psychological or emotional problems,3 and their legitimacy ... anymore. That applies to all my somatising patients, they all don't work. You think, is it because ...
Family Practice © Oxford University Press 2002
Vol. 19, No. 2 Printed in Great Britain
Medically unexplained symptoms and the problem of power in the primary care consultation: a qualitative study Lindsey Wilemana, Carl Mayb and Carolyn A Chew-Grahama Wileman L, May C and Chew-Graham CA. Medically unexplained symptoms and the problem of power in the primary care consultation: a qualitative study. Family Practice 2002; 19: 178–182. Background. Patients presenting in primary care frequently exhibit physical symptoms that may be unrelated to organic pathology. Such symptoms are commonly regarded as products of psychological or emotional problems, and their legitimacy as ‘medical’ matters is often called into question. Objectives. Our aim was to explore GPs’ attitudes to the management of patients that present with medically unexplained symptoms in primary care. Methods. Semi-structured interviews were conducted with 15 GPs in North-West England. Interviews were audio-taped and subsequently transcribed and analysed using a constant comparison technique. Results. Subjects conceptualized patients presenting with medically unexplained symptoms as the presentation of psychological distress. They presented problems of control and authority in the consultation, and difficulties in managing this had a negative impact on the doctor–patient relationship. Such consultations were frustrating for the GP and potentially harmful to the patient. Conclusion. Patients with medically unexplained symptoms were seen to be presenting with inappropriate symptoms that were a manifestation of emotional or social distress. GPs felt illequipped to deal with the presentations and the frustrations they felt and may need help in actively and productively managing these patients. Keywords. Consultation, medically unexplained symptoms, primary care.
to interactional problems between doctors and patients5 and to their negative evaluation within the consultation.6 Existing research in the field of somatization in primary care has focused largely on aetiology, epidemiology and the experiences of sufferers, and neglected the experiences and views of clinicians. In this paper, we present results from an exploratory qualitative study that focuses on the constructs of unexplained symptoms outlined by a group of British GPs. The objective of the study was to understand better the ways GPs conceptualize those factors that promote and inhibit the management of medically unexplained symptoms in primary care.
Introduction Patients presenting in primary care commonly exhibit physical symptoms that on investigation appear to be unrelated to organic pathology. Such symptoms are also commonly encountered in community epidemiological studies.1 In one recent study, almost 20% of consecutive consultations were related to responding to such symptoms.2 In the absence of identifiable organic pathology, such symptoms commonly are regarded as products of psychological or emotional problems,3 and their legitimacy as ‘medical’ matters often are called into question.4 The contested legitimacy of such symptoms frequently leads
Methods Received 28 November 2000, Revised 26 July 2001; Accepted 1 November 2001. aSchool of Primary Care, Unviersity of Manchester, Oxford Road, Manchester M13 9PL, and bCentre for Health Services Research, University of Newcastle upon Tyne, UK. Correspondence to Professor CR May, Centre for Health Services Research, University of Newcastle upon Tyne, 21 Claremont Place, Newcastle upon Tyne NE2 4AA, UK.
A study group of 15 (11 male, six female) GPs working in North-West England was recruited in May 2000. The sampling frame was those GPs holding honorary lecturer appointments in the University of Manchester Medical School. We sought to recruit GPs from inner city and suburban areas, and potential subjects were 178
Medically unexplained symptoms and the problem of power
approached by letter. Each potential subject was invited to choose from one of three studies being undertaken by medical students for their final year research option. Eighteen GPs agreed to take part in this project, and consented to take part in a single semi-structured interview lasting ~45 min, conducted by LW. Interviews were audio-taped and transcribed. Transcripts formed the material subject to formal ‘constant comparative’ qualitative analysis7 in which thematic categories are identified in GPs’ narratives, and pursued developmentally as the study proceeds. In line with the broad precepts of ‘grounded theory’, no new data were sought after category saturation was achieved.8 Interpretation and coding of qualitative data was undertaken by LH with assistance from CRM and CACG.
Results Somatization as a product of psychological distress GPs unanimously accepted the concept of somatization as a product of psychological distress. Their accounts of the aetiology of physical symptoms focused largely on two areas: first, the unacceptability of psychological illness within society, especially amongst males; and secondly, patients’ lay beliefs and understanding of psychological illness. The latter was seen as encouraging patients to focus on and amplify minor somatic symptoms to legitimize their help seeking. The central difficulty here was that patients lacked insight about the relationship between unhappiness and physical well-being. One doctor described patients’ constructs of illness in precisely these terms: “I think patients tend to think of things more in boxes than doctors do. If they’ve got pain in their stomach then there’s something wrong with their stomach, rather than it being a reflection of gut motility that might be related to psychological ideas.” (GP 8) Negative attributions dominated GPs’ accounts of patients with these symptoms. Interviewees described how they seemed to dominate the day even though small in number. These patients seemed to have access to the one resource denied to the GP, i.e. they had time to develop a view of their problems and to pursue this in the consultation. “One person that I spoke to on this subject said that somatising patients always have the time to come and see you, and if they didn’t have the time to come and see you they wouldn’t somatise anymore. That applies to all my somatising patients, they all don’t work. You think, is it because they are all that ill they can’t work? But most of them didn’t work before they started to somatise, and so are they that bored that they haven’t got anything else to do? All these things must fit together.” (GP 10)
179
GPs’ accounts revealed a spectrum of responses to such patients. Central to these was the sense that they possessed real power, and could dominate and direct the course of the consultation. At the same time, GPs construed that personal gains derived from the sick role (notably attention from others) encouraged and amplified its presentation: “I’ve got another young girl who’s going off her feet slowly but surely, and there’s no reason . . . And she thinks it’s great, she’s got her mother running around after her, she’s got us running around after her. [She’s] got lots of publicity, so that was quite nice for her as well. But there is no physical reason for her to go off her legs. Try as we might we cannot get her to accept that it might be psychological. I can’t see a future for her. I think she’s going to be in a bed in a few years, despite all my best efforts to keep her moving. I don’t know what I can do about that. She’s one extreme.” (GP 13) “Some make your stomach churn when they come in . . . very nervous. They make it very clear they are taking charge; and they do, they take charge, and there’s nothing you can do.” (GP 5) Impact on the doctor–patient relationship Despite these negative responses, much emphasis was placed upon the importance of establishing a good doctor–patient relationship as the basis of successful management. Interviewees felt that showing an empathy with the patient, and taking an interest in them despite “the most bizarre symptoms in the world”, enabled the patients to gain personal trust in the doctor. If this could be established, the likelihood of patients accepting the GPs’ psychological explanations for their physical symptoms would be increased: “They have got to feel that their own anxieties and their symptoms are being taken seriously, otherwise you are not going to get anywhere with them at all. If they are absolutely convinced that they have got something wrong with them, and you dismiss that out of hand, they’ll just feel you are not doing your job properly . . . they are never going to believe you, whereas if you have got some trust there they will start to feel that bit safer.” (GP 14) There was disagreement, however, about the balance of authority and the consultation style that might lead to resolution. “You’re supposed to do these open-ended questions, patient-centred, patient-led consultations for everyone and that’s fine. But sometimes with patients on these lines, if you did that you’d never get your surgery finished . . . so you take more control earlier on in the consultation than otherwise.” (GP 7)
180
Family Practice—an international journal
The general view was that the relationship should be a partnership between doctor and patient but this was complicated, firstly by constraints of time that forced doctors into taking a more active and authoritative role, and secondly by patients using techniques to influence the GP and gain investigation or treatment. Management of a somatizing patient within a consultation Interviewees gave descriptions of how they attempted to control patient attendance by the agreement of a ‘contract’. For example, a compromise would be made between the frequency and duration of consultations, i.e. the patient would attend less frequent but regular consultations for which the GP would allocate more time. Within each consultation, an agenda could be set, appropriate to the time available, tackling the patient’s main worries on that occasion. “What I do for a lot of somatising patients when it’s obvious what is happening is, I explain how the practice works, explain how I work as a doctor, how I come to a diagnosis, I explain how much time they have with me, and I ask them what they think it would be reasonable to do in ten minutes. So, for example, if they had a headache, bowel pain, toenail ingrowing, and a problem with your piles, is it reasonable that in ten minutes I address and examine you for all those issues? To which they always reply ‘No, it’s not reasonable’, so I say . . . ‘Whatever is worrying you most we will address thoroughly, and then the other things will have to wait until next time you come’.” (GP 10) Displaying an understanding of the patient’s symptoms and illness fears, as employed in the reattribution techniques of Goldberg et al.,9 was regarded as imperative to the management success. If patients felt GPs were sympathetic and understanding, they would have more confidence in the GPs’ opinions, and therefore be more accepting of psychological attributions to disease put forward. In the case of psychological illness where there are a wide range of management options, reassurance and support were emphasized by GPs. Psychological issues were approached by reframing the complaint, linking it to psychosocial cues elicited from the history; the second stage of the reattribution technique: “It’s not uncommon for their particular symptoms to be explained through a psychological cause, and I say to them that this is a response to whatever, and try to give them something to hang that on like an event, like pressures at work, or whatever may have been going on in their life if you can identify a supposed cause. Even if it doesn’t particularly cause it, you’ve got something to hang it on, and clearly it helps them to identify that it might be a psychological problem.” (GP 12)
Here the GP was demonstrating to the patient a link between emotional distress and somatic symptoms in a manner with which the patient could identify, whilst avoiding a conflict of opinions by legitimizing the cause. Other interviewees attempted to explain symptoms in terms of the pathogenesis of symptoms, for example tension headaches, or more simply with analogies that associated stress or anxiety with a physical response: “I use certain analogies like, you say someone is a pain in the neck or someone gives me a headache, and say ‘Do you think your backache gets worse every time your boss shouts at you?’” (GP 13) Patients’ response to GPs’ attempts to explain psychological illness were reported to vary on a spectrum from relief: “If you catch it in terms of, well, it’s actually good news, it’s not a physical cause, therefore it’s something we can deal with in a different way, some people take it very, very well; some people are quite relieved.” (GP 12) to absolute rejection: “They just seem to be stuck with the belief that they have something wrong, and they can’t move forward. They can’t move forward in their own lives because they’ve not accepted it, and you are unable as a GP to help them. So both ways you are stuck. It means that perhaps they will continue to consult, but at the end of the consultation you are still no further on.” (GP 14) The central problem that GPs faced, therefore, was the extent to which they had little power to influence patients’ understandings of their illness, whilst patients were perceived to have much greater power to direct and control the course of events. Despite their negative attributions about this group of patients, GPs viewed general practice as the most appropriate and effective area within which patients could be managed despite their negative views of these patients. They felt that they had the opportunity to ‘know’ such patients better, and to build a relationship upon which successful management could be based. In addition, GPs observed that less emphasis could be placed on assigning a diagnosis in primary care. They regarded this as advantageous in dealing with patients who held a repertoire of lay diagnoses that otherwise undermined efforts to reattribute somatic complaints to psychological causes. “One of the advantages you have in general practice is, I suppose, to build up parts of a story over a period of time, rather than doing it all in one day or one consultation . . . I think you have to try and not leap to a diagnosis.” (GP 8)
Medically unexplained symptoms and the problem of power
181
General practice allowed time and development of symptoms to be utilized as a management tool:
doctor’s personal emotions compromising their clinical professionalism:
“Every person that comes into the GP surgery, you can’t investigate them all straight off. You have to evaluate the symptoms, see whether you think they are serious, because the majority of people who come to the GP do not have serious illness . . . And that is I suppose what being a GP is; you have to sift out between what is serious and what is not. People can always come back.” (GP 6)
“I felt I lost my judgement with her because I dislike her.” (GP 6)
Views on the involvement of specialists and other agencies were conflicting. The benefits of sharing the burden of management were appreciated and encouraged doctors to refer patients on to psychology, counselling, or cognitive–behavioural therapy. However, at the same time, some GPs saw psychological interventions as a problem in themselves:
Patients were seen by GPs as being able to gain authority by undermining the opinion of the doctor or lacking trust in the doctor’s abilities. This is frustrating for the doctor and potentially harmful to the outcome of the consultation.
“What it does give them is a huge audience and a huge opportunity to actually spend some time with someone, and sometimes the underlying cause becomes far more evident when they are speaking to someone for an hour, half an hour if it’s a psychologist or an independent therapist. So that way the patient has an opportunity to indulge themselves.” (GP 12) However, it was recognized that successful management might require a referral to hospital out-patients “I’ve noticed my habits are changing, as the years go by, that I am in fact sometimes over-investigating just to make sure, as a safety net, just to make sure you’re not missing anything. You’ve been caught out so many times with other things that you tend to worry a little bit about the litigation. You err on the side of caution. I do feel that pressure, because occasionally something turns up and you think oh God, I’m glad I did that. So that fear is there. But that’s the way medicine is going now.” (GP 3) Frustration for the GP; harm to the patient Negative emotions predominated in GPs’ accounts of patients with medically unexplained symptoms. Patients were described as ‘frustrating’ or ‘heartsink’. Exploration of such feelings revealed a spectrum of emotions from inadequacy to the resentment and fear of such patients who could dominate and manipulate the course of the consultation: “Some make your stomach churn when they come in . . . very nervous. They make it very clear they are taking charge; and they do, they take charge and there’s nothing you can do.” (GP 5) A strained doctor–patient relationship was recognized as being potentially harmful to the patient, with the
“You can get yourself into the position where you will never spot an illness in this patient if it was staring you in the face and they were dead on the floor, because you will feel it’s just their bloody somatising.” (GP 10)
Conclusion This paper reports a study limited in scope, and which examined the self-reported experiences of a relatively small group of doctors. It is not generalizable to the wider population of GPs. However, the results presented here fit well with those of a series of qualitative studies in which we have explored GPs’ responses to manifestations of psychological distress in the consultation.6,10,11 These have emphasized the sense of powerlessness that GPs express in the face of apparently intractable symptoms rooted in the realm of the social. The weight of these problems is sufficient to overwhelm the kinds of re-attribution techniques9 that might conventionally be deployed to deal with them. In this study, medically unexplained symptoms were conceptualized by GPs as a result of the medicalization of distress, and decreased tolerance of benign somatic symptoms. Social problems were named frequently in the aetiology of a patient’s symptoms which, however, the GP had little power to influence. GPs in this study saw patients presenting with medically unexplained symptoms as a problem not due to their numbers, but due to the diffuseness of their presentation and their resistance to medical explanations of their symptoms. GPs recognized that current teaching about the consultation, about patient-led consultations and about patient-centredness did not help them in their management of this group of patients. In addition, whilst GPs were aware that they had to help the patient link psychological factors with somatic symptoms, they often felt unable to do so. GPs reported that the balance of power was with the patient, and this felt uncomfortable to the GP. These patients were therefore seen to be difficult to manage and frustrating for the GP, but the importance of the relationship between the doctor and patient was emphasized frequently and actively sought by the GPs. A further difficulty that became apparent was the effect of a poor relationship where clinical judgement was lost.
182
Family Practice—an international journal
This was seen by respondents to impact negatively on the quality of care given to these patients. This study highlights the need for more training for GPs in the area of managing this difficult group of patients. GPs felt that they should continue to be managed in primary care, but they needed support in managing the negative feelings and frustrations that currently coping with these patients induces.
Acknowledgements
2
3
4
5
6
7
We are grateful to the GPs who took part in this study for their time and candour. We also thank Professor Peter Salmon for his helpful advice; and Manchester medical students Elizabeth Henderson, Scott Hedley and Hannah Cole for their practical help during the study, along with Mrs Caroline Connolly and Mrs Denise Mukadam for their secretarial support of our work.
8
9
10
11
References 1
Jenkins R, Lewis G, Bebbington P. The national psychiatric morbidity study of Great Britain: initial findings from the household survey. Psychol Med 1997; 27: 775–789.
Peveler R, Kilkenny L, Kinmonth A. Medically unexplained symptoms in primary care: a comparison of self-report screening questionnaires and clinical opinion. J Psychosom Res 1997; 42: 245–252. White P, Moorey S. Psychosomatic illnesses are not all in the mind. J Psychosom Res 1997; 42: 245–252. Grace VM. Mind/body dualism in medicine: the case of chronic pelvic pain without organic pathology—a critical review of the literature. Int J Health Serv 1998; 28: 127–151. Salmon P. Patients who present physical symptoms in the absence of physical pathology: a challenge to existing models of doctor– patient interaction. Pat Educ Couns 2000; 39: 105–113. Chew-Graham C, May C. Chronic low back pain in general practice: the challenge of the consultation. Fam Pract 1999; 16: 46–49. Glaser BG, Strauss A. The Discovery of Grounded Theory. Chicago: Aldine, 1968. Strauss A. Qualitative Analysis for Social Scientists. Cambridge: Cambridge University Press, 1987. Goldberg D, Gask L, O’Dowd T. The treatment of somatization— teaching techniques of reattribution. J Psychosom Res 1989; 33: 689–695. Chew-Graham CA, May C, Cole H, Hedley S. The burden of depression in primary care: a qualitative investigation of general practitioners’ constructs of depressed people in the inner city. Primary Care Psychiatry 2001; 6: 137–141. Rogers A, May C, Oliver D. Experiencing depression, experiencing the depressed: patients and doctors’ accounts. J Mental Health 2001; 10: 317–334.
