Management of somatisers in primary care: are family doctors motivated?

Persistent somatic symptom related stigmatisation by healthcare professionals: A systematic review of questionnaire measurement instruments

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.

Barriers and facilitators to implementing interventions for medically unexplained symptoms in primary and secondary care: A systematic review

OBJECTIVE

To integrate existing literature on barriers and facilitators to implementing interventions for Medically Unexplained Symptoms (MUS) in primary and secondary care.

METHOD

Systematic review following PRISMA guidelines. A search of PsychINFO/Pubmed/Web of Science was performed to select studies focusing on MUS-interventions and implementation. All included papers were checked for quality and bias. A narrative synthesis approach was used to describe the included papers by implementation level, ranging from the specific intervention to the broader economic/political context.

RESULTS

20 (quantitative/qualitative/mixed design) papers were included, but the quantitative studies especially, lacked methodological quality, with possible publication bias as a result. Results showed that the intervention needs to be acceptable and in line with daily practice routines. The professional's attitude and skills are important for implementation success, as well as for overcoming problems in the professional-patient interaction. If patients stick to finding a somatic cause, this hampers implementation. A lack of time is a frequently mentioned barrier at the organizational level. Barriers/facilitators at the social context level and at the economic/political level were barely reported on in the included papers.

CONCLUSION

Results were integrated into an existing implementation model, as an example of how MUS-interventions can be successfully implemented in practice.

Interrelationships between symptom burden and health functioning and health care utilization among veterans with persistent physical symptoms

Background

Between 10 and 50% of primary care patients present with persistent physical symptoms (PPS). Patients with PPS tend to utilize excessive or inappropriate health care services, while being stuck in a deleterious cycle of inactivity, deconditioning, and further worsening of symptoms and disability. Since military deployment (relative to non-deployment) is associated with greater likelihood of PPS, we examined the interrelationships of health care utilization, symptom burden and functioning among a sample of recently deployed Veterans with new onset persistent physical symptoms.

Methods

This study analyzed a cohort of 790 U.S. soldiers who recently returned from deployment to Iraq or Afghanistan. Data for this analysis were obtained at pre- and post-deployment. We used moderation analyses to evaluate interactions between physical symptom burden and physical and mental health functioning and four types of health care utilization one-year after deployment, after adjusting for key baseline measures.

Results

Moderation analyses revealed significant triple interactions between physical symptom burden and health functioning and: primary care (F = 3.63 [2, 303], R²Δ = .02, p = 0.03), specialty care (F = 6.81 [2, 303] R²Δ =0.03, p < .001), allied therapy care (F = 3.76 [2, 302], R²Δ = .02, p = 0.02), but not mental health care (F = 1.82 [1, 303], R²Δ = .01, p = .16), one-year after deployment.

Conclusions

Among U.S. Veterans with newly emerging persistent physical symptoms one-year after deployment, increased physical symptom burden coupled with decreased physical and increased mental health functioning was associated with increased medical care use in the year after deployment. These findings support whole health initiatives aimed at improving health function/well-being, rather than merely symptom alleviation.

Explanations for medically unexplained symptoms: a qualitative study on GPs in daily practice consultations

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.

Symptom management for medically unexplained symptoms in primary care: a qualitative study

BACKGROUND

GPs have a central position in the care of patients with medically unexplained symptoms (MUS), but GPs find their care challenging. Currently, little is known about symptom management by GPs in daily practice for patients with MUS.

AIM

This study aimed to describe management strategies used by GPs when confronted with patients with MUS in daily practice.

DESIGN AND SETTING

Qualitative study in which videos and transcripts of 39 general practice consultations involving patients with MUS in the region of Nijmegen in the Netherlands in 2015 were analysed.

METHOD

A thematic analysis of management strategies for MUS used by GPs in real-life consultations was performed.

RESULTS

The study revealed 105 management strategies in 39 consultations. Nearly half concerned symptom management; the remainder included medication, referrals, additional tests, follow-up consultations, and watchful waiting. Six themes of symptom management strategies emerged from the data: cognitions and emotions, interaction with health professionals, body focus, symptom knowledge, activity level, and external conditions. Advice on symptom management was often non-specific in terms of content, and ambiguous in terms of communication.

CONCLUSION

Symptom management is a considerable part of the care of MUS in general practice. GPs might benefit from support in how to promote symptom management to patients with MUS in specific and unambiguous terms.

Chinese perspectives on primary care for common mental disorders: Barriers and policy implications

BACKGROUND

The World Health Organization (WHO) has called for integration of mental health into primary care for a decade. In Western countries, around 15% to 25% of patients with common mental disorders including mood and anxiety disorders seek help from primary care physicians (PCPs). The rate is only about 5% in China.

AIMS

This article reviews the Chinese findings on the barriers to primary care for common mental disorders and how they compared with Western findings.

METHODS

A narrative literature review was conducted, focusing on literature published from mid-1990s in English or Chinese. Patient, PCP and health system factors were reviewed.

RESULTS

Although Chinese and Western findings show similar themes of barriers, the Chinese have stronger barriers in most aspects, including under-recognition of the need for treatment, stigma on mental illness, somatization, worries about taking psychiatric drugs, uncertainties in the role, competency and legitimacy of PCPs in mental health care and short consultation time.

CONCLUSION

Current policies in China emphasize enhancement of mental health facilities and workforce in the community. Our review suggests that patients' intention to seek help and PCPs' competency in mental health care are other fundamental factors to be addressed.

Medically unexplained symptoms and general practitioners: a comprehensive survey about their attitudes, experiences and management strategies

BACKGROUND

Medically unexplained symptoms (MUS) are common in primary care and are one of the most challenging clinical encounters for general practitioners (GPs).

OBJECTIVE

To assess GPs' clinical experience with MUS and its relationship with their gender, age and length of practice.

METHODS

Four hundred and thirty-three Italian GPs were invited to complete a questionnaire encompassing the following MUS-related features: workload, cognitive and emotional responses, management strategies, attitudes towards psychological interventions, sources of education and educational needs.

RESULTS

A total of 347 GPs (80.1%) participated in the study. About seven out of ten physicians spent 'much' or 'very much' time and energy for MUS during their daily practice. Fear of neglecting a medical disease was the most frequent (59.1%) response to MUS. Providing reassurance and support (73.8%) and listening to the patient (69.2%) were the most frequent management strategies. More than half of GPs rated psychological interventions as 'much' or 'very much' useful for MUS. However, only a third of GPs were well informed about the role of psychologists in MUS management. The main sources of education about MUS were scientific papers and continuing medical education courses. Most of GPs (77.5%) needed further education about MUS. GPs' younger age and lower length of practice were significantly associated with negative emotional responses to MUS.

CONCLUSION

The introduction of guidelines for MUS in Italian primary care settings would promote a collaborative clinical approach to MUS and more formal training on this topic.

"You kind of want to fix it don't you?" Exploring general practice trainees' experiences of managing patients with medically unexplained symptoms

BACKGROUND

Much of a General Practitioner's (GP) workload consists of managing patients with medically unexplained symptoms (MUS). GP trainees are often taking responsibility for looking after people with MUS for the first time and so are well placed to reflect on this and the preparation they have had for it; their views have not been documented in detail in the literature. This study aimed to explore GP trainees' clinical and educational experiences of managing people presenting with MUS.

METHOD

A mixed methods approach was adopted. All trainees from four London GP vocational training schemes were invited to take part in a questionnaire and in-depth semi-structured interviews. The questionnaire explored educational and clinical experiences and attitudes towards MUS using Likert scales and free text responses. The interviews explored the origins of these views and experiences in more detail and documented ideas about optimising training about MUS. Interviews were analysed using the framework analysis approach.

RESULTS

Eighty questionnaires out of 120 (67%) were returned and a purposive sample of 15 trainees interviewed. Results suggested most trainees struggled to manage the uncertainty inherent in MUS consultations, feeling they often over-investigated or referred for their own reassurance. They described difficulty in broaching possible psychological aspects and/or providing appropriate explanations to patients for their symptoms. They thought that more preparation was needed throughout their training. Some had more positive experiences and found such consultations rewarding, usually after several consultations and developing a relationship with the patient.

CONCLUSION

Managing MUS is a common problem for GP trainees and results in a disproportionate amount of anxiety, frustration and uncertainty. Their training needs to better reflect their clinical experience to prepare them for managing such scenarios, which should also improve patient care.

Psychosocial Risk Factors, Interventions, and Comorbidity in Patients with Non-Specific Low Back Pain in Primary Care: Need for Comprehensive and Patient-Centered Care

Non-specific low back pain (LBP) affects many people and has major socio-economic consequences. Traditional therapeutic strategies, mainly focused on biomechanical factors, have had moderate and short-term impact. Certain psychosocial factors have been linked to poor prognosis of LBP and they are increasingly considered as promising targets for management of LBP. Primary health care providers (HCPs) are involved in most of the management of people with LBP and they are skilled in providing comprehensive care, including consideration of psychosocial dimensions. This review aims to discuss three pieces of recent research focusing on psychosocial issues in LBP patients in primary care. In the first systematic review, the patients' or HCPs' overall judgment about the likely evolution of LBP was the factor most strongly linked to poor outcome, with predictive validity similar to that of multidimensional scales. This result may be explained by the implicit aggregation of many prognostic factors underlying this judgment and suggests the relevance of considering the patients from biopsychosocial and longitudinal points of view. The second review showed that most of the interventions targeting psychosocial factors in LBP in primary care have to date focused on the cognitive-behavioral factors, resulting in little impact. It is unlikely that any intervention focusing on a single factor would ever fit the needs of most patients; interventions targeting determinants from several fields (mainly psychosocial, biomechanical, and occupational) may be more relevant. Should multiple stakeholders be involved in such interventions, enhanced interprofessional collaboration would be critical to ensure the delivery of coordinated care. Finally, in the third study, the prevalence of psychosocial comorbidity in chronic LBP patients was not found to be significantly higher than in other patients consulting in primary care. Rather than specifically screening for psychosocial conditions, this suggests taking into account any potential comorbidity in patients with chronic LBP, as in other patients. All these results support the adoption of a more comprehensive and patient-centered approach when dealing with patients with LBP in primary care. As this condition is illustrative of many situations encountered in primary care, the strategies proposed here may benefit most patients consulting in this setting.

Being a botanist and a gardener: using diagnostic frameworks in general practice patients with medically unexplained symptoms

Patients with multiple medically unexplained symptoms commonly seek treatment in primary care. Many of these patients seem to have a psychological 'core' to their illness that affects the way they experience, conceptualise and communicate their distress. There is considerable debate around diagnosis for this group of patients. Existing diagnoses include somatoform disorders in psychiatry and functional disorders in the medical specialties. Some clinicians use the term 'heartsink' patients, which reflects the interpersonal frustration inherent in some therapeutic relationships. A good diagnosis should be clinically useful, helping clinicians and patients understand and manage illness. Diagnosis should also provide a reliable classification for research and evidence-based treatment. The allegory of the botanist and the gardener has been used to describe diagnosis. For the botanist, a good diagnosis produces a taxonomy that is rigorous and reliable. For the gardener, it informs the way a garden is described and understood in a specific context. Clinicians need both: a 'botanical' type of classification to bring rigour to research and therapy, and clinical 'gardening', which allows for multiple perspectives and diagnostic frameworks. Clinical reasoning is a form of research with therapeutic intent. Botany and gardening represent a mixed-methods approach that can enrich diagnosis. The challenge is to integrate multiple perspectives in clinically helpful ways that help us retain both richness and rigour.

Medically unexplained symptoms--a perspective from general practitioners in the developing world

OBJECTIVES

In this study, we explored the attitudes toward Medically Unexplained Symptoms (MUS) of 500 general practitioners (GPs) in Karachi, Pakistan. Using a questionnaire previously developed by Reid et al. (2001), we aimed to investigate whether GPs' attitudes toward medically unexplained symptoms are similar to those of GPs in the developed world.

METHODS

Five hundred GPs on the database of primary care centers at the Pakistan Institute of Learning and Living in Karachi were all sent a covering letter explaining the purpose of the survey with a case vignette, a questionnaire, and a stamped addressed envelope. One month later, non-respondents received a telephone call from an investigator to remind them of the study.

RESULTS

Of the 429 respondents, 68.5% (294) were male and 31.5% (135) female. Although 80.2% of respondents felt that the main role of GPs was to provide support and reassurance, 76.9% of respondents also agreed that GPs had a role in referring patients with MUS for further investigations to identify a cause. Two hundred and four (47.55%) respondents agreed that somatization was useful concept, only 146 (34.03%) felt that there was effective treatment for it.

CONCLUSION

For the most part, Pakistani GPs' attitudes toward MUS are not very different to those of their counterparts in the West. Both agree that the GP has an important role in providing reassurance and counseling. However, our survey also shows that Pakistani GPs are less likely to place emphasis on an underlying psychiatric diagnosis and tend to focus on looking for an underlying physical cause.

What do primary care doctors get out of a year-long postgraduate course in community psychological medicine?

OBJECTIVE

There are increasing expectations on primary care doctors to care for patients with common mental health problems. This study examines the outcomes of a postgraduate training course in psychological medicine for primary care doctors.

METHODS

A questionnaire developed by the research team was sent to the Course graduates (year 2003-2007). A retrospective design was adopted to compare their clinical practice characteristics before and after the Course. Differences in the ratings by the respondents before and after the Course were analyzed using the nonparametric Wilcoxon signed rank test.

RESULTS

Sixty-nine graduates replied with a response rate of 58.5% (69/118). Most respondents were confident of diagnosing (96.9%) and managing (97.0%) common mental health problems after the Course, compared to 50.0% and 50.7%, respectively, before the Course. Most graduates had modified their approach, increased their attention and empathy to patients with mental health problems. The percentage of respondents having enough time to treat these patients had increased from 55.8% to 72.1%. The median number of patients with mental health problems seen per week was in the range of 3-6 before, and had increased to the range of 7-10 after the Course. The proportion of respondents being confident of making appropriate referrals had increased from 72.8% to 97.0%, while the number of referrals to psychiatrists had dropped significantly.

CONCLUSIONS

The Course is effective in improving graduates' confidence, attitude, and skills in treating patients with common mental health problems. There are significant increases in the number of mental health patients handled, increased confidence in making referrals to psychiatrists, and decreased percentage of patients being referred.

[The reflection group as a tool for improving satisfaction and developing the introspective ability of health professionals]

OBJECTIVE

To describe the development of a reflection group of primary care professionals in Navarra, from October 2007 to June 2008, using case presentations.

DESIGN

Descriptive, retrospective study.

SETTING

Primary care.

PARTICIPANTS

One psychiatrist, one nurse and eleven family doctors.

METHOD

Eight sessions of two and a half hours were carried out; informal evaluations after each session; systematic taking of notes by three members of the group, with subsequent pooling of resources; evaluation of the group in the last session.

RESULTS

This was a participatory, self-reflective and practical group. A total of 52 cases were presented, which were grouped into six areas: difficult interviews, professional errors, female abuse, ethical dilemmas and Health care team relationships. The participants talked about the emotions of the clinic, obtaining tools and protocols for subsequent situations similar to the cases presented, as was expressed in the evaluation.

CONCLUSIONS

A wide range of cases were presented, with a series of emotions having been produced in the participants who from a pooling of resources and reflection emerged a self-perception of improved satisfaction and introspective ability. The variety of cases showed the complexity of the work of the health professional.

Primary care consultations about medically unexplained symptoms: how do patients indicate what they want?

BACKGROUND

Patients with medically unexplained physical symptoms (MUS) are often thought to deny psychological needs when they consult general practitioners (GPs) and to request somatic intervention instead. We tested predictions from the contrasting theory that they are transparent in communicating their psychological and other needs.

OBJECTIVE

To test predictions that what patients tell GPs when they consult about MUS is related transparently to their desire for (1) emotional support, (2) symptom explanation and (3) somatic intervention.

DESIGN

Prospective naturalistic study. Before consultation, patients indicated what they wanted from it using a self-report questionnaire measuring patients' desire for: emotional support, explanation and reassurance, and physical investigation and treatment. Their speech during consultation was audio-recorded, transcribed and coded utterance-by-utterance. Multilevel regression analysis tested relationships between what patients sought and what they said.

PARTICIPANTS

Patients (N = 326) consulting 33 GPs about symptoms that the GPs designated as MUS.

RESULTS

Patients who wanted emotional support spoke more about psychosocial problems, including psychosocial causes of symptoms and their need for psychosocial help. Patients who wanted explanation and reassurance suggested more physical explanations, including diseases, but did not overtly request explanation. Patients' wish for somatic intervention was associated only with their talk about details of such interventions and not with their requests for them.

CONCLUSIONS

In general, patients with medically unexplained symptoms provide many cues to their desire for emotional support. They are more indirect or guarded in communicating their desire for explanation and somatic intervention.

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

OBJECTIVE

We tested the theory that general practitioners (GPs) offer somatic intervention to patients with medically unexplained symptoms (MUS) as a defensive response to patients' dependence. We predicted that GPs most likely to respond somatically after patients indicated symptomatic or psychosocial needs had attachment style characterised by negative models of self and others.

METHOD

Twenty-five GPs identified 308 patients presenting MUS and indicated their own models of self and others. Consultations were audio recorded and coded speech-turn-by-speech-turn. We modeled the probability of GPs proposing somatic intervention on any turn as a function of their models of self and other and the number of prior turns containing symptomatic or psychosocial presentations.

RESULTS

Prior psychosocial presentations decreased the likelihood of GPs offering somatic intervention. The decrease was greatest in GPs with most positive models of self and, contrary to prediction, least positive models of others. The positive relationship between prior somatic presentations and the likelihood that GPs offered somatic intervention was unrelated to either model.

CONCLUSION

Findings are incompatible with our theory that GPs propose somatic interventions defensively. Instead, GPs may provide somatic intervention because they value patients (positive model of others) but devalue their own psychological skills (negative model of self).

Doctors' responses to patients with medically unexplained symptoms who seek emotional support: criticism or confrontation?

OBJECTIVE

Consultations about medically unexplained symptoms (MUSs) can resemble contests over the legitimacy of patients' demands. To understand doctors' motivations for speech appearing to be critical of patients with MUSs, we tested predictions that its frequency would be related to patients' demands for emotional support and doctors' patient-centered attitudes as well as adult attachment style.

METHODS

Twenty-four general practitioners identified 249 consecutive patients presenting with MUSs and indicated their own patient-centered attitudes as well as adult attachment style (positive models of self and others). Before consultation, patients self-reported their desire for emotional support. Consultations were audio recorded and coded utterance by utterance. The number of utterances coded as criticism was the response variable in the multilevel regression analyses.

RESULTS

Frequency of criticism was positively related to patients' demands for emotional support, to doctors' belief in sharing responsibility with patients and to doctors' positive model of themselves. It was inversely associated with doctors' belief that patients' feelings were legitimate business for consultation and was unrelated to their model of others.

CONCLUSIONS

From the perspective of doctors, speech that appears to be critical probably reflects therapeutic intent and might therefore be better described as "confrontation." Understanding doctors' motivations for what they say to patients with MUSs will allow for more effective interventions to improve the quality of consultations.

Conflict, collusion or collaboration in consultations about medically unexplained symptoms: the need for a curriculum of medical explanation

OBJECTIVE

To identify the basis of the communication problems that characterise consultations about medically unexplained symptoms (MUS) and to identify implications for clinical education.

METHOD

Recent research into the details of clinical communication about MUS was reviewed narratively and critically, and broader research literature was scrutinised from the perspective of a practitioner who wishes to provide patients with explanations for such symptoms.

RESULTS

Consultations about MUS often involve contest between patients' authority, resting on their knowledge of their symptoms, and practitioners' authority, based on the normal findings of tests and investigations. The outcome of consultations can therefore depend on the strategies that each party uses to press their authority, rather than on clinical need.

CONCLUSION

Contest is a product of patients and practitioners occupying separate conceptual 'ground'. Avoiding contest requires the practitioner to find common conceptual ground within which each party can understand and discuss the symptoms. Finding common ground by collusion with explanations that patients suggest can damage clinical relationships. Instead the practitioner needs to fashion explanation that is acceptable to both parties from available medical and lay material.

PRACTICE IMPLICATIONS

Although practitioners commonly fashion such explanations, this aspect of their professional role seems not to be greatly valued amongst practitioners or in medical curricula. Clinical education programmes could include curricula in symptom explanation, drawing from research in medicine, psychology and anthropology.

Primary care consultations about medically unexplained symptoms: patient presentations and doctor responses that influence the probability of somatic intervention

OBJECTIVE

In primary care, many consultations about physical symptoms that the doctor thinks are not explained by physical disease nevertheless lead to somatic interventions. Our objective was to test the predictions that somatic intervention becomes more likely a) when doctors provide simple reassurance rather than detailed symptom explanations and do not help patients discuss psychosocial problems and b) when patients try to engage doctors by extending their symptom presentation.

METHODS

Consultations of 420 patients presenting physical symptoms that the doctor considered unexplained by physical disease were audio-recorded, transcribed, and coded. Analysis modeled the probability of somatic intervention as a function of the quantity of specific types of speech by patients (symptomatic and psychosocial presentations) and doctors (normalization, physical explanations, psychosocial discussion).

RESULTS

Somatic intervention was associated with the duration of consultation. Controlling for duration, it was, as predicted, associated positively with symptom presentations and inversely with patients' and doctors' psychosocial talk. The relationship with doctors' psychosocial talk was accounted for by patients' psychosocial talk. Contrary to predictions, doctors' normalization was inversely associated with somatic intervention and physical explanations had no effect.

CONCLUSION

Somatic intervention did not result from the demands of patients. Instead, it became more likely as patients complained about their symptoms. Facilitating patients' psychosocial talk has the potential to divert consultations about medically unexplained symptoms from somatic interventions. To understand why such consultations often lead to somatic interventions, we must understand why patients progressively extend their symptom presentations and why doctors, in turn, apparently respond to this by providing somatic intervention.

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.

Why do primary care physicians propose medical care to patients with medically unexplained symptoms? A new method of sequence analysis to test theories of patient pressure

OBJECTIVE

We test predictions from contrasting theories that primary care physicians offer medical care to patients with medically unexplained symptoms in response to a) patients' attribution of symptoms to disease and demand for treatment or b) their progressive elaboration of their symptoms in the attempt to engage their physicians.

METHODS

Primary care physicians identified consecutive patients who consulted with symptoms that the physician considered unexplained by physical disease. Four hundred twenty consultations with 36 physicians were audio recorded and transcribed, and physician and patient speech was coded turn by turn. Hierarchical logistic regression analysis modeled the probability of the physician proposing medical care as a function of the quantity of patients' speech of specific kinds that preceded it.

RESULTS

Whether physicians proposed medical care was unrelated to patients' attributions to disease or demands for treatment. Proposals of explicitly somatic responses (drugs, investigation or specialist referral) became more likely after patients had elaborated their symptoms and less likely after patients indicated psychosocial difficulties. Proposals of a further primary care consultation were responses simply to lengthening consultation.

CONCLUSIONS

The findings are incompatible with the influential assumption that physicians offer medical care to patients with unexplained symptoms because the patients demand treatment for a physical disease. Instead, the reason why many of these patients receive high levels of medical care should be sought by investigating the motivations behind physicians' responses to patients' symptom presentation.

The somatising effect of clinical consultation: what patients and doctors say and do not say when patients present medically unexplained physical symptoms

Patients with symptoms that doctors cannot explain by physical disease are common in primary care. That they receive disproportionate amounts of physical intervention, which is largely ineffective and sometimes iatrogenic, is usually attributed to patients' belief that they are physically diseased, their denial of psychological difficulties, and their demand for physical intervention. The evidence for this view has mainly been doctors' subjective reports. By observing what patients and doctors say in consultation, we tested hypotheses arising from recent qualitative evidence. In particular, that physical intervention is proposed more often by general practitioners (GPs) than by patients, that most patients indicate psychosocial needs, and that GPs offer little effective explanation or empathy. Consultations of 420 consecutive patients identified by British GPs as presenting medically unexplained symptoms (MUS) were audio-recorded, transcribed and coded, utterance-by-utterance, using a specially developed coding scheme based on the previous qualitative analyses of these kinds of consultation. Physical intervention was, as predicted, proposed more often by GPs than patients. Also as predicted, almost all patients provided cues concerning psychosocial difficulties or their need for explanation. Although, contrary to prediction, most GPs did provide explanations other than physical disease, most also suggested physical disease. Few GPs empathised. The findings suggest that the explanation for the high level of physical intervention for MUS lies in GPs' responses rather than patients' demands, and we propose that explanations for 'somatisation' should be sought in doctor-patient interaction rather than in patients' psychopathology.

What do general practice patients want when they present medically unexplained symptoms, and why do their doctors feel pressurized?

OBJECTIVE

We tested predictions that patients with medically unexplained symptoms (MUS) want more emotional support and explanation from their general practitioners (GPs) than do other patients, and that doctors find them more controlling because of this.

DESIGN

Thirty-five doctors participated in a cross-sectional comparison of case-matched groups. Three hundred fifty-seven patients attending consecutively with MUS were matched for doctor and time of attendance with 357 attending with explained symptoms. Patients self-reported the extent to which they wanted somatic intervention, emotional support, explanation and reassurance. Doctors rated their perception of patients' influence on the consultation. Predictions were tested by multilevel analyses.

RESULTS

Patients with MUS sought more emotional support than did others, but no more explanation and reassurance or somatic intervention. A minority of doctors experienced them as exerting more influence than others. The experience of patient influence was related to the patients' desire for support.

CONCLUSIONS

Future research should examine why GPs provide disproportionate levels of somatic intervention to patients who seek, instead, greater levels of emotional support.

Do patients with unexplained physical symptoms pressurise general practitioners for somatic treatment? A qualitative study

OBJECTIVES

To identify the ways in which patients with medically unexplained symptoms present their problems and needs to general practitioners and to identify the forms of presentation that might lead general practitioners to feel pressurised to deliver somatic interventions.

DESIGN

Qualitative analysis of audiorecorded consultations between patients and general practitioners.

SETTING

7 general practices in Merseyside, England.

PARTICIPANTS

36 patients selected consecutively from 21 general practices, in whom doctors considered that patients' symptoms were medically unexplained.

MAIN OUTCOME MEASURES

Inductive qualitative analysis of ways in which patients presented their symptoms to general practitioners.

RESULTS

Although 34 patients received somatic interventions (27 received drug prescriptions, 12 underwent investigations, and four were referred), only 10 requested them. However, patients presented in other ways that had the potential to pressurise general practitioners, including: graphic and emotional language; complex patterns of symptoms that resisted explanation; description of emotional and social effects of symptoms; reference to other individuals as authority for the severity of symptoms; and biomedical explanations.

CONCLUSIONS

Most patients with unexplained symptoms received somatic interventions from their general practitioners but had not requested them. Though such patients apparently seek to engage the general practitioner by conveying the reality of their suffering, general practitioners respond symptomatically.

Topiramate as a treatment for pain in multisomatoform disorder patients: an open trial

Multisomatoform disorder (MSD), defined as 3 or more medically unexplained, currently distressing physical symptoms in addition to a long (> or =2 years) history of somatization, is a prevalent and disabling disorder in which few pharmacological trials have been referred to in the literature. Thirty-five MSD patients from the Somatoform Disorders Unit of the Miguel Servet University Hospital, Zaragoza, Spain, with pain of more than 3 months as the main symptom, were treated with topiramate in doses ranging from 300-400 mg/day. Patients were assessed at baseline and at one and six-months follow-up with the McGill Pain Questionnaire (MPQ), Pain Visual Analogue Scale (PVAS), Clinical Global Impresión (CGI), Global Assessment Functioning (GAF) and Hospital Anxiety Depression Scale (HADS). Eight patients (22.8%) dropped from the study, 3 due to side-effects and the other 5 because of lack of efficacy. All the outcome measures showed significant improvements at one-month except the ratings on the Hospital Anxiety Depression Scale. At six-months follow-up, clinician-rated assessments (CGI and GAF) still showed significant differences with baseline but less significant than at one-month follow-up. However, patient-rated assessments (MPQ and PVAS) did not present significant differences with baseline. Despite limitations of the study, topiramate seems to be effective in treating multisomatoform disorder patients with pain as the main symptom and a controlled randomized trial in these patients appears warranted. A possible "decay effect" in patient-rated assessments with any drug in somatoform disorder patients is discussed.

Development and feasibility of a modified reattribution model for somatising patients, applied by their own general practitioners

Reattribution has been developed as a cognitive-behavioural treatment model for somatisation in general practice. Our objective is to make reattribution suitable for application on patients with long-standing somatisation, including hypochondria, and to evaluate feasibility. Three modifications were developed: (1) dealing with persistent illness worry, (2) adjustment of the doctor's speed to that of the patient, and (3) the use of symptom diaries. Performance of ten experienced general practitioners (GPs), after a 20h training programme (six sessions of variable length), was measured by self-registrations and audio-taped consultations. GPs were interviewed on factors interfering with performance. Nine GPs completed the course. Reattribution was applied to 51 out of 75 indicated somatising patients, which required on average three consultations of 10-30min duration. We conclude that the modified reattribution model offers a feasible approach to the broad spectrum of somatisation seen in general practice; only the modification 'dealing with illness worry' showed limited feasibility.

Assessment of a pilot course on the management of somatization disorder for family doctors

Somatization disorder (SD) patients are difficult to treat and produce negative feelings in health professionals. Smith et al.'s guidelines have demonstrated cost-effectiveness in the treatment of these patients, but family doctors consider it difficult to put these into practice in the long term. The objective of this paper is to design and assess a pilot course, based on Smith's norms, to train general practitioners for the everyday management of SD patients in primary care. We have designed a 20-h practical course, using role-playing and video recording with standardized patients, and focusing on micro-skills recommended by the literature on the subject. Assessment of the efficacy of the course is made by evaluation of baseline and post course video recordings by researchers unaware of the order of the interviews. The comparison of baseline and post course assessments demonstrated a significant improvement in several key skills (giving a name to the illness, explaining the psychological and biological basis of the disease, and emphasizing stress reduction) but no change on others (explaining that SD is a well-known disorder, empowering the patient, not blaming the patient for his or her illness, and instilling hope). Finally, other skills such as assessing the patient's opinion of the illness, recognizing the reality of symptoms and informing that there is no life risk, were correctly done from the beginning and, therefore, showed no change. We found that training may facilitate the development of certain skills. However, some doctors' abilities might also require the use of techniques such as Balint groups to modify negative emotions, such as anger and fear, toward these patients.

Using literature to help physician-learners understand and manage "difficult" patients

Despite significant clinical and research efforts aimed at recognizing and managing "difficult" patients, such patients remain a frustrating experience for many clinicians. This is especially true for primary care residents, who are required to see a significant volume of patients with diverse and complex problems, but who may not have adequate training and life experience to enable them to deal with problematic doctor-patient situations. Literature--short stories, poems, and patient narratives--is a little-explored educational tool to help residents in understanding and working with difficult patients. In this report, the authors examine the mechanics of using literature to teach about difficult patients, including structuring the learning environment, establishing learning objectives, identifying teaching resources and appropriate pedagogic methods, and incorporating creative writing assignments. They also present an illustrative progression of a typical literature-based teaching session about a difficult patient.

Unexplained symptoms in primary care: perspectives of doctors and patients

This study evaluated unexplained symptoms in primary care from the perspective of both patients and physicians. The data were obtained from two 1998 statewide surveys, one targeting Medicaid patients and the other all primary care physicians in the state. There were 439 patients who responded (45% response rate) and 280 primary care physicians who responded (33% response rate). Half of the patients and half of the physicians were in non-metropolitan counties. Half of the patients reported unexplained symptom usually or always, and 75% of whom sought help for these symptoms. Fifty-two percent of these patients believed their physician was very concerned about their unexplained symptoms. Eighty percent of them rated their physician as providing the best possible care compared to only 49% of patients whose physician did not care about their unexplained symptoms (P=.001). Among the physicians, only 14% reported very good or excellent satisfaction with managing unexplained symptoms as compared to 44% who claimed similar satisfaction in managing psychological problems. Physicians who saw themselves as more effective in dealing with somatoform symptoms were more likely to be in solo practice (P<.005), or in the same location for at least five years (P=.04). Residence in a nonmetropolitan county did not affect patient reporting of symptoms, patient perception of physician concern about symptoms, or physician satisfaction in managing these symptoms. These results indicate the prevalence and importance of unexplained symptoms in the Medicaid population and the comfort of physicians in managing these symptoms. There is an unmet need among primary care physicians to learn how to manage patients with unexplained symptoms.