What's 'difficult'? A multi-stage qualitative analysis of secondary care specialists' experiences with medically unexplained symptoms

The role of the working alliance in improving outcomes among veterans with Gulf War Illness: a longitudinal study

Military Veterans with Gulf War Illness (GWI), a "medically unexplained" persistent physical syndrome (PPS), have difficult experiences of care, in part, due to non-concordant relationships with their healthcare providers. A critical factor in improving care for this population may be the working alliance, which is the extent to which patients and providers agree on the goals and tasks of treatment and have a shared bond. The present study examined if, for Veterans with GWI, perceptions of the working alliance over time predicted better experiences of care (i.e., patient satisfaction and treatment adherence) and improved health outcomes (i.e., reduced disability, depression symptoms, and physical symptoms). Positive Veteran perceptions of the working alliance at 4 weeks were related to better patient satisfaction and treatment adherence at 12 weeks. Veteran perceptions of the working alliance were not consistently related to reductions in disability, depression symptoms, or physical symptoms. The results of this study suggest that the working alliance is important for improving patient experiences of care but may not be sufficient to consistently impact health outcomes.

Healthcare professionals' views on factors influencing persistent somatic symptoms - ARISE-HCP online survey across countries

OBJECTIVE

The Health Care Online Survey Europe-Healthcare Professionals (ARISE-HCP) cross-sectionally investigated healthcare professionals' (HCPs) views on healthcare factors influencing the symptom course of persistent somatic symptoms (PSS) across four European countries.

METHODS

An online survey was developed for HCPs experienced in PSS care in Germany, Italy, Poland, and the Netherlands. The study employed a mixed-methods approach. Quantitatively, it assessed HCPs' perspectives on training, tools, and consultation times. Qualitatively, it explored their perceptions of healthcare-related factors influencing the PSS symptom course and systemic barriers encountered in treatment and diagnosis.

RESULTS

Overall, 258 HCPs participated: 152 from the Netherlands, 46 from Germany, 30 from Italy, and 30 from Poland (67% female, mean age = 47.68 ± 11.64 years). HCPs' views on PSS training, tool adequacy, and consultation time sufficiency differed significantly. Regarding symptom persistence and deterioration, HCPs from Italy and Poland highlighted access-related issues, whereas German and Dutch HCPs focused on care implementation. Across all countries, interdisciplinary collaboration was mentioned as important for symptom improvement. A more holistic approach was advocated, emphasizing the need for comprehensive PSS-focused training and the integration of these practices in care delivery, service coordination, and patient engagement.

CONCLUSION

Healthcare factors associated with the course of PSS and systemic treatment and diagnosis barriers varied across different countries, highlighting the importance of considering country-specific factors in managing PSS. Taking tailored measures to enhance multidisciplinary collaboration and HCP education is essential for improving patient outcomes, and sharing knowledge about effective healthcare practices across countries can improve patient care. Future research should focus on identifying systemic barriers to optimal care and developing country-specific interventions.

Stigmatisation in medical encounters for persistent physical symptoms/functional disorders: Scoping review and thematic synthesis

OBJECTIVE

To conduct a scoping review of stigma in medical encounters for persistent physical symptoms and functional disorders (PPS/FD). Stigma is a social attribute that links a person to an undesirable characteristic. It has been extensively studied in relation to mental illness but less so in relation to PPS/FD.

METHODS

We followed PRISMA-ScR reporting guidelines for scoping reviews. Searches for were designed using the SPIDER tool. We used descriptive and thematic analysis.

RESULTS

The searches identified 68 articles, of which 32 were eligible for inclusion. 31 out of the 32 studies used a qualitative methodology. 8 studies used an explicit definition of stigma, of which 6 used the Goffman (1963) definition. Only 2 studies directly examined clinical consultations, the remainder relied on recalled accounts by patients or professionals. Descriptive analysis identified the focus of the studies included: patient-physician interaction (n = 13); health care professionals' perceptions (n = 7); experiences of illness/stigma (n = 6); broader meaning of illness (n = 3); and patients' experiences of stigma in health care consultations (n = 3).

CONCLUSION

Patients experience stigmatisation in consultations for a wide range of PPS/FD. This suggests the presence of structural stigmatisation.

PRACTICE IMPLICATIONS

There is a need for effective stigma reduction strategies in consultations about persistent physical symptoms.

Characteristics of collaborative care networks in functional disorders: A systematic review

OBJECTIVE

Functional disorders (FD) are complex conditions, for which multidisciplinary involvement is often recommended. Collaborative care networks (CCN) may unlock the potential of the multidisciplinary team (MDT) in FD care. To understand what characteristics should be part of CCNs in FD, we studied the composition and characteristics of existing CCNs in FD.

METHODS

We performed a systematic review following PRISMA guidelines. A search of PubMed, WebofScience, PsycInfo, SocINDEX, AMED and CINAHL was undertaken to select studies describing CCNs in FD. Two reviewers extracted characteristics of the different CCNs. Characteristics were classified as relating to structure and processes of networks.

RESULTS

A total of 62 studies were identified representing 39 CCNs across 11 countries. Regarding structural characteristics, we found that most networks are outpatient, secondary-care based, with teams of between two and 19 members. Medical specialists were most commonly involved and the typical team leads as well as main patient contacts were general practitioners (GPs) or nurses. Regarding processes, collaboration was demonstrated mostly during assessment, management and patient education, less often during rehabilitation and follow-up, mostly using MDT meetings. CCNs provided a wide range of treatment modalities, reflecting a biopsychosocial approach, including psychological therapies, physiotherapy and social and occupational therapy.

CONCLUSION

CCNs for FD are heterogeneous, showing a wide variety of structures as well as processes. The heterogeneity of results provides a broad framework, demonstrating considerable variation in how this framework is applied in different contexts. Better development of network evaluation, as well as professional collaboration and education processes is needed.

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

Fibromyalgia remains a difficult condition to diagnose and treat. Research suggests that this leads to frustrating experiences for service users and healthcare professionals. This has led to negative healthcare professional attitudes towards working with those with fibromyalgia. The research to date reports negative attitudes and predominantly investigates attitudes of primary care physicians. This study explores the attitudes of a range of healthcare professionals towards those diagnosed with fibromyalgia. Using Q-methodology, 27 healthcare professionals completed a sorting task and questionnaire to prioritise statements relating to a range of different attitudes towards service users. All participants significantly loaded onto three factors that explained a total of 64% of the data variance. Factor 1 reflected the attitude 'Service users with fibromyalgia are no different to other service users and I enjoy working with them'. Factor 2 reflected the attitude 'Service users with fibromyalgia are inaccurate informants of their own condition due to lack of understanding of their condition and are not likely to engage in treatments'. Factor 3 reflected the attitude 'Service users with fibromyalgia are trustworthy with a lot of clinical problems [but I lack confidence in specialist skills to support them]'. Contrary to the current literature, there appears to be supportive attitudes from healthcare professionals towards service users diagnosed with fibromyalgia. Increased specialised training, clinical exposure to working with fibromyalgia and reflective practice spaces were identified as elements that could improve healthcare professional attitudes.

[In the final analysis, who is "problematic"? An integrative review of patients, physicians and problematic relationships]

The scope of this study was to assess the literature on the characteristics of patients, physicians, and physician-patient relationships considered 'problematic.' An integrative review of primary studies published between January 1, 2016, and September 30, 2021, in Portuguese, English and Spanish was conducted, Of the 3,414 papers identified in the PubMed, Embase, Scopus and Lilacs databases, 19 were selected for qualitative analysis. Seven studies were carried out in Europe, eight in North America, two in South America and two in China, totaling 1,694 patients, 1,903 assistant physicians, 101 residents and 160 medical academics. Physicians and academics considered the following to be problematic: patients with clinical conditions such as psychosomatic and chronic illnesses; symptoms and complaints such as pain; powerful emotions; problems in obtaining and sharing information, in decision-making, in the adherence to the therapeutic plan and in their self-care; and some sociodemographic and vulnerability characteristics. Among other aspects, patients, or their relatives, considered physicians to be problematic when they did not listen to them or appear to care about their children, Teaching medical communication and systemic interventions are recommended to improve physician-patient relationships.

Medical educators' experiences on medically unexplained symptoms and intercultural communication-an expert focus group study

BACKGROUND

Medically unexplained symptoms (MUS) are highly prevalent and remain challenging in healthcare and medical education, along with the increase in the importance of intercultural issues regarding MUS. However, less is known about the challenges of professionally addressing patients with MUS in the interprofessional and intercultural contexts. Thus, the present study aims to provide the first exploration of the experiences of medical specialists regarding treating MUS in intercultural contexts and inputs for training development on the intercultural aspects of MUS.

METHODS

Three focus groups (total n = 13) consisting of medical specialists from a Hungarian university who were teaching at the medical faculty in intercultural settings and also worked for the university health services were interviewed. The topics covered the participants' personal experiences on addressing MUS and the challenges of intercultural communication and the intercultural educational context. Thematic analysis was used to yield a qualitative account of the interviews as guided by the research questions.

RESULTS

Representing the different aspects of medical specialists, the study identified three main themes in the experiences of medical specialists, namely, 1) the need to adapt to the personal world of patients and search for common frames to understand MUS, 2) the need to discover methods for adapting to cultural differences and 3) the need to enhance the interprofessional coordination of knowledge and practices.

CONCLUSIONS

The results are in line with the distinct conclusions of previous studies. Moreover, an integrated educational program on the intercultural aspects of MUS may address the main themes separately and, subsequently, support their integration. Therefore, the study discusses the manner in which an integrated educational program on the intercultural aspects of MUS may address the needs recognized in these aspects.

Development and User Experiences of a Biopsychosocial Interprofessional Online Course on Persistent Somatic Symptoms

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.

Rebuilding a tolerable life: narratives of women recovered from fibromyalgia

Introduction: Fibromyalgia syndrome (FMS) is a chronic musculoskeletal pain and fatigue condition. Despite extensive research, there is currently no known therapy leading to a cure for FMS. Although studies have reported that some patients can regain their health, little is known about their personal process of becoming well.Objevtive: This study aimed to explore women's narratives about the process of recovering from FMS.Methods: The empirical material consists of qualitative interviews of eight Norwegian women who all have previously had, but do not have FMS any more. Inspired by a narrative approach we analyzed their experiences of becoming better with a focus on recovery as a meaning-making process.Results: The findings revealed a recovery process consisting of two intertwined narratives that are mutually nurturing each other. The first narrative telling moments of prompting changes refers to events during the recovery process where women understood themselves and their suffering in new ways and thereby enabled them to act in new ways or take further action. The second narrative a mundane process of rebuilding a tolerable daily life refers to a lasting, mundane everyday process of exploration how they initially should act to avoid becoming worse and, later, to promote improvement.Conclusion: Our findings show how the women explain their recovery in terms of overcoming fear of movement, making sense of their symptoms and becoming more active in everyday life. The close analysis reveals a recovery narrative portraying a complex and ambiguous process consisting of small dramas about the efforts trying to rebuild a meaningful life.

Emerging models for successful treatment of complex regional pain syndrome in children and young adults

Complex regional pain syndrome (CRPS) is a relatively common condition that is often not well recognised or treated adequately. Patients are usually referred to multidisciplinary pain services, but outcomes remain variable. This case report describes a recent patient with CRPS who was treated quickly and effectively through a simple explanation of the relationship between mind and body, and who then was able to modify her own thought processes and behaviours. This single intervention enabled a complete resolution of symptoms. This report illustrates the clinical application of recent insights into neuroplasticity and individually tailored patient self-management that may now offer successful treatment of an otherwise chronic and disabling condition, especially in younger patients. There are implications for doctors in current practice, as well as for the training of medical students and junior doctors.

Identifying subgroups based on self-management skills in primary care patients with moderate medically unexplained physical symptoms

OBJECTIVE

Medically Unexplained Physical Symptoms (MUPS) are a major burden on both patients and society and frequently develop into chronic MUPS. Self-management interventions may prevent moderate MUPS from becoming chronic. Tailoring interventions to the patient population is strongly recommended. This can be facilitated by identifying subgroups based on self-management skills. This study aimed to identify these subgroups and their clinical profiles in primary care patients with moderate MUPS.

METHODS

A cross-sectional study was performed on baseline measurements from a randomized clinical trial (PARASOL-study). To identify subgroups based on self-management skills, a hierarchical cluster analysis was conducted for adults with moderate MUPS from primary health care centers. Self-management skills were measured with the Health education impact Questionnaire. Cluster variables were seven constructs of this questionnaire. Additionally, specific patient profiles were determined by comparing the identified clusters on the clinical variables pain, fatigue and physical functioning.

RESULTS

Four subgroups were identified: High-Self-Management Skills (SMS) (n = 29), Medium-SMS (n = 55), Low-SMS (n = 49) and Active & Low Distress-SMS (n = 20). The latter showed a distinctly different pattern on cluster variables, while the other subgroups differed significantly on means of the cluster variables (p < .001). On clinical variables, significant differences between subgroups were mainly found on fatigue and physical functioning.

CONCLUSION

This study found four specific subgroups based on self-management skills in moderate MUPS-patients. One subgroup demonstrated a distinctly different pattern on self-management skills. In other subgroups, more similar patterns on self-management skills were found that negatively correlated with pain and fatigue and positively correlated with physical functioning.

Helpful ways providers can communicate about persistent medically unexplained physical symptoms

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.

'If it's a medical issue I would have covered it by now': learning about fibromyalgia through the hidden curriculum: a qualitative study

BACKGROUND

Fibromyalgia syndrome (FMS) is a long-term condition that affects between 1 and 5% of the general population and lies within the spectrum of medically unexplained symptoms (MUS). FMS can be difficult to diagnose and is usually done so as a diagnosis of exclusion. There is continuing debate regarding its legitimacy excluding other causes of symptoms. It is known that the diagnosis and management of MUS, including FMS, receives little attention in medical curricula and attitudes towards patients with FMS amongst medical professionals and trainees can be negative. The purpose of this study was to investigate how attitudes and perspectives of undergraduate medical students towards FMS are acquired during their training.

METHODS

Qualitative interviews with 21 medical students were conducted to explore their views on FMS, encounters with patients with FMS, and where learning about FMS occurs. Participants were recruited from two English medical schools and the study was approved by two University Ethics committees. Interviews were digitally recorded with consent and data analysed thematically, using principles of constant comparison.

RESULTS

The data were organised within three themes: i) FMS is a complex, poorly understood condition; ii) multiple sources for learning about FMS; and iii) consequences of negative attitudes for patients with FMS.

CONCLUSION

Undergraduate medical students have limited understanding of, and are sceptical over the existence of FMS. These attitudes are influenced by the 'hidden curriculum' and witnessing attitudes and actions of their clinical teachers. Students interpret a lack of formal curriculum teaching around FMS to mean that it is not serious and hence a low priority. Encountering a patient, friend or family member with FMS can increase knowledge and lead to altered perceptions of the condition. Teaching and learning about FMS needs to be consistent to improve knowledge and attitudes of clinicians. Undergraduate students should be exposed to patients with FMS so that they better understand patients with FMS.

Clinical features of outpatients with somatization symptoms treated at a Japanese psychosomatic medicine clinic

Background

Somatization is produced due to the summation of psychological factors, irrespective of the presence or absence of physical factors. A group of diseases with severe pain and other disorders exhibit so-called Medically Unexplained Symptoms (MUS), and the characteristics of patients with MUS are largely unexplained. In this paper, the characteristics of a series of new patients with somatization treated in a Japanese university hospital are discussed.

Method

The subjects were 871 patients who newly visited the Department of Psychosomatic Medicine, Toho University Omori Medical Center between January and December of 2015. Under the assumption that the definition of somatization is same as that of MUS, the correlation between somatization and the age, sex, academic background, chief complaints, reasons for visiting the medical center, diagnosis, symptoms, presence or absence of a referral form, continued treatment after the first visit, and marital status of these patients at the time of their respective examinations were evaluated.

Results

Of the patients studied, 68% suffered from somatization. Among them, 11% met the definition of Functional Somatic Symptoms (FSS) and 74% had somatization associated with mood disorder or anxiety disorder. Digestive symptoms were reported by 33%, headaches by 24%, and unusual sensations by 21%. Whereas no correlation was found between somatization symptoms and the patients’ academic background, marital history, or medical history after the first visit, a positive correlation (p < 0.05) was found between somatization and patients who had been referred by their doctor.

Conclusion

Many of the studied patients who suffered from somatization, regardless of age and sex, were referred to us by doctors from other hospitals. It was concluded that many patients difficult to diagnose or deal with are referred the Department of Psychosomatic Medicine of Japanese university hospitals, thus these hospitals must assume great responsibility for preventing mistaken diagnoses by conducting effective psychological treatment and thorough medical examinations.

A window into living with an undiagnosed disease: illness narratives from the Undiagnosed Diseases Network

BACKGROUND

Patients' stories of their illnesses help bridge the divide between patients and providers, facilitating more humane medical care. Illness narratives have been classified into three types: restitution (expectation of recovery), chaos (suffering and loss), and quest (unexpected positive effect from illness). Undiagnosed patients have unique illness experiences and obtaining their narratives would provide insights into the medical and emotional impact of living with an undiagnosed illness. Adults and children with undiagnosed diseases apply to be evaluated by the Undiagnosed Diseases Network (UDN). Written illness narratives from 40 UDN applicants, including 20 adult probands who applied for themselves and 20 parents who applied for their children, were analyzed for: 1) narrative content and 2) narrative type.

RESULTS

Narrative content: could be grouped into three themes: 1) Expectations of the UDN: the majority felt they had no further healthcare options and hoped the UDN would provide them with a diagnosis, with the adults expecting to return to their previously healthy life and the parents wanting information to manage their child's healthcare. 2) Personal medical information: the narratives reported worsening of symptoms and some offered opinions regarding the cause of their illness. The proband narratives had few objective findings, while parental narratives had detailed objective information. 3) Experiences related to living with their undiagnosed illness: frustration at being undiagnosed was expressed. The adults felt they had to provide validation of their symptoms to providers, given the lack of objective findings. The parents worried that something relevant to their child's management was being overlooked. Narrative type: All the narratives were of the chaos type, but for different reasons, with the probands describing loss and suffering and the parents expressing fear for their child's future. The parental narratives also had elements of restitution and quest, with acceptance of "a new normal", and an emphasis on the positive aspects of their child's illness which was absent from the probands.

CONCLUSIONS

These narratives illustrate the chaos that coexists with being undiagnosed. The differences between the proband and parental narratives suggest that these two groups have different needs that need to be considered during their evaluation and management.