Surgery in the absence of pathology The relationship of patients' presentation to gynecologists' decisions for hysterectomy

doi:10.1016/S0022-3999(00)00103-3

Journal of Psychosomatic Research

Volume 49, Issue 2, August 2000, Pages 119-124

https://doi.org/10.1016/S0022-3999(00)00103-3 Get rights and content

Abstract

Objective: To test predictions from a theory about patients' influence over doctors' treatment decisions when physical symptoms are presented in the absence of physical pathology. Method: We audiotaped 88 gynecological consultations of consecutive patients who presented menstrual symptoms without pathology. Each consultation was coded according to a scheme, developed from previous qualitative research, which identified specific strategies of patients and gynecologists. The occurrence of each strategy was compared between consultations in which hysterectomy was decided upon (N=15) and those leading to conservative treatment. Results: Consultations were more likely to lead to hysterectomy if patients deployed specific strategies, including reporting social effects of symptoms, catastrophization, requesting surgery and citing clinical or lay authority in support. Each strategy could account statistically for gynecologists' perceptions that decisions for hysterectomy reflected patients', rather than gynecologists', influence. Conclusion: The findings are consistent with the theory that, in the absence of physical pathology, patients deploy specific strategies that influence gynecologists to offer surgery.

Introduction

It is often assumed that doctors determine the outcome of medical consultations and that patients tend to be passive in the face of doctors' expertise. Nevertheless, some patients have clear expectations about the effectiveness of different interventions [1], [2] and value their own authority over that of doctors [3], [4], [5]. Therefore, it is to be expected that they will often be motivated to seek specific treatments. However, despite detailed evidence about how doctors influence consultation, we lack a corresponding understanding of patients' influence. Reports of ‘patients' pressure’ for prescription or referral [6], [7] are of limited value because they are defined by doctors' subjective feelings.

A type of consultation in which patients' influence might be particularly important occurs where patients seek physical treatment for physical symptoms in the absence of pathology. In this situation, a doctor's knowledge of the symptoms depends entirely on what the patient says about them. Qualitative analyses have identified several strategies whereby such patients might influence their surgeons to operate, including an emphasis on associated psychosocial problems rather than physical symptoms [1], [8].

Quantification is necessary to test the hypotheses that arise from the qualitative findings. However, the existing schemes for quantifying doctor–patient communication cannot be used for this purpose because they emphasize the form that communication takes, for example, distinguishing verbal effect from information exchange, rather than its function in leading to treatment decisions [9], [10], [11], [12], [13].

In the present study, we, therefore, first developed a procedure for quantifying the aspects of consultation that were identified in previous qualitative research. Then, we used this procedure to test the predictions that arose from the theory that, by using certain strategies, patients influence surgeons to operate in the absence of pathology. For several reasons, we have studied decisions for hysterectomy. It is a relatively common surgical procedure, and is frequently performed in response to mennorrhagia in the absence of physical or hormonal abnormality [14], [15], [16]. Furthermore, the patients' expectations of the effects of gynecological treatment show that hysterectomy is seen as having unique power to improve menstrual problems, while having no more harmful effects than alternative responses, including endometrial resection and drugs [2]. We first confirmed that decisions specifically for hysterectomy were experienced by gynecologists as predominantly reflecting patients' influence. Next, we tested whether specific patient strategies (and gynecologist responses) were more likely to occur in consultations that led to hysterectomy. Finally, we examined whether these strategies explained gynecologists' perception that decisions for hysterectomy reflected patients' influence.

Section snippets

Patients and consultations

Following the approval of ethical committees, consecutive patients at outpatient gynecology clinics at one of the five study hospitals were approached if they had: (i) been referred by their general practitioner to one of 11 participating gynecologists because of menstrual problems; (ii) received one previous consultation as part of the current referral episode; (iii) undergone one or more investigative procedures, including dilatation and curretage (D and C), hysteroscopy or laparoscopy; (iv)

Results

The patients' mean age was 39 years (range: 24–50); 79 (89%) were white Europeans, 54 (61%) were married or cohabiting, 23 (26%) were nulliparous, 59 (67%) described themselves as employed or self-employed. The mean duration of consultation was 11 min (range 2–32); 54 (61%) were with registrars and the remainder were with consultants. Treatment decisions were: hysterectomy (N=15); endometrial resection (5); pharmacotherapy (28); and no change in treatment or further investigation (40). The

Discussion

We have described a way to quantify the elements of the patients' presentation which, from prior qualitative research in the present sample, were hypothesized to influence the gynecologists' treatment decisions. In addition, the procedure detected different ways in which gynecologists state or explain the absence of pathology. The scheme's validity is derived from the qualitative analysis on which it was based [1], [8]. It meets Inui and Carter's [9] recommendations for consultation coding

Acknowledgements

We are grateful for the enthusiastic cooperation of Mr. B.V. Lewis, Professor A. Singer, Mr. D. Liu, Mr. N. Nicholas, Mr. N.C. Drew, Miss H. Morgan and their colleagues and for the assistance of Dr. D. Echlin with coding of transcripts. Mr. B.V. Lewis and Dr. G. Humphris provided helpful comments on an earlier draft of this manuscript.

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Patients with symptoms that doctors cannot explain by physical disease are common in primary care. That they receive disproportionate amounts of physical intervention, which is largely ineffective and sometimes iatrogenic, is usually attributed to patients’ belief that they are physically diseased, their denial of psychological difficulties, and their demand for physical intervention. The evidence for this view has mainly been doctors’ subjective reports. By observing what patients and doctors say in consultation, we tested hypotheses arising from recent qualitative evidence. In particular, that physical intervention is proposed more often by general practitioners (GPs) than by patients, that most patients indicate psychosocial needs, and that GPs offer little effective explanation or empathy. Consultations of 420 consecutive patients identified by British GPs as presenting medically unexplained symptoms (MUS) were audio-recorded, transcribed and coded, utterance-by-utterance, using a specially developed coding scheme based on the previous qualitative analyses of these kinds of consultation. Physical intervention was, as predicted, proposed more often by GPs than patients. Also as predicted, almost all patients provided cues concerning psychosocial difficulties or their need for explanation. Although, contrary to prediction, most GPs did provide explanations other than physical disease, most also suggested physical disease. Few GPs empathised. The findings suggest that the explanation for the high level of physical intervention for MUS lies in GPs’ responses rather than patients’ demands, and we propose that explanations for ‘somatisation’ should be sought in doctor–patient interaction rather than in patients’ psychopathology.
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We tested predictions that patients with medically unexplained symptoms (MUS) want more emotional support and explanation from their general practitioners (GPs) than do other patients, and that doctors find them more controlling because of this.
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Surgery in the absence of pathology The relationship of patients' presentation to gynecologists' decisions for hysterectomy

Abstract

Introduction

Section snippets

Patients and consultations

Results

Discussion

Acknowledgements

Psychosomatics

Soc Sci Med

Soc Sci Med

Soc Sci Med

Patient Educ Counseling

Patients' expectations of outcome of hysterectomy and alternative treatments for menstrual problems

J Behav Med

Patients' accounts of medically unexplained symptoms: sources of patients' authority and implications for demands on medical care

Soc Sci Med

Doctors' perceptions of pressure from patients for referral

Br Med J

Factors influencing general practitioners' referral decisions

Family Practice