Family Practice Vol. 21, No. 2, 199-203
Family Practice Vol. 21, No. 2 © Oxford University Press 2004, all rights reserved.
Article |
Medically unexplained symptoms: perceptions of physicians in primary health care
a The Nordic School of Public Health, Göteborg, c Centre for Health Equity Studies, CHESS, Stockholm University and Karolinska Institute, Stockholm, Sweden, b Åland Primary Health Care, Mariehamn, Åland and d Department of Public Health, University of Helsinki, Finland
Correspondence to Karin C Ringsberg, The Nordic School of Public Health, Box 121 33, 402 42 Göteborg, Sweden; E-mail: karin{at}nhv.se
Received 28 May 2003; Accepted 3 November 2003.
Woivalin T, Krantz G, Mäntyranta T and Ringsberg KC. Medically unexplained symptoms: perceptions of physicians in primary health care. Family Practice 2004; 21: 199–203.
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Abstract |
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Background. Patients presenting with multiple symptoms represent a substantial part of a GP's total work load. At the same time, these patients account for the majority of the people on long-term sick-leave in Sweden today.
Objective. The aim of this study was to explore GPs' perceptions and ways of managing patients with medically unexplained symptoms (MUS).
Methods. Five focus group discussions were conducted with a total of 27 GPs. In the collection and analysis of data, a phenomenographic approach was used.
Results. The GPs described how they used four different approaches to manage patients with MUS: a biomedical, a psychological, an educational and a psychosocial approach. Different approaches were used, depending on the patient and the situation, and the GPs even switched approach when working with the same patient.
Conclusions. In their work with patients with MUS, GPs need support and further training to improve the way the biomedical frame of reference is integrated with the humanistic perspective.
Keywords. General practice, management of care, medically unexplained symptoms, phenomenography.
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Introduction |
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Physicians in primary health care often encounter patients presenting with physical and mental symptoms which, upon investigation, appear to be difficult to classify in accordance with the recognized classification system.1 Brage et al. found that, of all the cases appearing in primary health care, a well-defined disease was diagnosed in 61%, while in 21% of the cases a symptom or a complaint was used for a diagnosis.2 In the absence of identifiable organic pathology, these symptoms are often regarded as somatization and are referred to as medically unexplained symptoms (MUS). Some researchers state that behind the symptoms that are presented lie the patient's psychological or emotional reactions to personal life circumstances, and their legitimacy as medical matters is often questioned.3,4
Previous studies describe situations in which physicians have experienced difficulties in the doctor–patient encounter, how physicians deal with emotions such as frustration, inadequacy and powerlessness, and how these emotions influence clinical decision making and the doctor–patient relationship.4–7 These negative emotions then influence the medical quality of care and lead to unnecessary investigations and treatments, with the underlying psychosocial problems remaining undetected.8 Differences in expectations between the patient and the physician are also factors that are known to cause a low level of job satisfaction, stress and burnout among physicians.5,9,10
Increasing sickness absence rates in Sweden are due to women, but also men, suffering simultaneously from a multitude of physical and mental symptoms which are difficult to classify according to acknowledged classification systems.11 Patients presenting with multiple symptoms represent a substantial part of a GP's total work load, and GPs also shoulder a great responsibility when it comes to issuing sick leave certificates. The aim of this study was therefore to explore GPs' perceptions and ways of managing patients with MUS.
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Methods |
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Selection of informants
Five centres for primary health care, selected to represent rural areas and towns of small and medium size in Sweden, were contacted. All fully qualified GPs with several years of clinical experience were invited to participate in focus group discussions. In all, 27 doctors, 16 female and 11 male, agreed to participate. For the characteristics of the participants, see Table 1.
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Data collection and analysis
When collecting and analysing data, the qualitative phenomenographic approach was used.12 Data were collected in five focus group discussions henceforth called interviews.13 The interviews were conducted at the participants' workplaces and lasted for 1.5 h. All the groups were mixed in terms of gender and work experience, and within each group the participants knew each other in advance. The interviews, open and semi-structured, were tape recorded and typewritten verbatim. The guiding questions were of a comprehensive character with follow-up questions, such as: ‘What comes to your mind when discussing patients presenting with medically unexplained conditions?’, ‘How do you feel about these patients?’ and ‘How much of your working day do they occupy?’
Two of the researchers (GK and TM), both physicians and one also a GP, carried out the interviews. A third researcher (TW), also a physician, was the person with primary responsibility for the analysis. A fourth researcher (KCR), a physiotherapist familiar with the phenomenographic approach, was assigned to test the credibility of the evolving results by supervising and continuously discussing the analysis. The quotations presented here are intended to facilitate the reader's evaluation of the validity of the findings. As is the case with qualitative studies in general, one must be cautious about generalizations.
The Research Ethics Committee at Göteborg University approved the study. All the GPs were informed about the project orally and in writing and about their unquestioned right to withdraw from the project at any point in time.
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Results |
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There was strong agreement among the GPs about the kind of patients that should be defined as suffering from MUS. They were described as patients that consult a physician for various symptoms such as pain, tiredness, dizziness, exhaustion, anxiousness, repeated infections, musculoskeletal symptoms and allergic disorders, i.e. a mixture of physical and mental symptoms. All the GPs agreed that patients with MUS consume a great deal of the physician's mental energy, but there was no agreement about whether this group is large or small. When working with these patients, the GPs experienced frustration, as they felt they never came close to the real problem.
Based on the GPs' perceptions of patients with MUS and how the symptoms could be explained, four qualitatively different ways of managing these patients emerged: a biomedical, a psychological, an educational and a psychosocial approach. The GPs used different approaches, depending on the patient or the situation. With the same patient, the GP would switch approach when no progress was made with the previous one. Different approaches could thus be used with the same patient, even during the same consultation.
Biomedical approach
In this approach, conceptions that deal with a traditional biomedical perspective are brought together, i.e. considering medical investigations and referrals to secondary care in search of treatable conditions.
The GPs said that their main duty was to diagnose serious diseases. Some of the GPs felt that pathological test results must be available before a person can be regarded as sick and decisions made about sick listing. However, they agreed that there is a problem with patients with MUS, as the biomedical approach does not offer sufficient explanations for all symptoms. At the same time, there was a constant fear of missing a condition that could be treated medically. In order to deal with this insecurity, the GPs felt a need to perform new medical investigations at times. As one GP put it,
"We have examples of people who have come back time and time again for that kind of thing (unspecific symptoms) and they have then naturally developed something serious. They had unfortunately not been taken seriously."
Another way of dealing with this insecurity was to switch approach and, at a later stage, return to the biomedical one in order to verify a clinical suspicion. Some of the GPs said that this could temporarily increase worry in the patient. This was managed by the GPs underlining their medical responsibility and they felt that one reason for this was to keep a line of retreat open, especially as medicine has become more litigious. This phenomenon was described by a GP:
"As a GP, I still think you have to start by looking at the somatic aspects. The people who work with cognitive therapy say that this isn't always necessary. However, you have to analyse that part first in order to satisfy the disciplinary board and so on. If a patient complains of chest pains, you have to do an ECG and that kind of thing."
On the other hand, one common dilemma during the consultation was when a patient expected to be examined and diagnosed according to traditional biomedical routines, but the doctor suspected causes of the problem other than biomedical ones. In these circumstances, the GPs felt they were being controlled by the patient. The GPs further explained that, in these cases, they often agreed, at least in part, to the demands for medical investigations in order to reassure the patient and maintain the doctor–patient relationship, even if they knew that the tests would not reveal anything new.
The GPs said that medical tests and referrals were used to a greater extent when they were young and inexperienced, while, with more experience, they considered taking this kind of action more carefully. Some of them said that they had developed more interest in patients of this kind as they became more experienced, mainly because the frustration and insecurity had decreased.
Psychological approach
When using this approach, there is an assumption that psychological mechanisms, such as the repression of traumatic events, result in bodily manifestations.
The GPs who used this approach were eager to reach behind defence mechanisms and barriers in the patient, in order to find underlying causes, such as traumatic life events, abuse or incest. Some GPs expressed their admiration for everything the patients had been through but were still able to manage and go on in life. Some patients were regarded as being more fragile than others, so that minor problems would be enough to cause illness and turn life into a disaster.
In many cases, the underlying causes were hidden to both the patient and the physician. One GP put it like this,
"But the problem is some patients you just don't understand. There is nothing somatic, but they feel bad. There are no illnesses, but they experience ailments of various kinds and do not feel well. There are many things about which I have absolutely no idea. On one occasion, I asked a patient to bring his wife with him. The patient suffered from pain in his neck. It emerged that the wife did not consider this strange at all as his father had died unexpectedly and suddenly and she was convinced this caused the neck problems."
To refer the patient to a social worker or a psychologist could then be of help for the patient and sometimes the problem was revealed in this way. However, this became somewhat problematic when the patient did not accept a psychosomatic explanation.
When a patient already had a psychiatric diagnosis, or the GP suspected a personality disorder, the GPs often felt they had no means of managing the situation. They explained how a special atmosphere was created in the room and the psychological perspective was no longer of any use in interpreting the situation. They felt they could not understand what it was all about and they experienced difficulties in reaching the patient.
Educational approach
When using the educational approach, the GPs focused on giving the patients medical explanations to make their illnesses more understandable.
In some cases, the GPs realized that the main problem was the patients' lack of knowledge of the human body and its function. Most frequently, the patient had some knowledge, which had to be explored by the GP, who then supplied explanations tailored to match the patient's level of knowledge. This task was easier if the patient signalled that he/she had an intellectual understanding and was prepared to accept the new information.
However, many patients had unrealistic expectations about the course of disease and about what the medical profession could do for them. With information about normal body processes, normal ageing or theories about how stress and crises cause tension and affect the bodily organisms, the patients were usually calmed and the symptoms did not become worse. As one GP said,
"People do not generally understand how the body works, how the mind functions, the effects of ageing and what orthopaedic specialists can do. There is an incredible lack of knowledge when it comes to recovery and the course of an illness."
The GPs noted that the media also play a role in increasing worry about disease, as many people were eager to make contact with their GP in need of reassurance after some new disease had been presented on TV.
Psychosocial approach
This approach includes GPs' understanding of patients' multiple symptoms as mirroring psychosocial problems and overall life circumstances.
The GPs were well aware that patients with MUS often had to handle complicated life circumstances, with what were at times almost insoluble problems. The underlying causes of the patient's illness might have been obvious to both parties, but there were no tools to manage the situation. One GP reflected, "Is this an expression of an illness or of disliking their jobs or some other social problem. Before you define it, I find it frustrating". Sometimes a malfunctioning personal relationship was the reason, this could be very obvious to the GP, while the patient was still looking for other explanations of the symptoms.
The GPs also noted that many of the patients with MUS had a poor social network and that the health care system thus became an important part of their network. One GP said,
"They don't usually have any network to support them. On many occasions, we become their network. These are patients that come more and more frequently. When you pick up the phone during telephone hours and hear them take a breath, you know immediately who it is."
More traumatic changes in social status also play a role in the development of symptoms; this applies, for example, to refugees who often lose their social position when coming to a new country.
Many remarks were made about how the labour market affects the individual, how people have to prioritize work before family, and how unemployment or the quest for a job imposes heavy demands on, and even splits up, families. One significant problem that was identified by the GPs was when patients were unable to go to work for reasons linked to various life circumstances. This required the symptoms to be labelled as a disease, to legalize absence from work and sick listing.
The GPs also noted that the postmodern society, which demands a high level of efficiency at all times and gives people no time for health problems and has created unrealistic expectations about what medicine can do for them. Many of the GPs claimed that the prevailing culture in society denies illness, suffering and death and leaves no room for people's existential needs.
Despite these unrealistic expectations of life, some GPs claimed that people nowadays are better equipped to accept physical and mental illness as a result of psychosocial factors. Discussions in the media about stress and work-related exhaustion have increased awareness about people's own susceptibility. The GPs were of the opinion that, even though the arena in which the patient and the physician meet is mainly biomedical, the new openness permits a wider range of explanations of people's sufferings.
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Discussion |
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This paper reports perceptions and approaches to the management of patients with MUS, as described by 27 GPs participating in five focus group discussions. The findings cannot be generalized to apply to the wider population of GPs but may serve as ‘eye-openers’ for GPs encountering the same kind of patients.
As in previous studies on this subject,4 the majority of the GPs conceptualized MUS as the result of distress, mirroring various earlier experiences or current life circumstances. However, the fear of missing a biomedical disease returned as a reminder from time to time. The GPs in this study expressed an eagerness to find explanations that could be of help in their understanding of these patients. The focus group setting encouraged the GPs to bring up and discuss their different working styles with each other, and they said that this was a fruitful exercise.
Even if the GPs reported occasional frustration and powerlessness in the management of patients with MUS, the desire to meet the patient at his/her standpoint was well developed. The way of shifting approach in managing the patient, even during the same consultation, served as a way of improving the quality of the doctor–patient encounter. Some of the GPs were more focused on finding a biomedical diagnosis and subsequent treatment, while others who expressed an interest in psychological and psychosocial issues managed to establish a doctor–patient relationship based on other approaches, such as the psychological and educational approach described above. However, in some cases, it was evidently a matter of current life circumstances that produced the symptoms, and this evoked stress in the GPs and they said that they had less knowledge and experience of how to handle this situation. GPs are trained to solve people's medical problems, but in these cases the problem-solving procedure often resulted in the medicalization of a person's psychosocial problem by labelling it with a medical diagnosis and legitimizing absenteeism from work by issuing a sick leave certificate. Many GPs felt that this was frustrating.
The GPs in this study were well aware of general shortcomings in the health care system, and mentioned, as an example, the risk of reinforcing sickness behaviour in patients, who enter a spiral of care with many players. Through new examinations and sick listing, additional diagnoses will be made that may stigmatize these people as sick, which will in turn make it difficult for the physician to present alternative explanations of the symptoms.
In line with the findings in this study, we argue that, in the case of patients with MUS, physicians need to recognize their own perceptions and make use of them when developing their professional attitude and working style. The tendency to dichotomize medical practice into a biomedical and a psychosocial perspective leads many doctors to dismiss parts of their knowledge and may then result in feelings of distress, insecurity and incompetence.
Patients suffering from multiple symptoms represent a substantial part of a GP's total work load and they account for the majority of people on long-term sick leave in Sweden.14 Increased sick leave rates have caused the Swedish government to take extraordinary measures. Part of the blame has been placed on the health care services and on GPs in particular for their increasing tendency to medicalize psychosocial problems. This study identifies the GPs' needs for support and further training to improve their tools and enable them more effectively to manage the growing number of men and women suffering from illnesses related to adverse life circumstances where the biomedical and the psychosocial perspectives need to be integrated. Counselling groups (Balint or the like), discussions with peers and supervision can also reduce feelings of frustration and cynicism and encourage good quality patient work using flexible approaches.
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Acknowledgments |
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This project was supported by the Research Department at the Nordic School of Public Health, Göteborg, Sweden.
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