teachers described three teaching methods for these communication elements: (1) awareness and reflection of GPs about their feelings towards MUS patients, (2) assessment of GPs' individual needs and (3) training and supervision in daily practice. CONCLUSION Teachers consider a focus on personal attitudes and needs, which should be guided by opportunities to practice and receive supervision, as the best method to teach GPs about communication in MUS consultations.KEY POINTSMany GPs experience difficulties in communication with patients with MUS.There is a need to equip GPs with communication skills to manage MUS consultations more adequately.Role-playing with simulation patients, reflection on video-consultations and joint consultations with the supervisor may increase the GPs' awareness of their attitude towards MUS patients and may help GPs to identify their individual learning-points.
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Affiliation(s)
- Juul Houwen
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- CONTACT Juul Houwen Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Centre, Geert Grooteplein, 21, Nijmegen6525 EZ, The Netherlands
| | - Peter L. B. J. Lucassen
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hugo W. Stappers
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Karel van Spaendonck
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Aniek van Duijnhoven
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, 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 Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
- Faculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway
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35
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Rask MT, Jakobsen PR, Clemensen J, Rosendal M, Frostholm L. Development of an eHealth programme for self-management of persistent physical symptoms: a qualitative study on user needs in general practice. BMC FAMILY PRACTICE 2021; 22:33. [PMID: 33550988 PMCID: PMC7869449 DOI: 10.1186/s12875-021-01380-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 01/31/2021] [Indexed: 11/24/2022]
Abstract
Background Persistent physical symptoms (PPS) are estimated to be present in 17% of patients in general practice. Hence, general practitioners (GPs) play a key role in both the diagnostic assessment and the management of PPS. However, research indicates a need to improve their strategies to support self-help in patients, and eHealth tools may serve as an opportunity. This study aimed to explore patients’ and GPs’ needs related to self-management of PPS. The study was designed to inform the future development of eHealth interventions in this field. Methods This qualitative study was based on 20 semi-structured interviews (6 GPs and 14 patients with PPS). Interviews were audiotaped, transcribed verbatim and analysed through a five-step thematic analysis approach. First, we conducted an inductive analysis to identify and explore emerging subthemes. Second, using a deductive mapping strategy, we categorised the derived subthemes according to the COM-B behaviour change model and its three domains: capability, opportunity and motivation. Results We identified eleven subthemes in the patient interviews and seven subthemes in the GP interviews. Several unmet needs emerged. First, we identified a need to consider PPS early in the illness trajectory by taking a bio-psycho-social approach. Second, both patients and GPs need better skills to manage uncertainty. Third, hope is important for the patients. Fourth, patients need guidance from their GP in how to self-manage their PPS. Conclusions This study provides important insight into key issues and needs related to capability, opportunity and motivation that should be addressed in the design of future eHealth self-management interventions targeting patients with PPS in general practice in order to support and improve care. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01380-5.
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Affiliation(s)
- Mette Trøllund Rask
- Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Nørrebrogade 44, 8000, Aarhus, Denmark.
| | - Pernille Ravn Jakobsen
- Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Nørrebrogade 44, 8000, Aarhus, Denmark.,University College Southern Denmark, Lembckesvej 3-7, 6100, Haderslev, Denmark
| | - Jane Clemensen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Kløvervænget 23, 5000, Odense, Denmark
| | - Marianne Rosendal
- Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Nørrebrogade 44, 8000, Aarhus, Denmark.,Research Unit for General Practice, Bartholins Allé 2, 8000, Aarhus, Denmark
| | - Lisbeth Frostholm
- Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Nørrebrogade 44, 8000, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Nørrebrogade 44, 8000, Aarhus C, Denmark
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Harish V, Morgado F, Stern AD, Das S. Artificial Intelligence and Clinical Decision Making: The New Nature of Medical Uncertainty. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2021; 96:31-36. [PMID: 32852320 DOI: 10.1097/acm.0000000000003707] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Estimates in a 1989 study indicated that physicians in the United States were unable to reach a diagnosis that accounted for their patient's symptoms in up to 90% of outpatient patient encounters. Many proponents of artificial intelligence (AI) see the current process of moving from clinical data gathering to medical diagnosis as being limited by human analytic capability and expect AI to be a valuable tool to refine this process. The use of AI fundamentally calls into question the extent to which uncertainty in medical decision making is tolerated. Uncertainty is perceived by some as fundamentally undesirable and thus, for them, optimal decision making should be based on minimizing uncertainty. However, uncertainty cannot be reduced to zero; thus, relative uncertainty can be used as a metric to weigh the likelihood of various diagnoses being correct and the appropriateness of treatments. Here, the authors make the argument, using as examples the experiences of 2 AI systems, IBM Watson on Jeopardy and Watson for Oncology, that medical decision making based on relative uncertainty provides a better lens for understanding the application of AI to medicine than one that minimizes uncertainty. This approach to uncertainty has significant implications for how health care leaders consider the benefits and trade-offs of AI-assisted and AI-driven decision tools and ultimately integrate AI into medical practice.
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Affiliation(s)
- Vinyas Harish
- V. Harish is a fourth-year MD-PhD student, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; ORCID: https://orcid.org/0000-0001-6364-2439
| | - Felipe Morgado
- F. Morgado is a fourth-year MD-PhD student, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; ORCID: https://orcid.org/0000-0003-3000-9455
| | - Ariel D Stern
- A.D. Stern is associate professor, Technology and Operations Management Unit, Harvard Business School, Harvard University, Cambridge, Massachusetts; ORCID: https://orcid.org/0000-0002-3586-1041
| | - Sunit Das
- S. Das is associate professor, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; ORCID: https://orcid.org/0000-0002-2146-4168
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Løchting I, Grotle M, Storheim K, Foldal V, Standal MI, Fors EA, Eik H. Complex return to work process - caseworkers' experiences of facilitating return to work for individuals on sick leave due to musculoskeletal disorders. BMC Public Health 2020; 20:1822. [PMID: 33256648 PMCID: PMC7708113 DOI: 10.1186/s12889-020-09804-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 10/30/2020] [Indexed: 12/14/2022] Open
Affiliation(s)
- Ida Løchting
- Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, Oslo, Norway.
| | - Margreth Grotle
- Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, Oslo, Norway.,Faculty of Health Science, Department of Physiotherapy, Oslo Metropolitan University, Oslo, Norway
| | - Kjersti Storheim
- Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, Oslo, Norway.,Faculty of Health Science, Department of Physiotherapy, Oslo Metropolitan University, Oslo, Norway
| | - Vegard Foldal
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Martin Inge Standal
- Department of Psychology, Faculty of Social and Educational Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Egil Andreas Fors
- General Practice Research Unit, Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Hedda Eik
- Faculty of Health Science, Department of Physiotherapy, Oslo Metropolitan University, Oslo, Norway
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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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Kumar R, Jahan M. Multimodal psychotherapy in the management of somatization disorder. Ind Psychiatry J 2020; 29:205-212. [PMID: 34158703 PMCID: PMC8188936 DOI: 10.4103/ipj.ipj_11_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Revised: 07/08/2020] [Accepted: 11/26/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Somatization is the presentation of physical symptoms without an objective and identifiable cause, and the condition is among the most common and challenging problems in primary medical care. Several modal of psychotherapy modal is being practiced but effective treatment in rarely delivered. AIM The aim of this study is to evaluate the efficacy and durability of multimodal psychotherapy in the management of somatization disorder. MATERIALS AND METHODS This is a hospital-based study using the pre-post design with control group. Thirty outpatient department patients with somatization disorder were selected and divided into two groups, i.e., intervention group and control group using the purposive sampling method. Intervention group was given 12 sessions of management package, i.e., symptoms monitoring form, scheduling of daily activity, sleep hygiene, diaphragmatic breathing, psycho-social intervention, psychodynamic individual psychotherapy, and cognitive restructuring (approximately 3-4 months). Efficacy and durability were measured by the Bradford somatic inventory, general health questionnaire-28 (GHQ-28), defense mechanism inventory (DMI), and Sack's sentence completion test (SSCT). RESULTS The results reveal that there are significant differences found among intervention group in comparisons to the control group in the context of somatic complaints (BSI), general health functioning (GHQ-28), life conflict (SSCT), and in defense mechanism (DMI). Significant improvement also found between postintervention and follow-up of the intervention group on different study variables. CONCLUSION The present study findings indicate that multimodal psychotherapy program is effective in the Indian context in the management of somatization disorder.
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Affiliation(s)
- Ranjan Kumar
- Department of Psychology, RKD College, PPU, Patna, Bihar, India
| | - Masroor Jahan
- Department of Clinical Psychology, RINPAS, Ranchi, Jharkhand, India
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Shedden-Mora MC, Kuby A, Tönnies J, Piontek K, Löwe B. Stepped, Collaborative, Coordinated Care for Somatic Symptom and Related Disorders (Sofu-Net). ZEITSCHRIFT FUR PSYCHOLOGIE-JOURNAL OF PSYCHOLOGY 2020. [DOI: 10.1027/2151-2604/a000405] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Abstract. To improve early detection and adequate treatment for patients with somatic symptom and related disorders (SSRD), we implemented Sofu-Net, a stepped, collaborative, and coordinated health care network. This mixed-methods study aimed to evaluate Sofu-Net from the health care professionals’ perspective. Network partners (primary care physicians (PCPs), psychotherapists, inpatient mental health clinics) completed an evaluation survey. Following, qualitative analysis of focus groups explored facilitating factors and barriers of Sofu-Net. Of 66 network partners who completed the survey (response 83.5%), the majority was satisfied with Sofu-Net, and perceived improvements regarding management, early detection, and referral to mental health care. Both survey and focus groups identified interdisciplinary collaboration and diagnostic screening as most relevant facilitating factors. Important barriers to implementation included challenges in patient referral and structural factors. Necessary prerequisites for future stepped collaborative care for SSRD include structures facilitating diagnosis, inter-professional collaboration and referral, availability of mental health care, inclusion of comorbidities, and adequate reimbursement.
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Affiliation(s)
- Meike C. Shedden-Mora
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Amina Kuby
- Department of Nursing and Management, Hamburg University of Applied Sciences, Hamburg, Germany
| | - Justus Tönnies
- Clinic for General Internal Medicine and Psychosomatics, University Medical Center Heidelberg, Germany
| | - Katharina Piontek
- Institute for Social Medicine and Health Systems Research, Medical Faculty, Otto-von-Guericke University Magdeburg, Germany
| | - Bernd Löwe
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Stortenbeker I, Stommel W, van Dulmen S, Lucassen P, Das E, Olde Hartman T. Linguistic and interactional aspects that characterize consultations about medically unexplained symptoms: A systematic review. J Psychosom Res 2020; 132:109994. [PMID: 32179304 DOI: 10.1016/j.jpsychores.2020.109994] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 03/06/2020] [Accepted: 03/08/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The apparent absence of any specific underlying diseases challenges patient-provider communication about medically unexplained symptoms (MUS). Previous research focused on general communication patterns in these interactions; however, an overview of more detailed interactional and linguistic aspects is lacking. This review aims to gain a detailed understanding of communicative challenges in MUS consultations by synthesizing evidence from conversation and discourse analytic research. METHODS A systematic review of publications using eight databases (PubMed, Embase, CINAHL, PsychINFO, Web of Science, MLA International Bibliography, LLBA and Communication Abstracts). Search terms included 'MUS', 'linguistics' and 'communication'. Additional studies were identified by contacting experts and searching bibliographies. We included linguistic and/or interactional analyses of natural patient-provider interactions about MUS. Two authors independently extracted the data, and quality appraisal was based on internal and external validity. RESULTS We identified 18 publications that met the inclusion criteria. The linguistic and interactional features of MUS consultations pertained to three dimensions: 1) symptom recognition, 2) double trouble potential (i.e. patients and providers may have differing views on symptoms and differing knowledge domains), and 3) negotiation and persuasion (in terms of acceptable explanations and subsequent psychological treatment). We describe the recurrent linguistic and interactional features of these interactions. CONCLUSIONS Despite the presence of a double trouble potential in MUS consultations, validation of symptoms and subtle persuasive conduct may facilitate agreement on illness models and subsequent (psychological) treatment.
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Affiliation(s)
- Inge Stortenbeker
- Centre for Language Studies, Radboud University, Nijmegen, The Netherlands.
| | - Wyke Stommel
- Centre for Language Studies, Radboud University, 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; Faculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway.
| | - Peter Lucassen
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Primary and Community Care, Nijmegen, The Netherlands.
| | - Enny Das
- Centre for Language Studies, Radboud University, Nijmegen, The Netherlands.
| | - Tim Olde Hartman
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Primary and Community Care, Nijmegen, The Netherlands.
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Burton C, Fink P, Henningsen P, Löwe B, Rief W. Functional somatic disorders: discussion paper for a new common classification for research and clinical use. BMC Med 2020; 18:34. [PMID: 32122350 PMCID: PMC7052963 DOI: 10.1186/s12916-020-1505-4] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 01/27/2020] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Functional somatic symptoms and disorders are common and complex phenomena involving both bodily and brain processes. They pose major challenges across medical specialties. These disorders are common and have significant impacts on patients' quality of life and healthcare costs. MAIN BODY We outline five problems pointing to the need for a new classification: (1) developments in understanding aetiological mechanisms; (2) the current division of disorders according to the treating specialist; (3) failure of current classifications to cover the variety of disorders and their severity (for example, patients with symptoms from multiple organs systems); (4) the need to find acceptable categories and labels for patients that promote therapeutic partnership; and (5) the need to develop clinical services and research for people with severe disorders. We propose 'functional somatic disorders' (FSD) as an umbrella term for various conditions characterised by persistent and troublesome physical symptoms. FSDs are diagnosed clinically, on the basis of characteristic symptom patterns. As with all diagnoses, a diagnosis of FSD should be made after considering other possible somatic and mental differential diagnoses. We propose that FSD should occupy a neutral space within disease classifications, favouring neither somatic disease aetiology, nor mental disorder. FSD should be subclassified as (a) multisystem, (b) single system, or (c) single symptom. While additional specifiers may be added to take account of psychological features or co-occurring diseases, neither of these is sufficient or necessary to make the diagnosis. We recommend that FSD criteria are written so as to harmonise with existing syndrome diagnoses. Where currently defined syndromes fall within the FSD spectrum - and also within organ system-specific chapters of a classification - they should be afforded dual parentage (for example, irritable bowel syndrome can belong to both gastrointestinal disorders and FSD). CONCLUSION We propose a new classification, 'functional somatic disorder', which is neither purely somatic nor purely mental, but occupies a neutral space between these two historical poles. This classification reflects both emerging aetiological evidence of the complex interactions between brain and body and the need to resolve the historical split between somatic and mental disorders.
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Affiliation(s)
- Christopher Burton
- Academic Unit of Primary Medical Care, University of Sheffield, Northern General Hospital, Samuel Fox House, Sheffield, S5 7AU, UK.
| | - Per Fink
- Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Aarhus, Denmark
| | - Peter Henningsen
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Bernd Löwe
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Winfried Rief
- Department of Clinical Psychology and Psychotherapy, University of Marburg, Marburg, Germany
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Terpstra T, Gol JM, Lucassen PLBJ, Houwen J, van Dulmen S, Berger MY, Rosmalen JGM, Olde Hartman TC. Explanations for medically unexplained symptoms: a qualitative study on GPs in daily practice consultations. Fam Pract 2020; 37:124-130. [PMID: 31392313 DOI: 10.1093/fampra/cmz032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND General practice is the centre of care for patients with medically unexplained symptoms (MUS). Providing explanations for MUS, i.e. making sense of symptoms, is considered to be an important part of care for MUS patients. However, little is known how general practitioners (GPs) do this in daily practice. OBJECTIVE This study aimed to explore how GPs explain MUS to their patients during daily general practice consultations. METHODS A thematic content analysis was performed of how GPs explained MUS to their patients based on 39 general practice consultations involving patients with MUS. RESULTS GP provided explanations in nearly all consultations with MUS patients. Seven categories of explanation components emerged from the data: defining symptoms, stating causality, mentioning contributing factors, describing mechanisms, excluding explanations, discussing the severity of symptoms and normalizing symptoms. No pattern of how GPs constructed explanations with the various categories was observed. In general, explanations were communicated as a possibility and in a patient-specific way; however, they were not very detailed. CONCLUSION Although explanations for MUS are provided in most MUS consultations, there seems room for improving the explanations given in these consultations. Further studies on the effectiveness of explanations and on the interaction between patients and GP in constructing these explanations are required in order to make MUS explanations more suitable in daily primary care practice.
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Affiliation(s)
- Tom Terpstra
- Interdisciplinary Center Psychopathology and Emotion Regulation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Janna M Gol
- Interdisciplinary Center Psychopathology and Emotion Regulation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Peter L B J Lucassen
- Department of Primary and Community Care, Radboud University Medical Center, Donders Institute for Brain Cognition and Behaviour, Nijmegen, The Netherlands
| | - Juul Houwen
- 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), BN Utrecht, The Netherlands.,Faculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway
| | - Marjolein Y Berger
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Judith G M Rosmalen
- Interdisciplinary Center Psychopathology and Emotion Regulation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Tim C Olde Hartman
- Department of Primary and Community Care, Radboud University Medical Center, Donders Institute for Brain Cognition and Behaviour, Nijmegen, The Netherlands
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Medically unexplained symptoms: time to and triggers for diagnosis in primary care consultations. Br J Gen Pract 2020; 70:e86-e94. [PMID: 31932294 DOI: 10.3399/bjgp20x707825] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 07/16/2019] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND It is currently not known when in the consultation GPs label symptoms as medically unexplained and what triggers this. AIM To establish the moment in primary care consultations when a GP labels symptoms as medically unexplained and to explore what triggers them to do so. DESIGN AND SETTING This was a qualitative study. Data were collected in the Netherlands in 2015. METHOD GPs' consultations were video-recorded. GPs stated whether the consultation was about medically unexplained symptoms (MUS). The GP was asked to reflect on the video-recorded consultation and to indicate the moment when they labelled symptoms as MUS. Qualitative interviewing and analysis were performed to explore the triggers GPs perceived that caused them to label the symptoms as MUS. RESULTS A total of 43 of the 393 video-recorded consultations (11%) were labelled as MUS. The mean time until GPs labelled symptoms as medically unexplained was about 4 minutes for newly presented symptoms and 2 minutes for symptoms for which the patients had already visited the GP before. GPs were triggered to label symptoms as MUS in the consultation by: the way patients presented their symptoms; the symptoms not fitting into a specific pattern; patients attributing the symptoms to a psychosocial context; and a discrepancy between symptom presentation and objective findings. CONCLUSION Most GPs labelled the presented symptoms as medically unexplained soon after the start of the consultation. GPs are triggered to label symptoms as medically unexplained by patients' symptom presentation, symptom patterns, and symptom attribution. This suggests that non-analytical reasoning was a central component in their thought process.
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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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47
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Sitnikova K, Leone SS, van Marwijk HWJ, Twisk J, van der Horst HE, van der Wouden JC. Effectiveness of a cognitive behavioural intervention for patients with undifferentiated somatoform disorder: Results from the CIPRUS cluster randomized controlled trial in primary care. J Psychosom Res 2019; 127:109745. [PMID: 31285038 DOI: 10.1016/j.jpsychores.2019.109745] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 06/09/2019] [Accepted: 06/16/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To examine the effectiveness of a cognitive behavioural intervention delivered by mental health nurse practitioners (MHNPs) to patients with undifferentiated somatoform disorder (USD), compared to usual care. METHODS We conducted a cluster randomized trial among primary care patients with USD comparing the intervention to usual care. The intervention consisted of six sessions with the MHNP. Primary outcome was physical functioning (RAND-36 physical component summary score). Secondary outcomes were the RAND-36 mental component summary score and the eight subscales; anxiety and depression (Hospital Anxiety and Depression Scale) and somatic symptom severity (Patient Health Questionnaire-15). Outcomes were assessed at baseline, 2, 4 and 12 months. We analysed data using linear mixed models by intention-to-treat, and investigated effect modifiers. RESULTS Compared to usual care (n = 87), the intervention group (n = 111) showed an improvement in physical functioning (mean difference 2.24 [95% CI 0.51; 3.97]; p = .011), a decrease in limitations due to physical problems (mean difference 10.82 [95% CI 2.14; 19.49]; p. = 0.015) and in pain (mean difference 5.08 [95% CI 0.58; 9.57]; p = .027), over 12 months. However effect sizes were small and less clinically relevant than expected. We found no differences for anxiety, depression and somatic symptom severity. Effects were larger and clinically relevant for patients with more recent symptoms and fewer physical diseases. CONCLUSION The cognitive behavioural intervention was effective in improving pain and physical functioning components of patients' health. It was particularly suitable for patients with symptoms that had been present for a limited number of years and with few comorbid physical diseases. TRIAL REGISTRATION The trial is registered in the Dutch Trial Registry, www.trialregister.nl, under NTR4686.
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Affiliation(s)
- Kate Sitnikova
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, De Boelelaan 1117, Amsterdam, Netherlands.
| | - Stephanie S Leone
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, De Boelelaan 1117, Amsterdam, Netherlands
| | - Harm W J van Marwijk
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, De Boelelaan 1117, Amsterdam, Netherlands
| | - Jos Twisk
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, De Boelelaan 1117, Amsterdam, Netherlands
| | - Henriëtte E van der Horst
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, De Boelelaan 1117, Amsterdam, Netherlands
| | - Johannes C van der Wouden
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, De Boelelaan 1117, Amsterdam, Netherlands
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48
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Stortenbeker I, Houwen J, van Dulmen S, Olde Hartman T, Das E. Quantifying implicit uncertainty in primary care consultations: A systematic comparison of communication about medically explained versus unexplained symptoms. PATIENT EDUCATION AND COUNSELING 2019; 102:2349-2352. [PMID: 31288956 DOI: 10.1016/j.pec.2019.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 06/26/2019] [Accepted: 07/03/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE General practitioners (GPs) disclose more uncertainty (e.g. "I don't know") in consultations with patients presenting medically unexplained symptoms (MUS) versus medically explained symptoms (MES), which could negatively affect patient outcomes. This study assessed if this pattern also holds for more subtle, implicit uncertainty expressions (e.g. "maybe", "might") during different consultation phases, and assessed their relation to patient pre-post consultation anxiety. METHODS We quantified implicit markers of uncertainty of 18 GPs in 82 consultations about MUS or MES during different consultation phases. Relative frequencies of implicit uncertainty per consultation were regressed on differences in momentary anxiety pre and post consultation. RESULTS We coded 2590 GP utterances. Uncertainty expressions were more frequent in MUS versus MES consultations (OR = 1.54, p = .004), especially during diagnosis and treatment recommendations compared to physical examinations (OR =0 .45, p = .001). Implicit uncertainty was not related to patients' changes in anxiety (b = -0.11, p = .817). CONCLUSIONS GPs express more uncertainty during MUS (versus MES) consultations, especially during the diagnostic phase and treatment recommendations. This does not necessarily affect patient anxiety. PRACTICE IMPLICATIONS Implicit uncertainty expressions reflect the mere complexity of communicating a medically unexplained diagnosis, which does not affect patient anxiety.
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Affiliation(s)
- Inge Stortenbeker
- Centre for Language Studies, Radboud University, Nijmegen, The Netherlands.
| | - Juul Houwen
- 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; Faculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway.
| | - Tim Olde Hartman
- Radboud university medical center, Radboud Institute for Health Sciences, Department of Primary and Community Care, Nijmegen, The Netherlands; Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands.
| | - Enny Das
- Centre for Language Studies, Radboud University, Nijmegen, The Netherlands.
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49
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Kvamme MF, Wang CEA, Waage T, Risør MB. Careful expressions of social aspects: How local professionals in high school settings, municipal services, and general practice communicate care to youth presenting persistent bodily complaints. HEALTH & SOCIAL CARE IN THE COMMUNITY 2019; 27:1175-1184. [PMID: 30969453 DOI: 10.1111/hsc.12762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 02/21/2019] [Accepted: 03/13/2019] [Indexed: 06/09/2023]
Abstract
Persistent health complaints pose communicative dilemmas in care encounters, adversely affecting patient experiences and pathways. Little is known about the impact and role of professionals in encounters with young people with incipient, debilitating, and persistent symptoms. This study aims to explore communicative dilemmas and the role of language in care provided by local professionals in high school settings, municipal services, and general practice to young people presenting persistent bodily complaints. The study is based on in-depth individual interviews conducted from April to July 2016 with 12 professionals identified and selected during anthropological multi-sited fieldwork in a Norwegian community. We identify two modalities of what we have chosen to call 'careful expression', used as strategies across professions to overcome communicative dilemmas. Professionals reflexively and pragmatically negotiated with the powers of language to influence illness experience and to enact empowered young subjects. These insights may prove relevant for future studies of care encounters while also indicating a critical attitude to institutional logics that affect care responses.
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Affiliation(s)
- Maria F Kvamme
- Department of Community Medicine, General Practice Research Unit, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Catharina E A Wang
- Department of Psychology, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Trond Waage
- Department of Social Sciences, Visual Cultural Studies, UiT The Arctic University of Norway, Tromsø, Norway
| | - Mette B Risør
- Department of Community Medicine, General Practice Research Unit, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
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50
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Patel M, James K, Moss-Morris R, Husain M, Ashworth M, Frank P, Ferreira N, Mosweu I, McCrone P, Hotopf M, David A, Landau S, Chalder T. Persistent physical symptoms reduction intervention: a system change and evaluation (PRINCE)-integrated GP care for persistent physical symptoms: protocol for a feasibility and cluster randomised waiting list, controlled trial. BMJ Open 2019; 9:e025513. [PMID: 31340956 PMCID: PMC6661663 DOI: 10.1136/bmjopen-2018-025513] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Persistent physical symptoms (PPS), also known as medically unexplained symptoms are associated with profound physical disability, psychological distress and high healthcare costs. England's annual National Health Service costs of attempting to diagnose and treat PPS amounts to approximately £3 billion. Current treatment relies on a positive diagnosis, life-style advice and drug therapy. However, many patients continue to suffer from ongoing symptoms and general practitioners (GPs) are challenged to find effective treatments. Training GPs in basic cognitive behavioural skills and providing self-help materials to patients could be useful, but availability in primary care settings is limited. METHODS AND ANALYSIS A cluster randomised waiting list, controlled trial will be conducted to assess the feasibility of an integrated approach to care in general practice. Approximately 240 patients with PPS will be recruited from 8 to 12 GP practices in London. GP practices will be randomised to 'integrated GP care plus treatment as usual' or waiting list control. Integrated GP care plus treatment as usual will include GP training in cognitive behavioural skills, GP supervision and written and audio visual materials for both GPs and participants. The primary objectives will be assessment of trial and intervention feasibility. Secondary objectives will include estimating the intracluster correlation coefficient for potential outcome measures for cluster effects in a sample size calculation. Feasibility parameters and identification of suitable primary and secondary outcomes for future trial evaluations will be assessed prerandomisation and at 12 and 24 weeks' postrandomisation, using a mixed-methods approach. ETHICS AND DISSEMINATION Ethical approval was granted by the Camberwell St Giles Ethics Committee. Results will be disseminated via peer-reviewed publications and conference presentations. This trial will inform researchers, clinicians, patients and healthcare providers about the feasibility and potential cost-effectiveness of an integrated approach to managing PPS in primary care. TRIAL REGISTRATION NUMBER NCT02444520; Pre-results.
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Affiliation(s)
- Meenal Patel
- Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Kirsty James
- Biostatistics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Rona Moss-Morris
- Health Psychology Section, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Mujtaba Husain
- Persistent Physical Symptoms Research and Treatment Unit, South London and Maudsley NHS Foundation Trust, London, UK
| | - Mark Ashworth
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Philipp Frank
- Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Nicola Ferreira
- Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Iris Mosweu
- King’s Health Economics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Paul McCrone
- King’s Health Economics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Matthew Hotopf
- Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Anthony David
- Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Sabine Landau
- Biostatistics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Trudie Chalder
- Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
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