Why do doctors not learn how to explain "medically unexplained symptoms"?

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.

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.

A multidimensional longitudinal dataset on functional somatic syndromes

Functional disorders represent a prevalent health issue, significantly impacting both individuals and healthcare systems. This multidisciplinary dataset aims to enhance our comprehension of the complex interplay among various factors that contribute to functional somatic syndromes. The dataset comprises data from seemingly healthy adults (aged 18-65) in Isfahan, Iran, who were randomly selected and monitored for four consecutive years. The research data encompasses seven distinct datasets: (a) functional symptom evaluations across multiple body organs, (b) psychological assessments, (c) lifestyle factors, (d) demographic and socioeconomic variables, (e) laboratory measurements, (f) clinical examinations, and (g) historical information. A total of 1930 participants were enrolled at the study's outset in 2017. The first, second, and third annual follow-up rounds were completed with 1697 (2018), 1616 (2019), and 1176 (2020) participants, respectively. This dataset is made available for further analysis by a diverse range of researchers, healthcare policymakers, and clinicians.

Education on medically unexplained symptoms: a systematic review with a focus on cultural diversity and migrants

BACKGROUND

Health care providers often struggle with the management of patients with medically unexplained symptoms (MUS), especially in case of a different ethnicity and/or cultural background. These challenges are insufficiently addressed in their training.

OBJECTIVES

A systematic review on education in the field of MUS in a diverse context to improve MUS healthcare provider-patient interaction focused on intercultural communication.

METHODS

Screening of PubMed, Web of Science, Cinahl and Cochrane Library on the keywords 'Medical unexplained (physical) symptoms (MUS)', 'Somatoform disorder', 'Functional syndrome', 'Diversity', 'Migrants', 'Ethnicity', 'Care models', 'Medical education', 'Communication skills', 'Health literacy'.

RESULTS

MUS patients, especially with a different ethnic background, often feel not understood or neglected. Health care providers experience feelings of helplessness, which may provoke medical shopping and resource consumption. Attitudes and perceptions from undergraduate trainees to senior physicians tend to be negative, impacting on the quality of the patient/health care provider relationship and subsequently on health outcomes, patient satisfaction and therapeutic adherence. Current undergraduate, graduate and postgraduate education and training does not prepare health care providers for diagnosing and managing MUS patients in a diverse context. A continuum of training is necessary to achieve a long term and lasting change in attitudes towards these patients and trainers play a key role in this process. Hence, education should pay attention to MUS, requiring a specific competency profile and training, taken into account the variety in patients' cultural backgrounds.

CONCLUSIONS

This systematic review identified significant gaps and shortcomings in education on MUS in a diverse context. These need to be addressed to improve outcomes.

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.

Multidisciplinary approach to functional somatic syndromes: study protocol for a population-based prospective cohort study

INTRODUCTION

Isfahan functional disorders (ISFUN) cohort study aims to describe the interplay of genetic and environmental factors in shaping the characteristics of functional somatic syndromes (FSS). This study is primarily intended to investigate the epidemiology, risk factors, course and prognosis of FSSs in a sample of adult Iranian population. The other aim is to develop a new delimitation of FSSs based on an integrated multidisciplinary approach comprising of phenotypic and multiomics data.

METHODS AND ANALYSIS

ISFUN is a population-based prospective cohort study designed to follow a population of randomly selected seemingly healthy adults (18-65 years) through annual visits during a 4-year observation period. Structured questionnaires are used for data collection and clinical assessment of the participants. Questionnaire-based diagnosis of FSSs are validated in a medical interview. Human DNA genotyping, microbial amplicon sequencing and urine analysis is under progress for genomics, microbiota and metabolomics profiling, respectively. Enrolment began in September 2017, and study completion is expected in 2022. A total number of 1943 participants were initially recruited.

ETHICS AND DISSEMINATION

Ethical approval for data collection was granted by the National Research Ethics Committee of the Iranian Ministry of Health and Medical Education and the Research Ethics Committee of Isfahan University of Medical Sciences (IR.MUI.REC.1395.1.149). Following the description of the study procedure, we obtained written informed consent from all study participants. Study findings will be disseminated through peer-reviewed publications and presentations at scientific meetings.

The experiences of adolescents diagnosed with functional gastrointestinal disorders: An interpretative phenomenological analysis

The aim of this study was to provide a qualitative perspective of adolescents' experiences of functional gastrointestinal disorders. In-depth semi structured interviews were conducted with eleven adolescents aged 11-16. The transcripts were analysed using Interpretative Phenomenological Analysis. Three superordinate themes were identified: 1) The journey to diagnosis: the good, the bad and the unknown; 2) Making sense of 'functional': the search for meaning; and 3) To share or conceal?: the impact of anticipated stigma on peer disclosure. The themes highlighted a complex process of meaning-making, with limited information about their diagnosis impacting on approaches to self-management and peer disclosure. Findings suggest adolescents would benefit from developmentally appropriate information and resources about the biopsychosocial aetiology of their presentation. It is considered that this may lead to greater self-efficacy in self-management of symptoms and reduce potential for perceived and self-stigma. Further implications for clinical practice and future research are discussed.

Perception of Physician Empathy Varies With Educational Level and Gender of Patients Undergoing Low-Yield Computerized Tomographic Imaging

OBJECTIVE

Lack of empathic communication between providers and patients may contribute to low value diagnostic testing in emergency care. Accordingly, we measured the perception of physician empathy and trust in patients undergoing low-value computed tomography (CT) in the emergency department (ED).

METHODS

Multicenter study of ED patients undergoing CT scanning, acknowledged by ordering physicians as unlikely to show an emergent condition. Near the end of their visit, patients completed the Jefferson Scale of Patient Perception of Physician Empathy (JSPPPE), Trust in Physicians Survey (TIPS), and the Group Based Medical Mistrust Scale (GBMMS). We stratified results by patient demographics including gender, race, and education.

RESULTS

We enrolled 305 participants across 9 sites with diverse geographic, racial, and ethnic representation. The median scores (interquartile ranges) for the JSPPPE, TIPS, and GBMMS for all patients were 29 (24-33.5), 55 (47-62), and 18 (12-29). Compared with white patients, nonwhite patients had similar JSPPPE and TIPS scores but had higher (worse) GBMMS scores. Females had significantly lower JSPPPE and TIPS scores than males, and scores were lower (worse) in females with college degrees. Patients in the lowest tier of educational status had the highest (better) JSPPPE and TIPS scores. Scores were invariant with physician characteristics.

CONCLUSION

Among patients undergoing low-value CT scanning in the ED, the degree of patient perception of physician empathy and trust varied based on the patients' level of education and gender. Given this variation, an intervention to increase patient perception of physician empathy should contain individualized strategies to address these subgroups, rather than a one-size-fits-all approach.