Empirical Evaluation of Veterans' Perceived Non-Concordance with Providers Regarding Medically Unexplained Symptoms

Treatment and life goals among veterans with Gulf War illness

Medically unexplained syndromes (MUS), also termed persistent physical symptoms, are both prevalent and disabling. Yet treatments for MUS are marked by high rates of patient dissatisfaction, as well as disagreement between patients and providers on the management of persistent physical symptoms. A better understanding of patient-generated goals could increase collaborative goal setting and promote person-centered care, a critical component of MUS treatment; yet research in this area is lacking. This paper aimed to develop a typology of treatment and life goals among Gulf War veterans with a medically unexplained syndrome (Gulf War Illness). We examined participants' responses to open-ended questions about treatment and life goals using Braun and Clarke's thematic analysis methodology. Results showed that treatment goals could be categorized into four overarching themes: 1) Get better/healthier, 2) Improve quality of life, 3) Improve or seek additional treatment, and 4) Don't know/Don't have any. Life goals were categorized into six overarching themes: 1) Live a fulfilling life, 2) Live a happy life, 3) Live a healthy life, 4) Be productive/financially successful, 5) Manage GWI, and 6) Don't know/Don't have any. Treatment goals were largely focused on getting better/healthier (e.g., improving symptoms), whereas life goals focused on living a fulfilling life. Implications for the treatment of Gulf War Illness and patient-provider communication are discussed. ClinicalTrials.gov Identifier: NCT02161133.

'She thought the same way I that I thought:' a qualitative study of patient-provider concordance among Gulf War Veterans with Gulf War Illness

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.

Exploring the acceptability of behavioral interventions for veterans with persistent "medically unexplained" physical symptoms

OBJECTIVE

This study evaluated the factors that led to enrollment in, and satisfaction with, behavioral interventions for Veterans living with Gulf War Illness (GWI).

METHODS

One-on-one interviews were conducted pre- and post-intervention with participants randomized to receive either telephone delivered problem-solving treatment (n = 51) or health education (N = 49). A total of 99 Veterans were interviewed pre-intervention and 60 post-intervention. Qualitative data were thematically coded and similarities in themes across the two interventions were examined.

RESULTS

Before the study began, participants reported desiring to learn new information about their GWI, learn symptom-management strategies, and support improvements to care for other patients with GWI. After the intervention, Veterans felt positively about both interventions because they built strong therapeutic relationships with providers, their experiences were validated by providers, and they were provided GWI information and symptom-management strategies. Results also suggested that interventions do not have to be designed to meet all of the needs held by patients to be acceptable. A minority of participants described that they did not benefit from the interventions.

CONCLUSION

The results suggest that satisfaction with behavioral interventions for GWI is driven by a strong therapeutic relationship, validating patient's experiences with GWI, and the intervention meeting some of the patient's needs, particularly increasing knowledge of GWI and improving symptom management.

Examining Clinical Presentation and Workup of Veterans with Irritable Bowel Syndrome in a Single Medical Centre: A Case Series

Irritable bowel syndrome (IBS) is a disorder of gut-brain interaction (DGBI) that affects about 10% of the adult population in the United States. IBS pathoetiology understanding has evolved and clinical management improved despite the underdevelopment of diagnostics. Within the Veterans Affairs (VA) system, the prevalence and impact of DGBIs are high. Yet there is a paucity of information on the patient demographic features. Our team examined the history and workup of patients referred to an IBS clinic within the VA's gastroenterology service through a systematic case series study to begin a quality improvement initiative.

The Common-Sense Model and Mental Illness Outcomes: A Meta-Analysis

Psychotherapists can improve their patients' outcomes during and after therapy by improving patients' self-management. Patients who do not effectively manage their mental illness generally have worse outcomes. Leventhal's Common-Sense Model of Self-Regulation theorizes that patients' perceptions of their illness (illness representations) guide their self-management, influencing health outcomes. The present study quantified the relations between illness representations, self-management, and outcomes for mental illnesses. We conducted a meta-analysis and included articles if they reported: 1) on adults with mental illnesses; and 2) the correlation between mental illness representations and mental illness outcomes. 25 articles were included which represented 28 independent samples. The pattern of correlations among illness representations (identity, consequences, timeline, control, coherence, and emotional representations), self-management strategies (attendance, engagement, and adherence to treatment) and mental illness outcomes (symptom severity and quality of life) was consistent with analyses from previous studies of mental and physical illnesses. The results found threat-related illness representations mostly had a large relationship with worse mental illness outcomes and self-management. Protective illness representations had a small-to-large relationship with better mental illness outcomes and self-management. The results suggest patients' perceptions of their mental illness may be a critical indicator of their mental illness outcomes, including symptom severity and quality of life. This theory-driven meta-analysis supports calls for the inclusion of illness representations in psychotherapy for mental illness.

Under-recognition of medically unexplained symptom conditions among US Veterans with Gulf War Illness

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.

Introducing the System for Observing Medical Alliances (SOMA): A Tool for Studying Concordance in Patient-Physician Relationships

We developed the System for Observing Medical Alliances (SOMA) to study relationships between medical providers and patients with medically unexplained symptoms (MUS). Based on literature in health psychology, medicine, and the psychotherapeutic alliance, the SOMA operationalizes three medical alliance dimensions: Engagement in the Consultation Process, Trust in the Provider, and Concordance of Illness Beliefs and Treatment Recommendations. Specific behavioral indicators, tallied as observed by trained judges, are used as the basis for rating each dimension. In a sample of 33 medical consultations with veterans who had MUS, interrater reliabilities ranged from .79 to .94. Notably, the other dimension ratings accounted for 40% of the variability in Concordance, with Trust in the Provider contributing unique variance. In addition to research, psychologists in integrated health settings can use the SOMA to consult and train medical providers on communication skills that enhance concordance.