"You kind of want to fix it don't you?" Exploring general practice trainees' experiences of managing patients with medically unexplained symptoms

Using framework analysis methods for qualitative research: AMEE Guide No. 164

Framework analysis methods (FAMs) are structured approaches to qualitative data analysis that originally stem from large-scale policy research. A defining feature of FAMs is the development and application of a matrix-based analytical framework. These methods can be used across research paradigms and are thus particularly useful tools in the health professions education (HPE) researcher's toolbox. Despite their utility, FAMs are not frequently used in HPE research. In this AMEE Guide, we provide an overview of FAMs and their applications, situating them within specific qualitative research approaches. We also report the specific characteristics, advantages, and disadvantages of FAMs in relation to other popular qualitative analysis methods. Using a specific type of FAM-i.e. the framework method-we illustrate the stages typically involved in doing data analysis with an FAM. Drawing on Sandelowski and Barroso's continuum of data transformation, we argue that FAMs tend to remain close to raw data and be descriptive or exploratory in nature. However, we also illustrate how FAMs can be harnessed for more interpretive analyses. We propose that FAMs are valuable resources for HPE researchers and demonstrate their utility with specific examples from the HPE literature.

Learning to navigate uncertainty in primary care: a scoping literature review

BACKGROUND

Clinical practice occurs in the context of uncertainty. Primary care is a clinical environment that accepts and works with uncertainty differently from secondary care. Recent literature reviews have contributed to understanding how clinical uncertainty is taught in educational settings and navigated in secondary care, and, to a lesser extent, by experienced GPs. We do not know how medical students and doctors in training learn to navigate uncertainty in primary care.

AIM

To explore what is known about primary care as an opportunity for learning to navigate uncertainty.

DESIGN & SETTING

Scoping review of articles written in English.

METHOD

Using a scoping review methodology, Embase, MEDLINE, and Web of Science databases were searched, with additional articles obtained through citation searching. Studies were included in this review if they: (a) were based within populations of medical students and/or doctors in training; and (b) considered clinical uncertainty or ambiguity in primary care or a simulated primary care setting. Study findings were analysed thematically.

RESULTS

Thirty-six studies were included from which the following three major themes were developed: uncertainty contributes to professional identity formation (PIF); adaptive responses; and maladaptive behaviours. Relational and social factors that influence PIF were identified. Adaptive responses included adjusting epistemic expectations and shared decision making (SDM).

CONCLUSION

Educators can play a key role in helping learners navigate uncertainty through socialisation, discussing primary care epistemology, recognising maladaptive behaviours, and fostering a culture of constructive responses to uncertainty.

Is there ever a single best answer (SBA): assessment driving certainty in the uncertain world of GP?

Uncertainty is inherent in all areas of medical practice, not least in primary care, which is defined by its acceptance of uncertainty and complexity. Single best answer (SBA) questions are a ubiquitous assessment tool in undergraduate medical assessments; however clinical practice, particularly in primary care, challenges the supposition that a single best answer exists for all clinical encounters and dilemmas. In this article, we seek to highlight several aspects of the relationship between this assessment format and clinical uncertainty by considering its influence on medical students' views of uncertainty in the contexts of their medical education, personal epistemology, and clinical expectations.

Prerequisites, barriers and opportunities in care for Q-fever patients: a Delphi study among healthcare workers

BACKGROUND

Q-fever is a zoonotic disease that can lead to illness, disability and death. This study aimed to provide insight into the perspectives of healthcare workers (HCWs) on prerequisites, barriers and opportunities in care for Q-fever patients.

METHODS

A two-round online Delphi study was conducted among 94 Dutch HCWs involved in care for Q-fever patients. The questionnaires contained questions on prerequisites for high quality, barriers and facilitators in care, knowledge of Q-fever, and optimization of care. For multiple choice, ranking and Likert scale questions, frequencies were reported, while for rating and numerical questions, the median and interquartile range (IQR) were reported.

RESULTS

The panel rated the care for Q-fever patients at a median score of 6/10 (IQR = 2). Sufficient knowledge of Q-fever among HCWs (36%), financial compensation of care (30%) and recognition of the disease by HCWs (26%) were considered the most important prerequisites for high quality care. A lack of knowledge was identified as the most important barrier (76%) and continuing medical education as the primary method for improving HCWs' knowledge (76%). HCWs rated their own knowledge at a median score of 8/10 (IQR = 1) and the general knowledge of other HCWs at a 5/10 (IQR = 2). According to HCWs, a median of eight healthcare providers (IQR = 4) should be involved in the care for Q-fever fatigue syndrome (QFS) and a median of seven (IQR = 5) in chronic Q-fever care.

CONCLUSIONS

Ten years after the Dutch Q-fever epidemic, HCWs indicate that the long-term care for Q-fever patients leaves much room for improvement. Facilitation of reported prerequisites for high quality care, improved knowledge among HCWs, clearly defined roles and responsibilities, and guidance on how to support patients could possibly improve quality of care. These prerequisites may also improve care for patients with persisting symptoms due to other infectious diseases, such as COVID-19.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical physiologists' experiences of working with people with nonepileptic attack disorder: A qualitative study

OBJECTIVES

To explore the perspectives of clinical physiologists on working with patients with nonepileptic attack disorder (NEAD). Nonepileptic attack disorder is a medically unexplained symptom frequently encountered by clinical physiologists in the field of neurophysiology. Studies in healthcare professionals show that they often find patients with medically unexplained symptoms challenging, uncomfortable, and frustrating to interact with. Clinical physiologists spend a substantial amount of time with patients and are key to the assessment of the condition. It is not known how physiologists experience working with patients with NEAD.

METHODS

Semi-structured interviews were conducted with clinical physiologists who frequently work with these patients. Interviews were recorded, transcribed, and analyzed according to grounded theory methodology.

RESULTS

Twelve participants including current trainees and qualified clinical physiologists working in neurophysiology were interviewed for the study. Participants described the experience of working with people with NEAD as anxiety provoking and unpredictable. The sources of this anxiety were the nature of the psychological aspects of the condition, the need to preserve professional boundaries and a lack of preparedness to manage conversations about distress or the psychological factors impacting the NEAD.

CONCLUSIONS

There is a risk that patient care is compromised by the lack of preparation and skills training of physiologists.

PRACTICE IMPLICATIONS

Physiologists need further training in counseling skills to increase tolerance to emotionally laden content in patient accounts and knowledge of suitable referral routes.

Diagnostic and treatment barriers to persistent somatic symptoms in primary care - representative survey with physicians

Background

Many patients consult their primary care physician with persistent somatic symptoms such as pain or sickness. Quite often these consultations and further diagnostic measures yield no medical explanation for the symptoms – patients and physicians are left in uncertainty. In fact, diagnostic and treatment barriers in primary care hinder timely health-care provision for patients suffering from persistent somatic symptoms (PSS). The significance of individual barriers is still unknown. We compare and quantify these barriers from the perspective of primary care physicians and identify subpopulations of primary care physicians who experience particular barriers as most severe.

Methods

We mailed a questionnaire to primary care physicians (PCP) in Germany and asked them which barriers they consider most important. We invited a random sample of 12,004 primary care physicians in eight federal states in Germany. Physicians provided anonymous mailed or online responses. We also mailed a postcard to announce the survey and a mail reminder. Main measures were Likert rating scales of items relating to barriers in the diagnosis and treatment of PSS in primary care. Information on demography and medical practice were also collected.

Results

We analyzed 1719 data sets from 1829 respondents. PCPs showed strongest agreement with statements regarding (1.) their lack of knowledge about treatment guidelines, (2.) their perceptions that patients with PSS would expect symptom relief, (3.) their concern to overlook physical disease in these patients, and (4.) their usage of psychotropic drugs with these patients. More experienced PCPs were better able to cope with the possibility of overlooking physical disease than those less experienced.

Conclusions

The PCPs in our survey answered that the obligation to rule out severe physical disease and the demand to relieve patients from symptoms belong to the most severe barriers for adequate treatment and diagnosis. Moreover, many physicians admitted to not knowing the appropriate treatment guidelines for these patients. Based on our results, raising awareness of guidelines and improving knowledge about the management of persistent somatic symptoms appear to be promising approaches for overcoming the barriers to diagnosis and treatment of persistent somatic symptoms in primary care.

Trial registration

German Clinical Trials Register (Deutschen Register Klinischer Studien, DRKS)

https://www.drks.de/drks_web/setLocale_EN.do

The date the study was registered: October 2^nd 2017

The date the first participant was enrolled: February 9^th 2018

DRKS-ID: DRKS00012942

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01397-w.

Development of an eHealth programme for self-management of persistent physical symptoms: a qualitative study on user needs in general practice

Background

Persistent physical symptoms (PPS) are estimated to be present in 17% of patients in general practice. Hence, general practitioners (GPs) play a key role in both the diagnostic assessment and the management of PPS. However, research indicates a need to improve their strategies to support self-help in patients, and eHealth tools may serve as an opportunity. This study aimed to explore patients’ and GPs’ needs related to self-management of PPS. The study was designed to inform the future development of eHealth interventions in this field.

Methods

This qualitative study was based on 20 semi-structured interviews (6 GPs and 14 patients with PPS). Interviews were audiotaped, transcribed verbatim and analysed through a five-step thematic analysis approach. First, we conducted an inductive analysis to identify and explore emerging subthemes. Second, using a deductive mapping strategy, we categorised the derived subthemes according to the COM-B behaviour change model and its three domains: capability, opportunity and motivation.

Results

We identified eleven subthemes in the patient interviews and seven subthemes in the GP interviews. Several unmet needs emerged. First, we identified a need to consider PPS early in the illness trajectory by taking a bio-psycho-social approach. Second, both patients and GPs need better skills to manage uncertainty. Third, hope is important for the patients. Fourth, patients need guidance from their GP in how to self-manage their PPS.

Conclusions

This study provides important insight into key issues and needs related to capability, opportunity and motivation that should be addressed in the design of future eHealth self-management interventions targeting patients with PPS in general practice in order to support and improve care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01380-5.

Harmony or dissonance? The affordances of palliative care learning for emerging professional identity

INTRODUCTION

Patient demographics demand physicians who are competent in and embrace palliative care as part of their professional identity. Published literature describes ways that learners acquire knowledge, skills and attitudes for palliative care. These studies are, however, limited by their focus on the individual where learning is about acquisition. Viewing learning as a process of becoming through the interplay of individual, social relationships and cultures, offers a novel perspective from which to explore the affordances for professional identity development.

METHODS

Qualitative narrative methods were used to explore 45 narratives of memorable learning (NMLs) for palliative care recounted by 14 graduating family medicine residents in one family medicine residency program. Thematic and narrative analyses identified the affordances that support and constrain the dynamic emergence of professional identity.

RESULTS

Participants recounted affordances that supported and/or constrained their learning acting on personal (e.g. past experiences of death), interpersonal (e.g. professional support) and systemic (e.g. patient continuity) levels. Opportunities for developing professional identity were dynamic: factors acted in harmony, were misaligned, or colliding to support or constrain an emerging professional identity for palliative care practice.

CONCLUSION

Findings highlight how individual factors interplay with interpersonal and structural conditions in the workplace in dynamic and emergent ways that may support or constrain the emergence of professional identity. Viewing learning as a process of becoming allows teachers, curriculum developers and administrators to appreciate the complexity and importance of the interplay between the individual and the workplace affordances to create environments that nurture professional identity for palliative care practice.

Behavioural modification interventions for medically unexplained symptoms in primary care: systematic reviews and economic evaluation

BACKGROUND

The term 'medically unexplained symptoms' is used to cover a wide range of persistent bodily complaints for which adequate examination and appropriate investigations do not reveal sufficiently explanatory structural or other specified pathologies. A wide range of interventions may be delivered to patients presenting with medically unexplained symptoms in primary care. Many of these therapies aim to change the behaviours of the individual who may have worsening symptoms.

OBJECTIVES

An evidence synthesis to determine the clinical effectiveness and cost-effectiveness of behavioural modification interventions for medically unexplained symptoms delivered in primary care settings was undertaken. Barriers to and facilitators of the effectiveness and acceptability of these interventions from the perspective of patients and service providers were evaluated through qualitative review and realist synthesis.

DATA SOURCES

Full search strategies were developed to identify relevant literature. Eleven electronic sources were searched. Eligibility criteria - for the review of clinical effectiveness, randomised controlled trials were sought. For the qualitative review, UK studies of any design were included. For the cost-effectiveness review, papers were restricted to UK studies reporting outcomes as quality-adjusted life-year gains. Clinical searches were conducted in November 2015 and December 2015, qualitative searches were conducted in July 2016 and economic searches were conducted in August 2016. The databases searched included MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO and EMBASE. Updated searches were conducted in February 2019 and March 2019.

PARTICIPANTS

Adult participants meeting the criteria for medically unexplained symptoms, including somatoform disorders, chronic unexplained pain and functional somatic syndromes.

INTERVENTIONS

Behavioural interventions were categorised into types. These included psychotherapies, exercise-based interventions, multimodal therapies (consisting of more than one intervention type), relaxation/stretching/social support/emotional support, guided self-help and general practitioner interventions, such as reattribution. Evidence synthesis: a network meta-analysis was conducted to allow a simultaneous comparison of all evaluated interventions in a single coherent analysis. Separate network meta-analyses were performed at three time points: end of treatment, short-term follow-up (< 6 months since the end of treatment) and long-term follow-up (≥ 6 months after the end of treatment). Outcomes included physical and psychological symptoms, physical functioning and impact of the illness on daily activities. Economic evaluation: within-trial estimates of cost-effectiveness were generated for the subset of studies where utility values (or quality-adjusted life-years) were reported or where these could be estimated by mapping from Short Form questionnaire-36 items or Short Form questionnaire-12 items outcomes.

RESULTS

Fifty-nine studies involving 9077 patients were included in the clinical effectiveness review. There was a large degree of heterogeneity both between and within intervention types, and the networks were sparse across all outcomes. At the end of treatment, behavioural interventions showed some beneficial effects when compared with usual care, in particular for improvement of specific physical symptoms [(1) pain: high-intensity cognitive-behavioural therapy (CBTHI) standardised mean difference (SMD) 0.54 [95% credible interval (CrI) 0.28 to 0.84], multimodal SMD 0.52 (95% CrI 0.19 to 0.89); and (2) fatigue: low-intensity cognitive-behavioural therapy (CBTLI) SMD 0.72 (95% CrI 0.27 to 1.21), relaxation/stretching/social support/emotional support SMD 0.87 (95% CrI 0.20 to 1.55), graded activity SMD 0.51 (95% CrI 0.14 to 0.93), multimodal SMD 0.52 (95% CrI 0.14 to 0.92)] and psychological outcomes [(1) anxiety CBTHI SMD 0.52 (95% CrI 0.06 to 0.96); (2) depression CBTHI SMD 0.80 (95% CrI 0.26 to 1.38); and (3) emotional distress other psychotherapy SMD 0.58 (95% CrI 0.05 to 1.13), relaxation/stretching/social support/emotional support SMD 0.66 (95% CrI 0.18 to 1.28) and sport/exercise SMD 0.49 (95% CrI 0.03 to 1.01)]. At short-term follow-up, behavioural interventions showed some beneficial effects for specific physical symptoms [(1) pain: CBTHI SMD 0.73 (95% CrI 0.10 to 1.39); (2) fatigue: CBTLI SMD 0.62 (95% CrI 0.11 to 1.14), relaxation/stretching/social support/emotional support SMD 0.51 (95% CrI 0.06 to 1.00)] and psychological outcomes [(1) anxiety: CBTHI SMD 0.74 (95% CrI 0.14 to 1.34); (2) depression: CBTHI SMD 0.93 (95% CrI 0.37 to 1.52); and (3) emotional distress: relaxation/stretching/social support/emotional support SMD 0.82 (95% CrI 0.02 to 1.65), multimodal SMD 0.43 (95% CrI 0.04 to 0.91)]. For physical functioning, only multimodal therapy showed beneficial effects: end-of-treatment SMD 0.33 (95% CrI 0.09 to 0.59); and short-term follow-up SMD 0.78 (95% CrI 0.23 to 1.40). For impact on daily activities, CBTHI was the only behavioural intervention to show beneficial effects [end-of-treatment SMD 1.30 (95% CrI 0.59 to 2.00); and short-term follow-up SMD 2.25 (95% CrI 1.34 to 3.16)]. Few effects remained at long-term follow-up. General practitioner interventions showed no significant beneficial effects for any outcome. No intervention group showed conclusive beneficial effects for measures of symptom load (somatisation). A large degree of heterogeneity was found across individual studies in the assessment of cost-effectiveness. Several studies suggested that the interventions produce fewer quality-adjusted life-years than usual care. For those interventions that generated quality-adjusted life-year gains, the mid-point incremental cost-effectiveness ratios (ICERs) ranged from £1397 to £129,267, but, where the mid-point ICER fell below £30,000, the exploratory assessment of uncertainty suggested that it may be above £30,000.

LIMITATIONS

Sparse networks meant that it was not possible to conduct a metaregression to explain between-study differences in effects. Results were not consistent within intervention type, and there were considerable differences in characteristics between studies of the same type. There were moderate to high levels of statistical heterogeneity. Separate analyses were conducted for three time points and, therefore, analyses are not repeated-measures analyses and do not account for correlations between time points.

CONCLUSIONS

Behavioural interventions showed some beneficial effects for specific medically unexplained symptoms, but no one behavioural intervention was effective across all medically unexplained symptoms. There was little evidence that these interventions are effective for measures of symptom load (somatisation). General practitioner-led interventions were not shown to be effective. Considerable heterogeneity in interventions, populations and sparse networks mean that results should be interpreted with caution. The relationship between patient and service provider is perceived to play a key role in facilitating a successful intervention. Future research should focus on testing the therapeutic effects of the general practitioner-patient relationship within trials of behavioural interventions, and explaining the observed between-study differences in effects within the same intervention type (e.g. with more detailed reporting of defined mechanisms of the interventions under study).

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015025520.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 46. See the NIHR Journals Library website for further project information.

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

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

An analysis of childhood consultations in general practice: a multi-practice study

BACKGROUND

The majority of illnesses in children are managed by general practitioners (GPs) and there is a need for up to date data on consultations with children in order to improve healthcare service planning and allocation of resources.

AIMS

To investigate the presenting symptoms, diagnoses and actions taken by the GP at consultations with children in general practice.

METHODS

Senior medical students on general practice placement and their GP supervisors used practice management software to collect data on 100 randomly selected patients aged between 12 months and 14 years of age in each practice. Presenting symptoms, diagnoses and actions taken by the GP for the most recent attendance in the previous 12 months were summarised by age group (1-4 years; 5-10 years; 11-14 years).

RESULTS

Data were collected from 5959 patients at 64 practices. During the 12-month study, 3241 (54%) of children had a consultation with their GP. The most common presenting symptoms were respiratory (1-4 yrs, 28%; 5-10 yrs, 39%; 11-14 yrs, 32%) and skin complaint (1-4 yrs, 13%; 5-10 yrs, 16%; 11-14 yrs, 21%). The most common actions for all age groups were prescribing (1-4 yrs, 55%; 5-10 yrs, 58%; 11-14 yrs, 56%) and providing reassurance (1-4 yrs, 53%; 5-10 yrs, 51%; 11-14 yrs, 48%). Rates of referral and requiring further investigation increased with age.

CONCLUSION

This study provides a comprehensive snapshot of what children commonly present with in general practice, common diagnoses and the actions taken by GPs. The findings will help GPs to organise their practice systems and will inform healthcare service planners.

Persistent unexplained physical symptoms: a prospective longitudinal cohort study in UK primary care

BACKGROUND

Unexplained physical symptoms (UPS) are extremely common among primary care attenders, but little is known about their longer-term outcome.

AIM

To investigate the persistence of somatic symptoms at 6 months among a cohort with multiple UPS, and identify prognostic factors associated with worsening symptom scores.

DESIGN AND SETTING

Prospective longitudinal cohort study involving adults attending UK general practice in North and Central London between January and December 2013.

METHOD

Consecutive adults attending nine general practices were screened to identify those with at least three UPS. Eligible participants completed measures of symptom severity (measured using the Patient Health Questionnaire Somatic Symptom Module [PHQ-15]), physical and mental wellbeing, and past health and social history, and were followed up after 6 months. Multivariable linear regression analysis was conducted to identify prognostic factors associated with the primary outcome: somatic symptom severity.

RESULTS

Overall, 245/294 (83%) provided 6-month outcome data. Of these, 135/245 (55%) reported still having UPS, 103/245 (42%) had symptoms still under investigation, and only 26/245 (11%) reported complete symptom resolution. Being female, higher baseline somatic symptom severity, poorer physical functioning, experience of childhood physical abuse, and perception of poor financial wellbeing were significantly associated with higher somatic symptom severity scores at 6 months.

CONCLUSION

This study has shown that at 6 months few participants had complete resolution of unexplained somatic symptoms. GPs should be made aware of the likelihood of UPS persisting, and the factors that make this more likely, to inform decision making and care planning. There is a need to develop prognostic tools that can predict the risk of poor outcomes.

"It´s incredible how much I´ve had to fight." Negotiating medical uncertainty in clinical encounters

Purpose: Clinical encounters related to medically unexplained physical symptoms (MUPS) are associated with high levels of conflict between patients and doctors. Collaborative difficulties are fused by the medical uncertainty that dominates these consultations. The main aim of this study is to explore the interactional dynamics of clinical encounters riddled by medical uncertainty, as experienced by people living with long-term medically unexplained fatigue in Norway. Method: A qualitative thematic analysis of written texts from 256 study participants. Results: We found that patients experience being met with disbelief, inappropriate psychological explanations, marginalisation of experiences, disrespectful treatment, lack of physical examination and damaging health advice. The main source of their discontent is not the lack of biomedical knowledge, but doctors who fail to communicate acknowledgement of patients’ experiences, knowledge and autonomy. War metaphors are emblematic of how participants describe their medical encounters. The overarching storyline depicts experiences of being caught in a power struggle with doctors and health systems, fused by a lack of common conceptual ground. Conclusion: When physical symptoms cannot be detected, explained and managed by biomedical knowledge and technology, good doctor-patient partnerships are crucial. Without clearly acknowledging patients’ perspectives and capabilities in clinical practice, such partnerships cannot be achieved.

Management of patients with persistent medically unexplained symptoms: a descriptive study

BACKGROUND

In 2013 the Dutch guideline for management of medically unexplained symptoms (MUS) was published. The aim of this study is to assess medical care for patients with persistent MUS as recorded in their electronic medical records, to investigate if this is in line with the national guideline for persistent MUS and whether there are changes in care over time.

METHODS

We conducted an observational study of adult primary care patients with MUS. Routinely recorded health care data were extracted from electronic medical records of patients participating in an ongoing randomised controlled trial in 30 general practices in the Netherlands. Data on general practitioners' (GPs') management strategies during MUS consultations were collected in a 5-year period for each patient prior. Management strategies were categorised according to the options offered in the Dutch guideline. Changes in management over time were analysed.

RESULTS

Data were collected from 1035 MUS consultations (77 patients). Beside history-taking, the most frequently used diagnostic strategies were physical examination (24.5%) and additional investigations by the GP (11.1%). Frequently used therapeutic strategies were prescribing medication (24.6%) and providing explanations (11.2%). As MUS symptoms persisted, GPs adjusted medication, discussed progress and scheduled follow-up appointments more frequently. The least frequently used strategies were exploration of all complaint dimensions (i.e. somatic, cognitive, emotional, behavioural and social) (3.5%) and referral to a psychologist (0.5%) or psychiatrist (0.1%).

CONCLUSIONS

Management of Dutch GPs is partly in line with the Dutch guideline. Medication was possibly prescribed more frequently than recommended, whereas exploration of all complaint dimensions, shared problem definition and referral to mental health care were used less.

How general practitioners understand and handle medically unexplained symptoms: a focus group study

Background

Medically unexplained symptoms (MUS) are a common yet challenging encounter in primary care. The aim of this study was to explore how general practitioners (GPs) understand and handle MUS.

Methods

Three focus group interviews were conducted with a total of 23 GPs. Participants with varied clinical experience were purposively recruited. The data were analysed thematically, using the concept of framing as an analytical lens.

Results

The GPs alternated between a biomedical frame, centred on disease, and a biopsychosocial frame, centred on the sick person. Each frame shaped the GPs’ understanding and handling of MUS. The biomedical frame emphasised the lack of objective evidence, problematized subjective patient testimony, and manifested feelings of uncertainty, doubt and powerlessness. This in turn complicated patient handling. In contrast, the biopsychosocial frame emphasised clinical experience, turned patient testimony into a valuable source of information, and manifested feelings of confidence and competence. This in turn made them feel empowered. The GPs with the least experience relied more on the biomedical frame, whereas their more seasoned seniors relied mostly on the biopsychosocial frame.

Conclusion

The biopsychosocial frame helps GPs to understand and handle MUS better than the biomedical frame does. Medical students should spend more time learning biopsychosocial medicine, and to integrate the clinical knowledge of their peers with their own.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0745-2) contains supplementary material, which is available to authorized users.

Responses to clinical uncertainty in Australian general practice trainees: a cross-sectional analysis

CONTEXT

Tolerance for ambiguity is essential for optimal learning and professional competence. General practice trainees must be, or must learn to be, adept at managing clinical uncertainty. However, few studies have examined associations of intolerance of uncertainty in this group.

OBJECTIVES

The aim of this study was to establish levels of tolerance of uncertainty in Australian general practice trainees and associations of uncertainty with demographic, educational and training practice factors.

METHODS

A cross-sectional analysis was performed on the Registrar Clinical Encounters in Training (ReCEnT) project, an ongoing multi-site cohort study. Scores on three of the four independent subscales of the Physicians' Reaction to Uncertainty (PRU) instrument were analysed as outcome variables in linear regression models with trainee and practice factors as independent variables.

RESULTS

A total of 594 trainees contributed data on a total of 1209 occasions. Trainees in earlier training terms had higher scores for 'Anxiety due to uncertainty', 'Concern about bad outcomes' and 'Reluctance to disclose diagnosis/treatment uncertainty to patients'. Beyond this, findings suggest two distinct sets of associations regarding reaction to uncertainty. Firstly, affective aspects of uncertainty (the 'Anxiety' and 'Concern' subscales) were associated with female gender, less experience in hospital prior to commencing general practice training, and graduation overseas. Secondly, a maladaptive response to uncertainty (the 'Reluctance to disclose' subscale) was associated with urban practice, health qualifications prior to studying medicine, practice in an area of higher socio-economic status, and being Australian-trained.

CONCLUSIONS

This study has established levels of three measures of trainees' responses to uncertainty and associations with these responses. The current findings suggest differing 'phenotypes' of trainees with high 'affective' responses to uncertainty and those reluctant to disclose uncertainty to patients. More research is needed to examine the relationship between clinical uncertainty and clinical outcomes, temporal changes in tolerance for uncertainty, and strategies that might assist physicians in developing adaptive responses to clinical uncertainty.

Medically unexplained symptoms and general practitioners: a comprehensive survey about their attitudes, experiences and management strategies

BACKGROUND

Medically unexplained symptoms (MUS) are common in primary care and are one of the most challenging clinical encounters for general practitioners (GPs).

OBJECTIVE

To assess GPs' clinical experience with MUS and its relationship with their gender, age and length of practice.

METHODS

Four hundred and thirty-three Italian GPs were invited to complete a questionnaire encompassing the following MUS-related features: workload, cognitive and emotional responses, management strategies, attitudes towards psychological interventions, sources of education and educational needs.

RESULTS

A total of 347 GPs (80.1%) participated in the study. About seven out of ten physicians spent 'much' or 'very much' time and energy for MUS during their daily practice. Fear of neglecting a medical disease was the most frequent (59.1%) response to MUS. Providing reassurance and support (73.8%) and listening to the patient (69.2%) were the most frequent management strategies. More than half of GPs rated psychological interventions as 'much' or 'very much' useful for MUS. However, only a third of GPs were well informed about the role of psychologists in MUS management. The main sources of education about MUS were scientific papers and continuing medical education courses. Most of GPs (77.5%) needed further education about MUS. GPs' younger age and lower length of practice were significantly associated with negative emotional responses to MUS.

CONCLUSION

The introduction of guidelines for MUS in Italian primary care settings would promote a collaborative clinical approach to MUS and more formal training on this topic.

Clinical practitioners' views on the management of patients with medically unexplained physical symptoms (MUPS): a qualitative study

OBJECTIVES

By identifying strategies that practicing physicians use in managing patients with medically unexplained physical symptoms (MUPS), we present an interim practical management guide (IPMG) that clinical practitioners may find useful in their clinical practices and that may help guide future research.

DESIGN

A qualitative research study based on interview data from practicing physicians with experience in dealing with MUPS and known to the physician members of the research team. A parallel exploration of patient experiences was carried out simultaneously and is reported elsewhere.

SETTING

2 urban centres in 2 different Canadian provinces in a healthcare system where family physicians provide the majority of primary care and self-referral to specialists rarely occurs.

PARTICIPANTS

The physician members of the research team invited practicing family and specialty physicians to participate in the study.

RESULTS

We characterise the care of patients with MUPS in terms of a 4-part framework: (1) the challenge of diagnosis; (2) the challenge of management/treatment; (3) the importance of communication and (4) the importance of the therapeutic relationship.

CONCLUSIONS

On the basis of the details in the different parts of the framework, we propose an IPMG that practitioners may find useful to facilitate the clinical care of patients with MUPS. The guide can be readily implemented into the practice of any physician who cares for patients with MUPS.