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Sullivan N, Schorpp H, Crosky S, Thien S, Helmer DA, Litke DR, Pigeon WR, Quigley KS, McAndrew LM. Treatment and life goals among veterans with Gulf War illness. PLoS One 2023; 18:e0295168. [PMID: 38033143 PMCID: PMC10688846 DOI: 10.1371/journal.pone.0295168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 11/16/2023] [Indexed: 12/02/2023] Open
Abstract
Medically unexplained syndromes (MUS), also termed persistent physical symptoms, are both prevalent and disabling. Yet treatments for MUS are marked by high rates of patient dissatisfaction, as well as disagreement between patients and providers on the management of persistent physical symptoms. A better understanding of patient-generated goals could increase collaborative goal setting and promote person-centered care, a critical component of MUS treatment; yet research in this area is lacking. This paper aimed to develop a typology of treatment and life goals among Gulf War veterans with a medically unexplained syndrome (Gulf War Illness). We examined participants' responses to open-ended questions about treatment and life goals using Braun and Clarke's thematic analysis methodology. Results showed that treatment goals could be categorized into four overarching themes: 1) Get better/healthier, 2) Improve quality of life, 3) Improve or seek additional treatment, and 4) Don't know/Don't have any. Life goals were categorized into six overarching themes: 1) Live a fulfilling life, 2) Live a happy life, 3) Live a healthy life, 4) Be productive/financially successful, 5) Manage GWI, and 6) Don't know/Don't have any. Treatment goals were largely focused on getting better/healthier (e.g., improving symptoms), whereas life goals focused on living a fulfilling life. Implications for the treatment of Gulf War Illness and patient-provider communication are discussed. ClinicalTrials.gov Identifier: NCT02161133.
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Affiliation(s)
- Nicole Sullivan
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, East Orange, NJ, United States of America
| | - Hannah Schorpp
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, East Orange, NJ, United States of America
- Department of Psychology, William Paterson University, Wayne, NJ, United States of America
| | - Sarah Crosky
- Department of Educational and Counseling Psychology, University at Albany, Albany, NY, United States of America
| | - Scott Thien
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, East Orange, NJ, United States of America
| | - Drew A. Helmer
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States of America
- Department of Medicine, Baylor College of Medicine, Houston, TX, United States of America
| | - David R. Litke
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, East Orange, NJ, United States of America
- Department of Rehabilitation Medicine, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Wilfred R. Pigeon
- Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY, United States of America
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, United States of America
| | - Karen S. Quigley
- Department of Psychology, Northeastern University, Boston, MA, United States of America
| | - Lisa M. McAndrew
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, East Orange, NJ, United States of America
- Department of Educational and Counseling Psychology, University at Albany, Albany, NY, United States of America
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Weigel A, Hüsing P, Junge M, Löwe B. Helpful explanatory models for persistent somatic symptoms (HERMES): Results of a three-arm randomized-controlled pilot trial. J Psychosom Res 2023; 172:111419. [PMID: 37352693 DOI: 10.1016/j.jpsychores.2023.111419] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 06/14/2023] [Accepted: 06/16/2023] [Indexed: 06/25/2023]
Abstract
OBJECTIVE This three-arm randomized controlled trial aimed to test the efficacy of an etiological model for persistent somatic symptoms (PSS) translated into video-animated explanatory models in comparison to a control group, and to examine additional value of personalization of the explanatory models (i.e. possibility to choose information based on mechanisms of symptom persistence). METHODS Outpatients with PSS were shown one of three 15-min video animations: a) explanatory model without personalization, b) explanatory model with personalization, c) no explanatory model control group. Changes in somatic symptom severity (PHQ-15) and psychological burden related to somatic symptoms or associated health concerns (SSD-12) from baseline to one-month follow-up were the primary outcome. Health-related quality of life (SF-12) and perceived usefulness (USE) were also assessed. RESULTS Seventy-five patients with PSS were allocated to the study arms (Mage = 44.2 ± 13.3 years, 56% female). The study arms did not differ significantly on the primary outcomes. However, no explanatory model participants reported significantly greater mental quality of life improvements than explanatory model without personalization participants (Mdiff = 7.50 [0.43; 14.56]). Further, explanatory model with personalization participants rated the individual fit of the intervention significantly higher than no explanatory model participants (Mdiff = 2.05 [0.17; 3.93]). All groups rated credibility of the intervention as very high. CONCLUSION The HERMES materials seemed to have been too brief to improve symptom related outcomes. However, all three interventions were positively evaluated regarding their usefulness, particularly in case of additional personalization. Future studies should investigate potential effects of an increased intervention dose. TRIAL REGISTRATION DRKS00018803.
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Affiliation(s)
- Angelika Weigel
- University Medical Center Hamburg-Eppendorf, Department of Psychosomatic Medicine and Psychotherapy, Hamburg, Germany.
| | - Paul Hüsing
- University Medical Center Hamburg-Eppendorf, Department of Psychosomatic Medicine and Psychotherapy, Hamburg, Germany.
| | - Magdalena Junge
- University Medical Center Hamburg-Eppendorf, Department of Psychosomatic Medicine and Psychotherapy, Hamburg, Germany.
| | - Bernd Löwe
- University Medical Center Hamburg-Eppendorf, Department of Psychosomatic Medicine and Psychotherapy, Hamburg, Germany.
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McGhie-Fraser B, Lucassen P, Ballering A, Abma I, Brouwers E, van Dulmen S, Olde Hartman T. Persistent somatic symptom related stigmatisation by healthcare professionals: A systematic review of questionnaire measurement instruments. J Psychosom Res 2023; 166:111161. [PMID: 36753936 DOI: 10.1016/j.jpsychores.2023.111161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Patients with persistent somatic symptoms (PSS) experience stigmatising attitudes and behaviours by healthcare professionals. While previous research has focussed on individual manifestations of PSS related stigma, less is known about sound ways to measure stigmatisation by healthcare professionals towards patients with PSS. This review aims to assess the quality of questionnaire measurement instruments and make recommendations about their use. METHODS A systematic review using six databases (PubMed, Embase, CINAHL, PsycINFO, Open Grey and EThOS). The search strategy combined three search strings related to healthcare professionals, PSS and stigma. Additional publications were identified by searching bibliographies. Three authors independently extracted the data. Data analysis and synthesis followed COSMIN methodology for reviews of outcome measurement instruments. RESULTS We identified 90 publications that met the inclusion criteria using 62 questionnaire measurement instruments. Stereotypes were explored in 92% of instruments, prejudices in 52% of instruments, and discrimination in 19% of instruments. The development process of the instruments was not rated higher than doubtful. Construct validity, structural validity, internal consistency and reliability were the most commonly investigated measurement properties. Evidence around content validity was inconsistent or indeterminate. CONCLUSION No instrument provided acceptable evidence on all measurement properties. Many instruments were developed for use within a single publication, with little evidence of their development or establishment of content validity. This is problematic because stigma instruments should reflect the challenges that healthcare professionals face when working with patients with PSS. They should also reflect the experiences that patients with PSS have widely reported during clinical encounters.
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Affiliation(s)
- Brodie McGhie-Fraser
- Radboud University Medical Center, Radboud Institute for Health Services Research, Department of Primary and Community Care, Nijmegen, the Netherlands.
| | - Peter Lucassen
- Radboud University Medical Center, Radboud Institute for Health Services Research, Department of Primary and Community Care, Nijmegen, the Netherlands.
| | - Aranka Ballering
- University of Groningen, University Medical Center Groningen, Department of Psychiatry, Groningen, the Netherlands.
| | - Inger Abma
- Radboud University Medical Center, Radboud Institute of Health Sciences, IQ Healthcare, Nijmegen, the Netherlands.
| | - Evelien Brouwers
- Tranzo, Scientific Center for Care and Wellbeing, Tilburg University, Tilburg, the Netherlands.
| | - Sandra van Dulmen
- Radboud University Medical Center, Radboud Institute for Health Services Research, Department of Primary and Community Care, Nijmegen, the Netherlands; Nivel (Netherlands Institute for Health Services Research), Utrecht, the Netherlands; Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Sweden.
| | - Tim Olde Hartman
- Radboud University Medical Center, Radboud Institute for Health Services Research, Department of Primary and Community Care, Nijmegen, the Netherlands.
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Swainston K, Thursby S, Bell B, Poulter H, Dismore L, Copping L. What psychological interventions are effective for the management of persistent physical symptoms (PPS)? A systematic review and meta-analysis. Br J Health Psychol 2023; 28:80-97. [PMID: 35837827 PMCID: PMC10084386 DOI: 10.1111/bjhp.12613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 06/17/2022] [Indexed: 01/10/2023]
Abstract
OBJECTIVES Presentation of persistent physical symptoms is associated with increased health care utilization, yet clinical outcomes often remain suboptimal. This systematic review aimed to determine whether psychological interventions are effective for the management of PPS and if so, what are the features of the interventions and at what level of care are they delivered. The review also set out to establish which symptoms in those diagnosed with PPS can be effectively managed with psychological intervention. METHODS Studies were included if they clearly reported a psychological intervention, specified the study sample as adults with a diagnosis of persistent physical symptoms, included a comparator and as a minimum an outcome measure of somatic symptoms. Risk of bias was assessed using the EPHPP. Meta-analysis was conducted to estimate the overall effect of interventions on somatic symptoms (the primary outcome), anxiety and depression (secondary outcomes). RESULTS Seventeen papers of varying quality indicated that psychological interventions can be effective for the management of somatic symptoms reported by individuals with PPS within a primary care setting. Psychological interventions were also found to be effective at reducing depression symptoms in individuals with PPS in twelve of the included studies. However, the meta-analysis results suggest that the psychological interventions utilized within eleven of the included studies did not significantly impact anxiety symptoms. CONCLUSIONS Psychological interventions have some success in managing somatic symptoms in PPS patients within primary care settings although their effects on other psychological symptoms is more mixed. The review highlights the importance of establishing a clearer diagnostic classification to inform treatment trajectories and the need for appropriate training and support within a multi-disciplinary team to enable the provision of such therapies.
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Affiliation(s)
- Katherine Swainston
- Faculty of Medical Sciences, School of Psychology, Newcastle University, Newcastle-upon-Tyne, UK
| | - Stacie Thursby
- Northumbria Healthcare NHS Foundation Trust, North Tyneside General Hospital, North Shields, UK
| | - Blossom Bell
- School of Social Sciences, Humanities & Law, Teesside University, Middlesbrough, UK
| | - Hannah Poulter
- School of Social Sciences, Humanities & Law, Teesside University, Middlesbrough, UK
| | - Lorelle Dismore
- Northumbria Healthcare NHS Foundation Trust, North Tyneside General Hospital, North Shields, UK
| | - Lee Copping
- School of Social Sciences, Humanities & Law, Teesside University, Middlesbrough, UK
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Stieler M, Pockney P, Campbell C, Thirugnanasundralingam V, Gan L, Spittal MJ, Carter G. OUP accepted manuscript. BJS Open 2022; 6:6633165. [PMID: 35796068 PMCID: PMC9260183 DOI: 10.1093/bjsopen/zrac046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 02/26/2022] [Accepted: 03/08/2022] [Indexed: 11/21/2022] Open
Abstract
Background Somatic syndromes are present in 30 per cent of primary healthcare populations and are associated with increased health service use and health costs. Less is known about secondary care surgical inpatient populations. Methods This was a prospective longitudinal cohort study (n = 465) of consecutive adult admissions with an episode of non-traumatic abdominal pain, to the Acute General Surgical Unit at a tertiary hospital in New South Wales, Australia. Somatic symptom severity (SSS) was dichotomized using the Patient Health Questionnaire (PHQ)-15 with a cut-off point of 10 or higher (medium–high SSS) and compared pre-admission and during admission. Total healthcare utilization and direct costs were stratified by a PHQ-15 score of 10 or higher. Linear regression was used to examine differences in costs, and a multivariable linear regression was used to examine the relationship of PHQ-15 scores of 10 or higher to total costs, reported as mean total costs of care and percentage difference (95 per cent confidence intervals). Results Fifty-two per cent (n = 242) of participants had a medium–high SSS with greater pre-admission and admission interval health service costs. Mean total direct costs of care were 25 per cent (95 per cent c.i. 8 to 44 per cent) higher in the PHQ-15 score of 10 or higher group: mean difference €1401.93 (95 per cent c.i. €512.19 to €2273.67). The multivariable model showed a significant association of PHQ-15 scores of 10 or higher (2.1 per cent; 0.2–4.1 per cent greater for each one-point increase in score) with total hospital costs, although the strongest contributions to cost were older age, operative management, and lower socioeconomic level. There was a linear relationship between PHQ scores and total healthcare costs. Conclusions Medium to high levels of somatic symptoms are common in surgical inpatients with abdominal pain and are independently associated with greater healthcare utilization.
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Affiliation(s)
| | - Peter Pockney
- College of Health, Medicine and Wellbeing, School of Medicine and Health Sciences, University of Newcastle, Callaghan, New South Wales, Australia
| | - Cassidy Campbell
- Department of Surgery, John Hunter Hospital, Newcastle, New South Wales, Australia
| | | | - Lachlan Gan
- Department of Surgery, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Matthew J Spittal
- Melbourne School of Population and Global Health, The University of Melbourne, Victoria, Australia
| | - Gregory Carter
- College of Health, Medicine and Wellbeing, School of Medicine and Health Sciences, University of Newcastle, Callaghan, New South Wales, Australia
- Department of Consultation-Liaison Psychiatry, Calvary Mater Newcastle, Waratah, New South Wales, Australia
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Testa S, Joshi M, Lotfi J, Lin B, Artandi M, Chiang KF, Chang K, Singh B, Geng LN. Training Internal Medicine Residents in Difficult Diagnosis: A Novel Diagnostic Second Opinion Clinic Experience. JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2022; 9:23821205221091036. [PMID: 35372696 PMCID: PMC8972929 DOI: 10.1177/23821205221091036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 03/14/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND In primary care clinics, time constraints and lack of exposure to highly complex cases may limit the breadth and depth of learning for internal medicine residents. To address these issues, we piloted a novel experience for residents to evaluate patients with puzzling symptoms referred by another clinician. OBJECTIVE To increase internal medicine residents' exposure to patients with perplexing presentations and foster a team-based approach to solving diagnostically challenging cases. METHODS During the academic year 2020-2021, residents participating in their 2-week primary care "block" rotation were given protected time to evaluate 1-2 patients from the Stanford Consultative Medicine clinic, an internist-led diagnostic second opinion service, and present their patients at the case conference. We assessed the educational value of the program with resident surveys including 5-point Lickert scale and open-ended questions. RESULTS 21 residents participated in the pilot with a survey response rate of 66.6% (14/21). Both the educational value and overall quality of the experience were rated as 4.8 out of 5 (SD 0.4, range 4-5; 1:"very poor"; 5:"excellent"). Residents learned about new diagnostic tools as well as how to approach complex presentations and diagnostic dilemmas. Residents valued the increased time devoted to patient care, the team-based approach to tackling difficult cases, and the intellectual challenge of these cases. Barriers to implementation include patient case volume, time, and faculty engagement. CONCLUSIONS Evaluation of diagnostically challenging cases in a structured format is a highly valuable experience that offers a framework to enhance outpatient training in internal medicine.
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Affiliation(s)
| | - Mugdha Joshi
- Stanford Department of Medicine, Stanford, CA, USA
| | - Justin Lotfi
- Stanford Department of Medicine, Stanford, CA, USA
| | - Bryant Lin
- Stanford Department of Medicine, Stanford, CA, USA
| | - Maja Artandi
- Stanford Department of Medicine, Stanford, CA, USA
| | | | - Kevin Chang
- Stanford Department of Medicine, Stanford, CA, USA
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Stortenbeker I, Olde Hartman T, Kwerreveld A, Stommel W, van Dulmen S, Das E. Unexplained versus explained symptoms: The difference is not in patients' language use. A quantitative analysis of linguistic markers. J Psychosom Res 2021; 152:110667. [PMID: 34775157 DOI: 10.1016/j.jpsychores.2021.110667] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 11/02/2021] [Accepted: 11/03/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Patients with medically unexplained symptoms (MUS) are believed to have a deviant way of talking about complaints. This study systematically compared linguistic markers in symptom presentations of patients with MUS and medically explained symptoms (MES). METHODS This content analysis (cross-sectional study) conceptualized relevant linguistic markers based on previous research about MUS communication. Linguistic markers included negations ("not"), intensifiers ("very"), diminishers ("a little"), first or third person subject ("I" vs. "my body"), subjectivity markers ("I think") and abstraction ("I'm gasping for breath" vs. "I'm short of breath"). We also coded valence, reference to physical or mental states, and consultation phase. We compared 41 MUS and 41 MES transcribed video-recorded general practice consultations. Data were analyzed with binary random intercepts models. RESULTS We selected and coded 2752 relevant utterances. Patients with MUS used less diminishers compared to patients with MES, but this main effect disappeared when consultation phase was included as predictor. For all other linguistic variables, the analyses did not reveal any variation in language use based on whether patients had MUS or MES. Importantly, utterances' valence and reference to physical or mental state did predict the use of linguistic markers. CONCLUSION We observed no systematic variations in linguistic markers for patients who suffered from MUS compared to MES. Patients varied their language use based on utterances' valence and reference to physical or mental states. Current ideas about deviant patient communication may be based on stigmatized perceptions of how patients with MUS communicate, rather than actual differences in their talk.
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Affiliation(s)
- Inge Stortenbeker
- Centre for Language Studies, Radboud University, Nijmegen, the Netherlands.
| | - Tim Olde Hartman
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Primary and Community Care, Nijmegen, the Netherlands
| | - Anita Kwerreveld
- Centre for Language Studies, Radboud University, Nijmegen, the Netherlands
| | - Wyke Stommel
- Centre for Language Studies, Radboud University, Nijmegen, the Netherlands
| | - Sandra van Dulmen
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Primary and Community Care, Nijmegen, the Netherlands; NIVEL (Netherlands institute for health services research), Utrecht, the Netherlands; Faculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway
| | - Enny Das
- Centre for Language Studies, Radboud University, Nijmegen, the Netherlands
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McAndrew LM, Khatib LA, Sullivan NL, Winograd DM, Kolar SK, Santos SL. Healthcare providers' perceived learning needs and barriers to providing care for chronic multisymptom illness and environmental exposure concerns. Life Sci 2021; 284:119757. [PMID: 34425128 DOI: 10.1016/j.lfs.2021.119757] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 06/08/2021] [Accepted: 06/16/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Patient provider encounters for chronic multisympom illness (CMI) and/or environmental exposures are difficult often resulting in Veterans and providers having high levels of dissatisfaction. Patients attribute these difficulties to providers lacking knowledge about these health concerns. It is not known whether providers perceive themselves as lacking expertise in CMI and environmental exposure concerns. METHODS This needs assessment used a descriptive online survey design. A total of 3632 VA healthcare providers across disciplines were surveyed. RESULTS Healthcare providers reported speaking with Veterans about CMI and environmental exposures despite feeling they have minimal to no knowledge of these topics. At the same time, only half of the providers had taken an available training on CMI or environmental exposure within the last year. CONCLUSION Healthcare providers recognize a knowledge gap regarding CMI and environmental exposures, despite this, there is low uptake of provider education on these topics. PRACTICE IMPLICATIONS A better understanding of barriers to uptake of training on CMI and environmental exposures is needed to increase engagement with these important trainings.
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Affiliation(s)
- Lisa M McAndrew
- War Related Illness and Injury Study Center (WRIISC), Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ 07018, USA; Department of Educational and Counseling Psychology, University at Albany, Albany, NY 12222, USA.
| | - Linda A Khatib
- War Related Illness and Injury Study Center (WRIISC), Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ 07018, USA.
| | - Nicole L Sullivan
- War Related Illness and Injury Study Center (WRIISC), Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ 07018, USA.
| | - Darren M Winograd
- Department of Educational and Counseling Psychology, University at Albany, Albany, NY 12222, USA.
| | - Stephanie K Kolar
- Employee Education System, Veterans Health Administration Veterans Affairs, Long Beach Medical Facility, 901 East 7thStreet, Long Beach, CA 90822, USA.
| | - Susan L Santos
- War Related Illness and Injury Study Center (WRIISC), Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ 07018, USA.
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Cathébras P. Patient-Centered Medicine: A Necessary Condition for the Management of Functional Somatic Syndromes and Bodily Distress. Front Med (Lausanne) 2021; 8:585495. [PMID: 33987188 PMCID: PMC8110699 DOI: 10.3389/fmed.2021.585495] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 03/10/2021] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Pascal Cathébras
- Department of Internal Medicine, Jean-Monnet University, Saint-Etienne, France
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Polakovská L, Řiháček T. What is it like to live with medically unexplained physical symptoms? A qualitative meta-summary. Psychol Health 2021; 37:580-596. [PMID: 33872098 DOI: 10.1080/08870446.2021.1901900] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Medically unexplained physical symptoms (MUPS) are a frequent phenomenon. Understanding adults and adolescents' lived experience with MUPS is essential for providing adequate care, yet a rigorous synthesis of existing studies is missing. Objective: This study aimed to summarize findings from primary qualitative studies focused on adults' and adolescents' experience of living with MUPS. Design: Qualitative studies were searched in the PsycINFO, PsycARTICLES, and Medline databases and manually. A total of 23 resources met the inclusion criteria and were subjected to a qualitative meta-summary. Results: Eight themes were found across the set of primary studies, namely, the need to feel understood, struggling with isolation, 'sense of self' in strain, facing uncertainty, searching for explanations, ambivalence about diagnosis, disappointed by healthcare, and active coping. Conclusion: The eight themes represent the core struggles adults' and adolescents' with MUPS face in their lives, psychologically and socially. Although these themes appear to be universal, the analysis also revealed considerable variability of experience in terms of expectations from healthcare professionals, attitude towards formal diagnoses, ability to cope with the illness, or potential to transform the illness experience into personal growth. Addressing this diversity of needs represents a significant challenge for the healthcare system.
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Affiliation(s)
- Lucia Polakovská
- Faculty of Social Studies, Department of Psychology, Masaryk University, Brno, Czech Republic
| | - Tomáš Řiháček
- Faculty of Social Studies, Department of Psychology, Masaryk University, Brno, Czech Republic
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Hüsing P, Löwe B, Olde Hartman TC, Frostholm L, Weigel A. Helpful explanatory models for somatoform symptoms (HERMES): study protocol of a randomised mixed-methods pilot trial. BMJ Open 2021; 11:e044244. [PMID: 33762239 PMCID: PMC7993177 DOI: 10.1136/bmjopen-2020-044244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Persistent somatic symptoms (PSS) are common both in the general population and primary care. They are bothersome in terms of psychological and somatic symptom burden. Health professionals often struggle with communication, as there is a lack of scientifically supported explanatory models for PSS or a focus merely on somatic aspects of the complaints, which both frustrate patients' needs. The objective of the present study is therefore to develop a psychoeducational intervention based on a current evidence-based explanatory model, to examine its feasibility and form the basis for a large-scale randomised controlled trial. METHODS AND ANALYSIS In a randomised controlled mixed-methods pilot trial, 75 adult psychosomatic outpatients with PSS (duration of symptoms ≥6 months) and accompanying psychological (Somatic Symptom B-Criteria Scale total score ≥18) and somatic symptom burden (Patient Health Questionnaire-15 score >10) and no prior psychosomatic treatment will be eligible. Participants will be presented with either the explanatory model without (intervention group 1, n=25) or with elements of personalisation (intervention group 2, n=25). Participants in the control group (n=25) will receive information on current PSS guidelines. Participants will be blinded to group assignment and interventions will be shown on tablet computers at the outpatient clinic. After 1 month, qualitative follow-up telephone interviews will be conducted. As primary outcomes, mean changes in psychological and somatic symptom burden will quantitatively be compared between groups, respectively. Behavioural change mechanisms and feasibility of the three interventions will be evaluated using quantitative and qualitative measures. ETHICS AND DISSEMINATION Ethics approval has been granted by the medical ethics board of the Hamburg Medical Chamber (PV5653). Results from this study will be published in peer-reviewed journals and presented at national and international conferences. TRIAL REGISTRATION NUMBER DRKS00018803.
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Affiliation(s)
- Paul Hüsing
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bernd Löwe
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tim C Olde Hartman
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lisbeth Frostholm
- Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Aarhus, Denmark
| | - Angelika Weigel
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Houwen J, Lucassen PLBJ, Stappers HW, van Spaendonck K, van Duijnhoven A, Hartman TCO, van Dulmen S. How to learn skilled communication in primary care MUS consultations: a focus group study. Scand J Prim Health Care 2021; 39:101-110. [PMID: 33569982 PMCID: PMC7971340 DOI: 10.1080/02813432.2021.1882088] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Many general practitioners (GPs) experience communication problems in medically unexplained symptoms (MUS) consultations as they are insufficiently equipped with adequate communication skills or do not apply these in MUS consultations. OBJECTIVE To define the most important learnable communication elements during MUS consultations according to MUS patients, GPs, MUS experts and teachers and to explore how these elements should be taught to GPs and GP trainees. METHODS Five focus groups were conducted with homogeneous groups of MUS patients, GPs, MUS experts and teachers. MUS patients and GPs formulated a list of important communication elements. MUS experts identified from this list the most important communication elements. Teachers explored how these elements could be trained to GPs and GP trainees. Two researchers independently analysed the data applying the principles of constant comparative analysis. RESULTS MUS patients and GPs identified a list of important communication elements. From this list, MUS experts selected five important communication elements: (1) thorough somatic and psychosocial exploration, (2) communication with empathy, (3) creating a shared understanding of the problem, (4) providing a tangible explanation and (5) taking control. Teachers described three teaching methods for these communication elements: (1) awareness and reflection of GPs about their feelings towards MUS patients, (2) assessment of GPs' individual needs and (3) training and supervision in daily practice. CONCLUSION Teachers consider a focus on personal attitudes and needs, which should be guided by opportunities to practice and receive supervision, as the best method to teach GPs about communication in MUS consultations.KEY POINTSMany GPs experience difficulties in communication with patients with MUS.There is a need to equip GPs with communication skills to manage MUS consultations more adequately.Role-playing with simulation patients, reflection on video-consultations and joint consultations with the supervisor may increase the GPs' awareness of their attitude towards MUS patients and may help GPs to identify their individual learning-points.
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Affiliation(s)
- Juul Houwen
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- CONTACT Juul Houwen Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Centre, Geert Grooteplein, 21, Nijmegen6525 EZ, The Netherlands
| | - Peter L. B. J. Lucassen
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hugo W. Stappers
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Karel van Spaendonck
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Aniek van Duijnhoven
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Tim C. olde Hartman
- Department of Primary and Community Care, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sandra van Dulmen
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
- Faculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway
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13
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Winograd DM, Sullivan NL, Thien SR, Pigeon WR, Litke DR, Helmer DA, Rath JF, Lu SE, McAndrew LM. Veterans with Gulf War Illness perceptions of management strategies. Life Sci 2021; 279:119219. [PMID: 33592197 DOI: 10.1016/j.lfs.2021.119219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 01/21/2021] [Accepted: 01/29/2021] [Indexed: 10/22/2022]
Abstract
AIMS Gulf War Illness (GWI) is a prevalent and disabling condition characterized by persistent physical symptoms. Clinical practice guidelines recommend self-management to reduce the disability from GWI. This study evaluated which GWI self-management strategies patients currently utilize and view as most effective and ineffective. MATERIALS AND METHODS Data were collected from 267 Veterans during the baseline assessment of a randomized clinical trial for GWI. Respondents answered 3 open-ended questions regarding which self-management strategies they use, view as effective, and view as ineffective. Response themes were coded, and code frequencies were analyzed. KEY FINDINGS Response frequencies varied across questions (in-use: n = 578; effective: n = 470; ineffective: n = 297). Healthcare use was the most commonly used management strategy (38.6% of 578), followed by lifestyle changes (28.5% of 578), positive coping (13% of 578), and avoidance (13.7% of 578). When asked about effective strategies, healthcare use (25.9% of 470), lifestyle change (35.7% of 470), and positive coping (17.4% of 470) were identified. Avoidance was frequently identified as ineffective (20.2% of 297 codes), as was invalidating experiences (14.1% of 297) and negative coping (10.4% of 297). SIGNIFICANCE Patients with GWI use a variety of self-management strategies, many of which are consistent with clinical practice guidelines for treating GWI, including lifestyle change and non-pharmacological strategies. This suggests opportunities for providers to encourage effective self-management approaches that patients want to use.
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Affiliation(s)
- Darren M Winograd
- University at Albany, State University of New York, 1400 Washington Ave., Albany, NY 12222, USA
| | - Nicole L Sullivan
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Healthcare System, East Orange, NJ 07018, USA
| | - Scott R Thien
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Healthcare System, East Orange, NJ 07018, USA
| | - Wilfred R Pigeon
- VISN 2 Center of Excellence for Suicide Prevention, Veterans Affairs Finger Lakes Healthcare System, Canandaigua, NY, USA; Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA
| | - David R Litke
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Healthcare System, East Orange, NJ 07018, USA; Department of Rehabilitation Medicine, NYU Grossman School of Medicine, New York, NY 10016, USA
| | - Drew A Helmer
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA
| | - Joseph F Rath
- Department of Rehabilitation Medicine, NYU Grossman School of Medicine, New York, NY 10016, USA
| | - Shou-En Lu
- Rutgers Unviersity, Piscataway, NJ 08854, USA
| | - Lisa M McAndrew
- University at Albany, State University of New York, 1400 Washington Ave., Albany, NY 12222, USA; War Related Illness and Injury Study Center, Veterans Affairs New Jersey Healthcare System, East Orange, NJ 07018, USA.
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14
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Yonatan-Leus R, Strauss AY, Cooper-Kazaz R. Psychodynamic psychotherapy is associated with sustained reduction in health care utilization and cost. Clin Psychol Psychother 2020; 28:642-655. [PMID: 33142005 DOI: 10.1002/cpp.2527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 10/27/2020] [Accepted: 10/27/2020] [Indexed: 11/10/2022]
Abstract
Our objective was to examine the effectiveness and efficiency of psychodynamic psychotherapy on the reduction in health care utilization and cost while controlling for age, gender, and year. Health care utilization and cost were examined yearly in 1,675 patients from 2 years before outpatient psychotherapy (i.e., baseline) to three consecutive years after psychotherapy in a naturalistic longitudinal design. A multilevel analytic approach (LMLM) was applied to account for repeated measures effect and missing data. In the year prior to psychotherapy, there was a significant increase in total cost compared with baseline (14.8%) and in use of health care services (primary and specialist doctors' visits and outsourced referrals). In the first year following therapy, there was a significant decrease in total cost (10%) and in use of health care services (all doctors' visits, imaging, and outsourced referrals). The decrease was to baseline levels or lower and was maintained for two additional years. Psychiatric medication usage increased significantly after psychotherapy and remained so. The overall cumulative decrease in total cost per patient over 3 years after therapy was 3,665.92 NIS, equalling a 69% average cost of psychotherapy. Further cost saving can be expected due to the reduction in sick leave, disability, and psychiatric hospitalization. These findings support the notion that providing outpatient psychodynamic psychotherapy can be financially beneficial to health care systems, although further research is required for causal inferences. Also, an increase in health care utilization along with scarce physical findings may indicate unaddressed psychological distress and warrant referral for mental assessment and possible psychotherapy.
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Affiliation(s)
- Refael Yonatan-Leus
- Department of Psychology, The Hebrew University of Jerusalem, Jerusalem, Israel.,Mental Health Services (Talbiya), Clalit Health Services-Jerusalem, Affiliated with The Faculty of Medicine at The Hebrew University Jerusalem, Jerusalem, Israel
| | - Asher Y Strauss
- Department of Psychology, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Rena Cooper-Kazaz
- Mental Health Services (Talbiya), Clalit Health Services-Jerusalem, Affiliated with The Faculty of Medicine at The Hebrew University Jerusalem, Jerusalem, Israel
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15
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Fardman A, Livne M, Goldkorn R, Goitein O, Shlomo N, Asher E, Grupper A, Naroditsky M, Matetzky S, Beigel R. The efficacy and safety of evaluating elderly patients using a comprehensive diagnostic protocol via a chest pain unit. Intern Emerg Med 2020; 15:1061-1066. [PMID: 32034673 DOI: 10.1007/s11739-020-02289-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 01/29/2020] [Indexed: 11/26/2022]
Abstract
Elderly patients are often excluded from a chest pain unit (CPU)-based evaluation of chest pain due to concern about adverse events and poorer outcomes. The aim of this study was to assess the feasibility and safety of thoroughly evaluating elderly patients ≥ 65 years of age presented with acute chest pain via a CPU. We evaluated 1220 consecutive patients admitted to our CPU, and stratified them according to age: those over and those under 65 years. Patients were evaluated for outcomes during hospitalization and for a composite endpoint at 60 days post discharge which included: recurrent hospitalization due to chest pain, need for coronary revascularization, acute coronary syndrome, and death. Overall, 241 (20%) patients were in the ≥ 65-year-old group and 979 (80%) patients in the group < 65 years of age. Older patients were more likely to be female, have more co-morbidities, and a history of prior coronary artery disease. There was no difference between the two groups regarding in-hospital course, including hospitalization in the CPU (9.5% vs. 11.6%, p = 0.37), coronary angiography (7.9% vs. 9.8%, p = 0.37), and revascularization performed during the evaluation period (4.5% vs. 3.3%, p = 0.42). Of those discharged, the primary endpoint at 60 days was observed in 11 (1.5%) and 7 (3.9%) patients in those under and over 65 years, respectively, (p = 0.13). No mortalities were recorded. Comprehensive evaluation via a CPU of patients who are ≥ 65 years of age is feasible and safe with in-hospital and short-term outcomes compared to their younger counterparts.
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Affiliation(s)
- Alexander Fardman
- Cardiovascular Division, Intensive Cardiac Care Unit, The Leviev Heart Center, Sheba Medical Center, 52621, Tel Hashomer, Israel
- The Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Moran Livne
- Cardiovascular Division, Intensive Cardiac Care Unit, The Leviev Heart Center, Sheba Medical Center, 52621, Tel Hashomer, Israel
- The Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Ronen Goldkorn
- Cardiovascular Division, Intensive Cardiac Care Unit, The Leviev Heart Center, Sheba Medical Center, 52621, Tel Hashomer, Israel
- The Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Orly Goitein
- Cardiovascular Division, Intensive Cardiac Care Unit, The Leviev Heart Center, Sheba Medical Center, 52621, Tel Hashomer, Israel
- The Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Nir Shlomo
- Cardiovascular Division, Intensive Cardiac Care Unit, The Leviev Heart Center, Sheba Medical Center, 52621, Tel Hashomer, Israel
- The Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Elad Asher
- Cardiovascular Division, Intensive Cardiac Care Unit, The Leviev Heart Center, Sheba Medical Center, 52621, Tel Hashomer, Israel
- The Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Avishay Grupper
- Cardiovascular Division, Intensive Cardiac Care Unit, The Leviev Heart Center, Sheba Medical Center, 52621, Tel Hashomer, Israel
- The Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Michael Naroditsky
- Cardiovascular Division, Intensive Cardiac Care Unit, The Leviev Heart Center, Sheba Medical Center, 52621, Tel Hashomer, Israel
- The Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Shlomi Matetzky
- Cardiovascular Division, Intensive Cardiac Care Unit, The Leviev Heart Center, Sheba Medical Center, 52621, Tel Hashomer, Israel
- The Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Roy Beigel
- Cardiovascular Division, Intensive Cardiac Care Unit, The Leviev Heart Center, Sheba Medical Center, 52621, Tel Hashomer, Israel.
- The Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel.
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16
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Terpstra T, Gol JM, Lucassen PLBJ, Houwen J, van Dulmen S, Berger MY, Rosmalen JGM, Olde Hartman TC. Explanations for medically unexplained symptoms: a qualitative study on GPs in daily practice consultations. Fam Pract 2020; 37:124-130. [PMID: 31392313 DOI: 10.1093/fampra/cmz032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND General practice is the centre of care for patients with medically unexplained symptoms (MUS). Providing explanations for MUS, i.e. making sense of symptoms, is considered to be an important part of care for MUS patients. However, little is known how general practitioners (GPs) do this in daily practice. OBJECTIVE This study aimed to explore how GPs explain MUS to their patients during daily general practice consultations. METHODS A thematic content analysis was performed of how GPs explained MUS to their patients based on 39 general practice consultations involving patients with MUS. RESULTS GP provided explanations in nearly all consultations with MUS patients. Seven categories of explanation components emerged from the data: defining symptoms, stating causality, mentioning contributing factors, describing mechanisms, excluding explanations, discussing the severity of symptoms and normalizing symptoms. No pattern of how GPs constructed explanations with the various categories was observed. In general, explanations were communicated as a possibility and in a patient-specific way; however, they were not very detailed. CONCLUSION Although explanations for MUS are provided in most MUS consultations, there seems room for improving the explanations given in these consultations. Further studies on the effectiveness of explanations and on the interaction between patients and GP in constructing these explanations are required in order to make MUS explanations more suitable in daily primary care practice.
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Affiliation(s)
- Tom Terpstra
- Interdisciplinary Center Psychopathology and Emotion Regulation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Janna M Gol
- Interdisciplinary Center Psychopathology and Emotion Regulation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Peter L B J Lucassen
- Department of Primary and Community Care, Radboud University Medical Center, Donders Institute for Brain Cognition and Behaviour, Nijmegen, The Netherlands
| | - Juul Houwen
- Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Sandra van Dulmen
- Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.,NIVEL (Netherlands Institute for Health Services Research), BN Utrecht, The Netherlands.,Faculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway
| | - Marjolein Y Berger
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Judith G M Rosmalen
- Interdisciplinary Center Psychopathology and Emotion Regulation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Tim C Olde Hartman
- Department of Primary and Community Care, Radboud University Medical Center, Donders Institute for Brain Cognition and Behaviour, Nijmegen, The Netherlands
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17
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Medically unexplained symptoms: time to and triggers for diagnosis in primary care consultations. Br J Gen Pract 2020; 70:e86-e94. [PMID: 31932294 DOI: 10.3399/bjgp20x707825] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 07/16/2019] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND It is currently not known when in the consultation GPs label symptoms as medically unexplained and what triggers this. AIM To establish the moment in primary care consultations when a GP labels symptoms as medically unexplained and to explore what triggers them to do so. DESIGN AND SETTING This was a qualitative study. Data were collected in the Netherlands in 2015. METHOD GPs' consultations were video-recorded. GPs stated whether the consultation was about medically unexplained symptoms (MUS). The GP was asked to reflect on the video-recorded consultation and to indicate the moment when they labelled symptoms as MUS. Qualitative interviewing and analysis were performed to explore the triggers GPs perceived that caused them to label the symptoms as MUS. RESULTS A total of 43 of the 393 video-recorded consultations (11%) were labelled as MUS. The mean time until GPs labelled symptoms as medically unexplained was about 4 minutes for newly presented symptoms and 2 minutes for symptoms for which the patients had already visited the GP before. GPs were triggered to label symptoms as MUS in the consultation by: the way patients presented their symptoms; the symptoms not fitting into a specific pattern; patients attributing the symptoms to a psychosocial context; and a discrepancy between symptom presentation and objective findings. CONCLUSION Most GPs labelled the presented symptoms as medically unexplained soon after the start of the consultation. GPs are triggered to label symptoms as medically unexplained by patients' symptom presentation, symptom patterns, and symptom attribution. This suggests that non-analytical reasoning was a central component in their thought process.
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18
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Houwen J, Lucassen PLBJ, Verwiel A, Stappers HW, Assendelft WJJ, Olde Hartman TC, van Dulmen S. Which difficulties do GPs experience in consultations with patients with unexplained symptoms: a qualitative study. BMC FAMILY PRACTICE 2019; 20:180. [PMID: 31884966 PMCID: PMC6935475 DOI: 10.1186/s12875-019-1049-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 11/12/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Many general practitioners (GPs) struggle with the communication with patients with medically unexplained symptoms (MUS). This study aims to identify GPs' difficulties in communication during MUS consultations. METHODS We video-recorded consultations and asked GPs immediately after the consultation whether MUS were presented. GPs and patients were then asked to reflect separately on the consultation in a semi-structured interview while watching the consultation. We selected the comments where GPs experienced difficulties or indicated they should have done something else and analysed these qualitatively according to the principles of constant comparative analysis. Next, we selected those video-recorded transcripts in which the patient also experienced difficulties; we analysed these to identify problems in the physician-patient communication. RESULTS Twenty GPs participated, of whom two did not identify any MUS consultations. Eighteen GPs commented on 39 MUS consultations. In 11 consultations, GPs did not experience any difficulties. In the remaining 28 consultations, GPs provided 84 comments on 60 fragments where they experienced difficulties. We identified three issues for improvement in the GPs' communication: psychosocial exploration, structure of the consultation (more attention to summaries, shared agenda setting) and person-centredness (more attention to the reason for the appointment, the patient's story, the quality of the contact and sharing decisions). Analysis of the patients' views on the fragments where the GP experienced difficulties showed that in the majority of these fragments (n = 42) the patients' comments were positive. The video-recorded transcripts (n = 9) where the patient experienced problems too were characterised by the absence of a dialogue (the GP being engaged in exploring his/her own concepts, asking closed questions and interrupting the patient). CONCLUSION GPs were aware of the importance of good communication. According to them, they could improve their communication further by paying more attention to psychosocial exploration, the structure of the consultation and communicating in a more person-centred way. The transcripts where the patient experienced problems too, were characterised by an absence of dialogue (focussing on his/her own concept, asking closed questions and frequently interrupting the patient).
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Affiliation(s)
- Juul Houwen
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Geert Grooteplein 21, 6525 EZ, Nijmegen, The Netherlands.
| | - Peter L B J Lucassen
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Geert Grooteplein 21, 6525 EZ, Nijmegen, The Netherlands
| | - Anna Verwiel
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Geert Grooteplein 21, 6525 EZ, Nijmegen, The Netherlands
| | - Hugo W Stappers
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Geert Grooteplein 21, 6525 EZ, Nijmegen, The Netherlands
| | - Willem J J Assendelft
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Geert Grooteplein 21, 6525 EZ, Nijmegen, The Netherlands
| | - Tim C Olde Hartman
- Department of Primary and Community care, Donders Institute for Brain, Cognition and Behaviour, Radboud university medical center, Nijmegen, The Netherlands
| | - Sandra van Dulmen
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Geert Grooteplein 21, 6525 EZ, Nijmegen, The Netherlands
- Faculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway
- NIVEL (Netherlands institute for health services research), Utrecht, The Netherlands
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19
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Friedlander ML, Kangos K, Maestro K, Muetzelfeld H, Wright ST, Silva ND, Kimber J, Helmer DA, McAndrew LM. Introducing the System for Observing Medical Alliances (SOMA): A Tool for Studying Concordance in Patient-Physician Relationships. COUNSELING PSYCHOLOGIST 2019; 47:796-819. [PMID: 32372766 DOI: 10.1177/0011000019891434] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
We developed the System for Observing Medical Alliances (SOMA) to study relationships between medical providers and patients with medically unexplained symptoms (MUS). Based on literature in health psychology, medicine, and the psychotherapeutic alliance, the SOMA operationalizes three medical alliance dimensions: Engagement in the Consultation Process, Trust in the Provider, and Concordance of Illness Beliefs and Treatment Recommendations. Specific behavioral indicators, tallied as observed by trained judges, are used as the basis for rating each dimension. In a sample of 33 medical consultations with veterans who had MUS, interrater reliabilities ranged from .79 to .94. Notably, the other dimension ratings accounted for 40% of the variability in Concordance, with Trust in the Provider contributing unique variance. In addition to research, psychologists in integrated health settings can use the SOMA to consult and train medical providers on communication skills that enhance concordance.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Lisa M McAndrew
- Veterans Affairs New Jersey Health Care System, University at Albany
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20
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Warburton L, Hider SL, Mallen CD, Scott IC. Suspected very early inflammatory rheumatic diseases in primary care. Best Pract Res Clin Rheumatol 2019; 33:101419. [PMID: 31810550 DOI: 10.1016/j.berh.2019.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
As primary care clinicians are typically the first point of contact for patients with musculoskeletal problems, they are crucial to the early diagnosis and treatment of patients with an incident inflammatory arthritis, like rheumatoid arthritis. Current UK and international guidelines recognise this, recommending the prompt referral of patients with suspected persistent synovitis to secondary care. In England and Wales, this is advised to occur within 3 working days. However, recent audit data suggests this recommendation is infrequently met, with some patients waiting many months for referral. In this review article we will discuss the various challenges to achieving the early referral of patients with a new-onset inflammatory arthritis from primary to secondary care. We will also describe how these challenges could potentially be overcome, with the ultimate goal of ensuring that the right patients are referred to the right services, and at the right time.
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Affiliation(s)
| | - Samantha L Hider
- Primary Care Centre Versus Arthritis, Research Institute for Primary Care and Health Sciences, Primary Care Sciences, Keele University, Keele, UK; Haywood Academic Rheumatology Centre, Haywood Hospital, Midlands Partnership NHS Foundation Trust, High Lane, Burslem, Staffordshire, UK
| | - Christian D Mallen
- Primary Care Centre Versus Arthritis, Research Institute for Primary Care and Health Sciences, Primary Care Sciences, Keele University, Keele, UK; Haywood Academic Rheumatology Centre, Haywood Hospital, Midlands Partnership NHS Foundation Trust, High Lane, Burslem, Staffordshire, UK
| | - Ian C Scott
- Primary Care Centre Versus Arthritis, Research Institute for Primary Care and Health Sciences, Primary Care Sciences, Keele University, Keele, UK; Haywood Academic Rheumatology Centre, Haywood Hospital, Midlands Partnership NHS Foundation Trust, High Lane, Burslem, Staffordshire, UK.
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21
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van Westrienen PE, Pisters MF, Toonders SAJ, Gerrits M, de Wit NJ, Veenhof C. Quality of life in primary care patients with moderate medically unexplained physical symptoms. Qual Life Res 2019; 29:693-703. [PMID: 31732910 DOI: 10.1007/s11136-019-02358-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE Medically Unexplained Physical Symptoms (MUPS) have a large impact on patient's quality of life. Most studies have been limited to chronic MUPS and thus, little is known about moderate MUPS. Improved knowledge concerning determinants influencing quality of life in moderate MUPS patients can be helpful in managing MUPS. This study is aimed at describing the common characteristics seen in moderate MUPS patients and compare them with characteristics seen in chronic MUPS patients and general population. We also identified determinants of the physical and mental components of quality of life in moderate MUPS patients. METHODS In a cross-sectional study, moderate MUPS patients (n = 160) were compared with chronic MUPS patients (n = 162) and general population (n = 1742) based on demographic characteristics and patient's quality of life. Multivariable linear regression analyses were performed to identify determinants associated with a patient's quality of life, assessed with the RAND-36. RESULTS Moderate MUPS patients experienced a better quality of life than chronic MUPS patients, but a worse quality of life as compared to the general population. Determinants associated with the physical and mental components of quality of life explain 49.1% and 62.9% of the variance, respectively. CONCLUSION Quality of life of patients with MUPS varies with MUPS disease stage. Based on their quality of life scores, moderate MUPS patients would be adequately distinguished from chronic MUPS patients. Half of the variance in the physical component and almost two thirds of the mental component would be explained by a number of MUPS-related symptoms and perceptions.
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Affiliation(s)
- P E van Westrienen
- Department of Health Innovation and Technology, Fontys University of Applied Sciences, Ds Th Fliednerstraat 2, 5600 AH, Eindhoven, The Netherlands.
- Center for Physical Therapy Research and Innovation in Primary Care, Leidsche Rijn Julius Health Care Centers, Utrecht, The Netherlands.
- Physical Therapy Research, Department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - M F Pisters
- Department of Health Innovation and Technology, Fontys University of Applied Sciences, Ds Th Fliednerstraat 2, 5600 AH, Eindhoven, The Netherlands
- Center for Physical Therapy Research and Innovation in Primary Care, Leidsche Rijn Julius Health Care Centers, Utrecht, The Netherlands
- Physical Therapy Research, Department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - S A J Toonders
- Department of Health Innovation and Technology, Fontys University of Applied Sciences, Ds Th Fliednerstraat 2, 5600 AH, Eindhoven, The Netherlands
- Center for Physical Therapy Research and Innovation in Primary Care, Leidsche Rijn Julius Health Care Centers, Utrecht, The Netherlands
- Physical Therapy Research, Department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M Gerrits
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - N J de Wit
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - C Veenhof
- Center for Physical Therapy Research and Innovation in Primary Care, Leidsche Rijn Julius Health Care Centers, Utrecht, The Netherlands
- Physical Therapy Research, Department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
- Research Group Innovation of Human Movement Care, University of Applied Sciences Utrecht, Utrecht, The Netherlands
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Sharma S, Breckons M, Brönnimann Lambelet B, Chung J, List T, Lobbezoo F, Nixdorf DR, Oyarzo JF, Peck C, Tsukiyama Y, Ohrbach R. Challenges in the clinical implementation of a biopsychosocial model for assessment and management of orofacial pain. J Oral Rehabil 2019; 47:87-100. [DOI: 10.1111/joor.12871] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 07/18/2019] [Accepted: 08/05/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Sonia Sharma
- Department of Oral Diagnostic Sciences, School of Dental Medicine University at Buffalo Buffalo NY USA
- Department of Orofacial Pain and Jaw Function, Faculty of Odontology Malmö University Malmö Sweden
| | | | - Ben Brönnimann Lambelet
- Psychiatric Services of District Aargau Ambulatory Center for Psychiatry and Psychotherapy Aarau Switzerland
| | - Jin‐Woo Chung
- Department of Oral Medicine and Oral Diagnosis, School of Dentistry Seoul National University Seoul Korea
| | - Thomas List
- Department of Orofacial Pain and Jaw Function, Faculty of Odontology Malmö University Malmö Sweden
| | - Frank Lobbezoo
- Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam (ACTA) University of Amsterdam and Vrije Universiteit Amsterdam Amsterdam The Netherlands
| | - Donald R. Nixdorf
- Division of TMD and Orofacial Pain, School of Dentistry University of Minnesota Minneapolis MN USA
| | - Juan Fernando Oyarzo
- TMD and Orofacial Pain, Faculty of Odontology Universidad Andres Bello Santiago Chile
| | - Christopher Peck
- Faculty of Dentistry The University of Sydney Surry Hills NSW Australia
| | - Yoshihiro Tsukiyama
- Section of Dental Education, Faculty of Dental Science Kyushu University Fukuoka Japan
| | - Richard Ohrbach
- Department of Oral Diagnostic Sciences, School of Dental Medicine University at Buffalo Buffalo NY USA
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Kvamme MF, Wang CEA, Waage T, Risør MB. 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. HEALTH & SOCIAL CARE IN THE COMMUNITY 2019; 27:1175-1184. [PMID: 30969453 DOI: 10.1111/hsc.12762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 02/21/2019] [Accepted: 03/13/2019] [Indexed: 06/09/2023]
Abstract
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.
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Affiliation(s)
- Maria F Kvamme
- Department of Community Medicine, General Practice Research Unit, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Catharina E A Wang
- Department of Psychology, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Trond Waage
- Department of Social Sciences, Visual Cultural Studies, UiT The Arctic University of Norway, Tromsø, Norway
| | - Mette B Risør
- Department of Community Medicine, General Practice Research Unit, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
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24
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Phillips LA, McAndrew LM. Empirical Evaluation of Veterans' Perceived Non-Concordance with Providers Regarding Medically Unexplained Symptoms. COUNSELING PSYCHOLOGIST 2019; 47:770-795. [PMID: 32015569 DOI: 10.1177/0011000019890317] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Medically unexplained symptoms (MUS) are common among veterans and are difficult to treat. Optimal treatment entails continued care from providers, including primary care and counseling psychologists. Non-concordance between veterans' and providers' views of MUS may contribute to poor veteran satisfaction with care and possibly disengagement with care (e.g., non-adherence to treatment recommendations, including counseling and graded exercise). The current study surveyed 243 veterans with MUS post-deployment and evaluated the degree of non-concordance perceived by veterans with their primary care providers regarding their MUS and the effect of perceived non-concordance on treatment behaviors and outcomes. Many veterans in the current sample perceived non-concordance with their provider regarding their MUS (19% reporting quite a bit or complete disagreement). Perceived non-concordance (regarding MUS overall and specific causal perceptions) predicted important outcomes of interest, particularly veterans' satisfaction with their provider. Perceived concordance with primary care doctors may be required for sufficient adherence to MUS treatment recommendations, such as seeking and maintaining psychological counseling. Research should evaluate the effect of perceived concordance with the counseling psychologist on adherence to and outcomes from counseling for MUS.
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Affiliation(s)
| | - Lisa M McAndrew
- War Related Illness and Injury Study Center (WRIISC), Veterans Affairs New Jersey Healthcare System, East Orange, USA.,Department of Educational and Counseling Psychology EDU220, University at Albany, Albany, USA
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25
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McAndrew LM, Friedlander ML, Litke D, Phillips LA, Kimber J, Helmer DA. Medically Unexplained Physical Symptoms: What They Are and Why Counseling Psychologists Should Care about Them. COUNSELING PSYCHOLOGIST 2019; 47:741-769. [PMID: 32015568 PMCID: PMC6996203 DOI: 10.1177/0011000019888874] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Lisa M McAndrew
- Veterans Affairs New Jersey Health Care System University at Albany
| | | | - David Litke
- Veterans Affairs New Jersey Health Care System
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26
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Renkema E, Ahaus K, Broekhuis M, Tims M. Triggers of defensive medical behaviours: a cross-sectional study among physicians in the Netherlands. BMJ Open 2019; 9:e025108. [PMID: 31243028 PMCID: PMC6597621 DOI: 10.1136/bmjopen-2018-025108] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES This study investigated whether the attitudes of physicians towards justified and unjustified litigation, and their perception of patient pressure in demanding care, influence their use of defensive medical behaviours. DESIGN Cross-sectional survey using exploratory factor analysis was conducted to determine litigation attitude and perceived patient pressure factors. Regression analyses were used to regress these factors on to the ordering of extra tests or procedures (defensive assurance behaviour) or the avoidance of high-risk patients or procedures (defensive avoidance behaviour). SETTING Data were collected from eight Dutch hospitals. PARTICIPANTS Respondents were 160 physicians and 54 residents (response rate 25%) of the hospital departments of (1) anaesthesiology, (2) colon, stomach and liver diseases, (3) gynaecology, (4) internal medicine, (5) neurology and (6) surgery. PRIMARY OUTCOME MEASURES Respondents' application of defensive assurance and avoidance behaviours. RESULTS 'Disapproval of justified litigation' and 'Concerns about unjustified litigation' were positively related to both assurance (β=0.21, p<0.01, and β=0.28, p<0.001, respectively) and avoidance (β=0.16, p<0.05, and β=0.18, p<0.05, respectively) behaviours. 'Self-blame for justified litigation' was not significantly related to both defensive behaviours. Perceived patient pressures to refer (β=0.18, p<0.05) and to prescribe medicine (β=0.23, p<0.01) had direct positive relationships with assurance behaviour, whereas perceived patient pressure to prescribe medicine was also positively related to avoidance behaviour (β=0.14, p<0.05). No difference was found between physicians and residents in their defensive medical behaviour. CONCLUSIONS Physicians adopted more defensive medical behaviours if they had stronger thoughts and emotions towards (un)justified litigation. Further, physicians should be aware that perceived patient pressure for care can lead to them adopting defensive behaviours that negatively affects the quality and safety of patient care.
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Affiliation(s)
- Erik Renkema
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
| | - Kees Ahaus
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
- Department of Health Services Management & Organisation, Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Manda Broekhuis
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
| | - Maria Tims
- Department of Management and Organisation, School of Business and Economics, Amsterdam Business Research Institute, VU University Amsterdam, Amsterdam, The Netherlands
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27
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Symptom management for medically unexplained symptoms in primary care: a qualitative study. Br J Gen Pract 2019; 69:e254-e261. [PMID: 30858336 DOI: 10.3399/bjgp19x701849] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 11/12/2018] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND GPs have a central position in the care of patients with medically unexplained symptoms (MUS), but GPs find their care challenging. Currently, little is known about symptom management by GPs in daily practice for patients with MUS. AIM This study aimed to describe management strategies used by GPs when confronted with patients with MUS in daily practice. DESIGN AND SETTING Qualitative study in which videos and transcripts of 39 general practice consultations involving patients with MUS in the region of Nijmegen in the Netherlands in 2015 were analysed. METHOD A thematic analysis of management strategies for MUS used by GPs in real-life consultations was performed. RESULTS The study revealed 105 management strategies in 39 consultations. Nearly half concerned symptom management; the remainder included medication, referrals, additional tests, follow-up consultations, and watchful waiting. Six themes of symptom management strategies emerged from the data: cognitions and emotions, interaction with health professionals, body focus, symptom knowledge, activity level, and external conditions. Advice on symptom management was often non-specific in terms of content, and ambiguous in terms of communication. CONCLUSION Symptom management is a considerable part of the care of MUS in general practice. GPs might benefit from support in how to promote symptom management to patients with MUS in specific and unambiguous terms.
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Ibeziako P, Brahmbhatt K, Chapman A, De Souza C, Giles L, Gooden S, Latif F, Malas N, Namerow L, Russell R, Steinbuchel P, Pao M, Plioplys S. Developing a Clinical Pathway for Somatic Symptom and Related Disorders in Pediatric Hospital Settings. Hosp Pediatr 2019; 9:147-155. [PMID: 30782623 PMCID: PMC11034856 DOI: 10.1542/hpeds.2018-0205] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Somatic symptom and related disorders (SSRDs) are commonly encountered in pediatric hospital settings. There is, however, a lack of standardization of care across institutions for youth with these disorders. These patients are diagnostically and psychosocially complex, posing significant challenges for medical and behavioral health care providers. SSRDs are associated with significant health care use, cost to families and hospitals, and risk for iatrogenic interventions and missed diagnoses. With sponsorship from the American Academy of Child and Adolescent Psychiatry and input from multidisciplinary stakeholders, we describe the first attempt to develop a clinical pathway and standardize the care of patients with SSRDs in pediatric hospital settings by a working group of pediatric consultation-liaison psychiatrists from multiple institutions across North America. The authors of the SSRD clinical pathway outline 5 key steps from admission to discharge and include practical, evidence-informed approaches to the assessment and management of children and adolescents who are medically hospitalized with SSRDs.
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Affiliation(s)
- Patricia Ibeziako
- Department of Psychiatry, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts;
| | - Khyati Brahmbhatt
- Langley Porter Psychiatric Institute
- Department of Psychiatry, Weill Institute for Neurosciences, and Benioff Children's Hospital, University of California, San Francisco, San Francisco, California
| | - Andrea Chapman
- Department of Psychiatry, British Columbia Children's Hospital and The University of British Columbia, Vancouver, Canada
| | - Claire De Souza
- Department of Psychiatry, The Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Lisa Giles
- Department of Psychiatry and Behavioral Health, Primary Children's Hospital and School of Medicine, The University of Utah, Salt Lake City, Utah
| | - Shanti Gooden
- Department of Psychiatry, Weill Institute for Neurosciences, and Benioff Children's Hospital, University of California, San Francisco, San Francisco, California
| | - Finza Latif
- Department of Psychiatry and Behavioral Sciences, Children's National Medical Center and The George Washington University, Washington, District of Columbia
| | - Nasuh Malas
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, C.S. Mott Children's Hospital, University of Michigan Hospital Systems, Ann Arbor, Michigan
| | - Lisa Namerow
- Department of Psychiatry, Connecticut Children's Medical Center and Institute of Living, School of Medicine, University of Connecticut, Hartford, Connecticut
| | - Ruth Russell
- Department of Psychiatry, Montreal Children's Hospital and McGill University, Montreal, Canada
| | - Petra Steinbuchel
- Department of Psychiatry, Weill Institute for Neurosciences, and Benioff Children's Hospital, University of California, San Francisco, San Francisco, California
| | - Maryland Pao
- Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland; and
| | - Sigita Plioplys
- Department of Child and Adolescent Psychiatry, Ann and Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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29
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Anastasides N, Chiusano C, Gonzalez C, Graff F, Litke DR, McDonald E, Presnall-Shvorin J, Sullivan N, Quigley KS, Pigeon WR, Helmer DA, Santos SL, McAndrew LM. Helpful ways providers can communicate about persistent medically unexplained physical symptoms. BMC FAMILY PRACTICE 2019; 20:13. [PMID: 30651073 PMCID: PMC6334465 DOI: 10.1186/s12875-018-0881-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 11/23/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Communication between patients and providers about persistent "medically unexplained" physical symptoms (MUS) is characterized by discordance. While the difficulties are well documented, few studies have examined effective communication. We sought to determine what veterans with Gulf War Illness (GWI) perceive as the most helpful communication from their providers. Veterans with GWI, a type of MUS, have historically had complex relationships with medical providers. Determining effective communication for patients with particularly complex relationships may help identify the most critical communication elements for all patients with MUS. METHODS Two hundred and-ten veterans with GWI were asked, in a written questionnaire, what was the most useful thing a medical provider had told them about their GWI. Responses were coded into three categories with 10 codes. RESULTS The most prevalent helpful communication reported by patients was when the provider offered acknowledgement and validation (N = 70). Specific recommendations for managing GWI or its symptoms (N = 48) were also commonly reported to be helpful. In contrast, about a third of the responses indicated that nothing about the communication was helpful (N = 63). There were not differences in severity of symptoms, disability or healthcare utilization between patients who found acknowledgement and validation, specific recommendations or nothing helpful. CONCLUSIONS Previous research has documented the discord between patients and providers regarding MUS. This study suggests that most patients are able to identify something helpful a provider has said, particularly acknowledgement and validation and specific treatment recommendations. The findings also highlight missed communication opportunities with a third of patients not finding anything helpful.
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Affiliation(s)
- Nicole Anastasides
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA
| | - Carmelen Chiusano
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA
| | - Christina Gonzalez
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA
| | - Fiona Graff
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA
| | - David R Litke
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA
- Department of Rehabilitation Medicine, New York University School of Medicine, New York, NY, USA
| | - Erica McDonald
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA
| | - Jennifer Presnall-Shvorin
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA
| | - Nicole Sullivan
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA
| | - Karen S Quigley
- Edith Nourse Rogers Memorial VA Hospital, Bedford, 01730, MA, USA
- Department of Psychology, Northeastern University, Boston, 02115, MA, USA
| | - Wilfred R Pigeon
- Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY, USA
| | - Drew A Helmer
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA
| | - Susan L Santos
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA
| | - Lisa M McAndrew
- War Related Illness and Injury Study Center, Veterans Affairs New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, USA.
- Department of Educational and Counseling Psychology, University at Albany, 1400 Washington Ave Ext, Albany, NY, 12222, USA.
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30
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McAndrew LM, Friedlander ML, Alison Phillips L, L Santos S, Helmer DA. Concordance of illness perceptions: The key to improving care of medically unexplained symptoms. J Psychosom Res 2018; 111:140-142. [PMID: 29935748 DOI: 10.1016/j.jpsychores.2018.05.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 05/24/2018] [Accepted: 05/24/2018] [Indexed: 10/16/2022]
Affiliation(s)
- Lisa M McAndrew
- Veterans Affairs New Jersey Health Care System, East Orange, NJ United States.
| | | | | | - Susan L Santos
- Veterans Affairs New Jersey Health Care System, United States
| | - Drew A Helmer
- Veterans Affairs New Jersey Health Care System, United States
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31
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Kromme NMH, Ahaus KTB, Gans ROB, van de Wiel HBM. Internists' dilemmas in their interactions with chronically ill patients; A comparison of their interaction strategies and dilemmas in two different medical contexts. PLoS One 2018; 13:e0194133. [PMID: 29847552 PMCID: PMC5976145 DOI: 10.1371/journal.pone.0194133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 02/15/2018] [Indexed: 11/21/2022] Open
Abstract
Background Internists appear to define productive interactions, key concept of the Chronic Care Model, as goal-directed, catalyzed by achieving rapport, and depending on the medical context: i.e. medically explained symptoms (MES) or medically unexplained symptoms (MUS). Objective To explore internists’ interaction strategy discourses in the context of MES and MUS. Methods We interviewed twenty internists working in a Dutch academic hospital, identified relevant text fragments in the interview transcripts and analyzed the data based on a discourse analysis approach. Results We identified four interaction strategy discourses: relating, structuring, exploring, and influencing. Each was characterized by a dilemma: relating by ‘creating nearness versus keeping distance’; structuring by ‘giving space versus taking control’; exploring by ‘asking for physical versus psychosocial causes’; and influencing by ‘taking responsibility versus accepting a patient’s choice. The balance sought in these dilemmas depended on whether the patient’s symptoms were medically explained or unexplained (MES or MUS). Towards MUS the internists tended to maintain greater distance, take more control, ask more cautiously questions related to psychosocial causes, and take less responsibility for shared decision making. Discussion and conclusions Adopting a basic distinction between MES and MUS, the internists in our study appeared to seek a different balance in each of four rather fundamental clinical dilemmas. Balancing these dilemmas seemed more difficult regarding MUS where the internists seemed more distancing and controlling, and tended to draw on their medical expertise. Moving in this direction is counterproductive and in contradiction to guidelines which emphasize that MUS patients warrant emotional support requiring a shift towards interpersonal, empathic communication.
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Affiliation(s)
- Nicolien M. H. Kromme
- University of Groningen, University Medical Center Groningen, SectorA Chronic and Vascular Disease, Groningen, The Netherlands
- * E-mail:
| | - Kees T. B. Ahaus
- University of Groningen, Faculty of Economics and Business, Centre of Expertise Healthwise, Groningen, The Netherlands
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Reinold O. B. Gans
- University of Groningen, University Medical Center Groningen, Department of Internal Medicine, Groningen, The Netherlands
| | - Harry B. M. van de Wiel
- University of Groningen, University Medical Center Groningen, Wenckebach Institute, Groningen, The Netherlands
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van Westrienen PE, Pisters MF, Toonders SA, Gerrits M, Veenhof C, de Wit NJ. Effectiveness of a Blended Multidisciplinary Intervention for Patients with Moderate Medically Unexplained Physical Symptoms (PARASOL): Protocol for a Cluster Randomized Clinical Trial. JMIR Res Protoc 2018; 7:e120. [PMID: 29739735 PMCID: PMC5964304 DOI: 10.2196/resprot.9404] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 03/05/2018] [Accepted: 03/22/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Medically unexplained physical symptoms are an important health problem in primary care, with a spectrum from mild to chronic. The burden of chronic medically unexplained physical symptoms is substantial for patients, health care professionals, and society. Therefore, early identification of patients with moderate medically unexplained physical symptoms is needed in order to prevent chronicity. The preventive screening of medically unexplained physical symptoms (PRESUME) screening method was developed using data from the electronic medical record of the patients' general practitioner and demonstrated its prognostic accuracy to identify patients with moderate medically unexplained physical symptoms. In the next step, we developed a proactive blended and integrated mental health and physical therapy intervention program (PARASOL) to reduce complaints of moderate medically unexplained physical symptoms, stimulate self-management, and prevent chronicity. OBJECTIVE The primary objective of this study is to investigate the effectiveness of the blended PARASOL intervention on the impact of symptoms and quality of life in patients with moderate medically unexplained physical symptoms compared with usual care. Secondary objectives are to study the effect on severity of physical and psychosocial symptoms, general health, physical behavior, illness perception, and self-efficacy in patients with moderate medically unexplained physical symptoms as well as to determine the cost-effectiveness of the program. METHODS This paper presents the study protocol of a multicenter cluster randomized clinical trial. Adult patients with moderate medically unexplained physical symptoms will be identified from electronic medical record data using the PRESUME screening method and proactively recruited for participation in the study. Cluster randomization will be performed at the level of the participating health care centers. In total 248 patients with moderate medically unexplained physical symptoms (124 patients per arm) are needed. The PARASOL intervention is a 12-week blended primary care program consisting of 4 face-to-face consultations with the mental health nurse and 5 physical therapy sessions, supplemented with a Web-based program. The Web-based program contains (1) information modules and videos on self-management and educative themes, (2) videos and instructions on prescribed home exercises, and (3) assignments to gradually increase the physical activity. The program is directed at patients' perception of symptoms as well as modifiable prognostic risk factors for chronicity using therapeutic neuroscience education. It encourages self-management, as well as an active lifestyle using a cognitive behavioral approach and graded activity. Primary outcomes are impact of symptoms and quality of life. Secondary outcomes are severity of physical and psychosocial symptoms, general health, physical behavior, illness perceptions, self-efficacy, and cost-effectiveness. All measurements will be performed at baseline, 3 and 12 months after baseline. Retrospective cost questionnaires will also be sent at 6 and 9 months after baseline and these will be used for the cost-effectiveness analysis. RESULTS The intervention has been developed, and the physical therapists and mental health nurses in the participating experimental health care centers have received two days of training on the content of the blended PARASOL intervention. The recruitment of health care centers started in June 2016 and inclusion of patients began in March 2017. Follow-up assessments of patients are expected to be completed in March 2019. CONCLUSIONS This study is the first randomized clinical trial to determine the effectiveness (including cost-effectiveness) of a proactive, blended, and integrated mental health and physical therapy care program for patients with moderate medically unexplained physical symptoms. The findings will help to improve the treatment for patients with moderate medically unexplained physical symptoms and prevent chronicity. TRIAL REGISTRATION Netherlands Trial Register NTR6755; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=6755 (Archived by WebCite at http://www.webcitation.org/6ywporY7u).
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Affiliation(s)
- Paula Elisabeth van Westrienen
- Department of Health Innovation and Technology, Fontys University of Applied Sciences, Eindhoven, Netherlands
- Center for Physical Therapy Research and Innovation in Primary Care, Utrecht, Netherlands
- Physical Therapy Research, Department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, Netherlands
| | - Martijn F Pisters
- Department of Health Innovation and Technology, Fontys University of Applied Sciences, Eindhoven, Netherlands
- Center for Physical Therapy Research and Innovation in Primary Care, Utrecht, Netherlands
- Physical Therapy Research, Department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, Netherlands
| | - Suze Aj Toonders
- Department of Health Innovation and Technology, Fontys University of Applied Sciences, Eindhoven, Netherlands
- Center for Physical Therapy Research and Innovation in Primary Care, Utrecht, Netherlands
- Physical Therapy Research, Department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, Netherlands
| | - Marloes Gerrits
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Cindy Veenhof
- Center for Physical Therapy Research and Innovation in Primary Care, Utrecht, Netherlands
- Physical Therapy Research, Department of Rehabilitation, Physical Therapy Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, Netherlands
- Research Group Innovation of Human Movement Care, University of Applied Sciences Utrecht, Utrecht, Netherlands
| | - Niek J de Wit
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
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Duration of untreated illness in patients with somatoform disorders. J Psychosom Res 2018; 107:1-6. [PMID: 29502757 DOI: 10.1016/j.jpsychores.2018.01.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 12/20/2017] [Accepted: 01/18/2018] [Indexed: 01/23/2023]
Abstract
OBJECTIVE A long duration of untreated mental illness (DUI) has been found to be associated with negative long-term outcomes. Although somatic symptom and related disorders are frequent in the general population and in primary care, data regarding the DUI of these disorders is scarce. The aim of this study was to investigate the DUI in patients with somatoform disorders. METHODS In a cross-sectional study, primary care patients at high risk of having a somatoform disorder were identified using the Patient Health Questionnaire (PHQ). In a second step, life-time somatoform disorder diagnosis was established using the Composite International Diagnostic Interview (CIDI). Additionally, DUI was retrospectively assessed via self-reporting and sociodemographic information was collected. Survival analysis was used to estimate the DUI and to identify patient-related predictors of DUI. RESULTS A total of 139 patients with somatoform disorders were included in the analyses. The mean DUI in these patients was 25.2years (median 23.1years). Higher education significantly predicted shorter DUI, whereas gender and age of onset were unrelated to DUI. CONCLUSIONS The results reveal a substantial delay in adequate treatment of patients with somatoform disorders. The reported DUI emphasizes the importance of improvements in the management of patients with these disorders.
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Improving GP communication in consultations on medically unexplained symptoms: a qualitative interview study with patients in primary care. Br J Gen Pract 2017; 67:e716-e723. [PMID: 28847774 DOI: 10.3399/bjgp17x692537] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 06/13/2017] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Many GPs find the care of patients with medically unexplained symptoms (MUS) challenging. Patients themselves are often not satisfied with the care they receive. AIM To explore the problems patients with MUS experience in communication during consultations, with the aim of improving such consultations DESIGN AND SETTING: A qualitative analysis of semi-structured interviews. METHOD GP consultations were videorecorded and the GPs were asked immediately afterwards whether MUS were presented. Patients in these MUS consultations were asked to reflect on the consultation in a semi-structured interview while watching a recording of their own consultation. RESULTS Of the 393 videorecorded consultations, 43 contained MUS. Patients who did identified six categories of problems. First, they reported a mismatch between the GP's and their own agenda. Second, patients indicated that the GP evoked an uncomfortable feeling in them during the consultation. Third, they found that GPs did not provide a specific management plan for their symptoms. Fourth, patients indicated that the GP was not well prepared for the consultation. Fifth, they perceived prejudices in the GP during the consultation. Finally, one patient found that the GP did not acknowledge a limited understanding of the origin of the symptoms. CONCLUSION According to patients, GPs can improve their consultations on MUS by making genuine contact with their patients, by paying more attention to the patient's agenda, and by avoiding evoking uncomfortable feelings and displaying prejudices. They should prepare their consultations and focus on the issues that matter to patients, for example, symptom management. GPs should be honest to patients when they do not understand the origin of symptoms.
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Cathébras P. La perspective de la médecine centrée sur la personne : une condition nécessaire pour apporter une réponse adéquate aux syndromes somatiques fonctionnels. Rev Med Interne 2017. [DOI: 10.1016/j.revmed.2017.03.340] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Kleinstäuber M, Lambert MJ, Hiller W. Early response in cognitive-behavior therapy for syndromes of medically unexplained symptoms. BMC Psychiatry 2017; 17:195. [PMID: 28545580 PMCID: PMC5445472 DOI: 10.1186/s12888-017-1351-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Accepted: 05/05/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Early dramatic treatment response suggests a subset of patients who respond to treatment before most of it has been offered. These early responders tend to be over represented among those who are well at termination and at follow-up. Early response patterns in psychotherapy have been investigated only for a few of mental disorders so far. The main aim of the current study was to examine early response after five therapy-preparing sessions of a cognitive behavior therapy (CBT) for syndromes of medically unexplained symptoms (MUS). METHODS In the context of a randomized, waiting-list controlled trial 48 patients who suffered from ≥3 MUS over ≥6 months received 5 therapy-preparing sessions and 20 sessions of CBT for somatoform disorders. They completed self-report scales of somatic symptom severity (SOMS-7 T), depression (BDI-II), anxiety (BSI), illness anxiety and behavior (IAS) at pre-treatment, after 5 therapy-preparing sessions (FU-5P) and at therapy termination (FU-20 T). RESULTS The current analyses are based on data from the treatment arm only. Repeated measure ANOVAs revealed a significant decrease of depression (d = 0.34), anxiety (d = 0.60), illness anxiety (d = 0.38) and illness behavior (d = 0.42), but no change of somatic symptom severity (d = -0.03) between pre-treatment and FU-5P. Hierarchical linear multiple regression analyses showed that symptom improvements between pre-treatment and FU-5P predict a better outcome at therapy termination for depression and illness anxiety, after controlling for pre-treatment scores. Mixed-effect ANOVAs revealed significant group*time interaction effects indicating differences in the course of symptom improvement over the therapy between patients who fulfilled a reliable change (i.e., early response) during the 5 therapy-preparing sessions and patients who did not reach an early reliable change. Demographic or clinical variables at pre-treatment were not significantly correlated with differential scores between pre-treatment and FU-5P (-.23 ≤ r ≤ .23). CONCLUSIONS Due to several limitations (e.g., small sample size, lack of a control group) the results of this study have to be interpreted cautiously. Our findings show that reliable changes in regard to affective-cognitive and behavioral variables can take place very early in CBT of patients with distressing MUS. These early changes seem to be predictive of the outcome at therapy termination. Future studies are needed in order to replicate our results, and to identify mechanisms of these early response patterns in somatoform patients. TRIAL REGISTRATION ISRCTN. ISRCTN17188363 . Registered retrospectively on 29 March 2007.
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Affiliation(s)
- Maria Kleinstäuber
- Division of Clinical Psychology and Psychotherapy, Philipps-University, Gutenbergstr. 18, D-35037 Marburg, Germany
- Psychological Medicine, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Hospital Bldg. 599, 2 Park Rd, Grafton Auckland, Auckland, 1023 New Zealand
| | | | - Wolfgang Hiller
- Department of Clinical Psychology and Psychotherapy, Johannes Gutenberg-University, Mainz, Germany
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Rosendal M, Olde Hartman TC, Aamland A, van der Horst H, Lucassen P, Budtz-Lilly A, Burton C. "Medically unexplained" symptoms and symptom disorders in primary care: prognosis-based recognition and classification. BMC FAMILY PRACTICE 2017; 18:18. [PMID: 28173764 PMCID: PMC5297117 DOI: 10.1186/s12875-017-0592-6] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 01/25/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Many patients consult their GP because they experience bodily symptoms. In a substantial proportion of cases, the clinical picture does not meet the existing diagnostic criteria for diseases or disorders. This may be because symptoms are recent and evolving or because symptoms are persistent but, either by their character or the negative results of clinical investigation cannot be attributed to disease: so-called "medically unexplained symptoms" (MUS). MUS are inconsistently recognised, diagnosed and managed in primary care. The specialist classification systems for MUS pose several problems in a primary care setting. The systems generally require great certainty about presence or absence of physical disease, they tend to be mind-body dualistic, and they view symptoms from a narrow specialty determined perspective. We need a new classification of MUS in primary care; a classification that better supports clinical decision-making, creates clearer communication and provides scientific underpinning of research to ensure effective interventions. DISCUSSION We propose a classification of symptoms that places greater emphasis on prognostic factors. Prognosis-based classification aims to categorise the patient's risk of ongoing symptoms, complications, increased healthcare use or disability because of the symptoms. Current evidence suggests several factors which may be used: symptom characteristics such as: number, multi-system pattern, frequency, severity. Other factors are: concurrent mental disorders, psychological features and demographic data. We discuss how these characteristics may be used to classify symptoms into three groups: self-limiting symptoms, recurrent and persistent symptoms, and symptom disorders. The middle group is especially relevant in primary care; as these patients generally have reduced quality of life but often go unrecognised and are at risk of iatrogenic harm. The presented characteristics do not contain immediately obvious cut-points, and the assessment of prognosis depends on a combination of several factors. CONCLUSION Three criteria (multiple symptoms, multiple systems, multiple times) may support the classification into good, intermediate and poor prognosis when dealing with symptoms in primary care. The proposed new classification specifically targets the patient population in primary care and may provide a rational framework for decision-making in clinical practice and for epidemiologic and clinical research of symptoms.
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Affiliation(s)
- Marianne Rosendal
- Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Alle 2, DK-8000 Aarhus C, Denmark
- Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, J.B. Winslows Vej 9 A, DK-5000 Odense, Denmark
| | - Tim C Olde Hartman
- Department of Primary and Community Care, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Aase Aamland
- Research Unit for General Practice, Uni Research Health, Bergen, Norway
| | - Henriette van der Horst
- Department of General Practice and Elderly Care Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| | - Peter Lucassen
- Department of Primary and Community Care, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Anna Budtz-Lilly
- Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Alle 2, DK-8000 Aarhus C, Denmark
| | - Christopher Burton
- Academic Unit of Primary Medical Care, University of Sheffield, Samuel Fox House, Northern General Hospital, Sheffield, S5 7 AU UK
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Hanssen DJC, Oude Voshaar RC, Naarding P, Rabeling-Keus IM, Olde Hartman TC, Lucassen PLBJ. Social characteristics and care needs of older persons with medically unexplained symptoms: a case-control study. Fam Pract 2016; 33:617-625. [PMID: 27538425 DOI: 10.1093/fampra/cmw067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Research in younger patients with medically unexplained symptoms (MUS) has shown impairments in social functioning, such as loneliness and a reduced quality of the patient-doctor relationship. As far as we know, no studies have been performed on social functioning in older MUS patients; self-reported care needs of older MUS patients remain unknown. OBJECTIVE To explore social characteristics and care needs of older persons with chronic MUS, when compared to older persons with chronic medically explained symptoms (MES). METHODS Patient characteristics of 107 older persons (>60 years) with chronic MUS were compared to 150 older persons with chronic MES in a case-control design. Participants were recruited via advertisements, general practices and a specialized clinic. All participants completed questionnaires on social functioning; the Camberwell Assessment of Need for the Elderly was used to draw up care needs. Linear regression analyses were performed to explore the association between social characteristics and group (MUS/MES), adjusted for demographic and physical determinants. Multiple chi-square tests were performed to detect between-group differences regarding care needs. RESULTS After adjustments, older MUS patients were slightly but significantly lonelier, reported a somewhat lower quality of their patient-doctor relationship, but reported equal social support levels when compared to MES patients. MUS patients more often reported unmet care needs regarding health and information provision about their health status. CONCLUSION Only small differences in social functioning were found between older MUS and MES patients. Possibly, training future doctors in giving acceptable explanations for the patient's complaints could improve the unmet care need of information provision in older MUS patients.
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Affiliation(s)
- Denise J C Hanssen
- Department of Psychiatry, Radboud Institute for Health Sciences, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands,
| | - Richard C Oude Voshaar
- Interdisciplinary Center for Psychopathology of Emotion Regulation (ICPE), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Paul Naarding
- Department of Old-Age Psychiatry, GGNet, Apeldoorn, The Netherlands
| | - Inge M Rabeling-Keus
- School of Psychology and Artificial Intelligence, Radboud University Nijmegen, Nijmegen, The Netherlands and
| | - Tim C Olde Hartman
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Peter L B J Lucassen
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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Menon V, Shanmuganathan B, Babu Arun A, Thamizh JS, Selvakumar N, Sarkar S. A qualitative analysis of explanatory models in medically unexplained physical symptoms presenting to a tertiary health care psychiatric facility in South India. Int J Soc Psychiatry 2016; 62:608-615. [PMID: 27609766 DOI: 10.1177/0020764016662294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Knowledge about subjective perceptions and explanatory models has the potential to inform clinical evaluation and lead to development of patient-friendly treatment models in medically unexplained physical symptoms (MUPS). AIM To collect qualitative data about explanatory models in MUPS. METHODS A cross-sectional observational study was done among patients with MUPS presenting over a 2-year period to a specialty psychosomatic clinic. The Short Explanatory Model of Illness interview was used to gather qualitative data about explanatory models which were subsequently recoded using standard manuals. RESULTS A total of 123 subjects were evaluated. The nature of symptoms was most commonly reported as 'non-specific' ( n = 102, 82.9%) but of moderate to severe intensity ( n = 87, 73.8%). Getting cured or showing improvement was the most common expectation from treatment ( n = 58, 47.9%). Moderate to severe impact of symptoms was reported on work output ( n = 100, 84%), emotional life ( n = 85, 71.4%) and physical mobility ( n = 59, 49.1%). A considerable proportion was either dissatisfied ( n = 61, 50%) or frankly unhappy ( n = 38, 31.4%) with treatment received. CONCLUSION There is a need to re-calibrate the clinical approach to people with MUPS to enhance treatment satisfaction. Our findings could assist in evolving culturally sensitive conceptualizations of illness and in developing patient-centred models for therapy in MUPS patients.
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Affiliation(s)
- Vikas Menon
- 1 Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Balasubramanian Shanmuganathan
- 1 Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Anand Babu Arun
- 1 Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Jaiganesh Selvapandian Thamizh
- 1 Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Nivedhitha Selvakumar
- 1 Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Siddharth Sarkar
- 2 Department of Psychiatry, National Drug Dependence and Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
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Maatz A, Wainwright M, Russell AJ, Macnaughton J, Yiannakou Y. What's 'difficult'? A multi-stage qualitative analysis of secondary care specialists' experiences with medically unexplained symptoms. J Psychosom Res 2016; 90:1-9. [PMID: 27772554 DOI: 10.1016/j.jpsychores.2016.09.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 09/04/2016] [Accepted: 09/07/2016] [Indexed: 01/28/2023]
Abstract
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.
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Affiliation(s)
- Anke Maatz
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital, Zurich CH-8032, Switzerland.
| | - Megan Wainwright
- Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town 7925, South Africa
| | - Andrew J Russell
- Department of Anthropology, Durham University, Durham DH1 3LE, United Kingdom
| | - Jane Macnaughton
- Centre for Medical Humanities, Durham University, Durham DH1 1SZ, United Kingdom
| | - Yan Yiannakou
- County Durham and Darlington NHS Foundation Trust, Durham DH1 5TW, United Kingdom
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Arzt-Patient-Verhältnis aus Sicht von Studierenden der Medizin. PSYCHOTHERAPEUT 2016. [DOI: 10.1007/s00278-016-0130-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Morgan S, Morgan A, Kerr R, Tapley A, Magin P. Test ordering by GP trainees: Effects of an educational intervention on attitudes and intended practice. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2016; 62:733-741. [PMID: 27629671 PMCID: PMC5023346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To assess the effectiveness of an educational intervention on test-ordering attitudes and intended practice of GP trainees, and any associations between changes in test ordering and trainee characteristics. DESIGN Preworkshop and postworkshop survey of attitudes to test ordering, intended test-ordering practices for 3 clinical scenarios (fatigue, screening, and shoulder pain), and tolerance for uncertainty. SETTING Three Australian regional general practice training providers. PARTICIPANTS General practice trainees (N = 167). INTERVENTION A 2-hour workshop session and an online module. MAIN OUTCOME MEASURES Proportion of trainees who agreed with attitudinal statements before and after the workshop; proportion of trainees who would order tests, mean number of tests ordered, and number of appropriate and inappropriate tests ordered for each scenario before and after the workshop. RESULTS Of 167 trainees, 132 (79.0%) completed both the preworkshop and postworkshop questionnaires. A total of 122 trainees attended the workshop. At baseline, 88.6% thought that tests can harm patients, 84.8% believed overtesting was a problem, 72.0% felt pressured by patients, 52.3% believed that tests would reassure patients, and 50.8% thought that they were less likely to be sued if they ordered tests. There were desirable changes in all attitudes after the workshop. Before the workshop, the mean number of tests that trainees would have ordered was 4.4, 4.8, and 1.5 for the fatigue, screening, and shoulder pain scenarios, respectively. After the workshop there were decreases in the mean number of both appropriate tests (decrease of 0.94) and inappropriate tests (decrease of 0.24) in the fatigue scenario; there was no change in the mean number of appropriate tests and a decrease in inappropriate tests (decrease of 0.76) in the screening scenario; and there was an increase in the proportion of trainees who would appropriately not order tests in the shoulder pain scenario. There were no significant associations between changes in test ordering and trainee demographic characteristics or tolerance for uncertainty subscale scores. CONCLUSION General practice trainees have conflicting attitudes to test ordering and demonstrate nonrational test ordering in 3 common scenarios. A workshop on rational test ordering led to desirable changes in attitudes and more rational intended test ordering. Our findings inform the development of appropriate educational interventions that address nonrational testing in family medicine.
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Affiliation(s)
- Simon Morgan
- GP and Medical Educator with General Practice Training Valley to Coast, practising in Newcastle, NSW, Australia.
| | - Andy Morgan
- Senior Medical Educator at Victorian Metropolitan Alliance and Senior Lecturer in the Department of General Practice at Monash University in Melbourne, Australia
| | - Rohan Kerr
- Senior Medical Educator with General Practice Training Tasmania and a GP at Claremont Village Medical Centre in Hobart, Australia
| | - Amanda Tapley
- Research officer at General Practice Training Valley to Coast
| | - Parker Magin
- GP and Medical Educator at General Practice Training Valley to Coast, and Conjoint Professor in the Discipline of General Practice at the University of Newcastle
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Open Trial of Integrated Primary Care Consultation for Medically Unexplained Symptoms. J Behav Health Serv Res 2016; 44:590-601. [PMID: 27530260 DOI: 10.1007/s11414-016-9528-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Within primary care settings, patients with medically unexplained symptoms (MUS) are common, often present with comorbid psychopathology, and have high rates of healthcare utilization. Despite increased healthcare utilization, these patients often have poor outcomes that frustrate patients and providers alike. A behavioral consultation intervention for primary care patients with MUS (n = 10) was developed and assessed. All participants completed all intervention and assessment sessions and rated the intervention favorably. Participants self-report scores revealed statistically significant improvements from baseline to 3-month follow-up on physical functioning, mental functioning, and physical symptoms. Notwithstanding the limitations of open trial designs, these findings demonstrate high feasibility for a behavioral health consultation treatment model for patients with MUS and highlight the need for further research.
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den Boeft M, Twisk JWR, Terluin B, Penninx BWJH, van Marwijk HWJ, Numans ME, van der Wouden JC, van der Horst HE. The association between medically unexplained physical symptoms and health care use over two years and the influence of depressive and anxiety disorders and personality traits: a longitudinal study. BMC Health Serv Res 2016; 16:100. [PMID: 27125311 PMCID: PMC4848781 DOI: 10.1186/s12913-016-1332-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 02/23/2016] [Indexed: 11/28/2022] Open
Abstract
Background Medically unexplained physical symptoms (MUPS) are highly prevalent and are associated with frequent health care use (HCU). MUPS frequently co-occur with psychiatric disorders. With this study we examined the longitudinal association between MUPS and HCU over 2 years and the influence of depressive and anxiety disorders and personality traits on this association. Methods We analysed follow-up data from 2045 to 2981 participants from the Netherlands Study of Depression and Anxiety (NESDA), a multisite cohort study. The study population included participants with a current depressive and/or anxiety disorder, participants with a lifetime risk and/or subthreshold symptoms for depressive and/or anxiety disorders and healthy controls. HCU, measured with the Trimbos and iMTA questionnaire on Costs associated with Psychiatric illness (TIC-P), was operationalized as the number of used medical services and the number of associated contacts. MUPS were measured with the Four Dimensional Symptoms Questionnaire, depressive and anxiety disorders with the Composite International Diagnostic Interview and personality traits with the NEO Five-Factory Inventory. Measurements were taken at baseline, 1 and 2 years follow-up. We used generalized estimating equations (GEE), using HCU at all three measurements as (multivariate) outcome. GEE also takes into account the dependency of observations within participants. Results MUPS were positively associated with HCU over 2 years (medical services: RR 1.020, 95 % CI 1.017–1.022; contacts: RR 1.037, 95 % CI 1.030–1.044). Neuroticism and depression had the strongest influence on the associations. After adjustment for these factors, the associations between MUPS and HCU weakened, but remained significant (services: RR 1.011, 95 % CI 1.008–1.014; contacts: RR 1.023, 95 % CI 1.015–1.032). Conclusions Our results show that MUPS were positively associated with HCU over 2 years, even after adjusting for depressive and anxiety disorders and personality traits. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1332-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Madelon den Boeft
- Department of General Practice and Elderly Care Medicine, EMGO Institute for Health and Care Research, VU University Medical Center, van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands.
| | - Jos W R Twisk
- Department of Epidemiology and Biostatistics, VU University Medical Center, van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands
| | - Berend Terluin
- Department of General Practice and Elderly Care Medicine, EMGO Institute for Health and Care Research, VU University Medical Center, van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands
| | - Brenda W J H Penninx
- Department of Psychiatry and EMGO Institute for Health and Care Research, VU University Medical Center, A.J. Ernststraat 1187, 1081 HL, Amsterdam, The Netherlands
| | - Harm W J van Marwijk
- Department of General Practice and Elderly Care Medicine, EMGO Institute for Health and Care Research, VU University Medical Center, van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands
| | - Mattijs E Numans
- Department of General Practice and Elderly Care Medicine, EMGO Institute for Health and Care Research, VU University Medical Center, van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands.,Department of Public Health and Primary Care, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Johannes C van der Wouden
- Department of General Practice and Elderly Care Medicine, EMGO Institute for Health and Care Research, VU University Medical Center, van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands
| | - Henriette E van der Horst
- Department of General Practice and Elderly Care Medicine, EMGO Institute for Health and Care Research, VU University Medical Center, van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands
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Murray AM, Toussaint A, Althaus A, Löwe B. The challenge of diagnosing non-specific, functional, and somatoform disorders: A systematic review of barriers to diagnosis in primary care. J Psychosom Res 2016; 80:1-10. [PMID: 26721541 DOI: 10.1016/j.jpsychores.2015.11.002] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 11/05/2015] [Accepted: 11/06/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Despite their prevalence and impact on patients and the health care system, non-specific, functional, and somatoform disorders are underdiagnosed. This problem is especially problematic in primary care if we are moving towards an integrated care model. The objective of the current study was to identify and aggregate potential barriers to the diagnosis in primary care settings. METHODS Our systematic review methodology followed a pre-published protocol and was registered in PROSPERO (CRD42013002540). We combined qualitative and quantitative data from studies identified in online databases and by hand searching of reference lists. Data were synthesized in a data-driven way using a grounded-theory approach. The level of evidence and assessment of bias for the final included studies was independently conducted. RESULTS Data from n=177 full text publications were independently extracted and combined in a custom database. The final list of included studies was n=42. From these, a total of n=379 barriers were identified comprising 77 barrier-level codes, 16 thematic categories and five over-arching themes, i.e., patient-related, primary-care-practitioner related, doctor-patient interactional, situational, and conceptual and operational barriers. CONCLUSION Given the thematic range of the identified barriers, the diagnostic process of non-specific, functional, and somatoform disorders in primary care is highly complex. Individual or practice-level interventions, as well as public awareness initiatives are needed to help address the diagnostic challenges. A multi-factorial understanding of symptoms with a biopsychosocial parallel diagnostic approach should be encouraged. More direct empirical investigations are also needed.
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Affiliation(s)
- Alexandra M Murray
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf & University Hospital of Psychosomatic Medicine and Psychotherapy, Schön Clinic Hamburg Eilbek, Germany.
| | - Anne Toussaint
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf & University Hospital of Psychosomatic Medicine and Psychotherapy, Schön Clinic Hamburg Eilbek, Germany
| | - Astrid Althaus
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf & University Hospital of Psychosomatic Medicine and Psychotherapy, Schön Clinic Hamburg Eilbek, Germany
| | - Bernd Löwe
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf & University Hospital of Psychosomatic Medicine and Psychotherapy, Schön Clinic Hamburg Eilbek, Germany
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Stone J, Carson A, Hallett M. Explanation as treatment for functional neurologic disorders. HANDBOOK OF CLINICAL NEUROLOGY 2016; 139:543-553. [PMID: 27719870 DOI: 10.1016/b978-0-12-801772-2.00044-8] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
There is widespread agreement that the way health professionals communicate the diagnosis of functional neurologic disorders (FND) has a central role in treatment, as it does arguably for most conditions. In this chapter we discuss barriers to effective diagnosis, different models of explanation and evidence regarding the importance of effective communication of the diagnosis in FND, especially movement disorders, and dissociative (nonepileptic) seizures. Debates and disagreements about how to go about this task often reflect different theoretic models held by health professionals rather than evidence. More evidence is required to know whether an initial emphasis on one model is more or less effective than another (e.g., a functional model vs. a psychologic model). We conclude, however, that there are a number of generic components to effective explanation shared by most authors on the topic that form the basis of a consensus. These include taking the patient seriously, giving the problem a diagnostic label, explaining the rationale for the diagnosis, some discussion of how the symptoms arise, emphasis on the potential for reversibility (rather than damage), and effective triage and referral for other treatment where appropriate. Although explanation can sometimes be therapeutic on its own, its role is probably more important as a facilitator to other therapy, including self-help, physical treatments, and psychotherapy.
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Affiliation(s)
- J Stone
- Department of Clinical Neurosciences, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
| | - A Carson
- Departments of Clinical Neurosciences and of Rehabilitation Medicine, NHS Lothian and Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - M Hallett
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
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Hinton D, Kirk S. Families' and healthcare professionals' perceptions of healthcare services for children and young people with medically unexplained symptoms: a narrative review of the literature. HEALTH & SOCIAL CARE IN THE COMMUNITY 2016; 24:12-26. [PMID: 25684117 DOI: 10.1111/hsc.12184] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/29/2014] [Indexed: 06/04/2023]
Abstract
Children and young people frequently report physical complaints that have no observable physical pathology known as medically unexplained symptoms (MUS). Research suggests that MUS are associated with substantial physical and psychological impairments and may have a negative impact on children's and young people's functional status and well-being in the long term. Due to the potentially complex needs of this group, children and young people with MUS may require timely access to suitable health and social care services to effectively manage symptoms and achieve their academic, social and personal potential. Families and professionals can offer important insights into the availability and appropriateness of current community and specialist health and social care services. This review is the first critical evaluation and synthesis of research that has examined families' and healthcare professionals' (HCP) perceptions of healthcare services for children and young people with MUS. A systematic search of electronic databases and manual searches of key journals and reference lists identified 17 papers from 15 studies for inclusion in the review. The review highlights the paucity of rigorously conducted research on this topic. Studies have been narrowly focused on the views of a homogeneous group of mothers and young people attending single centres. There has been some attempt to examine doctors' views, but the perceptions of children, fathers and health and social care professionals are absent or under-represented, and multi-site and longitudinal studies are lacking. Thematic analysis of the results from the included studies suggests that knowledge, communication, health beliefs and healthcare settings are factors that influence families' and HCPs' perceptions of services. Families report dissatisfaction with some HCPs' approach to managing MUS. The findings suggest that children and young people with MUS are at risk of receiving suboptimal care and support because there is insufficient research to inform high-quality, evidence-based practice.
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Affiliation(s)
- Denise Hinton
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Susan Kirk
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
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Yon K, Nettleton S, Walters K, Lamahewa K, Buszewicz M. Junior doctors' experiences of managing patients with medically unexplained symptoms: a qualitative study. BMJ Open 2015; 5:e009593. [PMID: 26628528 PMCID: PMC4679901 DOI: 10.1136/bmjopen-2015-009593] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To explore junior doctors' knowledge about and experiences of managing patients with medically unexplained symptoms (MUS) and to seek their recommendations for improved future training on this important topic about which they currently receive little education. DESIGN Qualitative study using in-depth interviews analysed using the framework method. SETTING Participants were recruited from three North Thames London hospitals within the UK. PARTICIPANTS Twenty-two junior doctors undertaking the UK foundation two-year training programme (FY1/FY2). RESULTS The junior doctors interviewed identified a significant gap in their training on the topic of MUS, particularly in relation to their awareness of the topic, the appropriate level of investigations, possible psychological comorbidities, the formulation of suitable explanations for patients' symptoms and longer term management strategies. Many junior doctors expressed feelings of anxiety, frustration and a self-perceived lack of competency in this area, and spoke of over-investigating patients or avoiding patient contact altogether due to the challenging nature of MUS and a difficulty in managing the accompanying uncertainty. They also identified the negative attitudes of some senior clinicians and potential role models towards patients with MUS as a factor contributing to their own attitudes and management choices. Most reported a need for more training during the foundation years, and recommended interactive case-based group discussions with a focus on providing meaningful explanations to patients for their symptoms. CONCLUSIONS There is an urgent need to improve postgraduate training about the topics of MUS and avoiding over-investigation, as current training does not equip junior doctors with the necessary knowledge and skills to effectively and confidently manage patients in these areas. Training needs to focus on practical skill development to increase clinical knowledge in areas such as delivering suitable explanations, and to incorporate individual management strategies to help junior doctors tolerate the uncertainty associated with MUS.
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Affiliation(s)
- Katherine Yon
- Research Department of Primary Care & Population Health, UCL, London, UK
| | | | - Kate Walters
- Research Department of Primary Care & Population Health, UCL, London, UK
| | - Kethakie Lamahewa
- Research Department of Primary Care & Population Health, UCL, London, UK
| | - Marta Buszewicz
- Research Department of Primary Care & Population Health, UCL, London, UK
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A qualitative study of adolescents with medically unexplained symptoms and their parents. Part 2: How is healthcare perceived? J Adolesc 2015; 45:317-26. [DOI: 10.1016/j.adolescence.2015.10.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 09/28/2015] [Accepted: 10/05/2015] [Indexed: 11/18/2022]
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50
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Morgan S, Henderson KM, Tapley A, Scott J, Van Driel ML, Spike NA, Mcarthur LA, Davey AR, Oldmeadow C, Ball J, Magin PJ. Pathology test-ordering behaviour of Australian general practice trainees: a cross-sectional analysis. Int J Qual Health Care 2015; 27:528-35. [DOI: 10.1093/intqhc/mzv086] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2015] [Indexed: 12/16/2022] Open
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