By analysing patients’ experiences of consultations with doctors who were trained and untrained in a specific communication model, we identified potential barriers to the effectiveness of GPs’ attempts to manage MUS and improve clinical outcomes. Barriers included the perceived complexity of patients’ experiences, their simplification of their presentation and caution about disclosing psychosocial issues. The barriers identified within the study were not particular to patients of reattribution trained GPs, suggesting that they are features of interactions more generally and so may compromise a broader range of ways than reattribution for engaging with and managing MUS.
Patients’ beliefs and reasons for consulting were complex and multifaceted, and they found it hard to convey this complexity in the consultation. Nevertheless, they wanted GPs to understand the extent of their problems and valued those who helped them make sense of their (often) chaotic narrative. This suggests that the ‘feeling understood’ stage of reattribution is more challenging and central than envisaged hitherto. It also suggests that continuity of care is desirable so that GP and patient have the opportunity to understand the complexity of the problem over a series of consultations. Continuity of care is highly valued by patients
23 and in the US has been shown to be associated with the confidence felt by primary care physicians in managing MUS.
24 Current policy within UK primary care values access before continuity, meaning that it is now more difficult for people with complex chronic problems to achieve continuity of care with an individual provider.
Whilst a central goal of reattribution is to develop a shared new understanding of the illness, analysis revealed this was rarely the patient’s agenda; rather than explanation, many sought confirmation and/or support of their ideas. This suggests the potential for mismatch between GP and patient consultation agendas, which may act as an important obstacle to therapeutic alliance. Consultation agendas frequently go unspoken, leading to misunderstandings and frustration
25. Previous studies have found similar differences in patients’ and doctors’ goals, with patients primarily seeking support, whilst physicians primary goal is symptom alleviation.
26 Together this suggests a necessary task of patient-centred communication is for doctors to negotiate a common agenda for the consultation or series of consultations prior to embarking on therapeutic intervention.
Although patients were presenting with ‘unexplained’ symptoms, findings revealed patients had developed sophisticated models of their illness, which they contrasted with those held (or at least as communicated to the patients) by GPs. A misunderstanding of MUS is that patients hold physical attributions for their symptoms, a view that prompted the early developmental work for interventions such as reattribution.
4 However, contrary to this, both groups of patients described illness models rich in psychosocial components and had often considered how these impacted on their physical symptoms. Despite this, participants discussed how they elected not to share these aspects of their model with GPs. Hence, the task for the physician is not necessarily to change illness beliefs, but to develop a greater awareness of patients’ present and past help seeking and self-management strategies in problem resolution, and thereby greater ability to incorporate and relate to patients models of psychosocial distress.
There were a number of reasons why patients chose not to disclose psychosocial issues. Firstly, the belief that GPs were dualistic in their thinking about illness, making distinctions between ‘psyche’ and ‘soma’. This contrasted with patients’ own rich illness models. For psychosocial discussion to be possible, patients also needed to trust GPs to look after their physical health and not to generalise psychological distress as the cause of all current and future symptoms. Since many MUS patients also have co-existing physical illnesses, this is a reasonable and important concern. Factors that influence how trusted GPs are include feeling one’s individual experience has been understood and the perceived thoroughness of the evaluation.
27 This is likely to be particularly important in MUS where individuals recognise that their condition is at the limits of medical knowledge
28, describe the effort involved in presenting as credible and legitimate
29 and believe they are taken less seriously than their counterparts with explained symptoms.
30 Elsewhere, it has been shown that in order for patients to feel able to disclose psychological problems, GPs must first provide a safe place in which they feel listened to and understood.
31 Our findings resonate with this as some were willing to share psychosocial information, but only when a level of intimacy had been established. Furthermore, they preferred to initiate these discussions. GPs have many opportunities with MUS patients to respond to psychosocial patient-initiated cues, and by offering these, patients are seeking emotional rather than somatic support
32; moreover, when GPs do respond to such cues, the likelihood of somatic outcomes decreases significantly.
33 There is evidently scope for GPs to become more alert and responsive to these cues. However, in order to navigate the barriers to sharing their psychosocial formulation and to reduce the potential for the GP to be intrusive and offensive, there is also a need to first establish a productive and mutually beneficial relationship.
Gaining any patients’ trust is an important goal for physicians since it predicts adherence to medical recommendations and health behaviours.
34 Trusting one’s doctor is also associated with having a commitment to this relationship
34, which may help explain the paradox that MUS patients persist with GPs despite an impasse in treatment. It follows that developing trust between patient and physician allows for less conflictual discussion over issues such as uncertainty, disclosure of emotional distress and psychosocial issues. In a rare experimental study, empathic responses to emotional cues was associated with higher reports of trust for unexplained, but not explained symptoms.
35 This suggests that increasing GPs ability to recognise and respond to cues may be particularly important in gaining the trust of MUS patients, an important outcome in itself. To date, intervention studies aimed at GPs to specifically promote patient trust have been largely unsuccessful.
36 Our findings suggest that the initial stage of the reattribution model has potential to increase patients’ trust.
Perhaps because of these problems, patients largely did not perceive GPs as having a role in managing psychological problems. They described being engaged in a range of (often successful) non-medical strategies. It is unclear what role GPs can offer here, although patients did describe one function of seeing the GP was to seek support with self management. Evidently more work needs to address how this can be effectively facilitated in the primary care setting.
37A number of study limitations should be acknowledged. In recruiting our sample we didn’t seek a representative sample, rather to achieve variance in a number of key variables (physical complaint, training of GP, satisfaction with GP), thereby maximising the range of available views. This led to uneven subgroups, e.g., only 15% were male. This is unlikely to reveal a recruitment bias per se, due to our 100% recruitment rate and that the imbalance reflects the sample from which it was drawn where most participants (70%) were female.
15 Elsewhere, the literature demonstrates that woman are more likely than men to experience symptoms, including unexplained symptoms, although this is likely to be partly explained by increased rates of anxiety and depression in women
38. A further limitation of the study is that several weeks had passed since the index consultation. Interviewers made particular attempts to focus patients on the experience of the specific consultation, and in most cases, the audiotaped consultation was easily recalled. However, for some frequent consulters, it proved difficult to distinguish the index from subsequent consultations. Hence, we cannot be confident whether patients’ reasoning about what information they shared with GPs occurred at the same time as the audiotaped consultation or whether these views had evolved subsequently. A further limitation of the study is that participants’ GPs were taking part in training in MUS management (though those within the control arm were untrained at the time of interviewing). Such GPs (and hence their patients’ experiences) are not necessarily typical. It is however unlikely that the lack of trust described by patients in their GPs is
overrepresented since elsewhere we found that clinicians who choose to take up offers of MUS training are
more likely to value such patients and their own ability to manage such problems.
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1 Anne Rogers, PhD,2 Peter Salmon, DPhil,3 Linda Gask, PhD FRCPsych,2 Chris Dowrick, MD FRCGP,3 Maria Towey, BSc,2 Rebecca Clifford, PhD,3 and Richard Morriss, MD4
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