How patients and family physicians communicate about persistent medically unexplained symptoms. A qualitative study of video-recorded consultations

https://doi.org/10.1016/j.pec.2011.02.014Get rights and content

Abstract

Objective

To study doctor–patient interaction styles in consultations with patients presenting persistent medically unexplained symptoms (MUS) and to study on which stages of the consultation patients and doctors focus within the available time.

Methods

exploratory, qualitative analysis of transcripts of 20 videotaped consultations between family physicians (FP) and persistent MUS patients.

Results

Patients presented many symptoms in a rather unstructured way. However, FPs hardly used structuring techniques such as agenda setting and summarizing. Patients with persistent MUS got much opportunity to tell their story, but the reasons for encounter, their beliefs and concerns were not discussed in a structured manner. Although consultations were focused on these issues, mostly patients themselves initiated discussion of their ideas, concerns and expectations. FPs’ extensive explanations of the origin of the symptoms often did not take patients’ beliefs and concerns into account.

Conclusions

Due to patients’ multiple symptom presentation and the absence of FPs’ structuring techniques, consultations of persistent MUS patients proceed rather unfocused. However, patients got ample opportunity to tell their story.

Practice implications

Persistent MUS patients might benefit from structured consultations focused on the exploration of the reason for encounter.

Introduction

Patients complaining of physical symptoms in the absence of physical disease are common in primary care. These symptoms are often described as medically unexplained symptoms (MUS) [1], [2]. In patients with MUS, symptoms or impairment improve when consultations meet the patients’ expectations or when patients feel understood [3]. Recently, two studies showed that physicians’ communication during the initial presentation of MUS is hampered [4], [5]. Epstein et al. concluded that physicians face lack of time and do not explore and validate the MUS patient's reason for visit, their ideas, expectations and concerns [4]. Kappen and van Dulmen concluded that family physicians (FPs) explore patients’ concerns mainly medically [5]. Despite these physicians’ communication barriers during the initial presentation of MUS [6], only a minority (2.5%) of the patients will evolve into a chronic disabling condition of persistent MUS [7]. From this moment communication is often the only tool FPs have in handling these patients [4], [8]. However, doctor–patient interaction styles in consultations with patients with persistent MUS have not been well studied, and may bring important insights to improve the quality of care of these patients.

Consultations between doctors and persistent MUS patients are not straightforward but can be considered as complex consultations [9]. As symptoms are medically unexplained, the link between cause and symptom is unclear, and FPs are uncertain about the way forward [10]. Persistent MUS patients are aware of the complex nature of their problems [11], [12], [13]. They have to present complex and multifaceted reasons for consulting, discuss concerns about the symptoms and problems, and choose whether or not to present emotional aspects of their problems, in a 10–15 min consultation [13], [14], [15]. It is understandable that both patients and FPs report insufficient time to deal effectively with persistent MUS during consultations [16], [17]. However, it is still not clear how patients and FPs reach their goals during the consultations and on which stages in the consultation they focus.

Therefore, the aim of this study is to analyze (1) how patients present and how FPs explore the patients’ symptoms and problems during consultations and (2) on which stages of the consultation they focus within the available time.

Section snippets

Data source: Dutch National Survey of General Practice

Data for the present study were drawn from the Second Dutch National Survey in General Practice (DNSGP-2) [18]. This survey is a large-scale research project carried out in the Netherlands between May 2000 and April 2002 and studied a representative sample of 104 family practices with 195 FPs and 399,068 listed patients. The survey comprised an epidemiologic study about the work of FPs and a video observation study of consultations in which each participating FP consented to video tape

Sample characteristics

The total number of video consultations in the Second Dutch National Survey of General Practice (DNSGP2) was 2784. Fifty nine of these video consultations met our inclusion criteria and were screened by one of the authors (ToH). In 14 cases more than one video consultation of a FP appeared in the selection, 4 video consultations had a bad sound quality and in 1 video consultation one of the authors (PL) was the FP. These 19 video consultations were excluded. Therefore, a total of 40 video

Discussion

Our findings of the difficulties of discussing the reason for encounter and patients’ beliefs and concerns regarding the symptoms during the persistent MUS consultations are in line with the findings of Epstein et al. [4]. Furthermore, it is known from direct observation of patients’ presentations of MUS that almost all patients provide opportunities for FPs to address psychosocial issues, psychosocial concerns [5], [30]. Our study adds rigor to these findings as we studied doctor–patient

Conflict of interest

None.

Authors contributions

All authors participated in the research process; ToH, PL, SvD, CvW were responsible for study design; ToH, SvD, EvR collected the data; ToH, EvR, PL, SvD, EvW, CvW performed data analysis and interpretation; ToH, EvR and PL drafted the manuscript and all authors helped with revisions to the manuscript. All authors approved the final version.

Acknowledgments

The Second Dutch National Survey of General Practice was funded by the Ministry of Health, Welfare and Sports. The authors are grateful for the efforts of the family practices, the patients and the research staff of the DNSGP-2.

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      Previous observations of medical interactions demonstrated that GPs vary their communication style and language use during MUS versus MES consultations. For instance, when patients suffer from MUS, GPs generally perform fewer symptom explorations, and they use less structuring techniques [45,46] , less positive wordings [30] and more uncertainty markers [31] compared to when patients present with MES. GPs thus adjust their language and communication to the (un)explainedness of patient complaints, while findings of the current study demonstrate that systematic variations do not occur for patient language use.

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    Funding sources: This study was supported by grant 920-03-339 from ZonMw (Netherlands Organization for Health Research and Development).

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