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Thursby S, Dismore L, Swainston K. Clinical skills development for healthcare practitioners working with patients with persistent physical symptoms (PPS) in healthcare settings: a systematic review and narrative synthesis. BMC MEDICAL EDUCATION 2024; 24:328. [PMID: 38519955 PMCID: PMC10960475 DOI: 10.1186/s12909-024-05306-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 03/13/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND The complexity and uncertainty around Persistent Physical Symptoms (PPS) make it difficult to diagnose and treat, particularly under time-constrained consultations and limited knowledge. Brief interventions that can be utilised in day-to-day practice are necessary to improve ways of managing PPS. This review aimed to establish (i) what training primary and secondary healthcare practitioners have undertaken to develop their clinical skills when working with PPS, (ii) what training techniques or theoretical models have been used within these interventions, and (iii) how effective was the training. METHOD A systematic literature search was undertaken on eight databases to identify professional development interventions for healthcare practitioners working with PPS, were of any study design, and at a minimum were single measure studies (i.e., training outcome alone). Studies were assessed using the Mixed Methods Appraisal Tool (MMAT) and narratively synthesised. RESULTS Despite high methodological heterogeneity across the six included studies, they all aimed to improve healthcare practitioners' communication skills through educational (theory, awareness, attitudes, assessment, treatment, and management of PPS) and experiential (role play) learning. CONCLUSIONS The review findings demonstrate that developing healthcare practitioners' communicative behaviours led to increased confidence and self-efficacy when working with PPS, which facilitated improved consultations and improvements on some patient outcomes. Barriers to the uptake of training programmes and implementation into daily clinical practice are discussed, including the need for PPS to be formally implemented into undergraduate teaching and post-qualification continuous professional development. TRIAL REGISTRATION This review was registered at PROSPERO [CRD42022315631] prior to the review starting.
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Affiliation(s)
- Stacie Thursby
- Northumbria Healthcare NHS Foundation Trust, North Tyneside General Hospital, North Shields, NE29 8NH, United Kingdom
| | - Lorelle Dismore
- Northumbria Healthcare NHS Foundation Trust, North Tyneside General Hospital, North Shields, NE29 8NH, United Kingdom
| | - Katherine Swainston
- Faculty of Medical Sciences, School of Psychology, Newcastle University, 4 Floor Dame Margaret Barbour Building, Wallace Street, Newcastle Upon Tyne, NE1 7RU, England.
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Ropers FG, Rietveld S, Rings EHHM, Bossuyt PMM, van Bodegom-Vos L, Hillen MA. Diagnostic testing in children: A qualitative study of pediatricians' considerations. J Eval Clin Pract 2023; 29:1326-1337. [PMID: 37221991 DOI: 10.1111/jep.13867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/02/2023] [Accepted: 05/04/2023] [Indexed: 05/25/2023]
Abstract
AIMS AND OBJECTIVES Studies in adult medicine have shown that physicians base testing decisions on the patient's clinical condition but also consider other factors, including local practice or patient expectations. In pediatrics, physicians and parents jointly decide on behalf of a (young) child. This might demand more explicit and more complex deliberations, with sometimes conflicting interests. We explored pediatricians' considerations in diagnostic test ordering and the factors that influence their deliberation. METHOD We performed in-depth, semistructured interviews with a purposively selected heterogeneous sample of 20 Dutch pediatricians. We analyzed transcribed interviews inductively using a constant comparative approach, and clustered data across interviews to derive common themes. RESULTS Pediatricians perceived test-related burden in children higher compared with adults, and reported that avoiding an unjustified burden causes them to be more restrictive and deliberate in test ordering. They felt conflicted when parents desired testing or when guidelines recommended diagnostic tests pediatricians perceived as unnecessary. When parents demanded testing, they would explore parental concern, educate parents about harms and alternative explanations of symptoms, and advocate watchful waiting. Yet they reported sometimes performing tests to appease parents or to comply with guidelines, because of feared personal consequences in the case of adverse outcomes. CONCLUSION We obtained an overview of the considerations that are weighed in pediatric test decisions. The comparatively strong focus on prevention of harm motivates pediatricians to critically appraise the added value of testing and drivers of low-value testing. Pediatricians' relatively restrictive approach to testing could provide an example for other disciplines. Improved guidelines and physician and patient education could help to withstand the perceived pressure to test.
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Affiliation(s)
- Fabienne G Ropers
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Sophie Rietveld
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Edmond H H M Rings
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
- Department of Pediatrics, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Patrick M M Bossuyt
- Amsterdam University Medical Centers, University of Amsterdam, Epidemiology & Data Science, Amsterdam, The Netherlands
- Amsterdam Public Health, Methodology, Amsterdam, The Netherlands
| | - Leti van Bodegom-Vos
- Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Marij A Hillen
- Amsterdam University Medical Centers, location AMC, Amsterdam Public Health, Medical Psychology, Amsterdam, The Netherlands
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Crosky S, McFarlin M, Sullivan N, Winograd D, Litke D, Masheb RM, Lu SE, Costanzo M, Anastasides N, Gonzalez C, Doshi J, Graff F, Khatib L, Thien S, McAndrew LM. Randomized controlled trial protocol of health coaching for veterans with complex chronic pain. Trials 2023; 24:239. [PMID: 36997946 PMCID: PMC10061706 DOI: 10.1186/s13063-023-07113-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/23/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Pain predominant multisymptom illness (pain-CMI) refers to symptom-based conditions where pain is a primary symptom. There is initial evidence that health coaching may be efficacious in treating pain-CMI because it can be tailored to the veteran's goals and emphasizes long-term behavior change, which may indirectly impact the maintaining factors of pain-CMI (e.g., catastrophizing, poor pain control, and limited activity). This paper describes the study protocol and rationale of a randomized controlled trial that will compare the efficacy of remote-delivered health coaching in reducing disability and pain impairment for veterans with pain-CMI to remote-delivered supportive psychotherapy. METHODS This randomized controlled trial will consist of two treatment arms: remote-delivered health coaching and remote-delivered supportive psychotherapy, the active control. Each treatment condition will consist of twelve, weekly one-on-one meetings with a study provider. In addition to the baseline assessment, participants will also complete 6-week (mid-treatment), 12-week (post-treatment), and 24-week (follow-up) assessments that consist of questionnaires that can be completed remotely. The primary aims for this study are to determine whether health coaching reduces disability and pain impairment as compared to supportive psychotherapy. We will also examine whether health coaching reduces physical symptoms, catastrophizing, limiting activity, and increasing pain control as compared to supportive psychotherapy. DISCUSSION This study will contribute to the existing literature on pain-CMI and report the effectiveness of a novel, remote-delivered behavioral intervention.
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Affiliation(s)
- Sarah Crosky
- Department of Educational and Counseling Psychology, University at Albany-State University of New York, Albany, USA
| | - Mikhaela McFarlin
- Department of Educational and Counseling Psychology, University at Albany-State University of New York, Albany, USA
| | - Nicole Sullivan
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Healthcare System, 385 Tremont Ave., East Orange, NJ, 07018, USA
| | - Darren Winograd
- Department of Educational and Counseling Psychology, University at Albany-State University of New York, Albany, USA
| | - David Litke
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Healthcare System, 385 Tremont Ave., East Orange, NJ, 07018, USA
- Department of Rehabilitation Medicine, NYU Grossman School of Medicine, New York, NY, 10016, USA
| | - Robin M Masheb
- VA Connecticut Healthcare System, 950 Campbell Ave., West Haven, CT, 06516, USA
- Yale University School of Medicine, 333 Cedar St., New Haven, CT, 06610, USA
| | - Shou-En Lu
- Epidemiology and Statistics, School of Public Health, Rutgers University, Piscataway, NJ, 08854, USA
| | - Michelle Costanzo
- War Related Illness and Injury Study Center, Washington DC VA Medical Center, 50 Irving St. NW, Washington, DC, 20422, USA
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Nicole Anastasides
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Healthcare System, 385 Tremont Ave., East Orange, NJ, 07018, USA
| | - Christina Gonzalez
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Healthcare System, 385 Tremont Ave., East Orange, NJ, 07018, USA
| | - Jaineel Doshi
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Healthcare System, 385 Tremont Ave., East Orange, NJ, 07018, USA
| | - Fiona Graff
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Healthcare System, 385 Tremont Ave., East Orange, NJ, 07018, USA
| | - Linda Khatib
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Healthcare System, 385 Tremont Ave., East Orange, NJ, 07018, USA
| | - Scott Thien
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Healthcare System, 385 Tremont Ave., East Orange, NJ, 07018, USA
| | - Lisa M McAndrew
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Healthcare System, 385 Tremont Ave., East Orange, NJ, 07018, USA.
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McGhie-Fraser B, Lucassen P, Ballering A, Abma I, Brouwers E, van Dulmen S, Olde Hartman T. Persistent somatic symptom related stigmatisation by healthcare professionals: A systematic review of questionnaire measurement instruments. J Psychosom Res 2023; 166:111161. [PMID: 36753936 DOI: 10.1016/j.jpsychores.2023.111161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 01/22/2023]
Abstract
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.
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Affiliation(s)
- Brodie McGhie-Fraser
- Radboud University Medical Center, Radboud Institute for Health Services Research, Department of Primary and Community Care, Nijmegen, the Netherlands.
| | - Peter Lucassen
- Radboud University Medical Center, Radboud Institute for Health Services Research, Department of Primary and Community Care, Nijmegen, the Netherlands.
| | - Aranka Ballering
- University of Groningen, University Medical Center Groningen, Department of Psychiatry, Groningen, the Netherlands.
| | - Inger Abma
- Radboud University Medical Center, Radboud Institute of Health Sciences, IQ Healthcare, Nijmegen, the Netherlands.
| | - Evelien Brouwers
- Tranzo, Scientific Center for Care and Wellbeing, Tilburg University, Tilburg, the Netherlands.
| | - Sandra van Dulmen
- Radboud University Medical Center, Radboud Institute for Health Services Research, Department of Primary and Community Care, Nijmegen, the Netherlands; Nivel (Netherlands Institute for Health Services Research), Utrecht, the Netherlands; Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Sweden.
| | - Tim Olde Hartman
- Radboud University Medical Center, Radboud Institute for Health Services Research, Department of Primary and Community Care, Nijmegen, the Netherlands.
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Jøssang IH, Aamland A, Hjörleifsson S. Discovering strengths in patients with medically unexplained symptoms - a focus group study with general practitioners. Scand J Prim Health Care 2022; 40:405-413. [PMID: 36345858 PMCID: PMC9848323 DOI: 10.1080/02813432.2022.2139345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND When patients suffer medically unexplained symptoms, consultations can be difficult and frustrating for both patient and GP. Acknowledging the patient as a co-subject can be particularly important when the symptoms remain unexplained. One way of seeing the patient as a co-subject is by recognizing any among their strong sides. OBJECTIVES To explore GPs' experiences with discovering strengths in their patients with medically unexplained symptoms and elicit GPs' reflections on how this might be useful. METHODS Four focus-groups with 17 GPs in Norway. Verbatim transcripts from the interviews were analyzed by systematic text condensation. RESULTS Recollecting patients' strengths was quiet challenging to the GPs. Gradually they nevertheless shared a range of examples, and many participants had experienced that knowing patients' strong sides could make consultations less demanding, and sometimes enable the GP to provide better help. Identifying strengths in patients with unexplained symptoms required a deliberate effort on the GPs' behalf, and this seemed to be a result of a strong focus on biomedical disease and loss of function. CONCLUSIONS Acknowledging patients' strong sides can bolster GPs' ability to help patients with medically unexplained symptoms. However, the epistemic disadvantage of generalist expertise makes this hard to achieve. It is difficult for GPs to integrate person-centered perspectives with biomedical knowledge due to the privileged position of the latter. This seems to indicate a need for system-level innovations to increase the status of person-centered clinical work. Key pointsMUS is challenging for both patients and GPs mainly because of the incongruence between symptoms and the dominating biomedical model.GPs' focus on pathology and loss of function can prevent them from discovering patients' strengths.Awareness of patients' strengths can make consultations less demanding for GPs and enable them to provide better help.A conscious effort is needed to discover patients' strengths.
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Affiliation(s)
- Ingjerd Helene Jøssang
- Department of global public health and primary care, University of Bergen, Norway
- Research unit for general practice, NORCE Norwegian Research Centre, Bergen, Norway
- CONTACT Ingjerd Helene Jøssang Research unit for general practice, NORCE Norwegian Research Centre, Årstadveien 17, Bergen5016, Norway
| | - Aase Aamland
- Research unit for general practice, NORCE Norwegian Research Centre, Bergen, Norway
| | - Stefan Hjörleifsson
- Department of global public health and primary care, University of Bergen, Norway
- Research unit for general practice, NORCE Norwegian Research Centre, Bergen, Norway
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Lost in fragmentation: exploring patients’ experiences with coordination of care when somatic symptoms persist, a qualitative study. Br J Gen Pract 2022; 72:e790-e798. [DOI: 10.3399/bjgp.2021.0566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 04/13/2022] [Indexed: 10/31/2022] Open
Abstract
Background: GPs can play a central role in the care for patients with persistent somatic symptoms (PSS). To date, little is known about patients’ experiences with the coordination of care. Aim: Exploring experiences of patients with PSS with the coordination of care -in particular by their GP- during their illness trajectory. Design and setting: Qualitative study, part of a multi-center prospective cohort study on the course of PSS (PROSPECTS). Method: Thematic content analysis of fifteen interviews. Results: We identified three themes: 1) care fragmentation during the diagnostic trajectory; 2) transition from the search for a cure to coping; and 3) reframing to coping: GP’s role in facilitating supportive care. Patients experienced misalignment between healthcare providers (HCPs) during the diagnostic trajectory and some ended up in a ‘collusion of anonymity’ (repeated cross-referrals between specialists). Guidance by their GP in a process of shared decision making was positively valued. Moving focus from searching for a cure to coping with symptoms was described as a personal endeavor, challenged by ongoing uncertainty. When reframing to coping, the extent to which patients were aligned with their GP played a role in whether their supportive care request was met. Conclusion: Patients experienced difficulties navigating the diagnostic trajectory and shifting to coping. Our findings underline the importance of collaboration and alignment between GPs and other HCPs during the diagnostic trajectory. We recommend that GPs provide pro-active guidance and are sensitive to patients who shift to coping by providing supportive care in a process of shared decision making.
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Kimber J, Sullivan N, Anastasides N, Slotkin S, McAndrew LM. Understanding Veterans' Causal Attributions of Physical Symptoms. Int J Behav Med 2021; 28:299-307. [PMID: 32691396 PMCID: PMC7855405 DOI: 10.1007/s12529-020-09918-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Illness beliefs are significant contributors to health outcomes. Beliefs about the cause of physical symptoms are considered particularly important among those with medically unexplained symptoms and illnesses (MUS); yet little is known about causal beliefs among those with the most severe MUS (i.e., Veterans). The goal of the current study was to examine Veteran's causal attributions of their physical symptoms. METHOD A total of 91 combat Veterans with MUS were surveyed using a mixed-methods design about the cause of their physical symptoms, physical symptom severity, and PTSD symptoms. Causal attributions of physical symptoms were analyzed through thematic response analysis and grouped into categories. Chi-square analysis was used to assess the distribution of causal attribution types across Veterans with varying physical symptom severity and PTSD symptom severity. RESULTS Veterans with MUS reported an average of 7.9 physical symptoms, and attributed the cause of their symptoms to seven different categories ("Do not Know," "Stress/Mental Health," "Deployment/Environment," "Functional/Symptom," "Medically Explained," "Medically Unexplained Syndrome," and "Lifestyle"). Exploratory chi-square analysis revealed significant differences in causal attributions across physical symptom severity and severity of PTSD symptoms. Veterans with more severe PTSD and Veterans with more severe physical symptoms were more likely to attribute their MUS to stress/mental health or to a medically unexplained syndrome compared with those with low/no PTSD symptoms and physical symptom severity. Veterans with minimal PTSD and Veterans with minimal physical symptom severity were more likely to attribute the cause of their MUS to lifestyle choices (e.g., exercise/diet) compared with those with high PTSD and physical symptom severity. CONCLUSION Veterans with MUS endorse multiple, varied causal attributions for their physical symptoms, suggesting more complex causal beliefs than typically assumed. This has important implications for patient-provider communication and development of concordance around MUS treatment.
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Affiliation(s)
- Justin Kimber
- Department of Educational and Counseling Psychology, University at Albany, State University of New York, 1400 Washington Ave Ext, Albany, 12222, NY, USA.
| | - Nicole Sullivan
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, 07018, NJ, USA
| | - Nicole Anastasides
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, 07018, NJ, USA
| | - Sarah Slotkin
- Department of Educational and Counseling Psychology, University at Albany, State University of New York, 1400 Washington Ave Ext, Albany, 12222, NY, USA
| | - Lisa M McAndrew
- Department of Educational and Counseling Psychology, University at Albany, State University of New York, 1400 Washington Ave Ext, Albany, 12222, NY, USA
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8
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Polakovská L, Řiháček T. What is it like to live with medically unexplained physical symptoms? A qualitative meta-summary. Psychol Health 2021; 37:580-596. [PMID: 33872098 DOI: 10.1080/08870446.2021.1901900] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Medically unexplained physical symptoms (MUPS) are a frequent phenomenon. Understanding adults and adolescents' lived experience with MUPS is essential for providing adequate care, yet a rigorous synthesis of existing studies is missing. Objective: This study aimed to summarize findings from primary qualitative studies focused on adults' and adolescents' experience of living with MUPS. Design: Qualitative studies were searched in the PsycINFO, PsycARTICLES, and Medline databases and manually. A total of 23 resources met the inclusion criteria and were subjected to a qualitative meta-summary. Results: Eight themes were found across the set of primary studies, namely, the need to feel understood, struggling with isolation, 'sense of self' in strain, facing uncertainty, searching for explanations, ambivalence about diagnosis, disappointed by healthcare, and active coping. Conclusion: The eight themes represent the core struggles adults' and adolescents' with MUPS face in their lives, psychologically and socially. Although these themes appear to be universal, the analysis also revealed considerable variability of experience in terms of expectations from healthcare professionals, attitude towards formal diagnoses, ability to cope with the illness, or potential to transform the illness experience into personal growth. Addressing this diversity of needs represents a significant challenge for the healthcare system.
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Affiliation(s)
- Lucia Polakovská
- Faculty of Social Studies, Department of Psychology, Masaryk University, Brno, Czech Republic
| | - Tomáš Řiháček
- Faculty of Social Studies, Department of Psychology, Masaryk University, Brno, Czech Republic
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9
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Affiliation(s)
- Jon Hunter
- Department of Psychiatry, University of Toronto, and Sinai Health System, Toronto. Dr. Hunter is guest editor of the American Journal of Psychotherapy's special issue on consultation-liaison psychotherapy
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10
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Rask MT, Jakobsen PR, Clemensen J, Rosendal M, Frostholm L. Development of an eHealth programme for self-management of persistent physical symptoms: a qualitative study on user needs in general practice. BMC FAMILY PRACTICE 2021; 22:33. [PMID: 33550988 PMCID: PMC7869449 DOI: 10.1186/s12875-021-01380-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 01/31/2021] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Mette Trøllund Rask
- Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Nørrebrogade 44, 8000, Aarhus, Denmark.
| | - Pernille Ravn Jakobsen
- Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Nørrebrogade 44, 8000, Aarhus, Denmark.,University College Southern Denmark, Lembckesvej 3-7, 6100, Haderslev, Denmark
| | - Jane Clemensen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Kløvervænget 23, 5000, Odense, Denmark
| | - Marianne Rosendal
- Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Nørrebrogade 44, 8000, Aarhus, Denmark.,Research Unit for General Practice, Bartholins Allé 2, 8000, Aarhus, Denmark
| | - Lisbeth Frostholm
- Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Nørrebrogade 44, 8000, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Nørrebrogade 44, 8000, Aarhus C, Denmark
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11
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van Gils A, Tak LM, Sattel H, Rosmalen JGM. Development and User Experiences of a Biopsychosocial Interprofessional Online Course on Persistent Somatic Symptoms. Front Psychiatry 2021; 12:725546. [PMID: 34819884 PMCID: PMC8607516 DOI: 10.3389/fpsyt.2021.725546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 10/07/2021] [Indexed: 12/30/2022] Open
Abstract
Background: Communication between healthcare providers and patients with persistent somatic symptoms (PSS) is frequently hampered by mutual misunderstanding and dissatisfaction. Methods: We developed an online, interprofessional course to teach healthcare providers the knowledge, skills, and attitude they need to diagnose and treat PSS in a patient-centered manner based on the biopsychosocial model. The course consisted of six modules of 45-60 min. Each module contained different types of assignments, based on six cases: videos, discussion boards, reading assignments, polls, and quizzes. For this study, we included (1) medical residents, following the course as part of their residency training, and (2) healthcare providers (general practitioners, medical specialists, physiotherapists, nurses, and psychologists), following the course as continuing vocational training. Throughout the course, participants were asked to fill out online surveys, enquiring about their learning gains and satisfaction with the course. Results: The biopsychosocial approach was integrated across the modules and teached health care workers about recent insights on biological, psychological and social aspects of PSS. In total, 801 participants with a wide variety in clinical experience started the course; the largest groups of professionals were general practitioners (N = 400), physiotherapists (N = 124) and mental healthcare workers (N = 53). At the start of the course, 22% of the participants rated their level of knowledge on PSS as adequate. At the end of the course, 359 participants completed the evaluation questionnaires. Of this group, 81% rated their level of knowledge on PSS as adequate and 86% felt that following the course increased their competencies in communicating with patients with PSS (N = 359). On a scale from 1 to 10, participants gave the course a mean grade of 7.8 points. Accordingly, 85% stated that they would recommend the course to a colleague. Conclusion: Our course developed in a co-design process involving multiple stakeholders can be implemented, is being used, and is positively evaluated by professionals across a variety of health care settings.
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Affiliation(s)
- A van Gils
- University of Groningen, University Medical Center Groningen, Departments of Psychiatry and Internal Medicine, Groningen, Netherlands
| | - L M Tak
- Specialist Center for Persistent Somatic Symptoms & Somatic Symptom Disorders, Dimence Mental Health Care, Deventer, Netherlands
| | - H Sattel
- Department of Psychosomatic Medicine and Psychotherapy, The Technical University of Munich, Munich, Germany
| | - J G M Rosmalen
- University of Groningen, University Medical Center Groningen, Departments of Psychiatry and Internal Medicine, Groningen, Netherlands.,Specialist Center for Persistent Somatic Symptoms & Somatic Symptom Disorders, Dimence Mental Health Care, Deventer, Netherlands
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12
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What symptoms tell us: A multiple case study of oncology consultations. Palliat Support Care 2020; 19:421-436. [PMID: 32912373 DOI: 10.1017/s1478951520000899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES While patients' symptom experiences have been widely investigated, there is a lack of contextualized studies investigating how symptoms circulate in the medical consultation, how patients present them, what they convey, how physicians respond, and how patients and physicians negotiate with each other to find ways to address them. The aim of this study is to explore patients and physicians handling of symptoms throughout oncological consultations with a multiple case study approach. METHODS Five consultations, purposively selected from an existing dataset of audiotaped consultations with patients with advanced cancer, were analyzed by means of an inductive analytical approach based on a sensitive framework from the literature. RESULTS Patients' symptoms showed multiple dimensions such as medical, cognitive, emotional, psychological, interactional, symbolic, experiential, and existential. SIGNIFICANCE OF RESULTS Different symptom dimensions remained unnoticed and unaddressed in the consultations. The physician-centered symptom approach that was observed leads to consumed time and missed opportunities for relationship building with the patient. Physicians showed a lack of sensitivity regarding the multiple dimensions of symptoms. Based on the findings, strategies for a more comprehensive symptom approach can be conceived.
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Gol JM, Rosmalen JGM, Gans ROB, Voshaar RCO. The importance of contextual aspects in the care for patients with functional somatic symptoms. Med Hypotheses 2020; 142:109731. [PMID: 32335457 DOI: 10.1016/j.mehy.2020.109731] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/01/2020] [Accepted: 04/08/2020] [Indexed: 12/30/2022]
Abstract
Functional somatic symptoms refer to physical symptoms that cannot be (bio) medically explained. The pattern or clustering of such symptoms may lead to functional syndromes like chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, among many others. Since the underlying pathophysiology remains unknown, several explanatory models have been proposed, nearly all including social and psychological parameters. These models have stimulated effectiveness studies of several psychological and psychopharmacological therapies. While the evidence for their effectiveness is steadily growing, effect-sizes are at most moderate and many patients do not benefit. We hypothesize that the context in which interventions for functional somatic symptoms are delivered substantially influences their effectiveness. Although this hypothesis is in line with explanatory models of functional somatic symptoms, to our knowledge, studies primarily focusing on the influence of contextual aspects on treatment outcome are scarce. Contextual research in the field of somatic symptoms has (irrespective whether these symptoms can be medically explained or not), however, just begun and already yielded some valuable results. These findings can be organized according to Duranti's and Goodwin's theoretical approach to context in order to substantiate our hypothesis. Based on this approach, we categorized empirical findings in three contextual aspects, i.e. 1) the setting, 2) the behavioural environment, and 3) the language environment. Collectively, some support is found for the fact that early identification of patients with functional somatic symptoms, starting treatment as soon as possible, having a neat appearance and an organized office interior, a warm and friendly nonverbal approach and a language use without defensiveness are contextual parameters which enhance the assessment by the patient of the physician's competence to help. Nonetheless, in vivo studies addressing the most aspects, i.e. nonverbal behaviour and language, are needed for better understanding of these contextual aspect. Moreover, future research should address to what extent optimizing contextual aspects improve care for functional somatic symptoms.
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Affiliation(s)
- J M Gol
- University of Groningen & University Medical Center Groningen, Interdisciplinary Center for Psychopathology of Emotion Regulation (ICPE), PO Box 30.001 (CC72), 9700 RB Groningen, the Netherlands.
| | - J G M Rosmalen
- University of Groningen & University Medical Center Groningen, Interdisciplinary Center for Psychopathology of Emotion Regulation (ICPE), PO Box 30.001 (CC72), 9700 RB Groningen, the Netherlands
| | - R O B Gans
- University of Groningen & University Medical Center Groningen, Interdisciplinary Center for Psychopathology of Emotion Regulation (ICPE), PO Box 30.001 (CC72), 9700 RB Groningen, the Netherlands
| | - R C Oude Voshaar
- University of Groningen & University Medical Center Groningen, Interdisciplinary Center for Psychopathology of Emotion Regulation (ICPE), PO Box 30.001 (CC72), 9700 RB Groningen, the Netherlands
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14
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Platts-Mills TF, Nagurney JM, Melnick ER. Tolerance of Uncertainty and the Practice of Emergency Medicine. Ann Emerg Med 2019; 75:715-720. [PMID: 31874767 DOI: 10.1016/j.annemergmed.2019.10.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Indexed: 12/16/2022]
Affiliation(s)
| | - Justine M Nagurney
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, and the Institute for Aging Research, Hebrew Senior Life, Boston, MA
| | - Edward R Melnick
- Department of Emergency Medicine, Yale-New Haven Hospital, New Haven, CT
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15
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Friedlander ML, Kangos K, Maestro K, Muetzelfeld H, Wright ST, Silva ND, Kimber J, Helmer DA, McAndrew LM. Introducing the System for Observing Medical Alliances (SOMA): A Tool for Studying Concordance in Patient-Physician Relationships. COUNSELING PSYCHOLOGIST 2019; 47:796-819. [PMID: 32372766 DOI: 10.1177/0011000019891434] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
We developed the System for Observing Medical Alliances (SOMA) to study relationships between medical providers and patients with medically unexplained symptoms (MUS). Based on literature in health psychology, medicine, and the psychotherapeutic alliance, the SOMA operationalizes three medical alliance dimensions: Engagement in the Consultation Process, Trust in the Provider, and Concordance of Illness Beliefs and Treatment Recommendations. Specific behavioral indicators, tallied as observed by trained judges, are used as the basis for rating each dimension. In a sample of 33 medical consultations with veterans who had MUS, interrater reliabilities ranged from .79 to .94. Notably, the other dimension ratings accounted for 40% of the variability in Concordance, with Trust in the Provider contributing unique variance. In addition to research, psychologists in integrated health settings can use the SOMA to consult and train medical providers on communication skills that enhance concordance.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Lisa M McAndrew
- Veterans Affairs New Jersey Health Care System, University at Albany
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16
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Lee L, King G, Freeman T, Eva KW. Situational cues surrounding family physicians seeking external resources while self-monitoring in practice. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2019; 24:783-796. [PMID: 31123847 DOI: 10.1007/s10459-019-09898-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 05/17/2019] [Indexed: 06/09/2023]
Abstract
Many models of safe and effective clinical decision making in medical practice emphasize the importance of recognizing moments of uncertainty and seeking help accordingly. This is not always done effectively, but we know little about what cues prompt health professionals to call on resources beyond their own knowledge or skill set. Such information would offer guidance regarding how systems might be designed to offer better individual support. In this study, the authors explored the situational factors that are present during moments of uncertainty that lead primary care physicians to access external resources. To do so, a generic qualitative exploratory analysis was conducted on 72 narratives collected through audio recorder-based, self-observational, journaling completed by 12 purposively selected family physicians. Participants were asked to provide a detailed descriptive account of the circumstances surrounding their consultation of external resources immediately after 6 sequential patient encounters in which they felt compelled to seek such support. Thematic analysis of the transcripts was performed to better understand participants' experiences of the social, contextual, and personal features surrounding decisions to seek support. When doing so we observed that specific features of patient encounters were routinely present when physicians decided to access external sources for help. These included medical aspects of the case (e.g., complex presentations), social aspects (e.g., the presence of another individual), and personal factors (e.g., feeling a need for reassurance). External resources were seen as an opportunity for verification, a mechanism to increase patient satisfaction, and a means through which to defend decision-making. Accessing such resources appeared to influence the physician-patient relationship for various reasons. Recognition and further study of the cues that prompt use of external information will further our understanding of physicians' behavioural responses to challenging/uncertain situations, highlight mechanisms through which a culture of self-directed assessment seeking might be encouraged, and offer guidance regarding ways in which physicians can be encouraged to practice mindfully. Our results make it clear that reasons for which primary care physicians seek the support of external resources may be multifactorial and, therefore, one should be cautious when inferring reasons for the pursuit of such support.
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Affiliation(s)
- Linda Lee
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada.
- Schlegel Chair in Primary Care for Elders, The Schlegel-UW Research Institute for Aging, Waterloo, ON, Canada.
- Centre for Family Medicine Family Health Team, 10B Victoria St. South, Kitchener, ON, N2G 1C5, Canada.
| | - Gillian King
- Bloorview Research Institute, Toronto, ON, Canada
- Department of Occupational Science and Occupational Therapy, The University of Toronto, Toronto, ON, Canada
- Department of Family Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Thomas Freeman
- Department of Family Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Kevin W Eva
- Department of Medicine, Centre for Health Education Scholarship, The University of British Columbia, Vancouver, BC, Canada
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17
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Claréus B, Renström EA. Physicians' gender bias in the diagnostic assessment of medically unexplained symptoms and its effect on patient-physician relations. Scand J Psychol 2019; 60:338-347. [PMID: 31124165 PMCID: PMC6851885 DOI: 10.1111/sjop.12545] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 04/02/2019] [Indexed: 12/24/2022]
Abstract
Nonspecific, functional, and somatoform (NFS) syndromes is an umbrella term for various diagnoses with medically unexplained symptoms. These syndromes are more prevalent among women than among men, and associated with negative preconceptions that can impede rehabilitation. In two studies, we quantitatively assess how patients’ gender affects the diagnostic assessment of NFS syndromes, as well as the healthcare experiences of individuals diagnosed with NFS syndromes. In the first study, our vignette‐based experiment showed that Swedish general practitioners (N = 90) were gender biased in their diagnostic assessment of NFS syndromes, such that a female patient with back pain was more likely to be assigned a NFS syndrome compared to an otherwise identical male patient. In the second study, a large community sample of Swedish individuals with medically explained (n = 432) and unexplained pain (n = 521) evaluated their treating physician's relational conduct. Even after accounting for a variety of sociodemographic variables and other pain characteristics, women with at least one NFS syndrome percieved their physician's relational conduct as significantly poorer than other women as well as men with and without NFS syndromes. When women's pain is more likely than men's to be assessed as NFS, their rehabilitation could be prolonged as pertient alternative diagnoses and treatments are omittied and their negative healthcare experiences lower their volition to partake and persevere in treatment.
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Affiliation(s)
| | - Emma A Renström
- Department of psychology, Gothenburg University, Gothenburg, Sweden
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18
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Anastasides N, Chiusano C, Gonzalez C, Graff F, Litke DR, McDonald E, Presnall-Shvorin J, Sullivan N, Quigley KS, Pigeon WR, Helmer DA, Santos SL, McAndrew LM. Helpful ways providers can communicate about persistent medically unexplained physical symptoms. BMC FAMILY PRACTICE 2019; 20:13. [PMID: 30651073 PMCID: PMC6334465 DOI: 10.1186/s12875-018-0881-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 11/23/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Communication between patients and providers about persistent "medically unexplained" physical symptoms (MUS) is characterized by discordance. While the difficulties are well documented, few studies have examined effective communication. We sought to determine what veterans with Gulf War Illness (GWI) perceive as the most helpful communication from their providers. Veterans with GWI, a type of MUS, have historically had complex relationships with medical providers. Determining effective communication for patients with particularly complex relationships may help identify the most critical communication elements for all patients with MUS. METHODS Two hundred and-ten veterans with GWI were asked, in a written questionnaire, what was the most useful thing a medical provider had told them about their GWI. Responses were coded into three categories with 10 codes. RESULTS The most prevalent helpful communication reported by patients was when the provider offered acknowledgement and validation (N = 70). Specific recommendations for managing GWI or its symptoms (N = 48) were also commonly reported to be helpful. In contrast, about a third of the responses indicated that nothing about the communication was helpful (N = 63). There were not differences in severity of symptoms, disability or healthcare utilization between patients who found acknowledgement and validation, specific recommendations or nothing helpful. CONCLUSIONS Previous research has documented the discord between patients and providers regarding MUS. This study suggests that most patients are able to identify something helpful a provider has said, particularly acknowledgement and validation and specific treatment recommendations. The findings also highlight missed communication opportunities with a third of patients not finding anything helpful.
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Affiliation(s)
- Nicole Anastasides
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA
| | - Carmelen Chiusano
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA
| | - Christina Gonzalez
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA
| | - Fiona Graff
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA
| | - David R Litke
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA
- Department of Rehabilitation Medicine, New York University School of Medicine, New York, NY, USA
| | - Erica McDonald
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA
| | - Jennifer Presnall-Shvorin
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA
| | - Nicole Sullivan
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA
| | - Karen S Quigley
- Edith Nourse Rogers Memorial VA Hospital, Bedford, 01730, MA, USA
- Department of Psychology, Northeastern University, Boston, 02115, MA, USA
| | - Wilfred R Pigeon
- Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY, USA
| | - Drew A Helmer
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA
| | - Susan L Santos
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA
| | - Lisa M McAndrew
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA.
- Department of Educational and Counseling Psychology, University at Albany, 1400 Washington Ave Ext, Albany, NY, 12222, USA.
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19
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Houwen J, Moorthaemer BJE, Lucassen PLBJ, Akkermans RP, Assendelft WJJ, Olde Hartman TC, van Dulmen S. The association between patients' expectations and experiences of task-, affect- and therapy-oriented communication and their anxiety in medically unexplained symptoms consultations. Health Expect 2018; 22:338-347. [PMID: 30597697 PMCID: PMC6543164 DOI: 10.1111/hex.12854] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 07/18/2018] [Accepted: 11/14/2018] [Indexed: 11/30/2022] Open
Abstract
Background It is unknown whether patients with medically unexplained symptoms (MUS) differ from patients with medically explained symptoms (MES) regarding their expectations and experiences on task‐oriented communication (ie, communication in which the primary focus is on exchanging medical content), affect‐oriented communication (ie, communication in which the primary focus is on the emotional aspects of the interaction) and therapy‐oriented communication (ie, communication in which the primary focus is on therapeutic aspects) of the consultation and the extent to which GPs meet their expectations. Objective This study aims to explore (a) differences in patients’ expectations and experiences in consultations with MUS patients and patients with MES and (b) the influence of patients’ experiences in these consultations on their post‐visit anxiety level. Study design Prospective cohort. Setting Eleven Dutch general practices. Measurements Patients completed the QUOTE‐COMM (Quality Of communication Through the patients’ Eyes) questionnaire before and after the consultation to assess their expectations and experiences and these were related to changes in patients’ state anxiety (abbreviated State‐Trait Anxiety Inventory; STAI). Results Expectations did not differ between patients with MUS and MES. Patients presenting with either MUS or MES rated their experiences for task‐related and affect‐oriented communication of their GP higher than their expectations. GPs met patients’ expectations less often on task‐oriented communication in MUS patients compared to MES patients (70.2% vs 80.9%; P = ˂0.001). Affect‐oriented communication seems to be most important in reducing the anxiety level of MUS patients (β −0.63, 95% Cl = −1.07 to −0.19). Discussion Although the expectations of MUS patients are less often met compared to those of MES patients, GPs often communicate according to patients’ expectations. Experiencing affect‐oriented communication is associated with a stronger reduction in anxiety in patients with MUS than in those with MES. Conclusion GPs communicate according to patients’ expectations. However, GPs met patients’ expectations on task‐oriented communication less often in patients with MUS compared to patients with MES. Experiencing affect‐oriented communication had a stronger association with the post‐consultation anxiety for patients with MUS than MES.
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Affiliation(s)
- Juul Houwen
- Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Bas J E Moorthaemer
- Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Peter L B J Lucassen
- Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Reinier P Akkermans
- Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.,Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Willem J J Assendelft
- Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Tim C Olde Hartman
- Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Sandra van Dulmen
- Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.,NIVEL (Netherlands Institute for Health Services Research), Utrecht, The Netherlands.,Faculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway
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20
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Sanders T, Winter D, Payne H. Personal Constructs of Mind-Body Identity in People Who Experience Medically Unexplained Symptoms. JOURNAL OF CONSTRUCTIVIST PSYCHOLOGY 2018. [DOI: 10.1080/10720537.2018.1515047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Tom Sanders
- University of Hertfordshire, Hatfield, United Kingdom
| | - David Winter
- University of Hertfordshire, Hatfield, United Kingdom
| | - Helen Payne
- University of Hertfordshire, Hatfield, United Kingdom
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21
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Socially constructed and structurally conditioned conflicts in territories of medical uncertainty. SOCIAL THEORY & HEALTH 2018. [DOI: 10.1057/s41285-018-00082-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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22
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Hagiwara N, Mezuk B, Elston Lafata J, Vrana SR, Fetters MD. Study protocol for investigating physician communication behaviours that link physician implicit racial bias and patient outcomes in Black patients with type 2 diabetes using an exploratory sequential mixed methods design. BMJ Open 2018; 8:e022623. [PMID: 30341127 PMCID: PMC6196822 DOI: 10.1136/bmjopen-2018-022623] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 06/12/2018] [Accepted: 08/17/2018] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Patient-physician racial discordance is associated with Black patient reports of dissatisfaction and mistrust, which in turn are associated with poor adherence to treatment recommendations and underutilisation of healthcare. Research further has shown that patient dissatisfaction and mistrust are magnified particularly when physicians hold high levels of implicit racial bias. This suggests that physician implicit racial bias manifests in their communication behaviours during medical interactions. The overall goal of this research is to identify physician communication behaviours that link physician implicit racial bias and Black patient immediate (patient-reported satisfaction and trust) and long-term outcomes (eg, medication adherence, self-management and healthcare utilisation) as well as clinical indicators of diabetes control (eg, blood pressure, HbA1c and history of diabetes complication). METHODS AND ANALYSIS Using an exploratory sequential mixed methods research design, we will collect data from approximately 30 family medicine physicians and 300 Black patients with type 2 diabetes mellitus. The data sources will include one physician survey, three patient surveys, medical interaction videos, video elicitation interviews and medical chart reviews. Physician implicit racial bias will be assessed with the physician survey, and patient outcomes will be assessed with the patient surveys and medical chart reviews. In video elicitation interviews, a subset of patients (approximately 20-40) will watch their own interactions while being monitored physiologically to identify evocative physician behaviours. Information from the interview will determine which physician communication behaviours will be coded from medical interactions videos. Coding will be done independently by two trained coders. A series of statistical analyses (zero-order correlations, partial correlations, regressions) will be conducted to identify physician behaviours that are associated significantly with both physician implicit racial bias and patient outcomes. ETHICS AND DISSEMINATION Ethics approval was obtained from the Virginia Commonwealth University IRB. Study results will be disseminated through publications in peer-reviewed journals and presentations at conferences. A novel Medical Interaction involving Black Patients Coding System from this project will be made publicly available.
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Affiliation(s)
- Nao Hagiwara
- Department of Psychology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Briana Mezuk
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Jennifer Elston Lafata
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Scott R Vrana
- Department of Psychology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Michael D Fetters
- Department of Family Medicine, University of Michigan, Ann Arbor, Michigan, USA
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23
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McAndrew LM, Crede M, Maestro K, Slotkin S, Kimber J, Phillips LA. Using the common-sense model to understand health outcomes for medically unexplained symptoms: a meta-analysis. Health Psychol Rev 2018; 13:427-446. [PMID: 30196755 DOI: 10.1080/17437199.2018.1521730] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Consistent with the common-sense model of self-regulation, illness representations are considered the key to improving health outcomes for medically unexplained symptoms and illnesses (MUS). Which illness representations are related to outcomes and how they are related is not well understood. In response, we conducted a meta-analysis of the relationship between illness representations, self-management/coping, and health outcomes (perceived disease state, psychological distress, and quality of life) for patients with MUS. We reviewed 23 studies and found that threat-related illness representations and emotional representations were related to worse health outcomes and more negative coping (moderate to large effect). Generally, increases in negative coping mediated (with a moderate to large effect) the relationship of threat/emotional illness representations and health outcomes. Protective illness representations were related to better health outcomes, less use of negative coping and greater use of positive coping (small to moderate effect). The relationship of protective illness representations to better health outcomes was mediated by decreases in negative coping (moderate to large effect) and increases in positive coping (moderate effect). Perceiving a psychological cause to the MUS was related to more negative health outcomes (moderate to large effect) and more negative emotional coping (small effect). The relationship of perceiving a psychological cause and more negative health outcomes was mediated by increases in negative emotional coping. Improving our understanding of how illness representations impact health outcomes can inform efforts to improve treatments for MUS. Our results suggest behavioural treatments should focus on reducing threat-related illness representations and negative coping.
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Affiliation(s)
- Lisa M McAndrew
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Healthcare System, East Orange, NJ, USA.,Department of Educational and Counseling Psychology, University at Albany, Albany, NY, USA
| | - Marcus Crede
- Department of Psychology, Iowa State University, Ames, IA, USA
| | - Kieran Maestro
- Department of Educational and Counseling Psychology, University at Albany, Albany, NY, USA
| | - Sarah Slotkin
- Department of Educational and Counseling Psychology, University at Albany, Albany, NY, USA
| | - Justin Kimber
- Department of Educational and Counseling Psychology, University at Albany, Albany, NY, USA
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24
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Østbye SV, Wang CEA, Granheim IPH, Kristensen KE, Risør MB. Epistemological and methodological paradoxes: secondary care specialists and their challenges working with adolescents with medically unexplained symptoms. Int J Ment Health Syst 2018; 12:52. [PMID: 30258491 PMCID: PMC6151926 DOI: 10.1186/s13033-018-0232-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 09/19/2018] [Indexed: 12/03/2022] Open
Abstract
Background Early adolescence is considered a critical period for the development of chronic and recurrent medically unexplained symptoms (MUS), and referrals and system-initiated patient trajectories often lead to an excess of examinations and hospitalizations in the cross-section between mental and somatic specialist care for this group of patients. Dimensions of the relationship and communication between clinician and patient are shown in primary care studies to be decisive for subsequent illness pathways, often creating adverse effects, but knowledge on clinical communication in specialist care is still scarce. Methods This study explores communicative challenges specific to clinical encounters between health professionals and adolescent patients in specialist care, as presented through interviews and focus group data with highly experienced specialists working in adolescent and child services at a Norwegian university hospital. Results The results are presented in a conceptual model describing the epistemological and methodological paradoxes inherent in the clinical uncertainty of MUS. Within these paradoxes, the professionals try to solve the dilemmas by being creative in their communication strategies; applying metaphors and other rhetorical devices to explain complex ideas; creating clinical prototypes as a way to explain symptoms and guide them in clinical action; relying on principles from patient-centered care involving empathy; and trying to balance expertise and humility. Conclusion The challenges in communication arise as a result of opposing discourses on biomedicine, family, health and adolescence that create dilemmas in everyday clinical work. By moving away from a positivist and biomedical framework towards an interpretive paradigm, where culturally derived and historically situated interpretations are used to understand the social life-world of the patient, one can create a more humane health service in accordance with ideals of patient-centered care.
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Affiliation(s)
- Silje Vagli Østbye
- 1Department of Psychology, Faculty of Health, UiT-Arctic University of Norway, Tromsø, Norway
| | | | | | | | - Mette Bech Risør
- 4Department of Community Medicine, General Practice Research Unit, Faculty of Health, UiT-Arctic University of Norway, Tromsø, Norway
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25
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Stortenbeker IA, Houwen J, Lucassen PLBJ, Stappers HW, Assendelft WJJ, van Dulmen S, Olde Hartman TC, Das E. Quantifying positive communication: Doctor's language and patient anxiety in primary care consultations. PATIENT EDUCATION AND COUNSELING 2018; 101:1577-1584. [PMID: 29751948 DOI: 10.1016/j.pec.2018.05.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 04/18/2018] [Accepted: 05/01/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Positive communication is advocated for physicians during consultations with patients presenting medically unexplained symptoms (MUS), but studies generally focus on what is said rather than how it is said. This study quantified language use differences of general practitioners (GPs), and assessed their relation to patient anxiety. METHODS Language use of 18 Dutch GPs during 82 consultations was compared for patients with MUS versus medically explained symptoms (MES). Message content (positive or negative) was differentiated from its directness (direct or indirect), and related to changes in patient's state anxiety (abbreviated State Trait Anxiety Inventory; STAI). RESULTS In total, 2590 clauses were identified. GPs approached patients with MES with relatively more direct (vs. indirect) positive and indirect (vs. direct) negative messages (OR 1.91, 95% CI 1.42-2.59). Anxiety of both patient groups increased when GPs used more direct (vs. indirect) negative messages (b = 0.67, 95% CI 0.07-1.27) CONCLUSIONS: GPs use different language depending on the content of messages for patients with MES, but not MUS. Direct negative messages relate to an increase in patient anxiety. PRACTICE IMPLICATIONS GPs could manage patient's state anxiety by expressing negative messages in an indirect rather than direct manner.
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Affiliation(s)
| | - Juul Houwen
- Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, the Netherlands.
| | - Peter L B J Lucassen
- Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, the Netherlands.
| | - Hugo W Stappers
- Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, the Netherlands.
| | - Willem J J Assendelft
- Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, the Netherlands.
| | - Sandra van Dulmen
- Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, the Netherlands; NIVEL (Netherlands institute for health services research), Utrecht, the Netherlands; Faculty of Health and Social Sciences, University College of Southeast Norway, Drammen, Norway.
| | - Tim C Olde Hartman
- Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, the Netherlands.
| | - Enny Das
- Centre for Language Studies, Radboud University, Nijmegen, the Netherlands.
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Medically unexplained symptoms: continuing challenges for primary care. Br J Gen Pract 2018; 67:106-107. [PMID: 28232334 DOI: 10.3399/bjgp17x689473] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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Kromme NMH, Ahaus KTB, Gans ROB, van de Wiel HBM. Internists' dilemmas in their interactions with chronically ill patients; A comparison of their interaction strategies and dilemmas in two different medical contexts. PLoS One 2018; 13:e0194133. [PMID: 29847552 PMCID: PMC5976145 DOI: 10.1371/journal.pone.0194133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 02/15/2018] [Indexed: 11/21/2022] Open
Abstract
Background Internists appear to define productive interactions, key concept of the Chronic Care Model, as goal-directed, catalyzed by achieving rapport, and depending on the medical context: i.e. medically explained symptoms (MES) or medically unexplained symptoms (MUS). Objective To explore internists’ interaction strategy discourses in the context of MES and MUS. Methods We interviewed twenty internists working in a Dutch academic hospital, identified relevant text fragments in the interview transcripts and analyzed the data based on a discourse analysis approach. Results We identified four interaction strategy discourses: relating, structuring, exploring, and influencing. Each was characterized by a dilemma: relating by ‘creating nearness versus keeping distance’; structuring by ‘giving space versus taking control’; exploring by ‘asking for physical versus psychosocial causes’; and influencing by ‘taking responsibility versus accepting a patient’s choice. The balance sought in these dilemmas depended on whether the patient’s symptoms were medically explained or unexplained (MES or MUS). Towards MUS the internists tended to maintain greater distance, take more control, ask more cautiously questions related to psychosocial causes, and take less responsibility for shared decision making. Discussion and conclusions Adopting a basic distinction between MES and MUS, the internists in our study appeared to seek a different balance in each of four rather fundamental clinical dilemmas. Balancing these dilemmas seemed more difficult regarding MUS where the internists seemed more distancing and controlling, and tended to draw on their medical expertise. Moving in this direction is counterproductive and in contradiction to guidelines which emphasize that MUS patients warrant emotional support requiring a shift towards interpersonal, empathic communication.
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Affiliation(s)
- Nicolien M. H. Kromme
- University of Groningen, University Medical Center Groningen, SectorA Chronic and Vascular Disease, Groningen, The Netherlands
- * E-mail:
| | - Kees T. B. Ahaus
- University of Groningen, Faculty of Economics and Business, Centre of Expertise Healthwise, Groningen, The Netherlands
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Reinold O. B. Gans
- University of Groningen, University Medical Center Groningen, Department of Internal Medicine, Groningen, The Netherlands
| | - Harry B. M. van de Wiel
- University of Groningen, University Medical Center Groningen, Wenckebach Institute, Groningen, The Netherlands
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Rasmussen EB, Rø KI. How general practitioners understand and handle medically unexplained symptoms: a focus group study. BMC FAMILY PRACTICE 2018; 19:50. [PMID: 29720093 PMCID: PMC5932817 DOI: 10.1186/s12875-018-0745-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 04/23/2018] [Indexed: 11/10/2022]
Abstract
Background Medically unexplained symptoms (MUS) are a common yet challenging encounter in primary care. The aim of this study was to explore how general practitioners (GPs) understand and handle MUS. Methods Three focus group interviews were conducted with a total of 23 GPs. Participants with varied clinical experience were purposively recruited. The data were analysed thematically, using the concept of framing as an analytical lens. Results The GPs alternated between a biomedical frame, centred on disease, and a biopsychosocial frame, centred on the sick person. Each frame shaped the GPs’ understanding and handling of MUS. The biomedical frame emphasised the lack of objective evidence, problematized subjective patient testimony, and manifested feelings of uncertainty, doubt and powerlessness. This in turn complicated patient handling. In contrast, the biopsychosocial frame emphasised clinical experience, turned patient testimony into a valuable source of information, and manifested feelings of confidence and competence. This in turn made them feel empowered. The GPs with the least experience relied more on the biomedical frame, whereas their more seasoned seniors relied mostly on the biopsychosocial frame. Conclusion The biopsychosocial frame helps GPs to understand and handle MUS better than the biomedical frame does. Medical students should spend more time learning biopsychosocial medicine, and to integrate the clinical knowledge of their peers with their own. Electronic supplementary material The online version of this article (10.1186/s12875-018-0745-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Erik Børve Rasmussen
- Centre for the study of professions, OsloMet - Oslo Metropolitan University, P.O. Box. 4, St. Olavs plass, N-0130, Oslo, Norway.
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Cooper A, Abbass A, Town J. Implementing a Psychotherapy Service for Medically Unexplained Symptoms in a Primary Care Setting. J Clin Med 2017; 6:jcm6120109. [PMID: 29186054 PMCID: PMC5742798 DOI: 10.3390/jcm6120109] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 11/13/2017] [Accepted: 11/16/2017] [Indexed: 12/24/2022] Open
Abstract
Medically unexplained symptoms (MUS) are known to be costly, complex to manage and inadequately addressed in primary care settings. In many cases, there are unresolved psychological and emotional processes underlying these symptoms, leaving traditional medical approaches insufficient. This paper details the implementation of an evidence-based, emotion-focused psychotherapy service for MUS across two family medicine clinics. The theory and evidence-base for using Intensive Short-Term Dynamic Psychotherapy (ISTDP) with MUS is presented along with the key service components of assessment, treatment, education and research. Preliminary outcome indicators showed diverse benefits. Patients reported significantly decreased somatic symptoms in the Patient Health Questionnaire-15 (d = 0.4). A statistically significant (23%) decrease in family physicians’ visits was found in the 6 months after attending the MUS service compared to the 6 months prior. Both patients and primary care clinicians reported a high degree of satisfaction with the service. Whilst further research is needed, these findings suggest that a direct psychology service maintained within the family practice clinic may assist patient and clinician function while reducing healthcare utilization. Challenges and further service developments are discussed, including the potential benefits of re-branding the service to become a ‘Primary Care Psychological Consultation and Treatment Service’.
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Affiliation(s)
- Angela Cooper
- Centre for Emotions & Health, Departments of Psychiatry & Family Medicine, Dalhousie University, Halifax, NS B3H 2E2, Canada.
| | - Allan Abbass
- Centre for Emotions & Health, Department of Psychiatry, Dalhousie University, Halifax, NS B3H 2E2, Canada.
| | - Joel Town
- Centre for Emotions & Health, Department of Psychiatry, Dalhousie University, Halifax, NS B3H 2E2, Canada.
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Watson J, de Salis I, Banks J, Salisbury C. What do tests do for doctors? A qualitative study of blood testing in UK primary care. Fam Pract 2017; 34:735-739. [PMID: 28985303 DOI: 10.1093/fampra/cmx051] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Rates of blood testing are rising with significant geographical variability. Most research into diagnostic testing focuses on the role of tests in diagnostic decision-making. OBJECTIVE The aim of this study was to explore the non-medical motives for blood testing by considering what tests do for doctors, through qualitative interviews with general practitioners (GPs). METHODS We undertook 23 in-depth semi-structured interviews with UK GPs. Reasons for performing recent inflammatory marker blood tests were explored by reviewing GPs pathology inboxes to ground discussions in real-life clinical practice. Interviews were transcribed verbatim and analysed using a grounded theory approach. RESULTS Blood tests offer doctors a tool to manage uncertainty; within a context of increased litigation, risk aversion and reduced continuity of care. Tests can also be offered as a 'gift' for patients, a way to be seen to be 'doing something'; in the social context of time pressures and perceived patient pressures. There was a tension however. On the one hand, doctors talked about using tests for reassurance and as a 'gift' offering 'truth'. Yet paradoxically, they also discussed the challenges of uncertainty and anxiety from inconclusive test results. CONCLUSION Our study emphasises that defining 'unnecessary' blood testing may not be as simple as determining medical criteria for testing; psychosocial reasons may be equally valid and interlinked. Further research is needed to help GPs manage uncertainty within the context of a risk averse society, and to explore the congruence and dissonance between doctors' and patients' perceptions of testing.
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Affiliation(s)
- Jessica Watson
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK.,Collaboration for Leadership in Applied Health Research and Care West (CLAHRC West), Bristol, UK
| | - Isabel de Salis
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Jonathan Banks
- Collaboration for Leadership in Applied Health Research and Care West (CLAHRC West), Bristol, UK
| | - Chris Salisbury
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK.,Collaboration for Leadership in Applied Health Research and Care West (CLAHRC West), Bristol, UK
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Improving GP communication in consultations on medically unexplained symptoms: a qualitative interview study with patients in primary care. Br J Gen Pract 2017; 67:e716-e723. [PMID: 28847774 DOI: 10.3399/bjgp17x692537] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 06/13/2017] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Many GPs find the care of patients with medically unexplained symptoms (MUS) challenging. Patients themselves are often not satisfied with the care they receive. AIM To explore the problems patients with MUS experience in communication during consultations, with the aim of improving such consultations DESIGN AND SETTING: A qualitative analysis of semi-structured interviews. METHOD GP consultations were videorecorded and the GPs were asked immediately afterwards whether MUS were presented. Patients in these MUS consultations were asked to reflect on the consultation in a semi-structured interview while watching a recording of their own consultation. RESULTS Of the 393 videorecorded consultations, 43 contained MUS. Patients who did identified six categories of problems. First, they reported a mismatch between the GP's and their own agenda. Second, patients indicated that the GP evoked an uncomfortable feeling in them during the consultation. Third, they found that GPs did not provide a specific management plan for their symptoms. Fourth, patients indicated that the GP was not well prepared for the consultation. Fifth, they perceived prejudices in the GP during the consultation. Finally, one patient found that the GP did not acknowledge a limited understanding of the origin of the symptoms. CONCLUSION According to patients, GPs can improve their consultations on MUS by making genuine contact with their patients, by paying more attention to the patient's agenda, and by avoiding evoking uncomfortable feelings and displaying prejudices. They should prepare their consultations and focus on the issues that matter to patients, for example, symptom management. GPs should be honest to patients when they do not understand the origin of symptoms.
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Yon K, Habermann S, Rosenthal J, Walters KR, Nettleton S, Warner A, Lamahewa K, Buszewicz M. Improving teaching about medically unexplained symptoms for newly qualified doctors in the UK: findings from a questionnaire survey and expert workshop. BMJ Open 2017; 7:e014720. [PMID: 28450466 PMCID: PMC5719648 DOI: 10.1136/bmjopen-2016-014720] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Medically unexplained symptoms (MUS) present frequently in healthcare, can be complex and frustrating for clinicians and patients and are often associated with overinvestigation and significant costs. Doctors need to be aware of appropriate management strategies for such patients early in their training. A previous qualitative study with foundation year doctors (junior doctors in their first 2 years postqualification) indicated significant lack of knowledge about this topic and appropriate management strategies. This study reviewed whether, and in what format, UK foundation training programmes for newly qualified doctors include any teaching about MUS and sought recommendations for further development of such training. DESIGN Mixed-methods design comprising a web-based questionnaire survey and an expert consultation workshop. SETTING Nineteen foundation schools in England, Wales and Northern Ireland PARTICIPANTS: Questionnaire administered via email to 155 foundation training programme directors (FTPDs) attached to the 19 foundation schools, followed by an expert consultation workshop attended by 13 medical educationalists, FTPDs and junior doctors. RESULTS The 53/155 (34.2%) FTPDs responding to the questionnaire represented 15 of the 19 foundation schools, but only 6/53 (11%) reported any current formal teaching about MUS within their programmes. However, most recognised the importance of providing such teaching, suggesting 2-3 hours per year. All those attending the expert consultation workshop recommended case-based discussions, role-play and the use of videos to illustrate positive and negative examples of doctor-patient interactions as educational methods of choice. Educational sessions should cover the skills needed to provide appropriate explanations for patients' symptoms as well as avoid unnecessary investigations, and providing information about suitable treatment options. CONCLUSIONS There is an urgent need to improve foundation level training about MUS, as current provision is very limited. An interactive approach covering a range of topics is recommended, but must be delivered within a realistic time frame for the curriculum.
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Affiliation(s)
- Katherine Yon
- Research Department of Primary Care and Population Health, UCL, London, UK
| | | | - Joe Rosenthal
- Research Department of Primary Care and Population Health, UCL, London, UK
| | - Kate R Walters
- Research Department of Primary Care and Population Health, UCL, London, UK
| | | | - Alex Warner
- Research Department of Primary Care and Population Health, UCL, London, UK
| | - Kethakie Lamahewa
- Research Department of Primary Care and Population Health, UCL, London, UK
| | - Marta Buszewicz
- Research Department of Primary Care and Population Health, UCL, London, UK
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Houwen J, Lucassen PLBJ, Stappers HW, Assendelft PJJ, van Dulmen S, Olde Hartman TC. Medically unexplained symptoms: the person, the symptoms and the dialogue. Fam Pract 2017; 34:245-251. [PMID: 28122842 DOI: 10.1093/fampra/cmw132] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Many general practitioners (GPs) find the care for patients with medically unexplained symptoms (MUS) challenging. The patients themselves are often not satisfied with the care they receive. OBJECTIVES The aim of this study is to explore what patients with MUS expect from their GP by looking at relevant communication elements in consultations as identified by patients. METHODS We video-recorded everyday consultations with GPs and asked the GPs immediately after the consultation whether MUS were presented. The patients in these MUS consultations were asked to reflect on the consultation during a semi-structured interview while watching a recording of their own MUS consultation. The interviews were analysed qualitatively according to the principles of constant comparative analysis. RESULTS Of the 393 video-recorded consultations, 43 concerned MUS. All MUS patients said that they wanted to be taken seriously. According to the patients, their feeling of being taken seriously is enhanced when the GP: (i) pays empathic attention to them as individuals, meaning that the GP knows their personal circumstances and has an open and empathic approach, (ii) ensures a good conversation by treating the patient as an equal partner and (iii) is attentive to their symptoms by exploring these symptoms in depth and by acting on them. CONCLUSION Like chronic patients, patients with MUS value a personalised approach in which GPs pay attention to patients' personal circumstances, to proper somatic management of their symptoms and to a proper conversation in which they are treated as equal partners. Use of these basic consultation skills may greatly improve care of MUS patients.
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Affiliation(s)
- Juul Houwen
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Peter L B J Lucassen
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Hugo W Stappers
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Pim J J Assendelft
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Sandra van Dulmen
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.,NIVEL (Netherlands institute for health services research), Utrecht, The Netherlands.,Faculty of Health Sciences, University College of Southeast Norway, Drammen, Norway
| | - Tim C Olde Hartman
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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Johansen ML, Risor MB. What is the problem with medically unexplained symptoms for GPs? A meta-synthesis of qualitative studies. PATIENT EDUCATION AND COUNSELING 2017; 100:647-654. [PMID: 27894609 DOI: 10.1016/j.pec.2016.11.015] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 11/02/2016] [Accepted: 11/19/2016] [Indexed: 06/06/2023]
Abstract
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.
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Affiliation(s)
- May-Lill Johansen
- Dept. of Community Medicine, UiT The Arctic University of Norway, Tromso, Norway.
| | - Mette Bech Risor
- Dept. of Community Medicine, UiT The Arctic University of Norway, Tromso, Norway; General Practice Research Unit, UiT The Arctic University of Norway, Tromso, Norway
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Town JM, Lomax V, Abbass AA, Hardy G. The role of emotion in psychotherapeutic change for medically unexplained symptoms. Psychother Res 2017; 29:86-98. [PMID: 28287345 DOI: 10.1080/10503307.2017.1300353] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES Evidence of the contribution of emotional processes to the emergence, maintenance, and experience of medically unexplained symptoms (MUS) suggests that clinical approaches which target these processes could be beneficial. In this study, qualitative methods were used to examine patients' perspectives and subjective experiences of emotional processes in the context of a psychotherapy assessment and treatment service for MUS provided in a hospital emergency department (ED). METHODS Seven semi-structured interviews were conducted with ED patients presenting with MUS who received a course of intensive short-term dynamic psychotherapy treatment. RESULTS Interpretative phenomenological analysis was employed with three superordinate themes emerging: Barriers to examining emotional processes; reflections on the therapeutic process; psychological change; and improved well-being. Obstacles to clinical engagement in treatment for MUS were described in relation to patients' and therapists' ability to identify, address, and utilize emotion processes. Specific elements of this work were identified as integral components of the psychotherapy change process for MUS. CONCLUSIONS Directly observing the physical effects of emotional experiencing in MUS provides sensory evidence that can enable patients to make mind-body connections. Psycho-emotional processes warrant further study to explore the applicability to other conceptual models for assessing and treating MUS. Clinical and methodological significance: In this article, we highlight that Medically Unexplained Symptoms (MUS) are a priority area for both physical and mental health care services. We present findings relevant to the effectiveness of a novel psychotherapy innovation within a hospital emergency department (ED). The use of interpretative phenomenological analysis to study the experiences of ED clients with MUS offers an established qualitative method for exploring the processes underlying therapeutic change. The results provide new insights around obstacles to engagement alongside potential solutions when addressing the psychological needs of clients with MUS. Although emotion processes have been described as a potentially important change process for MUS and in psychotherapy more generally, little empirical research has studied these two areas collectively.
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Affiliation(s)
- Joel M Town
- a Centre for Emotions & Health, Department of Psychiatry , Dalhousie University , Halifax , Canada.,b Clinical Trials and Population Studies , Plymouth University Peninsula Schools of Medicine and Dentistry , Plymouth , UK
| | - Victoria Lomax
- c Department of Psychology , University of Sheffield , Sheffield , UK
| | - Allan A Abbass
- a Centre for Emotions & Health, Department of Psychiatry , Dalhousie University , Halifax , Canada
| | - Gillian Hardy
- c Department of Psychology , University of Sheffield , Sheffield , UK
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Weiss FD, Rief W, Kleinstäuber M. Health care utilization in outpatients with somatoform disorders: Descriptives, interdiagnostic differences, and potential mediating factors. Gen Hosp Psychiatry 2017; 44:22-29. [PMID: 28041572 DOI: 10.1016/j.genhosppsych.2016.10.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 10/12/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Somatoform disorders are characterized by increased health care utilization producing high health costs. The aim of this study was to assess facets of and interdiagnostic differences in health care use in somatoform disorders and to examine health anxiety, symptom-related disability, depression, and phobic anxiety as potential mediating factors of the relationship between somatization and health care use. METHOD An outpatient sample of N=254 patients with somatoform disorders was investigated by analyzing different facets of their health care use over the last 12months. Multiple mediation analyses were applied. RESULTS Participants reported a mean of 28.02 doctor visits over the last year. Patients fulfilling criteria of DSM-IV somatization disorder had a significantly higher number of doctor visits than patients with undifferentiated somatoform, and somatoform pain disorder, all p≤.006. In most health care use variables, patients with comorbid mental disorders did not differ from patients without comorbidities. The mediation model on the effect of all mediator variables on the relationship between somatization and health care use reached significance (b=0.32, 95% CI: 0.0576, 0.6435). Surprisingly, specific mediator effects were found for health anxiety (b=0.06, 95% CI: 0.0004, 0.1505) and disability (b=0.18, 95% CI: 0.0389, 0.3530), but not for depression and phobic anxiety. CONCLUSIONS Health anxiety and symptom-related disability should be further considered when investigating potential etiological factors of increased health care use.
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Affiliation(s)
- Frauke Dorothee Weiss
- Division of Clinical Psychology and Psychotherapy, Department of Psychology, Philipps-University, Marburg, Germany
| | - Winfried Rief
- Division of Clinical Psychology and Psychotherapy, Department of Psychology, Philipps-University, Marburg, Germany
| | - Maria Kleinstäuber
- Division of Clinical Psychology and Psychotherapy, Department of Psychology, Philipps-University, Marburg, Germany.
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Hanssen DJC, Oude Voshaar RC, Naarding P, Rabeling-Keus IM, Olde Hartman TC, Lucassen PLBJ. Social characteristics and care needs of older persons with medically unexplained symptoms: a case-control study. Fam Pract 2016; 33:617-625. [PMID: 27538425 DOI: 10.1093/fampra/cmw067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Research in younger patients with medically unexplained symptoms (MUS) has shown impairments in social functioning, such as loneliness and a reduced quality of the patient-doctor relationship. As far as we know, no studies have been performed on social functioning in older MUS patients; self-reported care needs of older MUS patients remain unknown. OBJECTIVE To explore social characteristics and care needs of older persons with chronic MUS, when compared to older persons with chronic medically explained symptoms (MES). METHODS Patient characteristics of 107 older persons (>60 years) with chronic MUS were compared to 150 older persons with chronic MES in a case-control design. Participants were recruited via advertisements, general practices and a specialized clinic. All participants completed questionnaires on social functioning; the Camberwell Assessment of Need for the Elderly was used to draw up care needs. Linear regression analyses were performed to explore the association between social characteristics and group (MUS/MES), adjusted for demographic and physical determinants. Multiple chi-square tests were performed to detect between-group differences regarding care needs. RESULTS After adjustments, older MUS patients were slightly but significantly lonelier, reported a somewhat lower quality of their patient-doctor relationship, but reported equal social support levels when compared to MES patients. MUS patients more often reported unmet care needs regarding health and information provision about their health status. CONCLUSION Only small differences in social functioning were found between older MUS and MES patients. Possibly, training future doctors in giving acceptable explanations for the patient's complaints could improve the unmet care need of information provision in older MUS patients.
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Affiliation(s)
- Denise J C Hanssen
- Department of Psychiatry, Radboud Institute for Health Sciences, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands,
| | - Richard C Oude Voshaar
- Interdisciplinary Center for Psychopathology of Emotion Regulation (ICPE), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Paul Naarding
- Department of Old-Age Psychiatry, GGNet, Apeldoorn, The Netherlands
| | - Inge M Rabeling-Keus
- School of Psychology and Artificial Intelligence, Radboud University Nijmegen, Nijmegen, The Netherlands and
| | - Tim C Olde Hartman
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Peter L B J Lucassen
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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Menon V, Shanmuganathan B, Babu Arun A, Thamizh JS, Selvakumar N, Sarkar S. A qualitative analysis of explanatory models in medically unexplained physical symptoms presenting to a tertiary health care psychiatric facility in South India. Int J Soc Psychiatry 2016; 62:608-615. [PMID: 27609766 DOI: 10.1177/0020764016662294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Knowledge about subjective perceptions and explanatory models has the potential to inform clinical evaluation and lead to development of patient-friendly treatment models in medically unexplained physical symptoms (MUPS). AIM To collect qualitative data about explanatory models in MUPS. METHODS A cross-sectional observational study was done among patients with MUPS presenting over a 2-year period to a specialty psychosomatic clinic. The Short Explanatory Model of Illness interview was used to gather qualitative data about explanatory models which were subsequently recoded using standard manuals. RESULTS A total of 123 subjects were evaluated. The nature of symptoms was most commonly reported as 'non-specific' ( n = 102, 82.9%) but of moderate to severe intensity ( n = 87, 73.8%). Getting cured or showing improvement was the most common expectation from treatment ( n = 58, 47.9%). Moderate to severe impact of symptoms was reported on work output ( n = 100, 84%), emotional life ( n = 85, 71.4%) and physical mobility ( n = 59, 49.1%). A considerable proportion was either dissatisfied ( n = 61, 50%) or frankly unhappy ( n = 38, 31.4%) with treatment received. CONCLUSION There is a need to re-calibrate the clinical approach to people with MUPS to enhance treatment satisfaction. Our findings could assist in evolving culturally sensitive conceptualizations of illness and in developing patient-centred models for therapy in MUPS patients.
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Affiliation(s)
- Vikas Menon
- 1 Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Balasubramanian Shanmuganathan
- 1 Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Anand Babu Arun
- 1 Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Jaiganesh Selvapandian Thamizh
- 1 Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Nivedhitha Selvakumar
- 1 Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Siddharth Sarkar
- 2 Department of Psychiatry, National Drug Dependence and Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
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Eikelboom EM, Tak LM, Roest AM, Rosmalen JGM. A systematic review and meta-analysis of the percentage of revised diagnoses in functional somatic symptoms. J Psychosom Res 2016; 88:60-67. [PMID: 27455914 DOI: 10.1016/j.jpsychores.2016.07.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Revised: 06/29/2016] [Accepted: 07/03/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND Functional somatic symptoms (FSS) are bodily complaints of unclear etiology, which are (currently) not fully explained by well-recognized somatic pathology. Doctors are often hesitant to diagnose FSS, due to the risk to miss a somatic disease. The purpose of this study is to review available literature on the percentage of patients diagnosed with FSS reported to have an underlying somatic disease that explains their symptoms previously labeled as FSS. METHODS We performed a systematic search of Medline, Embase and PsycINFO databases and reference lists of selected articles. We included studies published between January 1980 and July 2014 without language restrictions. Studies that measured the percentage of underlying somatic diseases after a diagnostic evaluation or naturalistic follow-up period in adult patients initially diagnosed with FSS were included. As primary outcome measure the weighted percentage of revised diagnoses was calculated using meta-analyses. RESULTS Six diagnostic evaluation studies (total N=1804 patients) and 16 follow-up studies (total N=2440 patients) were included. The percentage of revised diagnosis in patients initially diagnosed with FSS was 8.8% (95% CI 1.0 to 22.2, p=0.007) in diagnostic evaluation studies and 0.5% (95% CI 0.01 to 1.5, p=0.03) in follow-up studies. Partially or possibly related diagnoses were rarely found. No specific somatic diagnosis seemed to be missed systematically. CONCLUSIONS The percentage of underlying somatic diseases in patients previously diagnosed with FSS is relatively small but unneglectable.
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Affiliation(s)
- E M Eikelboom
- University of Groningen, University Medical Center Groningen, Interdisciplinary Center Psychopathology and Emotion regulation, P.O. Box 30.001, 9700 RB Groningen, The Netherlands.
| | - L M Tak
- University of Groningen, University Medical Center Groningen, Interdisciplinary Center Psychopathology and Emotion regulation, P.O. Box 30.001, 9700 RB Groningen, The Netherlands; Dimence, Institute for Mental Health Care. P.O. Box 5003, 7400 GC Deventer, The Netherlands.
| | - A M Roest
- University of Groningen, University Medical Center Groningen, Interdisciplinary Center Psychopathology and Emotion regulation, P.O. Box 30.001, 9700 RB Groningen, The Netherlands.
| | - J G M Rosmalen
- University of Groningen, University Medical Center Groningen, Interdisciplinary Center Psychopathology and Emotion regulation, P.O. Box 30.001, 9700 RB Groningen, The Netherlands.
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Taylor SJC, Carnes D, Homer K, Pincus T, Kahan BC, Hounsome N, Eldridge S, Spencer A, Diaz-Ordaz K, Rahman A, Mars TS, Foell J, Griffiths CJ, Underwood MR. Improving the self-management of chronic pain: COping with persistent Pain, Effectiveness Research in Self-management (COPERS). PROGRAMME GRANTS FOR APPLIED RESEARCH 2016. [DOI: 10.3310/pgfar04140] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BackgroundChronic musculoskeletal pain is a common problem that is difficult to treat. Self-management support interventions may help people to manage this condition better; however, there is limited evidence showing that they improve clinical outcomes. Our overarching research question was ‘Does a self-management support programme improve outcomes for people living with chronic musculoskeletal pain?’.AimTo develop, evaluate and test the clinical effectiveness and cost-effectiveness of a theoretically grounded self-management support intervention for people living with chronic musculoskeletal pain.MethodsIn phase 1 we carried out two systematic reviews to synthesise the evidence base for self-management course content and delivery styles likely to help those with chronic pain. We also considered the psychological theories that might underpin behaviour change and pain management principles. Informed by these data we developed the Coping with persistent Pain, Evaluation Research in Self-management (COPERS) intervention, a group intervention delivered over 3 days with a top-up session after 2 weeks. It was led by two trained facilitators: a health-care professional and a layperson with experience of chronic pain. To ensure that we measured the most appropriate outcomes we reviewed the literature on potential outcome domains and measures and consulted widely with patients, tutors and experts. In a feasibility study we demonstrated that we could deliver the COPERS intervention in English and, to increase the generalisability of our findings, also in Sylheti for the Bangladeshi community. In phase 2 we ran a randomised controlled trial to test the clinical effectiveness and cost-effectiveness of adding the COPERS intervention to a best usual care package (usual care plus a relaxation CD and a pain toolkit leaflet). We recruited adults with chronic musculoskeletal pain largely from primary care and musculoskeletal physiotherapy services in two localities: east London and Coventry/Warwickshire. We collected follow-up data at 12 weeks (self-efficacy only) and 6 and 12 months. Our primary outcome was pain-related disability (Chronic Pain Grade disability subscale) at 12 months. We also measured costs, health utility (European Quality of Life-5 Dimensions), anxiety, depression [Hospital Anxiety and Depression Scale (HADS)], coping, pain acceptance and social integration. Data on the use of NHS services by participants were extracted from NHS electronic records.ResultsWe recruited 703 participants with a mean age of 60 years (range 19–94 years); 81% were white and 67% were female. Depression and anxiety symptoms were common, with mean HADS depression and anxiety scores of 7.4 [standard deviation (SD) 4.1] and 9.2 (SD 4.6), respectively. Intervention participants received 85% of the course content. At 12 months there was no difference between treatment groups in our primary outcome of pain-related disability [difference –1.0 intervention vs. control, 95% confidence interval (CI) –4.9 to 3.0]. However, self-efficacy, anxiety, depression, pain acceptance and social integration all improved more in the intervention group at 6 months. At 1 year these differences remained for depression (–0.7, 95% CI –1.2 to –0.2) and social integration (0.8, 95% CI, 0.4 to 1.2). The COPERS intervention had a high probability (87%) of being cost-effective compared with usual care at a threshold of £30,000 per quality-adjusted life-year.ConclusionsAlthough the COPERS intervention did not affect our primary outcome of pain-related disability, it improved psychological well-being and is likely to be cost-effective according to current National Institute for Health and Care Excellence criteria. The COPERS intervention could be used as a substitute for less well-evidenced (and more expensive) pain self-management programmes. Effective interventions to improve hard outcomes in chronic pain patients, such as disability, are still needed.Trial registrationCurrent Controlled Trials ISRCTN22714229.FundingThe project was funded by the National Institute for Health Research Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 14. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Stephanie JC Taylor
- Centre for Primary Care and Public Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Dawn Carnes
- Centre for Primary Care and Public Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Kate Homer
- Centre for Primary Care and Public Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Tamar Pincus
- Department of Psychology, Royal Holloway University of London, Egham, UK
| | - Brennan C Kahan
- Centre for Primary Care and Public Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Natalia Hounsome
- Centre for Primary Care and Public Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Sandra Eldridge
- Centre for Primary Care and Public Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Anne Spencer
- Exeter Medical School, University of Exeter, Exeter, UK
| | - Karla Diaz-Ordaz
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Anisur Rahman
- Department of Rheumatology, University College Hospital, University College London, London, UK
| | - Tom S Mars
- Centre for Primary Care and Public Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Jens Foell
- Centre for Primary Care and Public Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Chris J Griffiths
- Centre for Primary Care and Public Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Martin R Underwood
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
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Hirsikangas S, Kanste O, Korpelainen J, Kyngäs H. Adherence to health regimens among frequent attenders of Finnish healthcare. Int J Circumpolar Health 2016; 75:30726. [PMID: 26996780 PMCID: PMC4800284 DOI: 10.3402/ijch.v75.30726] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 02/11/2016] [Accepted: 02/19/2016] [Indexed: 11/26/2022] Open
Abstract
Objectives The aim of the study was to describe adherence to health regimens and the factors associated with it among adult frequent attenders (FAs). Design This was a cross-sectional study. The study sample consisted of 462 healthcare FAs in 7 municipal health centres in northern Finland. An FA is a person who has had 8 or more outpatient visits to a GP (in a health centre) or 4 or more outpatient visits to a university hospital during 1 year. The main outcome was self-reported adherence to health regimens. Results Of the FAs, 82% adhered well to their health regimens. Carrying out self-care, medical care and feeling responsible for self-care were the most significant predictors to good adherence in all models. No significant differences in adherence were found in male and female subjects, age groups or educational levels. Support from healthcare providers and support from relatives were not significant predictors of good adherence. Conclusion FAs in Finland adhere well to health regimens and exceptionally well to medication. Variables that predict the best adherence of FAs to health regimens are carrying out self-care, receiving medical care and feeling responsible for self-care.
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Affiliation(s)
| | - Outi Kanste
- National Institute for Health and Welfare, Oulu, Finland
| | - Juha Korpelainen
- Medical Research Center Oulu, Oulu University Hospital, Oulu, Finland
| | - Helvi Kyngäs
- Research Group of Nursing Science and Health Management, University of Oulu, Oulu, Finland.,Northern Ostrobothnia Hospital District, Finland
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Hubley S, Uebelacker L, Eaton C. Managing Medically Unexplained Symptoms in Primary Care: A Narrative Review and Treatment Recommendations. Am J Lifestyle Med 2016; 10:109-119. [PMID: 30202265 PMCID: PMC6125096 DOI: 10.1177/1559827614536865] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 02/17/2014] [Accepted: 03/07/2014] [Indexed: 11/17/2022] Open
Abstract
Medically unexplained symptoms (MUS) are persistent physical symptoms in the absence of identifiable disease. MUS present a major challenge for primary care providers (PCPs) because complex symptom presentations, strained patient-physician relationships, and treatment-resistant symptoms can challenge a PCP's sense of competency. This review is intended to help PCPs understand the burden and theoretical context of MUS and to provide concise recommendations for managing MUS within primary care settings. Based on a narrative review of the literature, these recommendations emphasize in particular the importance of co-creating plausible explanations for MUS, understanding the pitfalls of consultations involving MUS, and developing multimodal treatment plans.
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Affiliation(s)
- Sam Hubley
- Alpert Medical School of Brown University, Center for Primary Care and Prevention, Memorial Hospital of Rhode Island and Brown University, Pawtucket, Rhode Island
| | - Lisa Uebelacker
- Alpert Medical School of Brown University, Center for Primary Care and Prevention, Memorial Hospital of Rhode Island and Brown University, Pawtucket, Rhode Island
| | - Charles Eaton
- Alpert Medical School of Brown University, Center for Primary Care and Prevention, Memorial Hospital of Rhode Island and Brown University, Pawtucket, Rhode Island
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Murray AM, Toussaint A, Althaus A, Löwe B. The challenge of diagnosing non-specific, functional, and somatoform disorders: A systematic review of barriers to diagnosis in primary care. J Psychosom Res 2016; 80:1-10. [PMID: 26721541 DOI: 10.1016/j.jpsychores.2015.11.002] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 11/05/2015] [Accepted: 11/06/2015] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Alexandra M Murray
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf & University Hospital of Psychosomatic Medicine and Psychotherapy, Schön Clinic Hamburg Eilbek, Germany.
| | - Anne Toussaint
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf & University Hospital of Psychosomatic Medicine and Psychotherapy, Schön Clinic Hamburg Eilbek, Germany
| | - Astrid Althaus
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf & University Hospital of Psychosomatic Medicine and Psychotherapy, Schön Clinic Hamburg Eilbek, Germany
| | - Bernd Löwe
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf & University Hospital of Psychosomatic Medicine and Psychotherapy, Schön Clinic Hamburg Eilbek, Germany
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Yon K, Nettleton S, Walters K, Lamahewa K, Buszewicz M. Junior doctors' experiences of managing patients with medically unexplained symptoms: a qualitative study. BMJ Open 2015; 5:e009593. [PMID: 26628528 PMCID: PMC4679901 DOI: 10.1136/bmjopen-2015-009593] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To explore junior doctors' knowledge about and experiences of managing patients with medically unexplained symptoms (MUS) and to seek their recommendations for improved future training on this important topic about which they currently receive little education. DESIGN Qualitative study using in-depth interviews analysed using the framework method. SETTING Participants were recruited from three North Thames London hospitals within the UK. PARTICIPANTS Twenty-two junior doctors undertaking the UK foundation two-year training programme (FY1/FY2). RESULTS The junior doctors interviewed identified a significant gap in their training on the topic of MUS, particularly in relation to their awareness of the topic, the appropriate level of investigations, possible psychological comorbidities, the formulation of suitable explanations for patients' symptoms and longer term management strategies. Many junior doctors expressed feelings of anxiety, frustration and a self-perceived lack of competency in this area, and spoke of over-investigating patients or avoiding patient contact altogether due to the challenging nature of MUS and a difficulty in managing the accompanying uncertainty. They also identified the negative attitudes of some senior clinicians and potential role models towards patients with MUS as a factor contributing to their own attitudes and management choices. Most reported a need for more training during the foundation years, and recommended interactive case-based group discussions with a focus on providing meaningful explanations to patients for their symptoms. CONCLUSIONS There is an urgent need to improve postgraduate training about the topics of MUS and avoiding over-investigation, as current training does not equip junior doctors with the necessary knowledge and skills to effectively and confidently manage patients in these areas. Training needs to focus on practical skill development to increase clinical knowledge in areas such as delivering suitable explanations, and to incorporate individual management strategies to help junior doctors tolerate the uncertainty associated with MUS.
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Affiliation(s)
- Katherine Yon
- Research Department of Primary Care & Population Health, UCL, London, UK
| | | | - Kate Walters
- Research Department of Primary Care & Population Health, UCL, London, UK
| | - Kethakie Lamahewa
- Research Department of Primary Care & Population Health, UCL, London, UK
| | - Marta Buszewicz
- Research Department of Primary Care & Population Health, UCL, London, UK
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Lian OS, Hansen AH. Factors facilitating patient satisfaction among women with medically unexplained long-term fatigue: A relational perspective. Health (London) 2015; 20:308-26. [DOI: 10.1177/1363459315583158] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Bodily conditions that are difficult to identify, explain and treat with the aid of medical knowledge and technology appear to be particularly challenging to medical encounters. Patients are often dissatisfied with the help they receive, and they often experience that their medical needs are not met. To explore factors facilitating patient satisfaction among patients with a medically unexplained condition, we ask: what is the importance of individual versus relational factors in facilitating patient satisfaction in clinical encounters between general practitioners (GPs) and women with medically unexplained long-term fatigue? We approach this question through a statistical analysis of survey data collected from a net sample of 431 women recruited through a patient organisation for people suffering from myalgic encephalomyelitis in 2013. Participants were asked about their experiences with general practitioners in the Norwegian national health system in two different phases: shortly after illness onset, and current regular general practitioner last 12 months. The questions evolved around themes concerning shared understanding and decision making, being taken seriously, being paid due respect and being treated as an equal partner. Through descriptive statistics and multivariable logistic regression analyses, we explored how their experiences were related to individual and relational factors, respectively. Free-text comments from the questionnaires were used while interpreting the results. The analysis illuminates that relational aspects in medical encounters between GPs and ME patients, especially continuity, congruence in doctor–patient views and being seen by a specialist, are important catalysts of patient satisfaction. The probability of being satisfied with the initial investigation was more than six times higher in women who were referred to specialists, compared to those who were not. We conclude that continuity of care and experiences of being in a partnership that operates on a common ground – a shared understanding of the patient’s illness – foster patient satisfaction among women with medically unexplained long-term fatigue.
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Affiliation(s)
- Olaug S Lian
- University of Tromsø – The Arctic University of Norway, Norway
| | - Anne Helen Hansen
- University of Tromsø – The Arctic University of Norway, Norway; University Hospital of North Norway, Norway
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Hagiwara N, Kashy DA, Penner LA. A novel analytical strategy for patient-physician communication research: the one-with-many design. PATIENT EDUCATION AND COUNSELING 2014; 95:325-331. [PMID: 24746894 PMCID: PMC4107636 DOI: 10.1016/j.pec.2014.03.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 03/19/2014] [Accepted: 03/23/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE We aimed to demonstrate how a novel analytic strategy - the one-with-many (OWM) design - can provide unique information about patient-physician communication that cannot be obtained using traditional analytic strategies. METHODS Using an OWM design we conducted a secondary analysis of behavioral (talk time) and self-reported (perceived teamness) data from a study of patient-physician communication, and examined variance decompositions of these variables. RESULTS Talk time was largely relational, suggesting that there is no behavioral consistency on the part of physicians across patients or behavioral similarity among patients who see the same physician. In contrast, there was significant actor variance in perceived teamness, suggesting that some physicians consistently reported higher teamness with their patients than others. However, those physicians' positive perceptions of the communication are not necessarily reciprocated by their patients. CONCLUSIONS OWM design provides researchers with the opportunity to take full advantage of rich non-independent data and explore interesting communication patterns (e.g., behavioral continuity, similarity, reciprocity unique to specific dyads) that have been omitted in prior literature. PRACTICAL IMPLICATIONS OWM can be used to determine the relative differences in how patients and physicians influence communication patterns and identify which aspects of physician-patient communication are relational and which are not.
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Affiliation(s)
- Nao Hagiwara
- Virginia Commonwealth University, Department of Psychology, Richmond, USA.
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Aamland A, Malterud K, Werner EL. Patients with persistent medically unexplained physical symptoms: a descriptive study from Norwegian general practice. BMC FAMILY PRACTICE 2014; 15:107. [PMID: 24885524 PMCID: PMC4041895 DOI: 10.1186/1471-2296-15-107] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 05/19/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND Further research on effective interventions for patients with peristent Medically Unexplained Physical Symptoms (MUPS) in general practice is needed. Prevalence estimates of such patients are conflicting, and other descriptive knowledge is needed for development and evaluation of effective future interventions. In this study, we aimed to estimate the consultation prevalence of patients with persistent MUPS in general practice, including patients' characteristics and symptom pattern, employment status and use of social benefits, and the general practitioners' (GPs) management strategy. METHOD During a four-week period the participating Norwegian GPs (n=84) registered all consultations with patients who met a strict definition of MUPS (>3 months duration and function loss), using a questionnaire with simple tick-off questions. Analyses were performed with descriptive statistics for all variables and split analysis on gender and age. RESULTS The GPs registered 526 patients among their total of 17 688 consultations, giving a consultation prevalence of persistent MUPS of 3%. The mean age of patients was 46 years, and 399 (76%) were women. The most frequent group of symptoms was musculoskeletal problems, followed by asthenia/fatigue. There was no significant gender difference in symptom pattern. Almost half of the patients were currently working (45%), significantly more men. The major GP management strategy was supportive counseling. CONCLUSION A consultation prevalence rate of 3% implies that patients with persistent MUPS are common in general practice. Our study disclosed heterogeneity among the patients such as differences in employment status, which emphasizes the importance of personalized focus rather than unsubstantiated stereotyping of "MUPS patients" as a group.
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Affiliation(s)
- Aase Aamland
- Research Unit for General Practice, Uni Research Health Bergen, Kalfarveien 31, N-5018 Bergen, Norway.
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Butalid L, Bensing JM, Verhaak PFM. Talking about psychosocial problems: an observational study on changes in doctor-patient communication in general practice between 1977 and 2008. PATIENT EDUCATION AND COUNSELING 2014; 94:314-321. [PMID: 24360508 DOI: 10.1016/j.pec.2013.11.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Revised: 10/31/2013] [Accepted: 11/19/2013] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To examine whether GPs' communication styles have changed since the introduction and implementation of clinical guidelines for psychosocial problems in Dutch general practice in the 1990s. METHODS From a database of 5184 consultations videotaped between 1977 and 2008, 512 consultations assessed by GPs as 'completely psychosocial' were coded with RIAS (Roter Interaction Analysis System). The 121 consultations prior to and 391 consultations after implementation of guidelines were analyzed whether communication styles have changed over time. RESULTS We found that GPs were more likely to consider consultations to be mainly (17%) or completely (12%) psychosocial after the implementation of guidelines. They gave more biomedical and psychosocial information and advice in the second period compared to the first period. We also found that empathy decreased over time (frequency of empathic statements by GPs changed from 2.9-3.2 to 1.4-1.6 between periods). CONCLUSION Communication in psychosocial consultations has changed; GPs have become more focused on task-oriented communication (asking questions, giving information and advice) and less on showing empathy. PRACTICE IMPLICATIONS GPs face the challenge of integrating an evidence-based approach of applying guidelines that promote active symptom exploration with understanding patients' personal contexts and giving room to their emotions.
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Affiliation(s)
- Ligaya Butalid
- NIVEL, Netherlands Institute for Health Services Research, The Netherlands.
| | - Jozien M Bensing
- NIVEL, Netherlands Institute for Health Services Research, The Netherlands; Department of Psychology, Faculty of Social and Behavioural Sciences, Utrecht University, The Netherlands
| | - Peter F M Verhaak
- NIVEL, Netherlands Institute for Health Services Research, The Netherlands; Department of General Practice, Faculty of Medical Sciences, University of Groningen, The Netherlands
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Abstract
There is one concept in medicine which is prominent, the symptom. The omnipresence of the symptom seems, however, not to be reflected by an equally prominent curiosity aimed at investigating this concept as a phenomenon. In classic, traditional or conventional medical diagnostics and treatment, the lack of distinction with respect to the symptom represents a minor problem. Faced with enigmatic conditions and their accompanying labels such as chronic fatigue syndrome, fibromyalgia, medically unexplained symptoms, and functional somatic syndromes, the contestation of the symptom and its origin is immediate and obvious and calls for further exploration. Based on a description of the diagnostic framework encompassing medically unexplained conditions and a brief introduction to how such symptoms are managed both within and outside of the medical clinic, we argue on one hand how unexplained conditions invite us to reconsider and re-think the concept we call a "symptom" and on the other hand how the concept "symptom" is no longer an adequate and necessary fulcrum and must be enriched by socio-cultural, phenomenological and existential dimensions. Consequently, our main aim is to expand both our interpretative horizon and the linguistic repertoire in the face of those appearances we label medically unexplained symptoms.
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Affiliation(s)
- Thor Eirik Eriksen
- Department of Occupational and Environmental Medicine, University Hospital of North Norway, Box 6060, 9038, Tromsø, Norway,
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