Open Access Open Access  Restricted Access Subscription or Fee Access

Training Medical Specialists in Communication about Medically Unexplained Physical Symptoms: Patient Outcomes from a Randomized Controlled Trial

Anne Weiland, Annette H Blankenstein, Jan L Van Saase, Henk T Van der Molen, David Kosak, René M Vernhout, Lidia R Arends

Abstract


Objectives: Medically unexplained physical symptoms (MUPS) burden patients in their well-being and functioning and have a prevalence of approximately 25-50% in primary and specialist care. Medical specialists often find patients with unexplained symptoms difficult to deal with, whereas patients are not always understood. We report effects on patient outcomes of an evidence-based MUPS-focused communication training for medical specialists.

Methods: In a multi-center randomized controlled trial medical specialists and residents allocated to the intervention received a 14-hour MUPS-focused communication training. They practiced a patient-centered approach, including multi-factorial symptom exploration and explanation of MUPS with perpetuating factors. To study intervention effects, each doctor had to include three MUPS patients before and three after the intervention and to ask them to complete questionnaires at baseline and at 3 and 6 months follow-up. The questionnaires included illness worries (Whitely Index), symptom severity (Visual Analogue Scale), distress, depression, anxiety and somatization (4DSQ) and daily functioning (SF-36).

Results: A sufficient number of 123 medical specialists and residents participated in the study. They included 478 MUPS patients. Out  of them, 297 patients filled out questionnaires at baseline, 165 patients at 3-months follow-up and 71 patients at 6-months follow-up. Recruitment of patients was lower than expected and patients’ non-response to baseline and follow-up questionnaires was higher than estimated. No significant effects were found on patient outcomes.

Conclusions: It remains unclear whether medical specialist training results in better patient outcomes in MUPS as the trial was underpowered. New research with special attention to patient recruitment and retention is needed to answer this question.


Keywords


Medically unexplained physical symptoms; randomized controlled trial; patient reported outcomes; costs; training programme; medical specialists.

Full Text:

PDF

References


. Olde Hartman TC, Borghuis M, Lucassen PL, Van de Laar FA, Speckens AE, Van Weel C. Medically unexplained symptoms, somatisation disorder and hypochondriasis: course and prognosis. A systematic review. J Psychosom Res. 2009;May;66(5):363-77.

. Kroenke K. A Practical and Evidence-Based Approach to Common Symptoms. A Narrative Review. Ann Intern Med. 2014;161(8):579-86.

. Rask MT, Rosendal M, Fenger-Grøn M, Bro F, Ørnbøl E, Fink P. Sick leave and work disability in primary care patients with recent-onset multiple medically unexplained symptoms and persistent somatoform disorders: a 10-year follow-up of the FIP study. Gen Hosp Psychiatry. 2015;37(1):53-9.

. Nimnuan C, Hotopf M, Wessely S. Medically unexplained symptoms: An epidemiological study in seven specialities. J Psychosom Res. 2001;51(1):361-7.

. Carson AJ, Stone J, Warlow C, Sharpe M. Patients whom neurologists find difficult to help. J Neurol Neurosurg Psychiatry. 2004;75(12):1776-8.

. Kouyanou K, Pither CE, Rabe-Hesketh S, Wessely S. A comparative study of iatrogenesis, medication abuse, and psychiatric morbidity in chronic pain patients with and without medically explained symptoms. Pain. 1998;76(3):417-26.

. Stephenson DT, Price JR. Medically unexplained physical symptoms in emergency medicine. Emergency Medicine Journal. 2006;23(8):595-600.

. Mariman A, Delesie L, Tobback E, Hanoulle I, Sermijn E, Vermeir P, et al. Undiagnosed and comorbid disorders in patients with presumed chronic fatigue syndrome. J Psychosom Res. 2013;75(5):491-6.

. Collins J, Farrall E, Turnbull DA, Hetzel DJ, Holtmann G, Andrews JM. Do we know what patients want? The doctor-patient communication gap in functional gastrointestinal disorders. Clin Gastroenterol Hepatol. 2009;7:1252-4.

. Siproudhis L, Delvaux M, Chaussade S, Charles F, Guyot P, Weber J, et al. [Patient-doctor relationship in the irritable bowel syndrome. Results of a French prospective study on the influence of the functional origin of the complaints]. Gastroenterol Clin Biol. 2002;26:1125-33.

. Van Dulmen AM, Fennis JF, Mokkink HG, Van der Velden HG, Bleijenberg G. Doctor-dependent changes in complaint-related cognitions and anxiety during medical consultations in functional abdominal complaints. Psychol Med. 1995 Sep;25(5):1011-8.

. Salmon P. Conflict, collusion or collaboration in consultations about medically unexplained symptoms: the need for a curriculum of medical explanation. Patient Educ Couns. 2007 Aug;67(3):246-54.

. Salmon P, Marchant-Haycox. Surgery in the absence of pathology the relationship of patients' presentation to gynecologists' decisions for hysterectomy. J Psychosom Res. 2000;49(2):119-24.

. Kappen T, van Dulmen S. General practitioners' responses to the initial presentation of medically unexplained symptoms: a quantitative analysis. Biopsychosoc Med. 2008;2:22.

. Bensing JM, Verhaak PFM, van Dulmen AM, Visser AP. Communication: the royal pathway to patient-centered medicine. Patient Educ Couns. 2000;39(1):1-3.

. Sloan TJ, Walsh DA. Explanatory and diagnostic labels and perceived prognosis in chronic low back pain. Spine. 2010;35(21):E1120-E5.

. Salmon P. The potentially somatizing effect of clinical consultation. CNS Spectr. 2006;11(3):190-200.

. Bensing JM, Verhaak PF. Somatisation: a joint responsibility of doctor and patient. Lancet. 2006 Feb 11;367(9509):452-4.

. olde Hartman TC, van Rijswijk E, van Dulmen S, van Weel-Baumgarten E, Lucassen PLBJ, van Weel C. How patients and family physicians communicate about persistent medically unexplained symptoms. A qualitative study of video-recorded consultations. Patient Educ Couns. 2013;90(3):354-60.

. Rosendal M, Bro F, Sokolowski I, Fink P, Toft T, Olesen F. A randomised controlled trial of brief training in assessment and treatment of somatisation: effects on GPs' attitudes. Family Practice. 2005;22(4):419-27.

. Aiarzaguena J, Grandes G, Gaminde I, Salazar A, Sanchez A, Arino J. A randomized controlled clinical trial of a psychosocial and communication intervention carried out by GPs for patients with medically unexplained symptoms. Psychol Med. 2007;37(2):283-94.

. Rief W, Martin A, Rauh E, Zech T, Bender A. Evaluation of General Practitioners’ Training: How to Manage Patients With Unexplained Physical Symptoms. Psychosomatics. 2006;47(4):304-11.

. van Ravenzwaaij J Olde Hartman T, van Ravesteijn H, Eveleigh R, van Rijswijk E, Lucassen P. Explanatory models of medically unexplained symptoms: a qualitative analysis of the literature. Ment Health Fam Med. 2010;7(4):223-31.

. Teutsch C. Patient-doctor communication. Medical Clinics of North America. 2003 Sep;87(5):1115-+45.

. Street Jr RL, Makoul G, Arora NK, Epstein RM. How does communication heal? Pathways linking clinician–patient communication to health outcomes. Patient Educ Couns. 2009;74(3):295-301.

. Weiland A, Blankenstein AH, Willems MHA, Van Saase JLCM, Van der Molen HT, Van Dulmen AM, et al. Post-graduate education for medical specialists focused on patients with medically unexplained physical symptoms; development of a communication skills training programme. Patient Educ Couns. 2013;92(3):355-60.

. Weiland A, Blankenstein AH, Willems MHA, Van Saase JLCM, Van Daele PLA, Van Molen HT, et al. Training specialists to write appropriate reply letters to general practitioners about patients with medically unexplained physical symptoms; a cluster-randomized trial. Patient Educ Couns. 2015;98(10):1229-35

. Weiland A, Blankenstein AH, Van Saase JLCM, Van der Molen HT, Jacobs ME, Abels DC, et al. Training medical specialists to communicate better with patients with medically unexplained physical symptoms. A randomized controlled trial. PLoS ONE. 2015;10(9): e0138342.

. Speckens AEM, Spinhoven P, Sloekers PPA, Bolk JH, van Hemert AM. A validation study of the whitely index, the illness attitude scales, and the somatosensory amplification scale in general medical and general practice patients. J Psychosom Res. 1996;40(1):95-104.

. Terluin B, van Marwijk H, Ader H, de Vet H, Penninx B, Hermens M, et al. The Four-Dimensional Symptom Questionnaire (4DSQ): a validation study of a multidimensional self-report questionnaire to assess distress, depression, anxiety and somatization. BMC Psychiatry. 2006;6(1):34.

. Ware Jr JE, Gandek B. Overview of the SF-36 Health Survey and the International Quality of Life Assessment (IQOLA) Project. Journal of Clinical Epidemiology. 1998;51(11):903-12.

. Blankenstein AH, van der Horst HE, Schilte AF, de Vries D, Zaat JOM, Knottnerus J, et al. Development and feasibility of a modified reattribution model for somatising patients, applied by their own general practitioners. Patient Educ Couns. 2002;47:229-35.

. Blankenstein AH, van der Horst HE, Essers G, Floor E. Training Course Policy towards MUPS patients in general practice; use of CBT for the GP. 2003.

. Morriss R, Gask L, Ronalds C, Downes-Grainger E, Thompson H, Leese B, et al. Cost-effectiveness of a new treatment for somatized mental disorder taught to GPs. Family Practice. 1998;15(2):119-25.

. Morriss R, Dowrick C, Salmon P, Peters S, Dunn G, Rogers A, et al. Cluster randomised controlled trial of training practices in reattribution for medically unexplained symptoms. Br J Psychiatry. 2007;191(6):536 - 42.

. Dessel Nv, Boeft Md, Wouden JCvd, Kleinstäuber M, Leone SS, Terluin B, et al. Non-pharmacological interventions for somatoform disorders and medically unexplained physical symptoms (MUPS) in adults. Cochrane database of systematic reviews (Online).2014;11:CD011142.

. Rosendal M, Blankenstein A, Morriss R, Fink P, Sharpe M, Burton C. Enhanced care by generalists for functional somatic symptoms and disorders in primary care. Cochrane Database of Systematic Reviews. 2013(10):CD008142.

. van der Wouden JC, Blankenstein AH, Huibers MJH, van der Windt DAWM, Stalman WAB, Verhagen AP. Survey among 78 studies showed that Lasagna's law holds in Dutch primary care research. Journal of Clinical Epidemiology. 2007;60(8):819-24.

. Dedding C, M S. The role of patients in research. The fraying of participation in health care De rafels van participatie in de gezondheidszorg, van participerende patient naar participerende omgeving (in Dutch). Den Haag: Boom Lemma; 2013. p. 87-110.




DOI: http://dx.doi.org/10.5750/ijpcm.v6i1.490

Refbacks

  • There are currently no refbacks.