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What Do Patients Choose to Tell Their Doctors? Qualitative Analysis of Potential Barriers to Reattributing Medically Unexplained Symptoms

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Abstract

BACKGROUND

Despite both parties often expressing dissatisfaction with consultations, patients with medically unexplained symptoms (MUS) prefer to consult their general practitioners (GPs) rather than any other health professional. Training GPs to explain how symptoms can relate to psychosocial problems (reattribution) improves the quality of doctor–patient communication, though not necessarily patient health.

OBJECTIVE

To examine patient experiences of GPs’ attempts to reattribute MUS in order to identify potential barriers to primary care management of MUS and improvement in outcome.

DESIGN

Qualitative study.

PARTICIPANTS

Patients consulting with MUS whose GPs had been trained in reattribution. A secondary sample of patients of control GPs was also interviewed to ascertain if barriers identified were specific to reattribution or common to consultations about MUS in general.

APPROACH

Thematic analysis of in-depth interviews.

RESULTS

Potential barriers include the complexity of patients’ problems and patients’ judgements about how to manage their presentation of this complexity. Many did not trust doctors with discussion of emotional aspects of their problems and chose not to present them. The same barriers were seen amongst patients whose GPs were not trained, suggesting the barriers are not particular to reattribution.

CONCLUSIONS

Improving GP explanation of unexplained symptoms is insufficient to reduce patients’ concerns. GPs need to (1) help patients to make sense of the complex nature of their presenting problems, (2) communicate that attention to psychosocial factors will not preclude vigilance to physical disease and (3) ensure a quality of doctor–patient relationship in which patients can perceive psychosocial enquiry as appropriate.

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References

  1. Salmon P, Peters S, Stanley I. Patients’ perceptions of medical explanations for somatisation disorders: qualitative analysis. BMJ. 1999;318:372–6.

    PubMed  CAS  Google Scholar 

  2. Kirmayer LJ, Robbins JM. Patients who somatize in primary care: a longitudinal study of cognitive and social characteristics. Psychol Med. 1996;26:937–951.

    Article  PubMed  CAS  Google Scholar 

  3. Arnold IA, Speckens AE, van Hemert AM. Medically unexplained physical symptoms: the feasibility of group cognitive–behavioural therapy in primary care. J Psychosom Res. 2004;57:517–20.

    Article  PubMed  CAS  Google Scholar 

  4. Goldberg D, Gask L, O’Dowd T. The treatment of somatisation: teaching techniques of reattribution. J Psychosom Res. 1989;33:689–95.

    Article  PubMed  CAS  Google Scholar 

  5. Morriss R, Dowrick C, Salmon P, et al. Turning theory into practice: rationale, feasibility and external validity of an exploratory randomized controlled trial of training family practitioners in reattribution to manage patients with medically unexplained symptoms (MUST). Gen Hosp Psychiatry. 2006;28:343–51.

    Article  PubMed  Google Scholar 

  6. Morriss R, Gask L, Dowrick C, Salmon P, Peters S. Primary care: management of persistent medically unexplained symptoms. In: Lloyd GG, Guthrie E, eds. Handbook of Liaison Psychiatry. Cambridge: Cambridge University Press; 2007.

    Google Scholar 

  7. Morriss RK, Gask L, Ronalds C, et al. Cost-effectiveness of a new treatment for somatized mental disorder taught to GPs. Fam Pract. 1998;15:119–25.

    Article  PubMed  CAS  Google Scholar 

  8. Morriss RK, Gask L, Ronalds C, Downes-Grainger E, Thompson H, Goldberg D. Clinical and patient satisfaction outcomes of a new treatment for somatized mental disorder taught to general practitioners. Br J Gen Pract. 1999;49:263–7.

    PubMed  CAS  Google Scholar 

  9. Blankenstein AH. Somatising patients in general practice reattribution, a promising approach. PhD thesis. Netherlands: Vrije Universiteit; 2001.

  10. Morriss RK, Gask L. Treatment of patients with somatized mental disorder: effects of reattribution training on outcomes under the direct control of the family doctor. Psychosomatics. 2002;43:394–9.

    Article  PubMed  Google Scholar 

  11. Larisch A, Schweickhardt A, Wirsching M, Fritzsche K. Psychosocial interventions for somatizing patients by the general practitioner: a randomized controlled trial. J Psychosom Res. 2004;57:507–14.

    Article  PubMed  Google Scholar 

  12. Frostholm L, Fink P, Oernboel E, et al. The uncertain consultation and patient satisfaction: the impact of patients’ illness perceptions and a randomized controlled trial on the training of physicians’ communication skills. Psychosom Med. 2005;67:897–905.

    Article  PubMed  Google Scholar 

  13. Rosendal M, Bro F, Sokolowski I, Fink P, Toft T, Olesen F. A randomised controlled trial of brief training in assessment and treatment of somatisation: effects on GPs’ attitudes. Fam Pract. 2005;22:419–27.

    Article  PubMed  Google Scholar 

  14. Aiarzaguena JM, Grandes G, Gaminde I, Salazar A, Sánchez A, Ariño J. A randomized controlled clinical trial of a psychosocial and communication intervention carried out by GPs for patients with medically unexplained symptoms. Psychol Med. 2007;37:283–94.

    Article  PubMed  Google Scholar 

  15. Morriss R, Dowrick C, Salmon P, et al. Exploratory randomised controlled trial of training practices and general practitioners in reattribution to manage patients with medically unexplained symptoms (MUST). Brit J Psychiatry. 2007;191:536–42.

    Article  Google Scholar 

  16. Haynes B, Haines A. Getting research findings into practice: Barriers and bridges to evidence based clinical practice. BMJ. 1998;317:273–6.

    PubMed  CAS  Google Scholar 

  17. Bradley F, Wiles R, Kinmonth A-L, Mant D, Gantley M. Development and evaluation of complex interventions in health services research: case study of the Southampton heart integrated care project (SHIP). BMJ. 1999;318:711–5.

    PubMed  CAS  Google Scholar 

  18. Campbell M, Fitzpatrick R, Haines A, et al. Framework for design and evaluation of complex interventions to improve health. BMJ. 2000;321:694–6.

    Article  PubMed  CAS  Google Scholar 

  19. Medical Research Council. A frame work for development and evaluation of RCTs for complex interventions to improve health. London: MRC; 2000.

    Google Scholar 

  20. Strauss A, Corbin J. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. 2Thousand Oaks, CA: Sage; 1998.

    Google Scholar 

  21. Henwood KL, Pidgeon NF. Qualitative research and psychological theorizing. Br J Psychol. 1992;83:97–111.

    PubMed  Google Scholar 

  22. Stiles WB. Quality-control in qualitative research. Clin Psychol Rev. 1993;13(6):593–618.

    Article  Google Scholar 

  23. Cheraghi-Sohi S, Hole AR, Mead N, et al. What patients want from primary care consultations: A discrete choice experiment to identify patients’ priorities. Annals of Family Medicine. 2008;6(2):107–15.

    Article  PubMed  Google Scholar 

  24. Hartz AJ, Noyes R, Bentler SE, Damiano PC, Willard JC, Momany ET. Unexplained symptoms in primary care: Perspectives of doctors and patients. Gen Hosp Psych. 2000;22(3):144–52.

    Article  CAS  Google Scholar 

  25. Barry CA, Bradley CP, Britten N, Stevenson FA, Barber N. Patients’ unvoiced agendas in general practice consultations: qualitative study. BMJ. 2000;320:1246–50.

    Article  PubMed  CAS  Google Scholar 

  26. Nordin T, Hartz AJ, Noyes R, et al. Empirically identified goals for the management of unexplained symptoms. Fam Med. 2006;38(7):476–82.

    PubMed  Google Scholar 

  27. Thom DH, Campbell B. Patient–physician trust: an exploratory study. J Family Pract. 1997;44(2):169–76.

    CAS  Google Scholar 

  28. Chew-Graham C, Cahill G, Dowrick C, Wearden A, Peters S. Using multiple sources of knowledge to reach clinical understanding of chronic fatigue syndrome. Annals of Family Medicine. 2008;6:340–8.

    Article  PubMed  Google Scholar 

  29. Werner A, Malterud K. It is hard work behaving as a credible patient: encounters between women with chronic pain and their doctors. Soc Sci Med. 2003;57(8):1409–19.

    Article  PubMed  Google Scholar 

  30. Dirkzwager AJE, Verhaak PFM. Patients with persistent medically unexplained symptoms in general practice: characteristics and quality of care. BMC Fam Pract. 2007;33(8).

  31. Buszewicz M, Pistrang N, Barker C, Cape J, Martin J. Patients’ experiences of GP consultations for psychological problems: a qualitative study. Br J Gen Pract. 2006;56:496–503.

    PubMed  Google Scholar 

  32. Salmon P, Ring A, Dowrick CF, et al. What do general practice patients want when they present medically unexplained symptoms, and why do their doctors feel pressurised? J Psychosom Res. 2005;59:255–60.

    Article  PubMed  Google Scholar 

  33. Salmon P, Humphris GM, Ring A, Davies JC, Dowrick CF. Primary care consultations about medically unexplained symptoms: patient presentations and doctor responses that influence the probability of somatic intervention. Psychosom Med. 2007;69:571–7.

    Article  PubMed  Google Scholar 

  34. Berry LL, Parish JT, Janakiraman R, et al. Patients’ commitment to their primary physician and why it matters. Annals of Family Medicine. 2008;6(1):6–13.

    Article  PubMed  Google Scholar 

  35. Epstein RM, Hadee T, Carroll J, Meldrum SC, Lardner LJ, Shields CG. “Could this be something serious?” — reassurance, uncertainty and empathy in response to patients’ expressions of worry. J Gen Intern Med. 2007;22(12):1731–9.

    Article  PubMed  Google Scholar 

  36. McKinstry B, Ashcroft AE, Car J, Freeman GK, Sheikh A. Interventions for improving patients’ trust in doctors and groups of doctors. Cochrane Database Syst Rev. 2006;3:CD004134.

    PubMed  CAS  Google Scholar 

  37. Blakeman T, Macdonald W, Bower P, Gately C, Chew-Graham C. A qualitative study of GPs’ attitudes to self-management of chronic disease. Br J Gen Pract. 2006;56:407–14.

    PubMed  Google Scholar 

  38. Kroenke K, Spitzer R. Gender differences in the reporting of physical and somatoform symptoms. Psychosom Med. 1998;60(2):150–5.

    PubMed  CAS  Google Scholar 

  39. Salmon P, Peters S, Clifford R, Iredale W, Gask L, Rogers A, Dowrick C, Morriss R. Why do general practitioners decline training to improve management of medically unexplained symptoms? J Gen Intern Med. 2007;22:565–71.

    Article  PubMed  Google Scholar 

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Acknowledgments

Funding for the project came from the UK Medical Research Council (grant reference no. G0100809, ISRCTN 44384258), Mersey Care NHS Trust and Mersey Primary Care Research Organisation. We are grateful for the cooperation of the participating patients and physicians and collaboration of Professor Francis Creed, Professor Graham Dunn, Dr Huw Charles Jones and Dr Barry Lewis in the design of the MUST trial, and to Judith Hogg for managing the trial.

Conflict of interest

None disclosed.

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Correspondence to Sarah Peters PhD.

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Peters, S., Rogers, A., Salmon, P. et al. What Do Patients Choose to Tell Their Doctors? Qualitative Analysis of Potential Barriers to Reattributing Medically Unexplained Symptoms. J GEN INTERN MED 24, 443–449 (2009). https://doi.org/10.1007/s11606-008-0872-x

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  • DOI: https://doi.org/10.1007/s11606-008-0872-x

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