Learning to provide patient-centered care with patients with medically unexplained symptoms: a grounded theory study in Australian general practice.
Keywords:General practice, Medical education, Mental health, Somatoform disorders, Patient-centered care, Diagnosis
AbstractBackground Culture shapes the way illness is experienced and disease is understood. Patients with medically unexplained symptoms describe feeling their suffering is not valued because they lack a “legitimate” diagnosis. Doctors also describe feeling frustrated with these patients. This is particularly problematic for young general practitioners (GPs) who lack experience in managing patients with medically unexplained symptoms in primary care settings.Objectives To explore how general practice supervisors help registrars to provide patient-centered care for patients with medically unexplained. Methods A constructivist grounded theory study was undertaken with 24 general practice registrars and supervisors from Australian GP training practices in urban, rural and remote environments. Participants were asked to describe patients with mixed emotional and physical symptoms without an obvious medical diagnosis. Results Registrars came from hospital posts into general practice equipped with skills to diagnose and manage organic disease but lacked a framework for assessing and managing patients with medically unexplained symptoms. They described feelings of helplessness, frustration and sometimes hostility. Because these feelings were inconsistent with their expressed value systems, they were uncomfortable and confronting. The registrars valued interactions that helped them explore this area. Conclusions In hospital practice, biomedical language and explanations predominate, but in general practice patients bring different explanatory illness models to the consultation, using their own language, beliefs and cultural frameworks. Medically unexplained symptoms occupy a contested space in both the social and medical worlds of the doctor and patient. Negative feelings and a lack of diagnostic language and frameworks may prevent registrars from providing patient-centered care.
. Kirmayer LJ, Sartorius N. Cultural models and somatic syndromes. Psychosomatic Medicine. Nov-Dec 2007;69(9):832-840. http://www.psychosomaticmedicine.org/content/69/9/832.full
. Arnault DS. Cultural Determinants of Help Seeking: A Model for Research and Practice. Research and Theory for Nursing Practice. 2009;23(4):259-278. http://www.ingentaconnect.com/content/springer/rtnp/2009/00000023/00000004/art00004
. Kirmayer L. Culture, context and experience in psychiatric diagnosis. Psychopathology. 2005;38(4):192-6. http://www.karger.com/Article/FullText/86090
. Association AP. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Fifth ed. Washington DC: American Psychiatric Publishing; 2013.
. Sadler JZ. Values and psychiatric diagnosis. New York: Oxford University Press; 2005.
. Gureje O. What can we learn from a cross-national study of somatic distress? Journal of Psychosomatic Research. 2004;56(4):409-412. http://www.jpsychores.com/article/S0022-3999(03)00623-8/abstract
. Koch H, van Bokhoven MA, ter Riet G, van der Weijden T, Dinant GJ, Bindels PJE. Demographic characteristics and quality of life of patients with unexplained complaints: a descriptive study in general practice. Quality of Life Research. 26 September 2007 2007;16(9):1483-1489. http://link.springer.com/article/10.1007/s11136-007-9252-y
de Waal MWM, Arnold IA, Eekhof JAH, Van Hemert AM. Somatoform disorders in general practice: prevalence, functional impairment and co-morbidity with anxiety and depression. British Journal of Psychiatry. 2004;184(6):470-476. http://bjp.rcpsych.org/content/184/6/470.abstract
. Fink P, Rosendal M, Olesen F. Classification of somatization and functional somatic symptoms in primary care. Australian and New Zealand Journal of Psychiatry. 2005;39(9):772 - 781. http://anp.sagepub.com/content/39/9/772.abstract
. Clarke DM, Piterman L, Byrne CJ, Austin DW. Somatic symptoms, hypochondriasis and psychological distress: a study of somatisation in Australian general practice. Medical Journal of Australia. 2008;189(10):560-564. https://www.mja.com.au/journal/2008/189/10/somatic-symptoms-hypochondriasis-and-psychological-distress-study-somatisation
. Bäärnhielm S. Restructuring Illness Meaning Through the Clinical Encounter: A Process of Disruption and Coherence. Culture, Medicine and Psychiatry. 2004;28(1):41-65. http://link.springer.com/article/10.1023/B%3AMEDI.0000018097.31002.79
. Steinmetz D, Tabenkin H. 'The difficult patient' as perceived by family physicians. Family Practice. 2001;18(5):495-500. http://fampra.oxfordjournals.org/content/18/5/495.full
. Hahn SR, Kroenke K, Spitzer RL, et al. The difficult patient: prevalence, psychopathology, and functional impairment. Journal of General Internal Medicine. 1996;11(1):1-8. http://link.springer.com/article/10.1007/BF02603477
. O'Dowd T. 'Heartsink' patients in general practice. British Journal of General Practice. 2011;61(588):437-438. http://bjgp.org/content/61/588/437.2.full
. Werner A, Isaksen LW, Malterud K. 'I am not the kind of woman who complains of everything': illness stories on self and shame in women with chronic pain. Social Science & Medicine. 2004;59(5):1035-1045. http://www.sciencedirect.com/science/article/pii/S0277953603006828
. Nettleton S. 'I just want permission to be ill': towards a sociology of medically unexplained symptoms. Social Science & Medicine. 2006;62(5):1167-1178. http://www.sciencedirect.com/science/article/pii/S027795360500403X
. Page LA, Wessely S. Medically unexplained symptoms: exacerbating factors in the doctor-patient encounter. Journal of the Royal Society of Medicine. 2003;96(5):223-7. http://jrs.sagepub.com/content/96/5/223.full
. Shattock L, Williamson H, Caldwell K, Anderson K, Peters S. ‘They’ve just got symptoms without science’: Medical trainees’ acquisition of negative attitudes towards patients with medically unexplained symptoms. Patient education and counseling. 2013;91(2):249-254. http://www.pec-journal.com/article/S0738-3991(13)00008-6/abstract
. Charmaz K. Constructing grounded theory. London: SAGE; 2006.
. Caldicott CV. “Sweeping up after the parade”: professional, ethical and patient care implications of “turfing”. Perspectives in Biology and Medicine. 2007; 50(1):136-149. http://muse.jhu.edu/login?auth=0&type=summary&url=/journals/perspectives_in_biology_and_medicine/v050/50.1caldicott.html
. Moral RR, Alamo MM, Jurado MA, de Torres LP. Effectiveness of a learner-centred training programme for primary care physicians in using a patient-centred consultation style. Family Practice. January 1, 2001 2001;18(1):60-63. http://fampra.oxfordjournals.org/content/18/1/60.full
. Williams G, Deci E. The importance of supporting autonomy in medical education. Annals of Internal Medicine. August 15, 1998 1998;129(4):303-308. http://annals.org/article.aspx?articleid=711623