Original articleWhat do general practice patients want when they present medically unexplained symptoms, and why do their doctors feel pressurized?
Introduction
Patients with unexplained physical symptoms are common in primary care, accounting for around 10–20% of patients who attend general practitioners (GPs; [1], [2]). They receive disproportionate levels of symptomatic investigation and treatment, which is largely ineffective and sometimes iatrogenic [3], [4]. The use of these interventions has been widely attributed to patients' belief that symptoms are caused by physical disease, their consequent insistence on somatic intervention and their rejection of psychological help [5], [6]. Consistent with this reasoning, many GPs and other doctors are dissatisfied with these consultations and feel that they are controlled by the patient [6], [9], [10], [11].
Although patients with medically unexplained symptoms (MUS) have long been labelled as “heartsink” or “difficult,” reflecting how doctors experience them [12], [13], doctors' experience is unreliable as evidence of how the patients do present. When interviewed, patients with persistent MUS described seeking support or convincing explanation rather than medical treatment [14]. When directly observed in consultations with GPs, transparent pressure for symptomatic intervention was rare [15]. Almost all patients indicated psychological needs—for convincing explanation or emotional support [16], [17]. These recent qualitative findings are incompatible with the influential assumption that patients with MUS demand somatic intervention. Instead, they suggest a very different hypothesis: that MUS patients differ from others because they seek more emotional support and explanation. The first aim of the present study was to test this hypothesis.
The view that patients with MUS influence the consultation more than do others has arisen from studies in which GPs and other doctors have been interviewed about their difficulties with such patients. Interviews about challenging subjects often produce justifications rather than valid descriptions or explanations. Therefore, it is unknown whether doctors' sense of patient influence arises as an immediate response to consultation or only later, in the context of interviews, as a way of justifying the somatic treatment that they give these patients. Therefore, our second aim was to test, across a large sample of consecutive patients, whether GPs feel more influenced by patients with MUS than by others.
The third aim was to test a hypothesis about why this should happen. Rather than the generally accepted, but never verified, assumption that patients pressurise GPs by seeking symptomatic interventions that the doctor does not want to give, we tested the view, suggested by qualitative findings [16], [17], that GPs feel more influenced by MUS patients because of the patients' desire for emotional support.
Section snippets
Participants and procedure
After approval by local ethics committees, 50 GPs from 11 practices in Liverpool and South Cheshire were approached to take part in the study; 42 (84%) agreed (22 males, 20 females), with 5–42 years medical experience. Practice size ranged from 1 to 10 GPs (mean=4.5) and from 2087 to 13,116 patients (mean=7564). Six practices were urban, four were suburban and one was rural. Jarman deprivation scores ranged from −11 to 56 (mean 21.27).
Consecutive patients attending participating doctors on
Samples
Of 2707 consenting patients for whom GPs completed checklists, 466 (17%) were identified as having MUS. Of these, 357 (77%) provided questionnaire data. The median number of clinics observed for each GP was 10 (range: 1–14); the median number of MUS patients recruited from each GP was 9.0 (range: 1–25); and the median ratio of MUS patients per clinic was 1 (range: 0.17–2.50). Out of those patients who were not identified as having MUS, GPs identified 1644 (73%) patients as having (explained)
Discussion
Current views of what patients with MUS want when they consult a GP have been shaped by what doctors say when interviewed about the difficulties that they have with these patients. In this study, we asked patients directly. The results negate the influential view that patients with MUS pressurise GPs by seeking more somatic intervention than do other patients. Instead, they are consistent with hypotheses, derived from recent observational studies, that they seek more emotional support.
MUS
Acknowledgments
The study was funded by the UK Medical Research Council Grant G9900294. We are grateful for the enthusiastic cooperation of the participating GPs.
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