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

Participatory design of bodysymptoms.org: An interactive web resource to explain multisystem functional somatic symptoms

OBJECTIVE

There is a lack of trustworthy information about Functional Somatic Symptoms (FSS) on the internet. This means integrative bio-psycho-social explanations of FSS and related health advice are not readily available to the public. To explore and address this problem, we carried out the bodysymptoms project, with the aim to build a website which presents current widely accepted explanations for FSS and shows how different explanations are inter-connected.

METHODS

Bodysymptoms was set up as a research-in-action project with a diverse range of international stakeholder-participants, combining approaches from patient and public involvement in healthcare with participatory design. 7 participants with lived experience of multi-system functional symptoms took part in the project and measures of meaningful engagement throughout the project were rated highly. This manuscript describes the methodology by which the website was developed.

RESULTS

Through iterative cycles we determined the requirements for an interactive explanatory model and co-created a novel online health interactive resource with integrated actionable health advice. The target end user are young adults with persistent physical symptoms, maintained by functional mechanisms. The overall aim is to empower people at risk of developing functional disorders to seek better health outcomes. The website is intended to be used prior to or alongside engagement with healthcare.

CONCLUSION

Bringing lived experience and multi-disciplinary perspectives into dialogue through participatory design can harness the power of research to create immediate shared value. This project has resulted in a usable open access website, bodysymptoms.org, which provides education about FSS for patients, healthcare professionals and members of the public looking to understand FSS.

What are medical students taught about persistent physical symptoms? A scoping review of the literature

BACKGROUND

Persistent Physical Symptoms (PPS) include symptoms such as chronic pain, and syndromes such as chronic fatigue. They are common, but are often inadequately managed, causing distress and higher costs for health care systems. A lack of teaching about PPS has been recognised as a contributing factor to poor management.

METHODS

The authors conducted a scoping review of the literature, including all studies published before 31 March 2023. Systematic methods were used to determine what teaching on PPS was taking place for medical undergraduates. Studies were restricted to publications in English and needed to include undergraduate medical students. Teaching about cancer pain was excluded. After descriptive data was extracted, a narrative synthesis was undertaken to analyse qualitative findings.

RESULTS

A total of 1116 studies were found, after exclusion, from 3 databases. A further 28 studies were found by searching the grey literature and by citation analysis. After screening for relevance, a total of 57 studies were included in the review. The most commonly taught condition was chronic non-cancer pain, but overall, there was a widespread lack of teaching and learning on PPS. Several factors contributed to this lack including: educators and learners viewing the topic as awkward, learners feeling that there was no science behind the symptoms, and the topic being overlooked in the taught curriculum. The gap between the taught curriculum and learners' experiences in practice was addressed through informal sources and this risked stigmatising attitudes towards sufferers of PPS.

CONCLUSION

Faculties need to find ways to integrate more teaching on PPS and address the barriers outlined above. Teaching on chronic non-cancer pain, which is built on a science of symptoms, can be used as an exemplar for teaching on PPS more widely. Any future teaching interventions should be robustly evaluated to ensure improvements for learners and patients.

Explanation for symptoms and biographical repair in a clinic for persistent physical symptoms

Introduction

Biographical disruption describes the process by which illness impacts not just on a person's body and their participation in activities, but also on their sense of self. Biographical disruption is often followed by a process of biographical repair in which identity is reconstructed and a new normality is restored. People with persistent physical symptoms (sometimes referred to as medically unexplained symptoms) experience biographical disruption. This can be complicated by lack of explanation and the implication that if the problem is not medical, then it might be the person/psychological. We aimed to examine this tension in people attending a novel "Symptoms Clinic" for people with persistent physical symptoms.

Methods

This study reports an embedded qualitative study in a UK based randomised controlled trial. Data were collected by audio recordings of consultations and semi-structured interviews with patients. We used theoretically informed thematic analysis with regular coding and discussion meetings of the analysis team. This analysis explores the role of intervention components in facilitating biographical repair.

Results

The lack of acceptable explanation for persistent symptoms acted as a block to biographical repair. In the clinic, multi-layered explanations were offered and negotiated that viewed persistent symptoms as understandable entities rather than as indicators of something still hidden. These explanations allowed study participants to make sense of their symptoms and in turn opened new opportunities for self-management. The result was that participants were able to reframe their symptoms in a way that enabled them to see themselves differently. Even if symptoms had not yet improved, there was a sense of being better. This can be understood as a process of biographical repair.

Conclusion

Explaining persistent physical symptoms enables biographical repair.

Meaning and role of functional-organic distinction: a study of clinicians in psychiatry and neurology services

The functional-organic distinction attempts to differentiate disorders with diagnosable biological causes from those without and is a central axis on which diagnoses, medical specialities and services are organised. Previous studies report poor agreement between clinicians regarding the meanings of the terms and the conditions to which they apply, as well as noting value-laden implications of relevant diagnoses. Consequently, we aimed to understand how clinicians working in psychiatry and neurology services navigate the functional-organic distinction in their work. Twenty clinicians (10 physicians, 10 psychologists) working in psychiatry and neurology services participated in semistructured interviews that were analysed applying a constructivist grounded theory approach. The distinction was described as often incongruent with how clinicians conceptualise patients' problems. Organic factors were considered to be objective, unambiguously identifiable and clearly causative, whereas functional causes were invisible and to be hypothesised through thinking and conversation. Contextual factors-including cultural assumptions, service demands, patient needs and colleagues' views-were key in how the distinction was deployed in practice. The distinction was considered theoretically unsatisfactory, eventually to be superseded, but clinical decision making required it to be used strategically. These uses included helping communicate medical problems, navigating services, hiding meaning by making psychological explanations more palatable, tackling stigma, giving hope, and giving access to illness identity. Clinicians cited moral issues at both individual and societal levels as integral to the conceptual basis and deployment of the functional-organic distinction and described actively navigating these as part of their work. There was a considerable distance between the status of the functional-organic distinction as a sound theoretical concept generalisable across conditions and its role as a gatekeeping tool within the structures of healthcare. Ambiguity and contradictions were considered as both obstacles and benefits when deployed in practice and strategic considerations were important in deciding which to lean on.

Acquiring a new understanding of illness and agency: a narrative study of recovering from chronic fatigue syndrome

BACKGROUND

The condition known as chronic fatigue syndrome or myalgic encephalomyelitis (CFS/ME) is poorly understood. Simplified medical models tend to neglect the complexity of illness, contributing to a terrain of uncertainty, dilemmas and predicaments. However, despite pessimistic pictures of no cure and poor prognosis, some patients recover.

PURPOSE

This study's purpose is to provide insight into people's experiences of suffering and recovery from very severe CFS/ME and illuminate understanding of how and why changes became possible.

METHODS

Fourteen former patients were interviewed about their experiences of returning to health. A narrative analysis was undertaken to explore participants' experiences and understandings. We present the result through one participant's story.

RESULTS

The analysis yielded a common plotline with a distinct turning point. Participants went through a profound narrative shift, change in mindset and subsequent long-time work to actively pursue their own healing. Their narrative understandings of being helpless victims of disease were replaced by a more complex view of causality and illness and a new sense of self-agency developed.

DISCUSSION

We discuss the illness narratives in relation to the disease model and its shortcomings, the different voices dominating the stories at different times in a clinically, conceptually, and emotionally challenging area.

Recognition, explanation, action, learning: Teaching and delivery of a consultation model for persistent physical symptoms

OBJECTIVE

To describe the teaching and delivery of an extended consultation model designed for clinicians to use with patients with persistent physical symptoms and functional disorders. The model is underpinned by current scientific knowledge about persistent physical symptoms and the communication problems that arise in dealing with them.

METHODS

Process evaluation of training and delivery of the Recognition, Explanation, Action, Learning (REAL) model within the Multiple Symptoms Study 3: a randomised controlled trial of an extended-role GP "Symptoms Clinic". Evaluation used clinician and patient interviews and consultation transcripts.

RESULTS

7 GPs were trained in the intervention and 6 of them went on to deliver the REAL model in Symptoms Clinics either face-to-face or online. The Symptoms Clinic provided a set of 4 extended consultations to approximately 170 patients. Evaluation of training indicated that there was a considerable load in terms of new knowledge and skills. Evaluation of delivery found clinicians could adapt the model to individual patients while maintaining a high level of fidelity to its core components.

CONCLUSION

REAL is a teachable consultation model addressing specific clinical communication issues for people with persistent physical symptoms.

PRACTICE IMPLICATIONS

REAL enables clinicians to explain persistent physical symptoms in a beneficial way.

'She thought the same way I that I thought:' a qualitative study of patient-provider concordance among Gulf War Veterans with Gulf War Illness

Objective: Medically unexplained symptoms (MUS), such as chronic fatigue syndrome, irritable bowel syndrome, and Gulf War Illness (GWI), are difficult to treat. Concordance-shared understanding between patient and provider about illness causes, course, and treatment-is an essential component of high-quality care for people with MUS. This qualitative paper focuses on the experiences of United States military Veterans living with GWI who have endured unique healthcare challenges. Methods & Measures: Qualitative interviews were conducted with 31 Veterans with GWI to explore factors that contribute to and detract from concordance with their Veteran Affairs (VA) healthcare providers. In addition to being seen by VA primary care, over half of participants also sought care at a War Related Illness and Injury Study Center, which specializes in post-deployment health. Deductive and inductive codes were used to organize the data, and themes were identified through iterative review of coded data. Results: Major themes associated with patient-provider concordance included validation of illness experiences, perceived provider expertise in GWI/MUS, and trust in providers. Invalidation, low provider expertise, and distrust detracted from concordance. Conclusion: These findings suggest providers can foster concordance with MUS patients by legitimizing patients' experiences, communicating knowledge about MUS, and establishing trust.

Patients' acceptance of explanatory models for persistent somatic symptoms: A qualitative analysis within the HERMES study

OBJECTIVE

The aim of this qualitative study was to provide an in-depth analysis of participants' experiences with video-animated explanatory models developed within the three-arm randomized controlled HERMES study ('Helpful explanatory models for somatic symptoms') and suggestions for further intervention improvement.

METHODS

Semi-structured qualitative interviews were conducted with psychosomatic outpatients with persistent somatic symptoms (PSS) after they were randomized to view one of three psychoeducational videos on a tablet computer: a) an explanatory model without personalization or b) an explanatory model with personalization in the two experimental groups or c) PSS guidelines without an explanatory model in the control group. Qualitative interviews were audiotaped, transcribed and analyzed applying thematic analysis.

RESULTS

Seventy-five patients with PSS were allocated to the study arms, mean duration of interviews was 8.19 min (SD = 3.19, range 4.02-19.49 min). Although all participants gave positive feedback regardless of their allocated study arm, those in the explanatory model without and with personalization groups were especially likely to rate the psychoeducational interventions as helpful. Results highlighted previous illness course, symptom perceptions and patient characteristics as key factors related to patients' response to the video interventions and optimal personalization of the explanatory model.

CONCLUSION

The present study not only demonstrated the acceptance of all three psychoeducational interventions developed within the HERMES study, but also provided valuable insights into potential key factors that may increase their impact and potential starting points for tailored psychoeducation in patients with PSS.

Randomized controlled trial protocol of health coaching for veterans with complex chronic pain

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.

Explanations for functional somatic symptoms across European treatment settings: A mixed methods study

OBJECTIVE

Engaging patients in treatment for functional somatic symptoms (FSS) relies on a shared understanding of the mechanisms underlying the complaints. Despite this, little is known about the explanatory models used in daily clinical practice. We aim to examine the approaches healthcare professionals use to explain FSS across European healthcare settings.

METHODS

This is an exploratory mixed methods study, combining sequential qualitative and quantitative analyses. 3 types of data were collected: a survey of Health-Care Professionals (HCPs) with special interest in FSS from 16 European countries (n = 186), Patient Education Material collected systematically from survey respondents (n = 72) and semi-structured Interviews with HCPs (n = 14). Survey results are summarized descriptively. Qualitative data was thematically coded following template analysis methods. Findings were integrated through mixed-methods triangulation.

RESULTS

Five main explanatory models for FSS that are used across treatment settings and diagnostic constructs were represented in the data. The 'Multisystem Stress' Approach explains FSS through physiological stress responses within a bio-psycho-social paradigm. 'Sensitized Alarm' and 'Malfunctioning software' are both approaches derived from the neurosciences. Explanations related to 'Embodied Experience' are often used within integrated psychosomatic therapies. In the person-centred 'Symptoms' approach, HCPs aim for co-constructed, individualized explanations. These approaches, which rely on different models of mind-body-environment are complementary and are used flexibly by skilled HCPs.

CONCLUSION

Taken together the explanatory models described might form the basis of a curriculum of medical explanation with the potential to equip clinicians to form more collaborative relationships with patients across healthcare.

(Dis)respect and shame in the context of 'medically unexplained' illness

A significant proportion of somatic symptoms remain, at present, medically unexplained. These symptoms are common, can affect any part of the body, and can result in a wide range of outcomes-from a minor, transient inconvenience to severe, chronic disability-but medical testing reveals no observable pathology. This paper explores two first-person accounts of so-called 'medically unexplained' illness: one that is published in a memoir, and the other produced during a semi-structured interview. Both texts are revelatory for their expression of shame in the context of encountering disrespect from healthcare professionals. The first section of my paper, clinical encounters, explores disrespect which, I argue, takes three interconnecting forms in these texts: disrespect for pain when it is seen as 'medically unexplained', disrespect for the patient's account of her own pain, and disrespect for the patient herself. The second section elucidates the shame that occurs as an affective and embodied consequence of encountering such disrespect. I claim that patients living with so-called 'medically unexplained' illnesses suffer a double burden. They endure both somatic and social suffering-not only their symptoms, but also disrespectful, traumatic and shame-inducing experiences of healthcare systems. I conclude with a reflection on the urgent need for changes in clinical training that could improve the quality of life for these patients, even in the absence of an explanation, treatment or cure for their symptoms.

Development of a blended communication training program for managing medically unexplained symptoms in primary care using the intervention mapping approach

BACKGROUND

General practice (GP) training in how to communicate with patients with medically unexplained symptoms (MUS) is limited.

OBJECTIVE

Development, implementation and evaluation of an evidence-based communication training program for GP residents focused on patients with MUS in primary care.

METHODS

We used the intervention mapping (IM) framework to systematically develop the MUS training program. We conducted a needs assessment to formulate change objectives and identified teaching methods for a MUS communication training program. Next, we developed, implemented and evaluated the training program with 46 residents by assessing their self-efficacy and by exploring their experiences with the training.

RESULTS

The resulting program is a blended training with an online course and two training days. After attending the training program, GP residents reported significantly higher self-efficacy for communication with patients with MUS at four weeks follow up compared to baseline. Furthermore, GP residents experienced the training program as useful and valued the combination of the online course and training days.

CONCLUSION AND PRACTICE IMPLICATIONS

We developed an evidence-based communication training program for the management of patients with MUS in primary care. Future research should examine the effect of the training on GP residents' communication skills in MUS consultations in daily practice.

How General Practitioners Raise Psychosocial Concerns as a Potential Cause of Medically Unexplained Symptoms: A Conversation Analysis

A common explanation for medically unexplained symptoms (MUS) relates patients' psychosocial concerns to their physical ailments. The present study used conversation analysis to examine how general practitioners (GPs) ascribe psychosocial causes to patients' unexplained symptoms during medical consultations. Our data consisted of 36 recorded consultations from Dutch general practice. We found that GPs raise psychosocial concerns as a potential cause of MUS in 14 consultations, either captured in 1) history-taking questions, or 2) diagnostic explanations. Whereas questions invited patient ideas, explanations did not make relevant patient responses in adjacent turns and subordinated patients' knowledge in symptom experiences to the GP's medical expertise. By questioning patients whether their symptoms may have psychosocial causes GPs enabled symptom explanations to be constructed collaboratively. Furthermore, additional data exploration showed that GPs lay ground for psychosocial ascriptions by first introducing psychosocial concerns as a consequence rather than a cause of complaints. Such preliminary activities allowed GPs to initiate rather delicate psychosocial ascriptions later in the consultation.

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.

Embodied Knowledge - the Phenomenon of Subjective Health Complaints reflected upon by Norwegian Psychomotor Physiotherapy specialists

Background: Many patients report subjective health complaints (SHCs) during primary health care consultations. Objective: To elucidate Norwegian Psychomotor Physiotherapy (NPMP) specialists' clinical experiences in treatment of patients suffering from SHCs. Methods: Twelve NPMP specialists were interviewed. The transcripts were qualitatively analyzed using systematic text condensation. Results: "Embodied knowledge" seemed to be an unfamiliar concept to those suffering from SHCs. The NPMP specialists regarded increased body awareness to be a vital element in the process of recovery from SHCs. Differences between NPMP specialists' professional view and that of some medical doctors were reported. Three categories emerged from the material: 1) "The process of establishing a joint understanding of subjective health complaints"; 2) "The process of increasing the patients' embodied awareness"; and 3) "The challenge of sharing embodied knowledge in inter-professional communication." Conclusion: The NPMP specialists emphasized the importance of increasing patients' consciousness of their embodied knowledge. They searched to adjust their therapeutic approaches, depending on the individual patient's specific problems and degree of emotional and/or bodily strain. The NPMP specialists experienced the importance of creating a shared understanding of the meaning embedded in SHCs between patients, NPMP specialists, and medical doctors.

Patient-Centered Medicine: A Necessary Condition for the Management of Functional Somatic Syndromes and Bodily Distress

This paper argues that “functional,” “medically unexplained,” or “somatoform” symptoms and disorders necessarily require a patient-centered approach from the clinicians. In the first part, I address the multiple causes of the patients' suffering and I analyze the unease of the doctors faced with these disorders. I emphasize the iatrogenic role of medical investigations and the frequent failure in attempting to reassure the patients. I stress the difficulties in finding the right terms and concepts, despite overabundant nosological categories, to give a full account of psychosomatic complexity. Finally, I discuss the moral dimension attached to assigning a symptom, at times arbitrarily, to a psychogenic origin. The following part presents a brief reminder of the patient-centered approach (PCA) in medicine. In the last part, I aim to explain why and how patient-centered medicine should be applied in the context of functional disorders. First, because PCA focuses on the patients' experience of illness rather than the disease from the medical point of view, which is, indeed, absent. Second, because PCA is the only way to avoid sterile attribution conflicts. Last, because PCA allows doctors and patients to collaboratively create plausible and non-stigmatizing explanations for the symptoms, which paves the way toward effective management.

A systematic review outlining the impact of education on patients and physicians in gastroenterology

Functional gastrointestinal symptoms (FGIDs) refer to a noticeable change in the body that is reported by the patient as being different from normal. FGIDs can have a significant impact on the patient's quality of life by interfering with daily functioning. The primary objective of the current paper was to identify short-term educational interventions for patients diagnosed with FGIDs and medically unexplained symptoms. This is with the aim of assessing its effectiveness on patient's quality of life and symptom severity. The second objective was to establish the current educational programmes and training opportunities available for physicians working with this subgroup of patients. This is in order to ascertain if these could change negative physician beliefs and attitudes. Databases such as PubMed and Google Scholar were searched from November to February 2018. A total of eight interventions were found which were evaluated using the Behavioural Change Techniques Taxonomy. Short-term educational programmes combining the use of lectures and practical sessions were found to be the most effective in improving patient quality of life and symptom severity. Managing patient exposure through the use of problem-based learning was considered the most effective teaching method for trainee physicians and could help to prevent the internalisation of negative attitudes. Definite conclusions about the effectiveness of patient and physician interventions are difficult to ascertain due to the small number of studies found and the high risk of bias. Future research should focus on providing a more unified approach to the management of this subgroup of patients.

Determinants of Frequent Attendance in Primary Care. A Systematic Review of Longitudinal Studies

Introduction: There is a lack of a systematic review synthesizing longitudinal studies investigating the determinants of frequent attendance in primary care. The goal of our systematic review was to fill this gap in knowledge.

Methods: Three electronic databases (Medline, PsycINFO, and CINAHL) were searched. Longitudinal observational studies analyzing the predictors of frequent attendance in primary care were included. Data extraction covered methods, sample characteristics, and main findings. Selection of the studies, extracting the data and evaluation of study quality was performed by two reviewers. In the results section, the determinants of frequent attendance were presented based on the (extended) Andersen model.

Results: In total, 11 longitudinal studies have been included in our systematic review. The majority of studies showed that frequent attendance was positively associated with the predisposing characteristics lower age, and unemployment. Moreover, it was mainly not associated with enabling resources. Most of the studies showed that need factors, and in particular worse self-rated health, lower physical functioning and physical illnesses were associated with an increased likelihood of frequent attendance. While most studies were of good quality, several of the included studies did not perform sensitivity analysis or described how they dealt with missing data.

Discussion: Our systematic review showed that particularly lower age, unemployment and need factors are associated with the likelihood of becoming a frequent attender. Enabling resources are mainly not associated with the outcome measure. Future research should concentrate on the determinants of persistent frequent attendance due to the high economic burden associated with it.

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.

Making and managing medical anomalies: Exploring the classification of 'medically unexplained symptoms'

This article explores the making and management of anomaly in scientific work, taking 'medically unexplained symptoms' (MUS) as its case. MUS is a category used to characterize health conditions that are widely held to be ambiguous, in terms of their nature, causes and treatment. It has been suggested that MUS is a 'wastebasket diagnosis'. However, although a powerful metaphor, it does neither the category nor the profession justice: Unlike waste in a wastebasket, unexplained symptoms are not discarded but contained, not ejected but managed. Rather than a 'wastebasket', I propose that we instead think about it as a 'junk drawer'. A junk drawer is an ordering device whose function is the containment of things we want to keep but have nowhere else to put. Based on a critical document analysis of the research literature on MUS (107 research articles from 10 medical journals, published 2001-2016), the article explores how the MUS category is constituted and managed as a junk drawer in medical science.

Engaging patients with "medically unexplained symptoms" in psychological therapy: An integrative and transdiagnostic approach

OBJECTIVES

Patients with "medically unexplained symptoms" or "MUS" experience subjectively compelling and distressing somatic symptoms that are not fully explained by underlying physical pathology. Effective treatment of these patients has been impeded by multiple barriers. Problems with patient engagement have been highlighted in the clinical and research literature, yet few exploratory studies have been conducted in this area. This research explores how experienced psychological therapists in a specialist MUS service work to engage these patients.

DESIGN

An in-depth qualitative study was conducted to explore the process of engaging patients with MUS in psychological therapy.

METHOD

Semi-structured depth interviews were conducted with psychological therapists who work with complex patients with MUS. The therapists interviewed were recruited from an NHS primary care psychological therapy service that specializes in working with this patient group. Data were analysed using grounded theory to develop a model of this process.

RESULTS

The analysis identified how multiple interacting layers of systemic, interpersonal, and intrapsychic disconnections impede engagement. The research introduces a new theoretical framework 'Negotiating disconnection' that conceptualizes the process of engagement in terms of a series of stages, namely 'Drawing in' (negotiating systemic disconnection), 'Meeting' (connecting in the disconnection), and 'Nudging Forward' (cultivating new connections), and illustrates how these are negotiated by therapists.

CONCLUSIONS

The model shows that it is critical for therapists to collaborate closely with GPs to engage these patients while also highlighting barriers to doing this, reflecting the complexities of organizational and cultural change. Clinically, the model illustrates the importance of adopting a flexible, pluralistic, and integrative approach that is person-centred and process-led. Doctors and therapists should embrace a holistic, biopsychosocial stance towards MUS and be sensitively attuned to its complex phenomenology.

PRACTITIONER POINTS

To engage patients with MUS psychological therapists should be person-centred and process-led rather than theory- or protocol-led. A pluralistic and integrative mindset facilitates this by enhancing clinicians' flexibility. A multidisciplinary approach is essential. Clinicians should embrace a biopsychosocial stance towards MUS and work closely with medical colleagues to help them do the same. Structural and cultural change is needed to tackle this issue effectively.

The importance of contextual aspects in the care for patients with functional somatic symptoms

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.

Illness perceptions of youths with functional disorders and their parents: An interpretative phenomenological analysis study

BACKGROUND

Functional disorders, defined as disorders with no clear medical explanation, are common and impose a significant burden on youths, their families, healthcare services and society as a whole. Currently, the literature describes resistance among patients and their families towards psychological symptom explanations and treatments. More knowledge about the thoughts and understandings of youths with functional disorders and their parents is needed. The aim of this study was to explore the illness perceptions of youths with severe functional disorders and their parents.

METHODS

A qualitative interview study using interpretative phenomenological analyses. The study included 11 youths aged 11-15 years with functional disorders and their parents, where interviews were performed at the point of referral from a somatic to a psychiatric treatment setting.

RESULTS

Analyses identified three main themes. Themes 1(Ascribing identity to the disorder) and 2 (Monocausal explanations) explore key elements of the participants' illness perceptions, and theme 3 (Mutable illness perceptions) explores how illness perceptions are influenced by experiences from healthcare encounters.

CONCLUSIONS

The label 'functional disorder' was poorly integrated in the illness perceptions of the youths and their parents. Participants used a monocausal and typically physical explanation rather than a multicausal biopsychosocial explanation for their symptoms.

Introducing the System for Observing Medical Alliances (SOMA): A Tool for Studying Concordance in Patient-Physician Relationships

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.

Careful expressions of social aspects: How local professionals in high school settings, municipal services, and general practice communicate care to youth presenting persistent bodily complaints

Persistent health complaints pose communicative dilemmas in care encounters, adversely affecting patient experiences and pathways. Little is known about the impact and role of professionals in encounters with young people with incipient, debilitating, and persistent symptoms. This study aims to explore communicative dilemmas and the role of language in care provided by local professionals in high school settings, municipal services, and general practice to young people presenting persistent bodily complaints. The study is based on in-depth individual interviews conducted from April to July 2016 with 12 professionals identified and selected during anthropological multi-sited fieldwork in a Norwegian community. We identify two modalities of what we have chosen to call 'careful expression', used as strategies across professions to overcome communicative dilemmas. Professionals reflexively and pragmatically negotiated with the powers of language to influence illness experience and to enact empowered young subjects. These insights may prove relevant for future studies of care encounters while also indicating a critical attitude to institutional logics that affect care responses.

Medically Unexplained Physical Symptoms: What They Are and Why Counseling Psychologists Should Care about Them

Medically unexplained symptoms and syndromes (MUS) affect the health of 20%-30% of patients seen in primary care. Optimally, treatment for these patients requires an interdisciplinary team consisting of both primary care and mental health providers. By developing an expertise in MUS, counseling psychologists can improve the care of patients with MUS who are already in their practice, expand the number of patients they help, and enhance the integration of counseling psychology into the broader medical community. Additionally, counseling psychologists' expertise in culture, attunement to therapeutic processes, and our focus on prioritizing patients' perspectives and quality of life can fill the gap in research on MUS and bringing increased attention to counseling psychologists' unique contributions to health service delivery.

Clinical and economic outcomes of remotely delivered cognitive behaviour therapy versus treatment as usual for repeat unscheduled care users with severe health anxiety: a multicentre randomised controlled trial

BACKGROUND

It is challenging to engage repeat users of unscheduled healthcare with severe health anxiety in psychological help and high service costs are incurred. We investigated whether clinical and economic outcomes were improved by offering remote cognitive behaviour therapy (RCBT) using videoconferencing or telephone compared to treatment as usual (TAU).

METHODS

A single-blind, parallel group, multicentre randomised controlled trial was undertaken in primary and general hospital care. Participants were aged ≥18 years with ≥2 unscheduled healthcare contacts within 12 months and scored >18 on the Health Anxiety Inventory. Randomisation to RCBT or TAU was stratified by site, with allocation conveyed to a trial administrator, research assessors masked to outcome. Data were collected at baseline, 3, 6, 9 and 12 months. The primary outcome was change in HAI score from baseline to six months on an intention-to-treat basis. Secondary outcomes were generalised anxiety, depression, physical symptoms, function and overall health. Health economics analysis was conducted from a health service and societal perspective.

RESULTS

Of the 524 patients who were referred and assessed for trial eligibility, 470 were eligible and 156 (33%) were recruited; 78 were randomised to TAU and 78 to RCBT. Compared to TAU, RCBT significantly reduced health anxiety at six months, maintained to 9 and 12 months (mean change difference HAI -2.81; 95% CI -5.11 to -0.50; P = 0.017). Generalised anxiety, depression and overall health was significantly improved at 12 months, but there was no significant change in physical symptoms or function. RCBT was strictly dominant with a net monetary benefit of £3,164 per participant at a willingness to pay threshold of £30,000. No treatment-related adverse events were reported in either group.

CONCLUSIONS

RCBT may reduce health anxiety, general anxiety and depression and improve overall health, with considerable reductions in health and informal care costs in repeat users of unscheduled care with severe health anxiety who have previously been difficult to engage in psychological treatment. RCBT may be an easy-to-implement intervention to improve clinical outcome and save costs in one group of repeat users of unscheduled care.

TRIAL REGISTRATION

The trial was registered at ClinicalTrials.gov on 19 Nov 2014 with reference number NCT02298036.

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.

The association between patients' expectations and experiences of task-, affect- and therapy-oriented communication and their anxiety in medically unexplained symptoms consultations

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.

Medical Students' Perspectives on Trauma-Informed Care Training

INTRODUCTION

Adults exposed to traumatic events during childhood commonly seek medical services, but health care practitioners hesitate to address and assess early trauma despite its known negative health effects. This study examines medical students' perspectives on a brief course that addressed the health care needs of patients exposed to adverse childhood experiences.

METHODS

A convenience sample of 20 University of California, Davis medical students from the Summer Institute on Race and Health received 6 hours of trauma-informed care training. The course was delivered in 2-hour modules during the course of 3 days, and included lectures, discussions, and practice. A questionnaire assessing students' perspectives on training benefits, current practice challenges, and necessary resources to provide trauma-informed medical care was distributed posttraining.

RESULTS

From the students' perspectives, this course increased their ability to recognize various clinical manifestations of adverse childhood experience exposure in adult patients. Students said they learned how to ask about and respond to adverse childhood experience disclosures and identify necessary resources to responsibly implement trauma-informed care in medical settings. Students identified provision of adequate resources and links to appropriate treatment identified as common challenges in providing health care to trauma-affected patients.

CONCLUSION

Study findings illustrate that trauma training can fill a knowledge gap and provide associated benefits for medical students. Initial training may pique students' interest by demonstrating the relevance of trauma knowledge in clinical practice; additional training likely is needed to support skills and confidence.

Meeting Patients' Right to the Correct Diagnosis: Ongoing International Initiatives on Undiagnosed Rare Diseases and Ethical and Social Issues

The time required to reach a correct diagnosis is a key concern for rare disease (RD) patients. Diagnostic delay can be intolerably long, often described as an “odyssey” and, for some, a diagnosis may remain frustratingly elusive. The International Rare Disease Research Consortium proposed, as ultimate goal for 2017–2027, to enable all people with a suspected RD to be diagnosed within one year of presentation, if the disorder is known. Subsequently, unsolved cases would enter a globally coordinated diagnostic and research pipeline. In-depth analysis of the genotype through next generation sequencing, together with a standardized in-depth phenotype description and sophisticated high-throughput approaches, have been applied as diagnostic tools to increase the chance of a timely and accurate diagnosis. The success of this approach is evident in the Orphanet database. From 2010 to March 2017 over 600 new RDs and roughly 3600 linked genes have been described and identified. However, combination of -omics and phenotype data, as well as international sharing of this information, has raised ethical concerns. Values to be assessed include not only patient autonomy but also family implications, beneficence, non-maleficence, justice, solidarity and reciprocity, which must be respected and promoted and, at the same time, balanced among each other. In this work we suggest that, to maximize patients’ involvement in the search for a diagnosis and identification of new causative genes, undiagnosed patients should have the possibility to: (1) actively participate in the description of their phenotype; (2) choose the level of visibility of their profile in matchmaking databases; (3) express their preferences regarding return of new findings, in particular which level of Variant of Unknown Significance (VUS) significance should be considered relevant to them. The quality of the relationship between individual patients and physicians, and between the patient community and the scientific community, is critically important for optimizing the use of available data and enabling international collaboration in order to provide a diagnosis, and the attached support, to unsolved cases. The contribution of patients to collecting and coding data comprehensively is critical for efficient use of data downstream of data collection.

Quantifying positive communication: Doctor's language and patient anxiety in primary care consultations

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.

Shared decision-making in tinnitus care - An exploration of clinical encounters

OBJECTIVES

This study examined clinical encounters between clinicians and patients to determine current practice for the diagnosis and treatment of tinnitus. The objective was to develop an understanding of the ideal clinical encounter that would facilitate genuine shared decision-making.

DESIGN

Video ethnography was used to examine clinical encounters for the diagnosis and treatment of tinnitus.

METHODS

Clinical encounters were video-recorded. Patients were interviewed individually following their clinic appointment. Data were analysed using constant comparison techniques from Grounded Theory. Initial inductive analyses were then considered against theoretical conceptualizations of the clinician-patient relationship and of the clinical encounter.

RESULTS

Alignment between clinician and patient was found to be essential to a collaborative consultation and to shared decision-making. Clinician groups demonstrated variation in behaviour in the encounter; some asked closed questions and directed the majority of the consultation; others asked open questions and allowed patients to lead the consultation.

CONCLUSIONS

A shift away from aetiology and physiological tests is needed so that tinnitus is managed as a persistent unexplained set of symptoms. This uncertainty is challenging for the medical professionals; lessons could be learned from the use of therapeutic skills. Further research is required to test techniques, such as the use of decision aids, to determine how we might create the ideal clinical encounter. Statement of contribution What is already known on this subject? Tinnitus is a condition in which sound is heard in the absence of an external source. Current approaches to managing tinnitus vary depending on clinical site (Hoare & Hall, ). In most instances, tinnitus does not have a straightforward medical cause. Tinnitus care is challenging to traditional biomedical encounters because the process of diagnosis may not lead to a defined treatment. Clinicians are required to consider not only what the tinnitus sounds like but more importantly, what it means for the affected individual. This requires a careful and skilled approach to eliciting a patient's current behaviour, coping, and preferences for both outcomes and treatment approaches. What does this study add? We provide the first in-depth description of decision-making in clinical services for tinnitus. Findings suggest a shift in focus is required to move away from the current prioritization of the biomedical treatment of tinnitus. There is variation to the extent different clinicians were able to deal with the uncertainty presented by the symptoms of tinnitus.

Preliminary evidence: the stress-reducing effect of listening to water sounds depends on somatic complaints: A randomized trial

BACKGROUND

Listening to natural sounds is applied in health contexts in order to induce relaxation. However, it remains unclear whether this effect is equally efficacious in all individuals or whether it depends on interindividual differences. Given that individuals differ in how they are impaired by somatic complaints, we investigated whether somatic complaints moderate the stress-reducing effect of listening to water sounds.

METHODS

Sixty healthy women (Mage = 25 years) were randomly allocated to 3 different conditions (listening to water sounds, a relaxing piece of music, or no auditory stimulus: n = 20 per condition) for 10 minutes before they were exposed to a standardized psychosocial stress task. Salivary cortisol was assessed before, during, and after the stress task. For binary logistic regression analyses, participants were divided into 2 groups: 1 group with a high salivary cortisol release and 1 group with low cortisol release. The Freiburg Complaints Inventory was used to assess occurrence of somatic complaints.

RESULTS

A significant moderating effect of somatic complaints on cortisol secretion was found in the group listening to water sounds (χ(1) = 5.87, P < .015) but not in the other 2 groups, explaining 35.7% of the variance and correctly classifying 78.9% of the cases.

CONCLUSION

The stress-reducing effect of listening to water sounds appears to depend on the occurrence of somatic complaints. This effect was not found in the music or silence condition. Individuals with somatic complaints may benefit from other, potentially more powerful forms of stress-reducing interventions, that is, combinations of visual and auditory stimuli.

TRIAL REGISTRATION

not applicable (pilot study).

How do hospital doctors manage patients with medically unexplained symptoms: a qualitative study of physicians

Objective Medically unexplained symptoms are a common presentation in medical practice and are associated with significant morbidity and high levels of service use. Most research exploring the attitudes and training of doctors in treating patients with unexplained symptoms has been conducted in primary care. This study aims to explore the ways in which doctors working in secondary care approach and manage patients with medically unexplained symptoms. Design A qualitative study using in-depth interviews and thematic analysis. Setting Three hospitals in the North Thames area. Participants Twenty consultant and training-grade physicians working in cardiology, gastroenterology, rheumatology and neurology. Main outcome measure Physicians' approach to patients with medically unexplained symptoms and their views on managing these patients. Results There was considerable variation in how the physicians approached patients who presented with medically unexplained symptoms. Investigations were often ordered without a clear rationale and the explanations given to patients when results of investigations were normal were highly variable, both within and across specialties. The doctor's level of experience appeared to be a more important factor in their investigation and management strategies than their medical specialty. Physicians reported little or no formal training in how to manage such presentations, with no apparent consistency in how they had developed their approach. Doctors described learning from their own experience and from senior role models. Organisational barriers were identified to the effective management of these patients, particularly in terms of continuity of care. Conclusions Given the importance of this topic, there is a need for serious consideration as to how the management of patients with medically unexplained symptoms is included in medical training and in the planning and delivery of services.

Evaluating challenges for improving medically unexplained symptoms in US military veterans via provider communication

OBJECTIVES

Medically unexplained symptoms (MUS) are common, with particularly high rates observed in military veterans. Effective patient-provider-communication is thought to be a key aspect of care; however there have been few empirical studies on the association between communication and outcomes for patients with MUS. We evaluate whether discussing veterans' MUS-illness representations and good interpersonal skills have the potential to promote MUS-treatment adherence and improvement.

METHODS

Veterans experiencing MUS (n=204) reported on their primary care providers' communication about illness representations and interpersonal skills; correlation, regression, and bootstrap-mediation analyses were conducted to test hypotheses regarding veteran-reported outcomes. Main outcomes included satisfaction with the provider, MUS-treatment adherence, intentions to adhere, and expectations for MUS improvement.

RESULTS

Veterans reported infrequent discussion of MUS illness representations but high degrees of provider interpersonal skills. Communication regarding patients' illness representations and treatment expectations was significantly related to treatment adherence and adherence intentions; provider interpersonal skills were not. Both were related to veteran satisfaction.

CONCLUSIONS AND PRACTICE IMPLICATIONS

Providers' interpersonal skills may be important in chronic illness contexts, such as MUS, by contributing to satisfaction with the provider. The current study suggests that providers may better promote MUS-treatment adherence through discussing MUS illness representations and treatment expectations.

Improving teaching about medically unexplained symptoms for newly qualified doctors in the UK: findings from a questionnaire survey and expert workshop

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.

Struggles for medical legitimacy among women experiencing sexual pain: A qualitative study

Given the prominent role of medical institutions in defining what is "healthy" and "normal," many women turn to medicine when experiencing pain during intercourse (dyspareunia). The medical encounter can become a contest between patients and providers when physicians do not grant legitimacy to patients' claims of illness. Drawing on interviews conducted from 2007 to 2008 and 2011 to 2012 with 32 women experiencing dyspareunia (ages 18-60 years) and living in New York City and its surrounding areas, this study examined women's and their physicians' claims regarding bodily expertise, particularly women's perceptions of physician invalidation, their understanding of this invalidation as gendered, and the consequences for women's pursuit of medicalization. Women overwhelmingly sought a medical diagnosis for their dyspareunia, in which they believed that providers would relieve uncertainty about its origin, give treatment alternatives, and permit them to avoid sexual activity. When providers did not give diagnoses, women reported feeling that their bodily self-knowledge was dismissed and their symptoms were attributed to psychosomatic causes. Furthermore, some women linked their perceptions of invalidation to both historical and contemporary forms of gender bias. Exploration of women's struggles for medical legitimacy may lead to a better understanding of the processes by which medicalization of female sexuality takes place.

Medically unexplained symptoms: the person, the symptoms and the dialogue

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.

A taxonomy of explanations in a general practitioner clinic for patients with persistent "medically unexplained" physical symptoms

OBJECTIVE

To develop a taxonomy of explanations for patients with persistent physical symptoms.

METHODS

We analysed doctors' explanations from two studies of a moderately-intensive consultation intervention for patients with multiple, often "medically-unexplained," physical symptoms. We used a constant comparative method to develop a taxonomy which was then applied to all verbatim explanations.

RESULTS

We analysed 138 explanations provided by five general practitioners to 38 patients. The taxonomy comprised explanation types and explanation components. Three explanation types described the overall structure of the explanations: Rational Adaptive, Automatic Adaptive, and Complex. These differed in terms of who or what was given agency within the explanation. Three explanation components described the content of the explanation: Facts - generic statements about normal or dysfunctional processes; Causes - person-specific statements about proximal or distal causes for symptoms; Mechanisms - processes by which symptoms arise or persist in the individual. Most explanations conformed to one type and contained several components.

CONCLUSIONS

This novel taxonomy for classifying clinical explanations permits detailed classification of explanation types and content. Explanation types appear to carry different implications of agency.

PRACTICE IMPLICATIONS

The taxonomy is suitable for examining explanations and developing prototype explanatory scripts in both training and research settings.

Negotiating explanations: doctor-patient communication with patients with medically unexplained symptoms-a qualitative analysis

BACKGROUND

Patients with medically unexplained physical symptoms (MUPS) seek explanations for their symptoms, but often find general practitioners (GPs) unable to deliver these. Different methods of explaining MUPS have been proposed. Little is known about how communication evolves around these explanations.

OBJECTIVE

To examine the dialogue between GPs and patients related to explanations in a community-based clinic for MUPS. We categorized dialogue types and dialogue outcomes.

METHODS

Patients were ≥18 years with inclusion criteria for moderate MUPS: ≥2 referrals to specialists, ≥1 functional syndrome/symptoms, ≥10 on the Patient Health Questionnaire-15 and GP's judgement that symptoms were unexplained. We analysed transcripts of 112 audio-recorded consultations (39 patients and 5 GPs) from two studies on the Symptoms Clinic Intervention, a consultation intervention for MUPS in primary care. We used constant comparative analysis to code and classify dialogue types and outcomes.

RESULTS

We extracted 115 explanation sequences. We identified four dialogue types, differing in the extent to which the GP or patient controlled the dialogue. We categorized eight outcomes of the sequences, ranging from acceptance to rejection by the patient. The most common outcome was holding (conversation suspended in an unresolved state), followed by acceptance. Few explanations were rejected by the patient. Co-created explanations by patient and GP were most likely to be accepted.

CONCLUSION

We developed a classification of dialogue types and outcomes in relation to explanations offered by GPs for MUPS patients. While it requires further validation, it provides a framework, which can be used for teaching, evaluation of practice and research.

"Struggle to obtain redress": Women's experiences of living with symptoms attributed to dental restorative materials and/or electromagnetic fields

The aim of this study was to explore the experiences of illness and the encounters with health care professionals among women who attributed their symptoms and illness to either dental restorative materials and/or electromagnetic fields, despite the fact that research on health effects from dental fillings or electricity has failed to substantiate the reported symptoms. Thirteen women (aged 37-63 years) were invited to the study and a qualitative approach was chosen as the study design, and data were collected using semi-structured interviews. The analysis was conducted with a constant comparative method, according to Grounded Theory. The analysis of the results can be described with the core category, "Struggle to obtain redress," the two categories, "Stricken with illness" and "A blot in the protocol," and five subcategories. The core category represents the women's fight for approval and arose in the conflict between their experience of developing a severe illness and the doctors' or dentists' rejection of the symptoms as a disease, which made the women feel like malingerers. The informants experienced better support and confirmation from alternative medicine practitioners. However, sick-leave certificates from alternative medicine practitioners were not approved and this led to a continuous cycle of visits in the health care system. To avoid conflicting encounters, it is important for caregivers to listen to the patient's explanatory models and experience of illness, even if a medical answer cannot be given.

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

BACKGROUND

The term 'difficult' is pervasively used in relation to medically unexplained symptoms (MUS) and patients with MUS. This article scrutinises the use of the term by analysing interview data from a study of secondary care specialists' experiences with and attitudes towards patients suffering from MUS.

DESIGN

Qualitative design employing semi-structured open-ended interviews systematically analysed in three stages: first, data were analysed according to the principles of content analysis. The analysis subsequently focused on the use of the term 'difficult'. Iterations of the term were extracted by summative analysis and thematic coding revealed its different meanings. Finally, alternative expressions were explored.

SETTING

Three NHS trust secondary care hospitals in North-East England.

PARTICIPANTS

17 senior clinicians from seven medical and two surgical specialities.

RESULTS

Unsolicited use of the term 'difficult' was common. 'Difficult' was rarely used as a patient characteristic or to describe the therapeutic relationship. Participants used 'difficult' to describe their experience of diagnosing, explaining, communicating and managing these conditions and their own emotional reactions. Health care system deficits and the conceptual basis for MUS were other facets of 'difficult'. Participants also reported experiences that were rewarding and positive.

CONCLUSIONS

This study shows that blanket statements such as 'difficult patients' mask the complexity of doctors' experiences in the context of MUS. Our nuanced analysis of the use of 'difficult' challenges preconceived attitudes. This can help counter the unreflexive perpetuation of negative evaluations that stigmatize patients with MUS, encourage greater acknowledgement of doctors' emotions, and lead to more appropriate conceptualizations and management of MUS.

The patient-physician interaction as a meeting of experts: one solution to the problem of patient non-adherence

Patient non-adherence is a common and important concern in clinical medicine. Some cases of patient non-adherence are cases in which the patient disagrees with the physician's recommended treatment based on particular reasons. Drawing upon science and technology studies literature, specifically the discussion by Collins and Evans and Wynne of how best to understand scientific controversies, I relate their ideas to the analogous conflict that may occur within a clinical interaction. I draw upon their recognition of the importance of contributory expertise and interactional expertise in providing legitimate knowledge. I also draw upon Wynne's idea of the 'negotiation of meanings' as an important element of the clinical interaction. To resolve potential conflicts between patient and physician before they develop into 'non-adherence', I propose the implementation of a new epistemological framework that recognizes legitimate knowledge offered by the patient as well as the physician. By situating this patient expertise framework within the paradigm of patient-centred medicine, and by assuming the goal of medical treatment to be treatment of suffering, patient expertise becomes centralized as a means of determining the nature of patient suffering. Two aspects of the patient's tacit knowledge - the body aspect and the meaning aspect - both of which are context-dependent and directly accessible only to the patient, are thus recognized as knowledge essential to the success of the interaction. The physician's role becomes that of both medical expert and possessor of 'interactional expertise', by which the physician recognizes and includes patient expertise in the treatment decision. By recognizing and incorporating the negotiation of meanings into the development of a treatment plan, this epistemological model of patient expertise should prevent cases of non-adherence based on disagreement.