Teaching about medically unexplained symptoms at medical schools ...

2012; 34: 327–329

SHORT COMMUNICATION

Teaching about medically unexplained symptoms at medical schools in the United Kingdom MARY HOWMAN, KATE WALTERS, JOE ROSENTHAL, MARY GOOD & MARTA BUSZEWICZ UCL Medical School, London

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Abstract Background: Medically unexplained symptoms (MUS) are very common in primary and secondary care. They are often inappropriately managed, resulting in potential harm to patients as well as wasted resources. To bring about change, it is important that newly qualified doctors are equipped with the skills to manage MUS effectively. We do not know if and how this topic is currently taught at UK medical schools. Aim: To document whether, how and when this topic is currently taught in UK medical schools. To assess potential barriers to this teaching and consider how it can be improved. Methods: A questionnaire survey emailed to GP and psychiatry teaching leads at all 31 UK medical schools. Results: Responses received from 24/31 schools showed that MUS teaching across UK medical schools is very variable in terms of amount, method, assessment and integration of the teaching within the curriculum. Most respondents identified a need for a greater quantity of cross-discipline teaching and for greater value to be attributed to the topic. Conclusion: Inconsistent and disparate teaching across medical schools may lead to very variable practice amongst qualified clinicians. In order to overcome this, consensus is needed as to how and where in the undergraduate curriculum there should be teaching about MUS.

Introduction Medically unexplained symptoms (MUS) are very common across both primary and secondary care (Peveler et al. 1997; Nimnuan et al. 2001) and can be challenging to manage. Not only is the often inappropriate management of MUS potentially frustrating for both patients and clinicians, but over-investigation and the tendency of people with MUS to re-present to different medical specialties can be linked with adverse outcomes for patients and place a significant financial strain on the health service (Barsky et al. 2005; Hatcher & Arroll 2008). Although such presentations can be complex, there is some consensus of opinion as to appropriate management strategies, as summarised in a 2008 British Medical Journal review (Hatcher et al. 2008). This stresses the importance of taking such symptoms seriously, screening for psychiatric diagnoses such as depression or anxiety which may or may not be present and providing an empowering explanation for symptoms the patient is experiencing. A qualitative study looking at the attributes of such explanations indicated patients appreciate explanations which describe a mechanism that makes sense to them and involves them in managing their symptoms (Salmon et al. 1999). In order to equip future doctors with the skills necessary to manage MUS effectively, it seems obvious that learning in this area should form part of their formal training. However, the reality is that the whole thrust of undergraduate teaching

focuses on medically explicable symptoms and building a portfolio of diagnoses. There is currently no consensus regarding how best to teach students about MUS, and no clarity or consistency as to whether, how or when this topic should be incorporated in the undergraduate medical curriculum.

Method Design A questionnaire survey comprising 13 questions. The questionnaire (Appendix) consisted of closed questions asking for information on if, when and how MUS teaching and assessment is carried out and three open questions on potential barriers to teaching, student response and suggestions for improvement.

Study population/setting Psychiatry and general practice teaching leads at all 31 UK Medical Schools.

Data collection Electronic request and subsequent email reminders at approximately 1 and 3 months.

Correspondence: M. Howman, Department of Primary Care and Population Health, Upper Third Floor UCL Medical School (Royal Free Campus), Rowland Hill Street, London NW3 2PF, UK. Email: [email protected] ISSN 0142–159X print/ISSN 1466–187X online/12/040327–3 ß 2012 Informa UK Ltd. DOI: 10.3109/0142159X.2012.660219

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Analysis Responses to closed questions (1–9, 13) were coded and analysed descriptively. Open questions (10–12) were analysed thematically. Each member of the research team (Mary Howman, Marta Buszewicz, Joe Rosenthal and Kate Walters) independently identified key themes, which were agreed by consensus.

Table 1. Summary of closed question responses. Question Is there teaching on MUS? Is it compulsory teaching? Is it offered as an optional course? Is there a discrete course?

Yes (21/24) no (3/24) Yes (17/24) no (5/24) unsure (2/24) Yes (11/24) no (6/24) unsure (7/24)

When is it taught (year)?

Year Year Year Year Year

When is it taught (during which attachment)?

Psychiatry (18/21) General practice (3/21) Neurology (3/21) Medicine (3/21) Paediatrics (1/21)

Across how many specialties is it taught?

1 (12/21)b 2 (6/21) 3 (1/21) Not stated (2/21)

Is there collaboration between those teaching MUS? How long is spent on teaching?

Yes (9/21), no (8/21), unsure (4/21)

How is teaching delivered?

Lecture (17/21) Tutorial/small group work (9/21) Patient contact (7/21) Seminar/workshop (4/21) Problem-based learning (2/21) Video (1/21) E-learning (1/21)

How is it assessed?

OSCE (12/21) Multiple choice question (8/21) Extended matching question (5/21) Not specifically assessed (4/21) Short answer question (3/21) Single best answer question (1/21) Essay (1/21) Log book (1/21) On-line self assessment (1/21)

Results


How MUS is currently being taught – questionnaire responses The response rate was 77% (24/31 medical schools); responders included schools in a variety of geographical locations and both established and newer schools. In total, 11 of the respondents were GPs and the rest psychiatrists. The results are documented in Table 1.

Potential barriers to this teaching – free text responses The most common issue raised was of curriculum overload and lack of clarity around where this teaching should best fit. There was disagreement over whether teaching should begin earlier in the curriculum; whilst one tutor suggested this, another said they felt this was potentially ‘dangerous’ and the topic should be taught towards the end of the course. The notion that the topic was not valued and sometimes negatively portrayed by other specialties, and its prevalence underestimated were the other main potential barriers identified in free text responses. Additional concerns mentioned by one or two respondents were the difficulty of finding teachers and patients, the complexity of the topic, the difficulties it raises for the doctor as well as the student, and lack of student interest.

Student response to teaching The majority of respondents described a varied but generally positive student response to teaching about MUS: ‘very variable, with some perceiving the relevance and becoming very engaged to those thinking it is irrelevant’ [Respondent 13]. Students were described as ‘positive’, ‘grateful’ and ‘interested’. There was a sense that students could be challenged by the topic although this was not explored in detail: one tutor described the topic as ‘daunting’ and another as making students ‘uneasy’. One said some students found the topic ‘irrelevant’, perhaps reinforced by the negative role-modelling from other doctors mentioned by two tutors.

Response

Yes (2/24) no (21/24) unsure (1/24) 1 2 3 4 5

(3/21)a (2/21)a (12/21) (11/21) (10/21)

Less than a day (14/21) 1–2 days (2/21) More than 2 days (3/21) Unsure (2/21)

Notes: aNo school taught the topic solely in years 1 or 2. b Of these, 11 being in psychiatry.

The need for curriculum mapping of the topic and specific objectives were highlighted. Other suggestions included assessment of the topic in examinations, promotion of tutor awareness, use of simulated patients, more liaison psychiatry placements and finally the need for more research on the topic in order to increase its perceived value.

Suggestions for improvement When asked how MUS teaching could be improved, the dominant theme identified was the need for a greater quantity of coordinated cross-discipline teaching. Tutors were keen for the subject to be taught and reinforced across disciplines, specifically within medicine and surgery: ‘would be better if more integrated and reinforced across all systems and blocks rather than linked particularly with psychiatry’ [Respondent 8]. 328

Conclusions This survey found teaching of MUS across UK medical schools to be highly variable, in terms of both the amount provided and the way it is integrated within the curriculum. It is most often taught within psychiatry placements, perhaps reinforcing a controversial view that all MUS are psychological in origin and ignoring possible physiological explanations. Only a


Teaching about medically unexplained symptoms

minority of respondents reported explicit teaching on MUS within general practice, despite evidence that around 30% of GP consultations involve MUS (Peveler et al. 1997). There is little evidence of formal teaching on MUS in earlier ( preclinical) years or in medical or surgical specialties, although this may be under-represented as respondents were educational leads in primary care or psychiatry. Most respondents identified a need for a greater quantity of coordinated crossdiscipline teaching. The current disparate teaching on MUS in our medical schools almost certainly leads to variable practice amongst clinicians and potentially negative outcomes for patients. Consistency of intellectual approach, alongside vertical and horizontal integration of teaching on MUS across a wide range of medical specialties, might well help students to grasp this vitally important but challenging area. Only by creating consensus as to how such teaching should take place, combined with rigorous evaluation, assessment and research, can we adequately prepare future doctors to effectively manage MUS.

Acknowledgements Thank you to all the tutors who took the time to fill out our questionnaire. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

Notes on contributors MARY HOWMAN, MRCGP is a clinical teaching fellow, in the Department of Primary Care and Population Health, UCL. KATE WALTERS, MRCGP, PhD is a senior clinical lecturer. JOE ROSENTHAL, MB, BCh is a Primary Care education lead in the Department of Primary Care and Population Health, UCL. MARY GOOD B.Lib.Stu was a departmental administrator and is now studying medicine in Sydney, Australia. MARTA BUSZEWICZ, MRGGP, MRCPsych is a senior lecturer. Marta Buszewicz, Kate Walters and Mary Howman run the MUS lecture at UCL for fourth year medical students, in the Department of Primary Care and Population Health, UCL.

References Barsky AJ, Oray EJ, Bates DW. 2005. Somatization increases medical utilization and costs independent of psychiatric and medical comorbidity. Arch Gen Psychiatry 62:903–910. Hatcher S, Arroll B. 2008. Assessment and management of medically unexplained symptoms. BMJ 336:1124–1128. Nimnuan C, Hotopf M, Wessely S. 2001. Medically unexplained symptoms: An epidemiological study in seven specialties. J Psychosom Res 51:361–367. Peveler R, Kilkenny L, Kinmoth AL. 1997. Medically unexplained physical symptoms in primary care: A comparison of self-report screening questionnaires and clinical opinion. J Psychosom Res 42:245–252. Salmon P, Peters S, Stanley I. 1999. Patients’ perceptions of medical explanations for somatisation disorders: Qualitative analysis. BMJ 318:372–376.

Appendix The questionnaire (1)

(2) (3) (4) (5)

(6)

Does teaching on medically unexplained symptoms and/or somatisation form part of the MBBS curriculum at your university? Is the study of these topics compulsory i.e. part of the core curriculum? Do these topics arise in elective subjects? Is there a discrete course offered on medically unexplained symptoms and/or somatisation? During which year(s) and module(s) is this subject delivered? Please be as specific as possible eg. Year 4 Psychiatry elective; Year 3 General Medicine If students encounter these topics more than once during the course of the degree is there

(7)

(8) (9) (10) (11) (12) (13)

collaboration or communication between all those involved in teaching? Approximately how much time is devoted to the study of these topics over the course of the degree? How is teaching delivered eg. lectures, workshops, tutorials, patient-contact? How are students assessed on the topic eg. MCQs, short answer questions, OSCEs How do you feel students respond to being taught about these topics? What barriers do you perceive to delivering teaching on this topic? What improvements do you feel could be made to teaching on this topic? Would you be willing to share your teaching resources with other teachers?

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