We have provided new information for GPs about what patients seek when they talk in specific ways in consultation. Our findings contradict previous views that patients deny psychological problems and overtly seek physical interventions instead16
. On the present evidence, patients are open about wanting emotional support, indicate indirectly that they want symptom explanation and are guarded in expressing desire for physical intervention.
Patients were transparent in indicating their wish for emotional support. Those who most wanted support were the most likely to describe or elaborate psychosocial problems, to talk about how to manage psychosocial problems, to attribute physical symptoms to psychosocial causes or to ask for help with those causes. By contrast, patients were less transparent in indicating their wish for explanation and reassurance, which was unrelated to their requests for explanation. This intention was instead associated with their own suggestions of physical explanations for their symptoms, which is consistent with previous evidence that patients presenting MUS generally entertain physical explanations tentatively as hypotheses rather than firm beliefs19
. Patients were particularly guarded in indicating their desire for physical intervention. In line with our predictions, and contrary to previous assumptions, patients’ suggestions of physical explanations did not indicate desire for physical intervention. Unexpectedly, their explicit requests for somatic intervention were also unrelated to whether they wanted it. Instead, patients indicated this intention indirectly by prompting discussion about details of such interventions. In general, relationships linking speech types to desire for emotional support were larger than those linking it to desire for explanation or intervention, indicating that patients are most revealing of their need for emotional support.
It is not clear why patients’ overt requests for explanation or for intervention were unrelated to their desire for it. Similarly, it is not clear why, although patients who wanted emotional support were more likely to request their GPs’ psychosocial help, this type of utterance remained relatively rare. It may be that patients avoid appearing overtly to challenge GPs’ authority, particularly in the core medical areas of explanation or intervention. Whatever the reason, it is important for GPs to know that patients are indirect in communicating their desire for explanation and intervention. In particular, when patients with MUS offer disease attributions, they are not revealing belief in the need for physical intervention, but are prompting the GP for explanation.
Extended symptom presentation was unrelated to any intention. Although not predicted, this finding is consistent with the suggestion that extended symptom complaint is a product of consultation and that patients use this with GPs who appear to resist engagement31
. That extended symptom presentation is not associated with patients’ wish for somatic intervention is particularly important because such presentation drives GPs’ offers of physical intervention. That is, the more that patients complain about symptoms, the more likely GPs are to propose physical intervention32
. Although patients’ criticisms and contradictory presentations were related to their desire for emotional support, they were related also to desire for somatic intervention. Therefore, while this kind of presentation indicates that patients are making demands on the GP, it does not indicate what those are.
The study has limitations. First, there are no agreed research diagnostic criteria for primary care patients with MUS. Criteria derived from psychiatric diagnoses have poor agreement amongst them or poor discriminating capacity33,34
, and use of standardised instruments can be restrictive35
. Because our study is focused on difficulties that patients present for doctors, we defined the study population according to GPs’ perception. Although some symptoms identified as MUS may have pathological causes36
, our procedure identifies a set of consultations defined by clinicians’ belief that such a cause is absent. Secondly, the measure of what patients wanted from consultation required conscious responses to a transparent questionnaire and cannot detect needs of which they are unaware. Conversely, their motivation for attending might differ from their accounts of what they would like when they attend. Qualitative research could explore these issues. Thirdly, the study was based within one area of England, and findings might not generalise. In addition, GPs who agree to such research may be particularly interested in psychosocial care37
, and strenuous efforts will be needed to engage a broader range of GPs in future research. Larger samples will be needed to study heterogeneity amongst GPs as well as patients. Finally, we lacked a comparison group without MUS, so cannot tell whether our findings apply more generally than to MUS. MUS patients take more time and doctors are less likely to explore and validate their symptoms38
, which suggests that some of these communication processes could operate differently in consultations about explained symptoms. However, a complete demarcation between explained and unexplained symptoms is impossible36
, and physicians miss opportunities to acknowledge psychosocial cues during routine consultations with any patients22
. It will therefore be important to test the generalisability of these findings across primary care settings and with GPs with varying attitudes to psychological care, as well as in patients without MUS.
Nevertheless, our findings already have potential implications for clinical practice, education and training. They are incompatible with the influential view that patients with MUS do not present their psychological needs and that GPs therefore should help them think more psychologically. Instead, confirmation of our findings would indicate that GPs should identify and respond to patients’ overt presentation of psychological needs, while being sensitive to more covertly expressed somatic concerns. Training GPs to manage MUS has had variable success39–41
. Our findings might inform future training by indicating specific communication strategies to help GPs manage patients with MUS. GPs may relatively easily facilitate psychological discussion with patients that seek it, by identifying and responding to their psychological cues and thereby potentially avoiding somatic intervention that patients do not want and that GPs think unnecessary42
. Contrary to the common view that GPs need to help patients with MUS recognise and express psychological needs, it seems that GPs may need to seek patients’ views more actively about somatic intervention.