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.