Coping with Patients with Medically Unexplained Symptoms

Exploring attitudes of healthcare professionals towards those with fibromyalgia: A Q-methodological approach

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.

Patients' acceptance of explanatory models for persistent somatic symptoms: A qualitative analysis within the HERMES study

OBJECTIVE

The aim of this qualitative study was to provide an in-depth analysis of participants' experiences with video-animated explanatory models developed within the three-arm randomized controlled HERMES study ('Helpful explanatory models for somatic symptoms') and suggestions for further intervention improvement.

METHODS

Semi-structured qualitative interviews were conducted with psychosomatic outpatients with persistent somatic symptoms (PSS) after they were randomized to view one of three psychoeducational videos on a tablet computer: a) an explanatory model without personalization or b) an explanatory model with personalization in the two experimental groups or c) PSS guidelines without an explanatory model in the control group. Qualitative interviews were audiotaped, transcribed and analyzed applying thematic analysis.

RESULTS

Seventy-five patients with PSS were allocated to the study arms, mean duration of interviews was 8.19 min (SD = 3.19, range 4.02-19.49 min). Although all participants gave positive feedback regardless of their allocated study arm, those in the explanatory model without and with personalization groups were especially likely to rate the psychoeducational interventions as helpful. Results highlighted previous illness course, symptom perceptions and patient characteristics as key factors related to patients' response to the video interventions and optimal personalization of the explanatory model.

CONCLUSION

The present study not only demonstrated the acceptance of all three psychoeducational interventions developed within the HERMES study, but also provided valuable insights into potential key factors that may increase their impact and potential starting points for tailored psychoeducation in patients with PSS.

Experiences of general practitioners explaining central sensitisation to patients with persistent physical symptoms: a focus group study

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.

The careful assessment tool for managing patients with medically unexplained symptoms – The experience of Slovenian family medicine trainees: A qualitative study

Introduction

Primary care physicians use various tools and methods to identify medically unexplained symptoms (MUS). The main purpose of our study is to determine the views of Slovenian family medicine trainees (FMT) about using the “Careful Assessment” tool for managing patients with MUS.

Methods

A qualitative study using open survey questions focused on the experience of family medicine trainees in managing patients with MUS. The sample consisted of surveys from 184 family medicine trainees. These trainees analysed a total of 702 patients with MUS. Manual coding was used for quantitative content analysis.

Results

In the coding process, 49 codes were developed that included broader research fields about using the “Careful Assessment” tool for managing patients with MUS. The codes were grouped into four theoretically grounded, logical categories in accordance with the elaborated theoretical concept: multi-purpose utility; improved patient management; in-depth knowledge and new skills; and patient response.

Conclusion

The study demonstrated that, in the view of Slovenian FMT, the “Careful Assessment” tool has multi-purpose utility. The study showed that FMT felt that this tool helps them in systematic patient management. Their opinion is that it helps them establish a trusting relationship with patients, which is a precondition for providing further treatment.

Development of an eHealth programme for self-management of persistent physical symptoms: a qualitative study on user needs in general practice

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.

Medically unexplained symptoms: time to and triggers for diagnosis in primary care consultations

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.

Predictors of Seeking Psychotherapy in Primary Care Patients with High Somatic Symptom Burden

Many primary care patients with high somatic symptom burden do not initiate mental health treatment. Using a cross-sectional design, this study aimed to identify predictors of psychotherapy seeking behavior for patients with high somatic symptom burden within the last 12 months. Data from 20 primary care practices were analyzed. Patients with high somatic symptom burden were identified using the Patient Health Questionnaire, structured interviews, and information from primary care physicians (PCPs). Within the final sample of 142 patients, 54 (38.03%) had been seeking psychotherapy. More severe somatic symptoms, taking psychopharmacological medication and frequently discussing psychosocial distress with PCPs, were associated with psychotherapy seeking behavior. Depressive and anxiety symptoms, and whether PCPs had diagnosed a somatoform disorder or recommended psychotherapy, were not. The results underline the importance of patient-related factors in psychotherapy seeking behavior.

Facilitators and barriers in the diagnostic process of vulvovaginal complaints (vulvodynia) in general practice: a qualitative study

BACKGROUND

The gap between the relatively high prevalence of provoked vulvodynia (PVD) in the general population and the low incidence in primary care can partly be explained by physicians' lack of knowledge about the assessment and management of PVD.

OBJECTIVES

To recognize barriers and facilitators of GPs in the diagnostic process of women presenting with recurrent vulvovaginal complaints.

METHODS

A qualitative focus group study in 17 Dutch GPs, five men and 12 women. An interview guide, based on the scientific literature and the expertise of the researchers, including a vignette of a patient, was used to direct the discussion between the GPs. The interviews were audiotaped and transcribed verbatim. A systematic text analysis of the transcripts was performed after data saturation was reached.

RESULTS

Analysis of the interviews generated three major themes: Identifying and discussing sexual complaints, importance of gender in professional experience, and coping with professional uncertainty. Within these themes, the reluctance regarding sexual complaints, male gender, negative emotional responses when faced with professional uncertainty, as well as lack of education were barriers to the diagnostic process and management of PVD. Female gender and understanding that patients can profit from enquiring about sexual health issues were found to be facilitating factors.

CONCLUSIONS

To improve the care for women with PVD, attitude and skills of GPs regarding taking a sexual history and performing a vulvovaginal examination should be addressed, as well as GPs' coping strategies regarding their professional uncertainty.

Contesting and Differentially Constructing Uncertainty: Negotiations of Contraceptive Use in the Clinical Encounter

Most women of reproductive age have access to highly effective contraception, and all available methods are associated with side effects. Whether a woman will experience side effects is uncertain, however, which can pose challenges for clinicians who discuss the methods with patients. In this study, we analyze 102 contraceptive counseling visits to understand how clinicians discursively construct knowledge in the context of uncertainty. We find that while some present the uncertainty of side effects in a straightforward, patient-accessible way, others negotiate their predictions by (1) differentially constructing uncertainty, suggesting that positive side effects are likely and negative side effects are unlikely, and (2) contesting uncertainty, presenting the risk of serious side effects as controllable. In the end, these strategies deemphasize consideration of negative side effects in women's contraceptive decision making. Our results demonstrate the importance of elucidating the translation, instantiation, and construction of medical uncertainty both in theory and in practice.

The work-related stressors and coping strategies of group-employed rural health care practitioners: A qualitative study

BACKGROUND

Escalating demands on practitioners, stagnating/dwindling resources, and diminishing autonomy have heightened patient-care work-related stress. Using qualitative content/thematic analysis of responses to open-ended survey questions, plus spontaneous comments, we sought to identify rural clinicians' subjective perceptions of their workplace stressors and typical adaptive/coping strategies.

METHODS

Within a hybrid inductive-deductive approach, we framed empirical themes (derived by consensus, corroborated with text segments, and extant literature) into theory-based coding templates by which we analyzed the data.

RESULTS

Of 308 (65.1% of) recipients completing questionnaires, 290 (94%) answered open-ended questions and/or provided comments. Categorizing stressors by socio-ecology, they cited four themes: Organizational, practitioner/staff-related, patient-related, and third party-induced stressors. Organizational stressors were referenced most conspicuously. How respondents described their coping fitted the Stress, Appraisal and Coping. [Lazarus and Folkman (1984): New York, NY: Springer Publishing Company, Inc] model. Emotion-focused were referenced more than problem-focused approaches. Themes scarcely differed by demographics, except for marital status.

CONCLUSIONS

Findings highlight needs for resilience coaching, rekindling work meaningfulness, mentorship in work-home balance/limit-setting, supportive peer networks, and deeper teamwork.

What is the problem with medically unexplained symptoms for GPs? A meta-synthesis of qualitative studies

OBJECTIVE

To gain a deeper understanding of challenges faced by GPs when managing patients with MUS.

METHODS

We used meta-ethnography to synthesize qualitative studies on GPs' perception and management of MUS.

RESULTS

The problem with MUS for GPs is the epistemological incongruence between dominant disease models and the reality of meeting patients suffering from persistent illness. GPs have used flexible approaches to manage the situation, yet patients and doctors have had parallel negative experiences of being stuck, untrustworthy and helpless. In the face of cognitive incongruence, GPs have strived to achieve relational congruence with their patients. This has led to parallel positive experiences of mutual trust and validation. With more experience, some GPs seem to overcome the incongruences, and later studies point towards a reframing of the MUS problem.

CONCLUSION

For GPs, the challenge with MUS is most importantly at an epistemological level. Hence, a full reframing of the problem of MUS for GPs (and for patients) implies broad changes in basic medical knowledge and education.

PRACTICE IMPLICATIONS

Short-term: Improve management of patients with MUS by transferring experience-based, reality-adjusted knowledge from senior GPs to juniors. Long-term: Work towards new models of disease that integrate knowledge from all relevant disciplines.

Group supervision for healthcare professionals within primary care for patients with psychosomatic health problems: a pilot intervention study

BACKGROUND

In primary health care, efficacious treatment strategies are lacking for these patients, although the most prominent symptoms accounting for consultation in primary care often cannot be related to any biological causes.

AIM

The aim was to explore whether group supervision from a specific phenomenological theory of psychosomatics could provide healthcare professionals treating patients with psychosomatic health issues within primary care a deeper understanding of these conditions and stimulate profession-specific treatment strategies. Our research questions were as follows: (i) What is the healthcare professionals' understanding of psychosomatics before and after the intervention? (ii) What are the treatment strategies for this group of patients before and after the intervention?

METHODS

The study was an explorative qualitative intervention pilot study. The six participants from a primary healthcare setting in a medium-sized city in Sweden participated in the study. A supervision group was formed, based on a mix of professions, age, gender and years of clinical experience. Supervision consisted of one 75-minutes meeting every month during the course of 6 months. Participants were interviewed before and after the supervision intervention.

FINDINGS

The study showed two distinct categories emerged from the data. One category of healthcare professionals espoused a psycho-educative approach, while the other lacked a cohesive approach. The supervision improved the second category of healthcare professionals' understanding of psychosomatics. The psycho-educative group did not change their understanding of psychosomatics, although they felt strengthened in their approach by the supervision. Profession-specific strategies were not developed.

IMPLICATIONS

This pilot study indicates that a relatively short supervision intervention can aid clinicians in their clinical encounters with these patients; however, further research is necessary to ascertain the value of the specific phenomenologically based supervision intervention.

Correspondence in Stakeholder Assessment of Health, Work Capacity and Sick Leave in Workers with Comorbid Subjective Health Complaints? A Video Vignette Study

Purpose The purpose of this study is to test if there is correspondence in stakeholders' assessments of health, work capacity and sickness certification in four workers with comorbid subjective health complaints based on video vignettes. Methods A cross sectional survey among stakeholders (N = 514) in Norway in 2009/2010. Logistic regression and multinomial logistic regression was used to obtain the estimated probability of stakeholders choosing 100 % sick leave, partial sick leave or work and the estimation of odds ratio of stakeholder assessment compared to the other stakeholders for the individual worker. Results The supervisors were less likely to assess poor health and reduced work capacity, and more likely to suggest partial sick leave and full time work compared to the GPs for worker 1. The public was less likely to assess comorbidity and reduced work capacity, and 6 and 12 times more likely to suggest partial sick leave and full time work compared to the GPs for worker 1. Stakeholders generally agreed in their assessments of workers 2 and 3. The public was more likely to assess poor health, comorbidity and reduced work capacity, and the supervisors more likely to assess comorbidity and reduced work capacity, compared to the GPs for worker 4. Compared to the GPs, all other stakeholders were less likely to suggest full time work for this worker. Conclusions Our results seem to suggest that stakeholders have divergent assessments of complaints, health, work capacity, and sickness certification in workers with comorbid subjective health complaints.

Multiple somatic symptoms in primary care patients: a cross-sectional study of consultation content, clinical management strategy and burden of encounter

Background

Consultations involving patients with multiple somatic symptoms may be considered as challenging and time-consuming by general practitioners (GPs). Yet, little is known about the possible links between consultation characteristics and GP-experienced burden of encounter. We aimed to explore consultation content, clinical management strategies, time consumption and GP-experienced burden of encounters with patients suffering from multiple somatic symptoms as defined by the concept of bodily distress syndrome (BDS).

Methods

Cross-sectional study of patient encounters in primary care from December 2008 to December 2009; 387 GPs participated (response rate: 44.4 %). Data were based on a one-page registration form completed by the GP and a patient questionnaire including the 25-item BDS checklist for somatic symptoms. Using logistic regression analyses, we compared patients who met the BDS criteria with patients who did not.

Results

A total of 1505 patients were included (response rate: 55.6 %). Health problems were less frequently reported as ‘new’ in patients with BDS (odds ratio (OR) = 0.73, 95 % confidence interval (CI): 0.54; 0.97). Medical prescriptions and referral rates were comparable in the two patient groups. Consultations focusing on mainly biomedical aspects were less frequent among patients with BDS (OR = 0.31, 95 % CI: 0.22; 0.43), whereas additional biomedical and psychosocial problems were more often discussed. GPs were more likely to ensure continuity of care in BDS patients by watchful waiting strategies (OR = 2.32, 95 % CI: 1.53; 3.52) or scheduled follow-up visits (OR = 1.61, 95 % CI: 1.09; 2.37). Patients with BDS were found to be more time-consuming (OR = 1.77, 95 % CI: 1.26; 2.48) and burdensome (OR = 2.54, 95 % CI: 1.81; 3.55) than patients without BDS. However, after adjustments for biomedical and psychosocial content of the consultation, the identified differences for time consumption and burden were no longer statistically significant.

Conclusions

Patients with BDS represent higher care complexity in terms of biomedical and psychosocial needs. GPs seem to allow space and time for discussing these issues and to aim at ensuring continuity in care through watchful waiting or scheduled follow-up consultations. However, the reported GP-experienced burden call for professional development.

The challenge of diagnosing non-specific, functional, and somatoform disorders: A systematic review of barriers to diagnosis in primary care

OBJECTIVE

Despite their prevalence and impact on patients and the health care system, non-specific, functional, and somatoform disorders are underdiagnosed. This problem is especially problematic in primary care if we are moving towards an integrated care model. The objective of the current study was to identify and aggregate potential barriers to the diagnosis in primary care settings.

METHODS

Our systematic review methodology followed a pre-published protocol and was registered in PROSPERO (CRD42013002540). We combined qualitative and quantitative data from studies identified in online databases and by hand searching of reference lists. Data were synthesized in a data-driven way using a grounded-theory approach. The level of evidence and assessment of bias for the final included studies was independently conducted.

RESULTS

Data from n=177 full text publications were independently extracted and combined in a custom database. The final list of included studies was n=42. From these, a total of n=379 barriers were identified comprising 77 barrier-level codes, 16 thematic categories and five over-arching themes, i.e., patient-related, primary-care-practitioner related, doctor-patient interactional, situational, and conceptual and operational barriers.

CONCLUSION

Given the thematic range of the identified barriers, the diagnostic process of non-specific, functional, and somatoform disorders in primary care is highly complex. Individual or practice-level interventions, as well as public awareness initiatives are needed to help address the diagnostic challenges. A multi-factorial understanding of symptoms with a biopsychosocial parallel diagnostic approach should be encouraged. More direct empirical investigations are also needed.

Barriers to the diagnosis of somatoform disorders in primary care: protocol for a systematic review of the current status

BACKGROUND

Somatoform-type disorders and functional medically unexplained symptoms are extremely common in primary care settings. These disorders, however, are consistently underdiagnosed and under-recognised which precludes effective treatment. Given that somatoform symptoms are associated with high impairment, healthcare costs and both physician and patient frustration, it is critical to improve early detection. The first step in improving patient care is to identify the current barriers which obstruct successful diagnosis to enable the design of targeted interventions. We aim to conduct a systematic review to identify the possible physician-, patient- and society-related factors and other practical constraints which may impede successful diagnosis. In the process, we will also be able to recognise the differences in methodological techniques, recommend potential avenues for future research and comment on the literature in this field as a whole.

METHODS/DESIGN

We aim to conduct a systematic review of the relevant peer-reviewed literature published in English or German in the past 10 years in MEDLINE, EMBASE, PsycINFO and the Cochrane Database of Systematic Reviews. Additional studies may be identified from the reference lists of included studies. Title and abstract screening and data extraction from full text manuscripts will be conducted by two independent reviewers. Because we are including a combination of qualitative and quantitative studies, the review will provide a broad understanding of the current situation. Wherever possible, the method and reporting of the review will adhere to the guidelines outlined in the PRISMA statement and bias will be assessed using the Cochrane collaboration's recommendations. We envisage that data will be synthesised using a multilevel (qualitative and quantitative) approach which combines textual narrative and thematic analysis. Barriers will be categorised as modifiable or non-modifiable according to a conceptual framework. The review has been registered in an international registry of systematic reviews PROSPERO (CRD42013002540).

DISCUSSION

We hope that this study will provide an insight into the barriers to diagnosis of somatoform-type disorders and the results can be used to target appropriate interventions to improve care for these patients.

Opinions of Slovenian family physicians on medically unexplained symptoms: A qualitative study

Objectives

To determine the views of Slovenian family physicians on medically unexplained symptoms (MUS) and learn more about potential types of treatment for such patients.

Methods

Five focus groups, comprising 24 family medicine physicians (FMPs) from two Slovenian University centres, were convened. Conversations were led towards the research objectives by professionally trained researchers and followed a preliminarily established protocol. Qualitative content analysis of audio and transcripts of the discussions was performed using ATLAS.ti software to establish categories (‘codes’) relevant to issues regarding MUS.

Results

Slovenian FMPs emphasized the importance of good communication and trust between physicians and patients with MUS. Systemic barriers to effective management of MUS arising from the Slovenian health system were highlighted. FMPs stressed the need for more education in the recognition and treatment of MUS in primary care. From the discussions, 64 codes comprising broader research fields of MUS were developed, then grouped into a further eight categories: communication; doctor–patient relationship; causes of MUS; patient characteristics; physician characteristics; courses of action so far; positive relationship with patients; proposals for treatment.

Conclusions

The results are valuable in terms of investigating the treatment of patients with MUS in Slovenia, thereby opening new avenues of research on the subject of MUS.

Phenomena associated with sick leave among primary care patients with Medically Unexplained Physical Symptoms: a systematic review

OBJECTIVE

To explore and synthesize the literature on phenomena associated with sick leave among patients with Medically Unexplained Physical Symptoms (MUPS).

DESIGN

A systematic review of the literature was undertaken in three phases: (1) a search of the following databases: Medline, Embase, Psych Info, Cochrane Collaboration Library, Digital Dissertations, DiVA, SweMed +, NORART, and ISI Web of Science, (2) selection of studies based on pre-specified inclusion criteria was undertaken, extracting study design and results, (3) quality assessment was undertaken independently by two reviewers. Due to heterogeneity in study designs, populations, interventions, and outcome measures, a mixed research synthesis approach was used. Results were assessed in a pragmatic and descriptive way; textual and numerical data were extracted from the included studies, and classified into patient- and doctor-related factors.

RESULTS

Sixteen studies were included. With regard to patients, an association was found between sick leave and psychiatric comorbidity as well as total symptom burden. With regard to doctors, knowledge of the patient, sympathy, and trust appeared to increase the probability of the patient being sick-listed. None of the interventions in the educational programmes aiming to improve doctors' management of MUPS patients succeeded in lowering sick leave.

IMPLICATIONS

Despite MUPS being a leading cause of sickness absence, the review identified only a small number of studies concerning phenomena associated with sick leave. The authors did not identify any studies regarding the impact of the working conditions on sick leave among MUPS patients. This is an important area for further studies.

"We need to get you focused": general practitioners' representations of chronic low back pain patients

Although subject to considerable research from perspectives including general practitioners, patients, and perspective guidelines, chronic low back pain (CLBP) continues to be a common but contentious condition in primary care. We used medical consultation records, critical incident interviews, and a think-aloud problem-solving task to examine how general practitioners applied professional knowledge of the condition, especially in relation to psychosocial care. Using qualitative content analysis and thematic analysis, we identified a pragmatic, goal-focused approach to patients, a schema based on biomedical knowledge and tacit theories of motivation. The doctors' expectations for CLBP included uncertainty over symptoms and doubts over patient credibility, which helped to explain an autonomous rather than collaborative approach to managing back pain patients. The findings are discussed in light of social representations theory, self-determination, and research on the therapeutic relationship.

Qualitative methodologies I: asking research questions with reflexive insight

The purpose of this paper, the first of a series of two discussion pieces, is to introduce some of the issues in the debate surrounding qualitative research to the readers of Musculoskeletal Care. Recent issues of the Journal have seen an informative focus on quantitative methods and statistical analysis, and here we provide an equivalent introduction to semi-structured interviewing and qualitative analysis in this series. In the qualitative tradition, we have tried to keep our discussion reflexive, transparent and contextualized within the history of the approach and the theoretical considerations that underlie it, including the origins, nature, methods and limits of the approach. We provide information that we hope is useful for readers with all levels of familiarity with qualitative research, building from an introduction to some basic assumptions and ethical issues. We also introduce one specific qualitative approach, interpretative phenomenological analysis, which researchers might wish to apply. In the accompanying paper in a subsequent issue of Musculoskeletal Care, we will describe the potential application of this approach.

Why do general practitioners decline training to improve management of medically unexplained symptoms?

BACKGROUND

General practitioners' (GPs) communication with patients presenting medically unexplained symptoms (MUS) has the potential to somatize patients' problems and intensify dependence on medical care. Several reports indicate that GPs have negative attitudes about patients with MUS. If these attitudes deter participation in training or other methods to improve communication, practitioners who most need help will not receive it.

OBJECTIVE

To identify how GPs' attitudes to patients with MUS might inhibit their participation with training to improve management.

DESIGN

Qualitative study.

PARTICIPANTS

GPs (N = 33) who had declined or accepted training in reattribution techniques in the context of a research trial.

APPROACH

GPs were interviewed and their accounts analysed qualitatively.

RESULTS

Although attitudes that devalued patients with MUS were common in practitioners who had declined training, these coexisted, in the same practitioners, with evidence of intuitive and elaborate psychological work with these patients. However, these practitioners devalued their psychological skills. GPs who had accepted training also described working psychologically with MUS but devalued neither patients with MUS nor their own psychological skills.

CONCLUSIONS

GPs' attitudes that suggested disengagement from patients with MUS belied their pursuit of psychological objectives. We therefore suggest that, whereas negative attitudes to patients have previously been regarded as the main barrier to involvement in measures to improve patient management, GPs devaluing of their own psychological skills with these patients may be more important.