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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Emotions of endometriosis in clinical encounters: An analysis of women's experiences of health care

BACKGROUND

A large number of illnesses that lack physical visibility are characterised by troubled clinical encounters. Endometriosis is one such condition with very real and often debilitating symptoms that remain invisible to the clinician's eye, but are experienced and lived by the patient.

METHOD

This paper probes into two first person accounts of endometriosis to find out how endometriosis patients experience health care. The Tiger and the Cage: A Memoir of a Body in Crisis (2022) by Emma Bolden and Vagina Problems: Endometriosis, Painful Sex, and Other Taboo Topics (2020) by Lara Parker are both memoirs that details on the trivialisation and delegitimization of the women's accounts of their own lived reality by a health care system that often privileges medical evidence over lived experiences of the patients. After giving a brief introduction on the condition, the paper goes on to detail on the method and conceptual frameworks chosen for analysis. This is followed by an in-depth analysis into the two texts using thematic analysis proposed by Virginia Braun and Victoria Clarke to identify shared patterns of meanings in the texts.

DISCUSSION

The identified themes take the form of emotions repeatedly narrated by the women. The findings indicate instances of disrespect, epistemic invalidation and compromised autonomy, due to which six shared categories of negative emotions are experienced by the patients: self-doubt, shame, fear, powerlessness, self-blame and anger.

CONCLUSION

The paper concludes by indicating the urgency of improved medical training, that better educates and facilitates health care professionals in dealing with conditions with complicated aetiology, difficult diagnosis and no cure.

Clinical relevance of resistance training in women with fibromyalgia: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

There has been an increase in the number of papers assessing the effects of resistance training (RT) in patients with fibromyalgia. Therefore, the objective of our study was to evaluate the clinical relevance and effectiveness of RT for pain intensity, functionality and severity of the disease specifically in women with fibromyalgia through a systematic review with meta-analysis.

DATABASES AND DATA TREATMENT

Seven databases were searched. Randomized controlled trials conducted in women over 18 years of age with fibromyalgia were included. Fifteen trials were included in the systematic review and 14 of these studies were included in the three meta-analyses performed. Study quality assessment was performed using the PEDro scale. In addition, the GRADE recommendations were used.

RESULTS

The global meta-analysis revealed statistically significant differences in the RT group versus the control group on pain intensity (SMD = -0.49; 95% CI [-0.74, -0.24], p = 0.0001), functionality (SMD = -0.23; 95% CI [0.01, 0.45], p = 0.04) and on severity of the disease (SMD = -0.58; 95% CI [-0.90, -0.26], p = 0.0005). Clinically relevant improvements in the overall outcome of the three variables studied in favour of RT were obtained.

CONCLUSIONS

RT is effective to improve pain intensity, functionality and severity of the disease in women with fibromyalgia. These improvements are clinically relevant. More clinical trials of RT are needed in women with fibromyalgia to support our results due to the low strength of evidence.

SIGNIFICANCE

This systematic review with meta-analysis provides evidence that RT produces clinically relevant improvements in women with fibromyalgia. The absence of immediate benefit is often a major barrier to adherence to treatment. Our findings will help clinicians to empower patients that if they continue treatment, they will achieve improvement in their disease.

Healthcare experiences of fibromyalgia patients and their associations with satisfaction and pain relief. A patient survey

OBJECTIVES

The etiology of fibromyalgia (FM) is disputed, and there is no established cure. Quantitative data on how this may affect patients' healthcare experiences are scarce. The present study aims to investigate FM patients' pain-related healthcare experiences and explore factors associated with high satisfaction and pain relief.

METHODS

An anonymous, online, and patient-administered survey was developed and distributed to members of the Norwegian Fibromyalgia Association. It addressed their pain-related healthcare experiences from both primary and specialist care. Odds ratios for healthcare satisfaction and pain relief were estimated by binary logistic regression. Directed acyclic graphs guided the multivariable analyses.

RESULTS

The patients (n = 1,626, mean age: 51 years) were primarily women (95%) with a 21.8-year mean pain duration and 12.7 years in pain before diagnosis. One-third did not understand why they had pain, and 56.6% did not know how to get better. More than half had not received satisfactory information on their pain cause from a physician, and guidance on how to improve was reported below medium. Patients regretted a lack of medical specialized competence on muscle pain and reported many unmet needs, including regular follow-up and pain assessment. Physician-mediated pain relief was low, and guideline adherence was deficient. Only 14.8% were satisfied with non-physician health providers evaluating and treating their pain, and 21.5% were satisfied (46.9% dissatisfied) with their global pain-related healthcare. Patients' knowledge of their condition, physicians' pain competence and provision of information and guidance, agreement in explanations and advice, and the absence of unmet needs significantly increased the odds of both healthcare satisfaction and pain relief.

CONCLUSIONS

Our survey describes deficiencies in FM patients' pain-related healthcare and suggests areas for improvement to increase healthcare satisfaction and pain relief. (REC# 2019/845, 09.05.19).

Flipping the hidden curriculum to transform pain education and culture

Though long-sought, transformation of pain management practice and culture has yet to be realized. We propose both a likely cause-entrenchment in a biomedical model of care that is observed and then replicated by trainees-and a solution: deliberately leveraging the hidden curriculum to instead implement a sociopsychobiological (SPB) model of care. We make use of Implicit Bias Recognition and Management, a tool that helps teams to first recognize and "surface" whatever is implicit and to subsequently intervene to change whatever is found to be lacking. We describe how a practice might use iterations of recognition and intervention to move from a biomedical to a SPB model by providing examples from the Chronic Pain Wellness Center in the Phoenix Veterans Affairs Health Care System. As pain management practitioners and educators collectively leverage the hidden curriculum to provide care in the SPB model, we will not only positively transform our individual practices but also pain management as a whole.

Survey of knowledge and attitude towards fibromyalgia among physicians in Karachi, Pakistan

Objectives

Our study aims to assess knowledge and understanding of FM among doctors employed at a tertiary care hospital in Karachi, Pakistan with a focus on its diagnostic criteria, treatment modalities, and general knowledge of symptoms.

Study Design

Cross-sectional Study.

Methods

Our cross-sectional study recruited participants through convenience sampling. A total of 104 participants responded, which included (a) House Officers, (b) Medical Officers, and (c) Residents. A structured questionnaire was used, and an electronic form was generated which was then emailed to the participants to acquire their responses.

Results

The majority (66.3%) of our respondents were female and the median age was 26 years. A majority (93.3%) accepted FM as a separate and distinct clinical identity, and 79.8% were confident in recognizing its general symptoms. Widespread pain (95.2%) and fatigue (80.8%) were correctly identified as most commonly observed symptoms. Moreover, 68.3% of respondents possessed no knowledge of both ACR 1990 and 2010 diagnostic criteria for FM. Of those aware, majority favored using the most recent ACR 2010 criteria (72.7%). Majority of our respondents (75%) preferred using pharmaceutical and non-pharmaceutical interventions simultaneously in the treatment.

Conclusions

Our study indicates that while physicians have satisfactory knowledge of the symptoms and treatment modalities of FM, a knowledge gap concerning its diagnostic criteria exists. Proper treatment can only be successful when physicians successfully diagnose FM, therefore, future training programs should use this fact as a stepping stone for advances in its healthcare.

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

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

Knowledge, Awareness, and Perceptions of the Diagnosis and Management of Fibromyalgia Among Physical Therapists in Saudi Arabia: A Cross-Sectional Survey

Aim

To explore awareness of the diagnostic criteria and management of fibromyalgia (FM) among physical therapists practicing in Saudi Arabia.

Methods

A cross-sectional survey was distributed electronically among musculoskeletal physical therapists. It was designed based on the research literature relevant to FM and reviewed by two rheumatologists for accuracy and comprehension. The survey included two sections: participants' demographic information and questions related to FM. The data were described using absolute and relative frequencies.

Results

A total of 234 physical therapists accepted the invitation to participate in the study, and 52 were excluded for not satisfying the inclusion criteria or not completing the survey. Responses were received from March to May 2020; only 118 (65%) respondents completed the FM section. The average age of the participants was 31.2 (SD=6.9) years, and 36% were females. Eighty percent reported seeing fewer than five patients with FM in the past year; 51% acquired FM-related knowledge through self-learning; half reported having little to no confidence in their FM assessments and management; and less than 20% were familiar with common diagnostic criteria and management guidelines for FM.

Conclusion

Participating physical therapists showed little awareness of or confidence in the assessment and management of patients with FM; moreover, their awareness was not supported by their adherence to recent FM guidelines. Despite the common practice of referring patients with FM for physical therapy, there are many misconceptions about FM. This study highlights the need for educational programs to provide up-to-date evidence in undergraduate and postgraduate education.

Stigma and functional neurological disorder: a research agenda targeting the clinical encounter

Stigma against patients with functional neurological disorder (FND) presents obstacles to diagnosis, treatment, and research. The lack of biomarkers and the potential for symptoms to be misunderstood, invalidated, or dismissed can leave patients, families, and healthcare professionals at a loss. Stigma exacerbates suffering and unmet needs of patients and families, and can result in poor clinical management and prolonged, repetitive use of healthcare resources. Our current understanding of stigma in FND comes from surveys documenting frustration experienced by providers and distressing healthcare interactions experienced by patients. However, little is known about the origins of FND stigma, its prevalence across different healthcare contexts, its impact on patient health outcomes, and optimal methods for reduction. In this paper, we set forth a research agenda directed at better understanding the prevalence and context of stigma, clarifying its impact on patients and providers, and promoting best practices for stigma reduction.

A Patient-Narrative Video Approach to Teaching Fibromyalgia

INTRODUCTION

Although fibromyalgia is one of the most common and clinically important rheumatologic entities, physicians frequently report that their training fails to prepare them to manage this disease. Many medical schools devote insufficient time and attention to the subject of fibromyalgia, resulting in training gaps that can manifest as failures of both knowledge and empathy. There is a need for evidence-based, time-efficient methods for teaching this important subject. We have developed a narrative-driven video presentation for clerkship students and sought to evaluate its impact on fibromyalgia-related knowledge and attitudes.

METHODS

Fibromyalgia: A Patient's Perspective (FPP), a 13-minute video, was presented to third-year medical students (N = 54). Surveys of knowledge and attitudes were collected before and after the video. Composite scores, as well as Knowledge and Attitudes subscales, were computed, and paired t tests were used to compare pre/post means for these scales, as well as for individual questions. Mann-Whitney U and Kruskal-Wallis tests were used to identify correlations between survey scores and student sex and specialty of interest.

RESULTS

Between pre-experience and post-experience surveys, there were statistically significant differences for 11 of 15 questions (73%). The composite score increased from 3.8 (SD = 0.44) to 4.2 (SD = 0.47) (P < .0001). Knowledge and Attitude subscale scores also increased, from 4.0 (SD = 0.5) to 4.38 (SD = 0.5) (P < .0001) and 3.6 (SD = 0.5) to 3.93 (SD = 0.5) (P < .0001), respectively. Students reported favorable impressions of the video, with 87% agreeing that the video was helpful to learners and 79% disagreeing that a lecture would be preferable to the video. No differences in scores by sex or intended specialty were observed.

CONCLUSION

The FPP video demonstrates promise as a tool for enhancing both knowledge of and positive, empathic attitudes toward fibromyalgia in medical learners. It may serve as a useful resource for educators looking to further develop their clinical pain management curricula.

Training tomorrow's doctors to explain 'medically unexplained' physical symptoms: An examination of UK medical educators' views of barriers and solutions

OBJECTIVE

Co-occuring physical symptoms, unexplained by organic pathology (known as Functional Syndromes, FS), are common and disabling presentations. However, FS is absent or inconsistently taught within undergraduate medical training. This study investigates the reasons for this and identifies potential solutions to improved implementation.

METHODS

Twenty-eight medical educators from thirteen different UK medical schools participated in semi-structured interviews. Thematic analysis proceeded iteratively, and in parallel with data production.

RESULTS

Barriers to implementing FS training are beliefs about the complexity of FS, tutors' negative attitudes towards FS, and FS being perceived as a low priority for the curriculum. In parallel participants recognised FS as ubiquitous within medical practice and erroneously assumed it must be taught by someone. They recommended that students should learn about FS through managed exposure, but only if tutors' negative attitudes and behaviour are also addressed.

CONCLUSION

Negative attitudes towards FS by educators prevents designing and delivering effective education on this common medical presentation. Whilst there is recognition of the need to implement FS training, recommendations are multifaceted.

PRACTICE IMPLICATIONS

Increased liaison between students, patients and educators is necessary to develop more informed and effective teaching methods for trainee doctors about FS and in order to minimise the impact of the hidden curriculum.