Dataset Information

General practitioners' responses to the initial presentation of medically unexplained symptoms: a quantitative analysis.

ABSTRACT:

Background

Physicians in primary and secondary care are frequently confronted with patients with medically unexplained symptoms (MUS). In order to solve their patients' problems and out of a fear of overlooking a serious disease, many physicians give their patients full physical examinations and interventions, thereby incorrectly confirming the somatic nature of their condition. Preventing somatization could be achieved by examining the patient's symptom presentation for clues to underlying psychosocial issues and by an appropriate physician response.

Methods

Ninety-seven videotaped medical visits from primary care patients presenting MUS for the first time were analyzed. Patients' presentations were categorized in: (1) symptoms only; (2) symptoms with a clue to an underlying concern; or (3) symptoms with an explicit concern. General practitioners' (GPs') responses to patients' presentation were classified into ignoring or more or less exploring responses. Exploring responses were further subdivided in non-directional explorations, clue explorations and medical explorations.

Results

Results show that most patients presented their symptoms together with a reference to an underlying concern. Yet, most of them did so in an implicit way. GPs usually explored the concern presented by the patients, but most often in a medical way only.

Conclusion

To address the potential psychological basis of patients' medically unexplained symptoms, GPs should pay more attention to the specific clues patients present to them. Likewise, in order to receive full attention, patients should try to present their concerns more explicitly.

SUBMITTER: Kappen T

PROVIDER: S-EPMC2596168 | biostudies-literature | 2008 Nov

REPOSITORIES: biostudies-literature

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Publications

General practitioners' responses to the initial presentation of medically unexplained symptoms: a quantitative analysis.

Kappen Teus T van Dulmen Sandra S

BioPsychoSocial medicine 20081117

<h4>Background</h4>Physicians in primary and secondary care are frequently confronted with patients with medically unexplained symptoms (MUS). In order to solve their patients' problems and out of a fear of overlooking a serious disease, many physicians give their patients full physical examinations and interventions, thereby incorrectly confirming the somatic nature of their condition. Preventing somatization could be achieved by examining the patient's symptom presentation for clues to underly ...[more]

PMID: 19014616

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Project description:BackgroundMedically unexplained symptoms (MUS) and somatoform disorders are common in general practices, but there is evidence that general practitioners (GPs) rarely use these codes. Assuming that correct classification and coding of symptoms and diseases are important for adequate management and treatment, insights into these processes could reveal problematic areas and possible solutions. Our study aims at exploring general practitioners' views on coding and reasons for not coding MUS/somatoform disorders.MethodsWe invited GPs to participate in six focus groups (N = 42). Patient vignettes and a semi-structured guideline were used by two moderators to facilitate the discussions. Recordings were transcribed verbatim. Two researchers analyzed the data using structuring content analysis with deductive and inductive category building.ResultsThree main categories turned out to be most relevant. For category a) "benefits of coding" GPs described that coding is seen as being done for reimbursement purposes and is not necessarily linked to the content of their reference files for a specific patient. Others reported to code specific diagnoses only if longer consultations to explore psychosomatic symptoms or psychotherapy are intended to be billed. Reasons for b) "restrained coding" were attempting to protect the patient from stigma through certain diagnoses and the preference for tentative diagnoses and functional coding. Some GPs admitted to c) "code inaccurately" attributing this to insufficient knowledge of ICD-10-criteria, time constraints or using "rules of thumb" for coding.ConclusionsThere seem to be challenges in the process of coding of MUS and somatoform disorders, but GPs appear not to contest the patients' suffering and accept uncertainty (about diagnoses) as an elementary part of their work. From GPs' points of view ICD-10-coding does not appear to be a necessary requirement for treating patients and coding might be avoided to protect the patients from stigma and other negative consequences. Our findings supply a possible explanation for the commonly seen difference between routine and epidemiological data. The recent developments in the DSM-5 and the upcoming ICD-11 will supposedly change acceptance and handling of these diagnoses for GPs and patients. Either way, consequences for GPs' diagnosing and coding behavior are not yet foreseeable.

Project description:BackgroundIn primary and secondary care medically unexplained symptoms (MUS) or functional somatic syndromes (FSS) constitute a major burden for patients and society with high healthcare costs and societal costs. Objectives were to provide an overview of the evidence regarding the cost-effectiveness of interventions for MUS or FSS, and to assess the quality of these studies.MethodsWe searched the databases PubMed, PsycINFO, the National Health Service Economic Evaluation Database (NHS-EED) and the CEA registry to conduct a systematic review. Articles with full economic evaluations on interventions focusing on adult patients with undifferentiated MUS or fibromyalgia (FM), irritable bowel syndrome (IBS) and chronic fatigue syndrome (CFS), with no restrictions on comparators, published until 15 June 2018, were included. We excluded preventive interventions. Two reviewers independently extracted study characteristics and cost-effectiveness data and used the Consensus on Health Economic Criteria Checklist to appraise the methodological quality.ResultsA total of 39 studies out of 1,613 articles met the inclusion criteria. Twenty-two studies reported costs per quality-adjusted life year (QALY) gained and cost-utility analyses (CUAs). In 13 CUAs the intervention conditions dominated the control conditions or had an incremental cost-effectiveness ratio below the willingness-to-pay threshold of € 50,000 per QALY, meaning that the interventions were (on average) cost-effective in comparison with the control condition. Group interventions focusing on MUS (n = 3) or FM (n = 4) might be more cost-effective than individual interventions. The included studies were heterogeneous with regard to the included patients, interventions, study design, and outcomes.ConclusionThis review provides an overview of 39 included studies of interventions for patients with MUS and FSS and the methodological quality of these studies. Considering the limited comparability due to the heterogeneity of the studies, group interventions might be more cost-effective than individual interventions.RegistrationStudy methods were documented in an international prospective register of systematic reviews (PROSPERO) protocol, registration number: CRD42017060424.

Project description:To conduct a pilot trial of a primary care Symptoms Clinic for patients with medically unexplained symptoms and evaluate recruitment and retention, and acceptability of the intervention and to estimate potential treatment effects for a full trial.Randomised parallel group pilot trial.Primary care in one locality.Primary care database and postal questionnaire were used to identify patients with multiple specialist referrals and multiple physical symptoms unlikely to be explained by disease.General practitioner (GP) with special interest 'Symptoms Clinic' + usual care versus usual care alone. The Symptoms Clinic comprised one long (1 h) and three short (20 min) appointments.Number of patients identified and recruited; acceptability of the intervention (items from Client Satisfaction Questionnaire and interview); Medical Outcomes Survey Short Form 12 (SF-12) physical component summary.Automated blocked randomisation accessed by telephone.None. NUMBERS RANDOMIZED: 16 to intervention and 16 to usual care alone.72 patients, from seven GP practices, had repeated specialist referrals and a Patient Health Questionnaire (PHQ)-15 score of ?10 indicating a high probability of medically unexplained symptoms. 15 were ineligible and 25 declined to participate. NUMBERS ANALYSED: 26 patients; two patients randomised to the intervention group were incorrectly included, three patients in the intervention group and one control did not complete outcome measures.Most patients randomised to the Symptoms Clinic found the intervention acceptable: eight out of 11 reported the intervention helped them to deal with their problems. The mean difference between groups in SF-12 physical component summary, adjusted for baseline, was 3.8 points (SD 6).No observed harms.Patients with multiple medically unexplained symptoms can be systematically identified in primary care; a randomised trial comparing the Symptoms Clinic with usual care is feasible and has the potential to show clinically meaningful benefit.ISRCTN63083469.

Dataset Information

General practitioners' responses to the initial presentation of medically unexplained symptoms: a quantitative analysis.

Background

Methods

Results

Conclusion

Publications

General practitioners' responses to the initial presentation of medically unexplained symptoms: a quantitative analysis.

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