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

OBJECTIVE: To identify the basis of the communication problems that characterise consultations about medically unexplained symptoms (MUS) and to identify implications for clinical education. METHOD: Recent research into the details of clinical communication about MUS was reviewed narratively and critically, and broader research literature was scrutinised from the perspective of a practitioner who wishes to provide patients with explanations for such symptoms. RESULTS: Consultations about MUS often involve contest between patients' authority, resting on their knowledge of their symptoms, and practitioners' authority, based on the normal findings of tests and investigations. The outcome of consultations can therefore depend on the strategies that each party uses to press their authority, rather than on clinical need. CONCLUSION: Contest is a product of patients and practitioners occupying separate conceptual 'ground'. Avoiding contest requires the practitioner to find common conceptual ground within which each party can understand and discuss the symptoms. Finding common ground by collusion with explanations that patients suggest can damage clinical relationships. Instead the practitioner needs to fashion explanation that is acceptable to both parties from available medical and lay material. PRACTICE IMPLICATIONS: Although practitioners commonly fashion such explanations, this aspect of their professional role seems not to be greatly valued amongst practitioners or in medical curricula. Clinical education programmes could include curricula in symptom explanation, drawing from research in medicine, psychology and anthropology.     

Quantifying implicit uncertainty in primary care consultations: A systematic comparison of communication about medically explained versus unexplained symptoms

ObjectiveGeneral practitioners (GPs) disclose more uncertainty (e.g. “I don’t know”) in consultations with patients presenting medically unexplained symptoms (MUS) versus medically explained symptoms (MES), which could negatively affect patient outcomes. This study assessed if this pattern also holds for more subtle, implicit uncertainty expressions (e.g. “maybe”, “might”) during different consultation phases, and assessed their relation to patient pre-post consultation anxiety.MethodsWe quantified implicit markers of uncertainty of 18 GPs in 82 consultations about MUS or MES during different consultation phases. Relative frequencies of implicit uncertainty per consultation were regressed on differences in momentary anxiety pre and post consultation.ResultsWe coded 2590 GP utterances. Uncertainty expressions were more frequent in MUS versus MES consultations (OR = 1.54, p = .004), especially during diagnosis and treatment recommendations compared to physical examinations (OR =0 .45, p = .001). Implicit uncertainty was not related to patients’ changes in anxiety (b = ?0.11, p = .817).ConclusionsGPs express more uncertainty during MUS (versus MES) consultations, especially during the diagnostic phase and treatment recommendations. This does not necessarily affect patient anxiety.Practice implicationsImplicit uncertainty expressions reflect the mere complexity of communicating a medically unexplained diagnosis, which does not affect patient anxiety.     

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

ObjectivesMedically unexplained symptoms (MUS) are common, with particularly high rates observed in military veterans. Effective patient-provider-communication is thought to be a key aspect of care; however there have been few empirical studies on the association between communication and outcomes for patients with MUS. We evaluate whether discussing veterans’ MUS-illness representations and good interpersonal skills have the potential to promote MUS-treatment adherence and improvement.MethodsVeterans experiencing MUS (n = 204) reported on their primary care providers’ communication about illness representations and interpersonal skills; correlation, regression, and bootstrap-mediation analyses were conducted to test hypotheses regarding veteran-reported outcomes. Main outcomes included satisfaction with the provider, MUS-treatment adherence, intentions to adhere, and expectations for MUS improvement.ResultsVeterans reported infrequent discussion of MUS illness representations but high degrees of provider interpersonal skills. Communication regarding patients’ illness representations and treatment expectations was significantly related to treatment adherence and adherence intentions; provider interpersonal skills were not. Both were related to veteran satisfaction.Conclusions and practice implicationsProviders’ interpersonal skills may be important in chronic illness contexts, such as MUS, by contributing to satisfaction with the provider. The current study suggests that providers may better promote MUS-treatment adherence through discussing MUS illness representations and treatment expectations.     

‘They’ve just got symptoms without science’: Medical trainees’ acquisition of negative attitudes towards patients with medically unexplained symptoms

Objective

Doctors find patients with medically unexplained symptoms (MUS) challenging to manage and some hold negative attitudes towards these patients. It is unknown when and how these views form. This study examines medical trainees’ beliefs and influences about MUS.

Methods

Semi-structured interviews with 43 medical trainees. Using an iterative approach, initial emergent themes were explored in subsequent interviews. Data generation continued until thematic saturation was achieved.

Results

Participants had received no training in MUS but had developed views about causes and management. They struggled with the concept of ‘diagnosis by exclusion’. Attitudes towards patients had developed through informal clinical observation and interactions with doctors. Many welcomed formal training but identified a need to integrate theoretical learning with clinical application.

Conclusion

Despite limited teaching, medical trainees are aware of the challenges in diagnosing and managing patients with MUS, acquiring attitudes through a hidden curriculum. To be welcomed, training must be evidence-based, theoretically informed, but clinically applicable.

Practical implications

Current medical training fails to equip doctors to engage with MUS and potentially fosters the development of unhelpful views of these patients. Informed teaching on diagnosis and management of MUS is necessary at a trainee level to limit the development of negative attitudes.     

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

BackgroundGeneral practice (GP) training in how to communicate with patients with medically unexplained symptoms (MUS) is limited.ObjectiveDevelopment, implementation and evaluation of an evidence-based communication training program for GP residents focused on patients with MUS in primary care.MethodsWe used the intervention mapping (IM) framework to systematically develop the MUS training program. We conducted a needs assessment to formulate change objectives and identified teaching methods for a MUS communication training program. Next, we developed, implemented and evaluated the training program with 46 residents by assessing their self-efficacy and by exploring their experiences with the training.ResultsThe resulting program is a blended training with an online course and two training days. After attending the training program, GP residents reported significantly higher self-efficacy for communication with patients with MUS at four weeks follow up compared to baseline. Furthermore, GP residents experienced the training program as useful and valued the combination of the online course and training days.Conclusion and practice implicationsWe developed an evidence-based communication training program for the management of patients with MUS in primary care. Future research should examine the effect of the training on GP residents’ communication skills in MUS consultations in daily practice.     

Self-management support activities in primary care: A qualitative study to compare provision across common health problems

ObjectiveTo explore the views of primary care teams about the provision of self-management support to patients with common health problems.MethodsSemi-structured interviews were conducted with twenty-one members of the primary care team from thirteen general practices. Interviews were transcribed verbatim, and analysed using the ‘Framework’ approach.ResultsThree categories and six sub-categories illustrating different self-management support activities across common health problems were identified from the analysis of interviews, and contributed to one major theme and one cross-cutting theme. Referral and signposting were frequently used to facilitate patient engagement with external services and resources. Practitioners faced some challenges in balancing medical management and psychosocial support and motivating patients to engage with self-management.ConclusionsPrimary care teams described providing a wide range of self-management support activities, but the pattern of use varied for different types of health problem. These patterns may have been influenced, in part, by general practices focusing upon achieving financially incentivised quality improvement goals.Practice implicationsTo improve self-management support, practitioners need a digital repository of services/resources, motivational interviewing skills, an understanding of the optimum duration and pattern of consultations, and incentivised targets that match a biopsychosocial model of care.     

Integrating family medicine and complementary medicine in cancer care: A cross-cultural perspective

In this paper, we describe the case study of a 27 year-old Arab female patient receiving palliative care for advanced breast cancer who was referred to complementary medicine (CM) consultation provided within a conventional oncology department. We explore the impact of the integrative CM practitioners’ team of three family physicians and one Chinese medicine practitioner on the patient's well-being and specifically on the alleviation of her debilitating hot flashes and insomnia. This quality of life improvement is also affirmed by comparing the Edmonton Symptom Assessment Scale (ESAS) and Measure Yourself Concerns and Well-being (MYCAW) questionnaires administered at the initial and follow-up assessment sessions. In conclusion, we suggest that family physicians trained in evidence-based complementary medicine are optimal integrators of holistic patient-centered supportive care. The inclusion of trained CM practitioners in a multi-disciplinary integrative team may enhance the bio-psycho-social-spiritual perspective, and provide additional practical therapies that improve the quality of life of patients confronting cancer.     

Factors affecting frequency of communication about family health history with family members and doctors in a medically underserved population

Objective

Family history contributes to risk for many common chronic diseases. Little research has investigated patient factors affecting communication of this information.

Methods

1061 adult community health center patients were surveyed. We examined factors related to frequency of discussions about family health history (FHH) with family members and doctors.

Results

Patients who talked frequently with family members about FHH were more likely to report a family history of cancer (p = .012) and heart disease (p < .001), seek health information frequently in newspapers (p < .001) and in general (p < .001), and be female (p < .001). Patients who talked frequently with doctors about FHH were more likely to report a family history of heart disease (p = .011), meet physical activity recommendations (p = .022), seek health information frequently in newspapers (p < .001) and in general (p < .001), be female (p < .001), and not have experienced racial discrimination in healthcare (p < .001).

Conclusion

Patients with a family history of some diseases, those not meeting physical activity recommendations, and those who do not frequently seek health information may not have ongoing FHH discussions.

Practice implications

Interventions are needed to encourage providers to update patients’ family histories systematically and assist patients in initiating FHH conversations in order to use this information for disease prevention and control.     

End-of-life expectations and experiences among nursing home patients and their relatives—A synthesis of qualitative studies

Objective

Synthesize research about patients’ and relatives’ expectations and experiences on how doctors can improve end-of-life care in nursing homes.

Methods

We systematically searched qualitative studies in English in seven databases (Medline, Embase, PsycINFO, CINAHL, Ageline, Cochrane Systematic Reviews and Cochrane Trials). We included 14 publications in the analysis with meta-ethnography.

Results

Patients and families emphasized the importance of health personnel anticipating illness trajectories and recognizing the information and palliation needed. Family members who became proxy decision-makers reported uncertainty and distress when guidance from health personnel was lacking. They worried about staff shortage and emphasized doctor availability. Relatives and health personnel seldom recognized patients’ ability to consent, and patients’ preferences were not always recognized.

Conclusion

Nursing home patients and their relatives wanted doctors more involved in end-of-life care. They expected doctors to acknowledge their preferences and provide guidance and symptom relief.

Practice implications

High-quality end-of-life care in nursing homes relies on organization, funding and skilled staff, including available doctors who are able to recognize illness trajectories and perform individualized Advance Care Planning.     

Face-to-face communication between patients and family physicians in Canada: A scoping review

Objective

Patient-provider communication is critical in primary care. Canada’s unique health system, population distribution, and cultural context suggest there is value in addressing the topic in the Canadian context. We conducted a scoping review to synthesize recent Canadian literature to inform practice in primary care settings and identify research agendas for patient-provider communication in Canada.

Online resources for family caregivers of cognitively competent patients: A review of user-driven reputable health website content on caregiver communication with health professionals

ObjectiveMost patients want their family involved in consultations and decisions, however some family caregivers report feeling overwhelmed and unsure of their role. As caregivers are increasingly looking to medical websites for guidance, this study aimed to review reputable web-resources available to inform family caregivers on how to be involved in medical consultations and decisions.MethodsGoogle searches were performed using lay search strings, to imitate how a cancer caregiver may locate information. Relevant webpages were included if they were directed at caregivers and from a reputable health organisation. Qualitative content analyses were performed on the included webpages.Results22 webpages were included and 8 were directed at caregivers of cancer patients. Six key categories of information were identified: preparing for consultations, helping during consultations, advocating for the patient, decision-making, communicating in hospital settings, and communicating with family and friends.ConclusionA range of online resources were found to guide family caregivers, particularly cancer caregivers, on involvement in consultations. However, few provided information to caregivers on complex situations such as treatment decision-making, advocating for patient’s needs, and communicating in a hospital setting.Practice implicationsClinicians can actively refer family caregivers to online resources that support caregiver communication in medical settings.     

How users of indwelling urinary catheters talk about sex and sexuality: a qualitative study

Background

An indwelling urinary catheter can solve the problem of incontinence and may be life-saving in individuals with retention, but it can cause problems such as infection and may have a negative impact on body image, sex, and sexuality.

Aim

To explore the individual’s perceptions of how a long-term urinary catheter can affect body image, sex, and sexuality; and to help GPs to discuss the subject in consultations.

Design and setting

Qualitative study of a diverse sample of individuals living with a long-term urinary catheter. Interviews took place all over the UK, usually in the individuals’ homes.

Method

Narrative interviews were audiorecorded, transcribed, and analysed thematically, using the constant comparative method.

Results

Some individuals said that sex was not an important part of their lives because of old age, illness, or the catheter. Others talked about how their catheter and their disability affected their sexual self-esteem, feelings of masculinity or femininity, and how the catheter caused pain, discomfort, or unexpected symptoms during sex. Many noted the lack of information on the subject and also said that health professionals were reluctant to talk about sex. For a minority a catheter was not a major problem in relation to sex.

Conclusion

Some individuals using a urinary catheter would benefit from information on how to have a sexual relationship with a catheter in place and a chance to discuss the subject with their doctors. GPs need to be aware that sex may matter to a person with a catheter and how illness, disability, and a catheter may affect sexuality.     

Attitudes toward integration of complementary and alternative medicine in primary care: perspectives of patients, physicians and complementary practitioners

OBJECTIVE: Our study explored the attitudes of patients toward complementary and alternative medicine (CAM) use, their family physicians' role regarding CAM, and models for CAM referral and treatment. We compared patients' perspectives regarding integration of CAM into primary care with attitudes of primary care physicians (PCPs) and CAM practitioners. METHODS: We conducted a comprehensive literature review and focus group discussions to develop a questionnaire, which we gave to three groups: a random sample of patients receiving care at an academic family medicine clinic and PCPs and CAM practitioners employed in the largest health maintenance organization in Israel. RESULTS: A total of 1150 patients, 333 PCPs, and 241 CAM practitioners responded to our questionnaire. Compared with PCPs, patients expected their family physician to refer them to CAM, to have updated knowledge about CAM, and to offer CAM treatment in the clinic based on appropriate training. When asked about CAM integration into medical care, more patients expected to receive CAM in a primary care setting compared to PCPs' expectations of prescribing CAM (62% vs. 30%; p=0.0001). Patients, CAM practitioners, and PCPs expected family practitioners to generate CAM referrals in an integrative primary care setting (85.6% vs. 82.4% vs. 62.6%; p<0.0001). Patients supported CAM practitioners providing CAM treatments in the primary care setting, regardless of whether the practitioner held a medical degree (MD). Also, more patients than PCPs or CAM practitioners expected their family physician to provide CAM (28.2% vs. 14.5% vs. 3.8%; p<0.0001). CONCLUSION: Patients, PCPs, and CAM practitioners suggested that family physicians play a central role in CAM referral and, to a lesser extent, that they actually provide CAM treatment themselves. PRACTICE IMPLICATIONS: PCPs need to be aware of their present and future role in informed referral to CAM and, to a lesser degree, in providing CAM in integrative primary care clinics. With the increasing use of CAM, patients may expect their family physician to be more knowledgeable, skillful, and have a balanced approach regarding CAM use. In addition, practitioners should learn how to communicate effectively and better collaborate with CAM practitioners to the benefit of their patients.     

Family communication about genomic sequencing: A qualitative study with cancer patients and relatives

ObjectiveThis study explored family communication about undertaking genomic sequencing, and intentions to communicate pertinent heritable results to family members.MethodsSemi-structured interviews were conducted with cancer patients (n = 53) and their relatives (n = 20) who underwent germline genome sequencing or molecular tumor testing. Interviews were audio-recorded, transcribed and analyzed using thematic analysis.ResultsKey themes relevant to family communication about undertaking sequencing included: perceiving family member interest, delaying discussion until results were received, having shared capacity to understand and cope, and having open communication in the family. Intended communication subsequent to receiving results was affected by: disease severity, risk management options, degree of closeness in the family, sense of responsibility, and potential adverse impacts on family. Resource and support needs varied based on the complexity of test results, health professionals’ availability, and disease severity. Unique subthemes were identified for specific subgroups.ConclusionCurrent findings support the need to assess the impact and resource needs specific to each clinical application of genomic sequencing.Practice implicationsIncreasingly sophisticated and complex clinical genomic sequencing warrants development of family-centered interventions and resources to facilitate preference-sensitive communication about genomic sequencing, including disseminating relevant information to family members.     

A qualitative study of lay beliefs about influenza immunisation in older people

BACKGROUND: Although influenza immunisation is now recommended for all people aged 65 years and over in the UK, many people in that age group still remain unimmunised. AIM: To investigate lay beliefs about influenza and influenza vaccine in older people to identify appropriate ways of promoting vaccine uptake. DESIGN: Qualitative study using narrative interviews. SETTING: Urban and rural communities in South Wales. METHOD: Participants were 54 people aged 65 years and over who were interviewed in their own home. Of these, 11 were regularly immunised, 18 had consistently refused immunisation (refusers), 15 had defaulted (defaulters), five had never been offered immunisation, and five had recently been immunised for the first time. RESULTS: There was an overwhelming consensus among immunised and unimmunised individuals that they were not at risk from influenza. Even if they did catch influenza, they would not suffer from any serious consequences. Refusers and defaulters were more likely to believe that the influenza vaccine had serious side-effects, while the regularly immunised group were more likely to perceive the vaccine as effective. Multiple prompts from family, friends, or primary care staff were important triggers for receiving immunisation. CONCLUSION: Many older people did not feel vulnerable to influenza, regardless of their age, and this influenced their views on the need for immunisation. Both refusers and defaulters overstated adverse effects from influenza vaccine so this is a potential target for an intervention. Individual prompts, particularly from GPs, seemed to be the most significant motivators to attend for immunisation.     

A comparison of GP,pharmacist and nurse prescriber responses to patients’ emotional cues and concerns in primary care consultations

Objective

Recognising patients’ cues and concerns is an important part of patient centred care. With nurses and pharmacists now able to prescribe in the UK, this study compared the frequency, nature, and professionals’ responses to patient cues and concerns in consultations with GPs, nurse prescribers and pharmacist prescribers.

Methods

Audio-recording and analysis of primary care consultations in England between patients and nurse prescribers, pharmacist prescribers and GPs. Recordings were coded for the number of cues and concerns raised, cue or concern type and whether responded to positively or missed.

Results

A total of 528 consultations were audio-recorded with 51 professionals: 20 GPs, 19 nurse prescribers and 12 pharmacist prescribers. Overall there were 3.5 cues or concerns per consultation, with no difference between prescriber groups. Pharmacist prescribers responded positively to 81% of patient's cues and concerns with nurse prescribers responding positively to 72% and GPs 53% (PhP v NP: U = 7453, z = −2.1, p = 0.04; PhP v GP: U = 5463, z = −5.9, p < 0.0001; NP v GP: U = 12,070, z = −4.9, p < 0.0001).

Conclusion

This evidence suggests that pharmacists and nurses are responding supportively to patients’ cues and concerns.

Practice implications

The findings support the importance of patient-centredness in training new prescribers and their potential in providing public health roles.     

The place of general practitioner in the management of patients with rare disease and intellectual disability: A qualitative study

The management of patients with rare diseases (RD) presents many challenges including diagnosis, coordination of care, and orientation in the health system. For these patients, the general practitioner (GP) is not always the referring physician. The aim of this study was to determine the place of the GP in management of patients with RD. We used a qualitative study by case-study. From March to October 2020, semi-structured interviews were conducted by telephone with the families of adult patients with RD and intellectual disability, and with the health professionals involved in their management. Patients were recruited through RD reference centres, patient associations or GPs. The interviews were transcribed and analysed by two independent investigators. A grounded theory-based analysis was performed. Eight case studies were conducted with 20 participants. Our results highlighted the trajectory of the patients through the development of the career of the primary informal caregiver. The caregivers developed skills required for the management of the care recipient. Within this trajectory, the GP found his place depended on the skills he could provide, their interest in the disease, the skills developed by the caregiver, and the caregiver/care recipient needs. The GP was mostly consulted for routine care and administrative procedures, but when a trusting relationship was established, they also accompanied the patient and their family by providing appropriate medical, social or psychological support. The GP will be all the more a privileged actor in the care process that he will be involved in the coordination of all other actors, professional as non-professionals.