Huisarts en wetenschap

, Volume 55, Issue 7, pp 301–305

Onverklaarde lichamelijke klachten

  • T. C. olde Hartman
  • H. van Ravesteijn
  • P. Lucassen
Beschouwing

Samenvatting

Olde Hartman TC, Van Ravesteijn H, Lucassen P. Onverklaarde lichamelijke klachten. Huisarts Wet 2012;55(7):301-5.

De huisarts wordt vaak geconfronteerd met patiënten met somatisch onvoldoende verklaarde lichamelijke klachten (SOLK). Slechts een minderheid (2,5%) van deze patiënten houdt chronisch last van deze klachten, maar die minderheid doet wel een groot beroep op de gezondheidszorg. Veel huisartsen vinden de behandeling en begeleiding van patiënten met chronische SOLK moeilijk, met name het geven van goede en concrete uitleg. Om de arts-patiëntrelatie in stand te houden vallen huisartsen terug op zorgrituelen, zoals het inplannen van regelmatige contacten. Veel huisartsen hebben een contraproductief beeld van patiënten met SOLK. Het idee dat patiënten druk uitoefenen op de huisarts voor het krijgen van somatische interventies klopt niet, evenals het idee dat patiënten met SOLK niet willen praten over psychosociale problemen. De communicatie in de consulten met patiënten met chronische SOLK is vaak weinig gericht op het structureel uitdiepen van hun ideeën, angsten en verwachtingen. Hierdoor sluit de uitleg die de huisarts geeft vaak niet aan bij de patiënt. Dit is jammer, want goede communicatie over de aard van de klacht is essentieel voor de effectiviteit van de behandeling en begeleiding. Patiënten met chronische SOLK willen, net als andere patiënten, patiëntgerichte communicatie. Ze geven bovendien aan dat ze een langdurige en persoonlijke relatie met hun huisarts erg belangrijk vinden. Een dergelijke arts-patiëntrelatie is een krachtig therapeutisch instrument in de eerste lijn. Het belang dat zowel huisartsen als patiënten toekennen aan de communicatie en de arts-patiëntrelatie past naadloos in de filosofie van de huisartsgeneeskunde. Hoewel er ruimte is voor verbetering, is de behandeling en begeleiding van patiënten met chronische SOLK daarom een aangewezen taak voor de huisarts..

Olde Hartman TC,Van Ravesteijn H, Lucassen P. Medically unexplained physical symptoms. Huisarts Wet 2012;55(7):301-5

GENERAL

practitioners often see patients with medically unexplaïnable physïcal symptoms. Whüe only a minority (2.5%) of patients are chronïcally affected by these problems, these patients take up a relatively large proportion of GPs’ time and resources. Many GPs jïnd ït dfffïcult to treat and manage these patients, for lack of a clear and concrete explanatïon. They often resort to ’care rituals’, such as planning regular appointments. In many cases, this is because GPs have a counterproductive image of these patients as demandïng treatmentfor physïcal problems and not being prepared to consider the possibïlïty that they may have psychosocial problems. Whüe this image is undeserved, ït does ensure that GPs pay lïttle attention to the patients’ ideas, worries, and expectations. This results in a breakdown in communïcation. Thïs ïs unfortunate because patients with unexplaïnable physical problems also state that they jïnd it important to have a long-lastïng, personal relatïonshïp with theïr doctor. The doctor-patiënt relationship is one of the most powerful instruments available in primary care and there is room for improvement.

LITERATUUR

  1. 1.
    Kroenke K, Spitzer RL. Gender differences in the reporting of physical and somatoform symptoms. Psychosom Med 1998;60:150–5.PubMedGoogle Scholar
  2. 2.
    Houtveen JH. De dokter kan niets vinden. Amsterdam: Uitgeverij Bert Bakker, 2009.Google Scholar
  3. 3.
    Green LA, Fryer GE, Jr., Yawn BP, Lanier D, Dovey SM. The ecology of medical care revisited. N Engl J Med 2001;344:2021–5.PubMedCrossRefGoogle Scholar
  4. 4.
    Van de Lisdonk EH. Ervaren en aangeboden morbiditeit in de huisartspraktijk [Proefschrift]. Nijmegen: Katholieke Universiteit Nijmegen, 1985.Google Scholar
  5. 5.
    Peveler R, Kilkenny L, Kinmonth AL. Medically unexplained physical symptoms in primary care: A comparison of self-report screening questionnaires and clinical opinion. J Psychosom Res 1997;42:245–52.PubMedCrossRefGoogle Scholar
  6. 6.
    Barsky AJ, Borus JF. Somatization and medicalization in the era of managedcare.JAMA 1995;274:1931–4.PubMedCrossRefGoogle Scholar
  7. 7.
    Van der Linden MW, Westert G, De Bakker DH, Schellevis F. Tweede Nationale Studie naar ziekten en verrichtingen in de huisartspraktijk: klachten en aandoeningen in de bevolking en in de huisartspraktijk. Utrecht: NIVEL, 2004.Google Scholar
  8. 8.
    Trimbos Instituut/Netherlands Institute of Mental H, Addiction. [Multi-disciplinary guideline medically unexplained symptoms and somato-form disorders]. Houten: Ladenius Communicatie, 2010.Google Scholar
  9. 9.
    Verhaak PF, Meijer SA, Visser AP, Wolters G. Persistent presentation of medically unexplained symptoms in general practice. Fam Pract 2006;23:414–20.PubMedCrossRefGoogle Scholar
  10. 10.
    Reid S, Whooley D, Crayford T, Hotopf M. Medically unexplained symptoms: GPs’ attitudes towards their cause and management. Fam Pract 2001;18:519–23.PubMedCrossRefGoogle Scholar
  11. 11.
    Garcia-Campayo J, Sanz-Carrillo C, Yoldi-Elcid A, Lopez-Aylon R, Monton C. Management of somatisers in primary care: are family doctors motivated?Aust N Z J Psychiatry 1998;32:528–33.PubMedCrossRefGoogle Scholar
  12. 12.
    Hartz AJ, Noyes R, Bentier SE, Damiano PC, Willard JC, Momany ET. Unexplained symptoms in primary care: perspectives of doctors and patients. Gen Hosp Psychiatry 2000;22:144–52.PubMedCrossRefGoogle Scholar
  13. 13.
    Steinmetz D, Tabenkin H. The ’difficult patiënt’ as perceived by family physicians. Fam Pract 2001;18:495–500.PubMedCrossRefGoogle Scholar
  14. 14.
    Mathers N, Jones N, Hannay D. Heartsink patients: A study of their general practitioners. Br J Gen Pract 1995;45:293–6.PubMedGoogle Scholar
  15. 15.
    Salmon P, Peters S, Stanley I. Patients’ perceptions of medical explanations for somatisation disorders: Qualitative analysis. BMJ 1999;318:372– 6.PubMedCrossRefGoogle Scholar
  16. 16.
    Olde Hartman TC, Hassink-Franke LJ, Lucassen PL, Van Spaendonck KP, Van Weel C. Explanation and relations. How do general practitioners deal with patients with persistent medically unexplained symptoms: A focus group study. BMC Fam Pract 2009;10:68.CrossRefGoogle Scholar
  17. 17.
    Stewart M. Reflections on the doctor-patiënt relationship: from evidence and experience. Br J Gen Pract 2005;55:793–801.PubMedGoogle Scholar
  18. 18.
    Balint M. The doctor, his patient and the illness. Edinburgh: Churchill Livingstone, 2000.Google Scholar
  19. 19.
    McWhinney IR. A textbook of family medicine. New York/Oxford: Oxford University Press, 1989.Google Scholar
  20. 20.
    Malterud K. Symptoms as a source of medical knowledge: Understanding medically unexplained disorders in women. Fam Med 2000;32:603–ll.PubMedGoogle Scholar
  21. 21.
    Page LA, Wessely S. Medically unexplained symptoms: exacerbating factors in the doctor-patient encounter. J R Soc Med 2003;96:223–7.PubMedCrossRefGoogle Scholar
  22. 22.
    Kouyanou K, Pither CE, Rabe-Hesketh S, Wessely S. A comparative study of iatrogenesis, medication abuse, and psychiatric morbidity in chronic pain patients with and without medically explained symptoms. Pain 1998;76:417–26.PubMedCrossRefGoogle Scholar
  23. 23.
    Peters S, Stanley I, Rose M, Salmon P. Patients with medically unexplained symptoms: sources of patients’ authority and implications for demands on medical care. Soc Sci Med 1998;46:559–65.PubMedCrossRefGoogle Scholar
  24. 24.
    Johansson EE, Hamberg K, Lindgren G, Westman G. ’I’ve been crying my way’: Qualitative analysis of a group of female patients’ consultation experiences. Fam Pract 1996;13:498–503.PubMedCrossRefGoogle Scholar
  25. 25.
    Nettleton S, Watt I, O’Malley L, Duffey P. Understanding the narratives of people who live with medically unexplained illness. Patient Educ Couns 2005;56:205–10.PubMedCrossRefGoogle Scholar
  26. 26.
    Deale A, Wessely S. Patients’ perceptions of medical care in chronic fatigue syndrome. Soc Sci Med 2001;52:1859–64.PubMedCrossRefGoogle Scholar
  27. 27.
    Sharpe M, Mayou R, Walker J. Bodily symptoms: New approaches to classification. J Psychosom Res 2006;60:353–6.PubMedCrossRefGoogle Scholar
  28. 28.
    Woivalin T, Krantz G, Mantyranta T, Ringsberg KC. Medically unexplained symptoms: Perceptions of physicians in primary health care. Fam Pract 2004;21:199–203.PubMedCrossRefGoogle Scholar
  29. 29.
    Wileman L, May C, Chew-Graham CA. Medically unexplained symptoms and the problem of power in the primary care consultation: A qualitative study. Fam Pract 2002;19:178–82.PubMedCrossRefGoogle Scholar
  30. 30.
    Asbring P, Narvanen AL. Ideal versus reality: Physicians perspectives on patients with chronic fatigue syndrome (CFS) and fibromyalgia. Soc Sci Med 2003;57:711–20.PubMedCrossRefGoogle Scholar
  31. 31.
    Armstrong D, Fry J, Armstrong P. Doctors’ perceptions of pressure from patients for referral. BMJ. 1991;302:1186–8.PubMedCrossRefGoogle Scholar
  32. 32.
    Goldberg DP, Bridges K. Somatic presentations of psychiatric illness in primary care setting. J Psychosom Res 1988;32:137–44.PubMedCrossRefGoogle Scholar
  33. 33.
    Salmon P, Ring A, Dowrick CF, Humphris GM. What do general practice patients want when they present medically unexplained symptoms, and why do their doctors feelpressurized?J Psychosom Res 2005;59:255–60.PubMedCrossRefGoogle Scholar
  34. 34.
    Cegala DJ. A study of doctors’ and patients’ communication during a primary care consultation: Implications for communication training. J Health Commun 1997;2:169–94.PubMedCrossRefGoogle Scholar
  35. 35.
    Salmon P, Dowrick CF, Ring A, Humphris GM. Voiced but unheard agendas: Qualitative analysis of the psychosocial cues that patients with unexplained symptoms present to general practitioners. Br J Gen Pract 2004;54:171–6.PubMedGoogle Scholar
  36. 36.
    Westert G, Jabaaij L, Schellevis F. Morbidity, performance and quality in primary care. Dutch general practice on stage. Oxford: Radcliff, 2006.Google Scholar
  37. 37.
    Van den Brink-Muinen A, Van Duimen S, De Haes HC, Visser AP, Schellevis FG, Bensing JM. Has patients’ involvement in the decision-making process changed over time? Health Expect 2006;9:333–42.PubMedCrossRefGoogle Scholar
  38. 38.
    Olde Hartman TC, Van RE, Van DS, Van Weel-Baumgarten E, Lucassen PL, Van Weel C. How patients and family physicians communicate about persistent medically unexplained symptoms: A qualitative study of video-recorded consultations. Patient Educ Couns 2011 Apr 7.Google Scholar
  39. 39.
    Metz JCM, Verbeek-Weel AMM, Huisjes HJ. Raamplan 2001 artsenopleiding: Bijgestelde eindtermen van de artsopleiding. Nijmegen: Mediagroep Nijmegen, 2001.Google Scholar
  40. 40.
    Olde Hartman TC, Van Ravesteijn HJ. ’Well doctor, it is all about how life is lived’: Cues as a tool in the medical consultation. Ment Health Fam Med 2008;5:183–7.Google Scholar
  41. 41.
    Thorne SE, Kuo M, Armstrong EA, McPherson G, Harris SR, Hislop TG. ’Being known’: Patients’ perspectives of the dynamics of human connection in cancer care. Psychooncology 2005;14:887–98.PubMedCrossRefGoogle Scholar
  42. 42.
    Hack TF, Degner LF, Parker PA. The communication goals and needs of cancer patients: A review. Psychooncology 2005;14:831–45.PubMedCrossRefGoogle Scholar
  43. 43.
    Thomas KB. General practice consultations: is there any point in being positive? Br Med J (Clin Res Ed) 1987;294:1200–2.CrossRefGoogle Scholar
  44. 44.
    Suarez-Almazor ME, Looney C, Liu Y, Cox V, Pietz K, Marcus DM, et al. A randomized controlled trial of acupuncture for osteoarthritis of the knee: Effects of patient-provider communication. Arthritis Care Res (Hoboken) 2010;62:1229–36.CrossRefGoogle Scholar
  45. 45.
    Olde Hartman TC. Persistent medically unexplained symptoms in primary care. The patient, the doctor and the consultation [Dissertation]. Nijmegen: Radboud University Nijmegen Medical Centre, 2011.Google Scholar
  46. 46.
    Cabana MD, Jee SH. Does continuity of care improve patient outcomes? J Fam Pract 2004;53:974–80.PubMedGoogle Scholar
  47. 47.
    Kim SC, Kim S, Boren D. The quality of therapeutic alliance between patiënt and provider predicts general satisfaction. Mil Med 2008;173:85–90.PubMedGoogle Scholar
  48. 48.
    Nutting PA, Goodwin MA, Flocke SA, Zyzanski SJ, Stange KC. Continuity of primary care: to whom does it matter and when? Ann Fam Med 2003;l:149– 55.CrossRefGoogle Scholar
  49. 49.
    Lambert MJ, Barley DE. Research summary on the therapeutic relationship and psychotherapy outcome. In: Norcross JC, editor. Psychotherapy relationship that work: therapist contributions and responsiveness to patients. Oxford: Oxford University Press, 2002.Google Scholar
  50. 50.
    DiBlasi Z, Harkness E, Ernst E, Georgiou A, Kleijnen J. Influence of context effects on health outcomes: A systematic review. Lancet 2001;357:757–62.CrossRefGoogle Scholar
  51. 51.
    Van Os TW, Van den Brink RH, Tiemens BG, Jenner JA, Van der Meer K, Ormel J. Communicative skills of general practitioners augment the effectiveness of guideline-based depression treatment. J Affect Disord 2005;84:43–51.PubMedCrossRefGoogle Scholar
  52. 52.
    Kaptchuk TJ, Kelley JM, Conboy LA, Davis RB, Kerr CE, Jacobson EE, et al. Components of placebo effect: Randomised controlled trial in patients with irritable bowel syndrome. BMJ 2008;336:999–1003.PubMedCrossRefGoogle Scholar

Copyright information

© Bohn, Stafleu van Loghum 2012

Authors and Affiliations

  • T. C. olde Hartman
    • 1
  • H. van Ravesteijn
    • 1
  • P. Lucassen
    • 1
  1. 1.afdeling EerstelijnsgeneeskundeUMC St. RadboudNijmegenThe Netherlands

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