Quality Education for a Healthier Scotland Medically Unexplained Symptoms: Current Thinking & Ideas...

Quality Education for a Healthier Scotland

Medically Unexplained Symptoms: Current Thinking &

Ideas for Teaching

Dr. Deirdre HollyResearch & Training Officer (Health

Psychology)Psychology Directorate


“Persistent and distressing somatic symptoms for which adequate somatic explanation does not reveal sufficient explanatory organic pathology”

-Shaefert et al, 2013


Vague symptoms, polypharmacology, high distress, insistent and frequent attendees.

Irritable Bowel Syndrome, Chronic Fatigue Syndrome, Fibromyalgia.


What problems as GPs and trainers do you see?


Key Figures


20% of Primary Care consultations

Up to 50% in Secondary Care

High levels of distress and disability

60% also have a diagnosed Long Term Condition

2% of Primary Care patients attend persistently

£3.1 billion cost annually in UK


What works and what doesn’t?


Most health professional encounters involve “expert” and “patient”

Problems arise when explanations don’t sit well

Tendency for many health professionals to push the same message

Frustration when the patient resists explanations

Presumption that patient has heard what you’ve said


Evidence to support CBT-based interventions (Van Dessel et al 2014)

Enhanced generalist care may be helpful (Rosendal et al 2013)

Reassurance/Psychosomatic ideas may not be helpful

Biopsychosocial perpetuation…(formulation vs diagnosis)

Personally relevant, mechanical explanations best (Burton (Ed) 2014)


Initial Thoughts


Full physical examination

Physiological aspects of the explanation:

• Pain Mechanisms (sensitisation)• Gut Motility• Vestibular aspects of dizziness


What not to say...and why


“Good news, there’s nothing wrong with you!”

“The results of the tests have ruled out anything bad”

“There is not much we can do with these symptoms”

“There could be psychological reasons for all this”

“I’m not sure your symptoms are as bad as you say”

“I’m going to refer you one more time for reassurance”

“You’re absolutely fine, it’s going to be ok”


How do we avoid this?


Perpetuating Factors


Perpetuating factors - Cause vs Perpetuation

Consequence of how symptoms are interpreted:• Avoidance of activity• Low mood and anxiety

Create “vicious cycle” – not a cause, but maintenance

Consequences add to the suffering of the patient


“So what do you notice when you’re doing less?”

“How hard is it to cope when you feel down?”

“How can you end up feeling with these worries?”

“What’s happened to your motivation?”

“So one thing affects another, affects another?”


Good way to validate the patient experience

Can be used to identify intervention strategies

Reflect on success of trying to look for cause


Move away from psychological cause

Don’t expect to do it all in one session

Personally relevant explanations including physiological elements

Recognise the difference between cause and perpetuation

Reject, collude or empower?


“...complex interactions of physiological and cognitive processes...”

Neither simple disease syndromes nor a general somatisation disorder are adequate to describe the diversity seen in primary care.

Somatisation is too restrictive a label; ‘functional somatic symptoms’ is a more appropriate term.”

-Burton, 2003


Core Communication Skills


Demonstrating genuine empathy

Checking you understand the patient

Summarising the information provided

Reflecting on what has been said

Validating what the patient has said

Checking the patient has picked you up correctly

Getting personally relevant information to use


How can we enable GP trainees to do this?


Mapping to RCGP Curriculum


Competence Component Rationale1. Primary Care Management 1.2.3 Develop the clinical skills you need in history-

taking, physical examination and the use of ancillary tests for diagnosis1.2.4 Develop the skills you need in therapeutics, including drug and non-drug approaches to treatment1.5.1 Develop your communication skills for counselling, teaching and treating patients and their families/carers1.6.1 Develop and maintain a relationship and style of communication that does not patronise but treats your patients as equals

The purpose of the MUS Toolkit is to provide users with the skills to enable them to develop a shared understanding with their patient to provide them insight into their patient’s experience of their condition and ultimately manage their symptoms within primary care/enable the patient to self-manage appropriately.

2. Person-centred care 2.1.3 Master patient illness, sickness and disease concepts2.2.1 Adopt a patient-centred consultation model that explores your patient’s ideas, concerns and expectations, integrates your agenda as a doctor, finds common ground and negotiates a mutual plan for the future2.3 Use your skills and attitude to establish a partnership

The Toolkit promotes a patient-centred approach through the use of approaches such as person-centred statements and open questions which should help the GP and their patient establish a partnership. This approach should also assist the co-development of a management plan.


Section Statements Link to MUS Toolkit3.01 Healthy people: Promoting health and preventing disease

2.5 Negotiate a shared understanding of problems and their management (including self-management), so that patients are empowered to look after their own health and have a commitment to health promotion and self-care2.6 Encourage patients, their carers (and family when appropriate) to access further information and use patient support groups

The MUS toolkit seems to fit well with aspects of person-centred care outlined in these clinical statements due to its emphasis on the use of a shared understanding of symptoms.In addition, the toolkit encourages GPs to support their patients to self-manage their conditions.

3.05 Care of Older Adults 1.9 Have an organisational approach that allows easy access to the primary healthcare team for older people, appropriate timing of appointments and the systematic management of chronic conditions and co-morbidities2.5 Have appropriate communication skills for counselling, teaching and treating patients, their families and carers, recognising the difficulties of communicating with older patients including the slower tempo, possible unreliability or having to rely on the evidence of third parties

The toolkit may have special relevance for elderly patients who tend to present with more LTCs.


COT Performance Criteria


PC1 The doctor is seen to demonstrate empathy, warmth and genuineness towards the patient

PC3 The doctor is seen to explicitly elicit the emotional, cognitive and behavioural effects of physical symptoms

PC5 The doctor is seen to bring information about the consequences of persistent symptoms together to demonstrate a “vicious cycle”

PC6 The doctor is seen to help the patient draw conclusions about the “vicious cycle”, exploring the likelihood of further investigations being effective, and the rationale for self management


Barriers to Implementation


Believing that referral is a good way of providing reassurance

Believing that referral is an effective management strategy when under pressure


How can you address these barriers?


Provide opportunities to master core communication skills

Highlight benefits of being able to manage people with MUS within primary care

Encourage use of approaches suggested within practice in manageable bite size chunks

-use additional resources, where necessary

Use of videos embedded within PESTO

Observation of other’s consultations


Key Points to Emphasise


You can’t do everything

Personally relevant explanations can be therapeutic

Providing physiological pathways may help

Keeping and re-appointing the patient can help

No one is advocating the “T” in CBT…

The trials of moving from “diagnosis” to “formulation”

Without core communication skills there’s little point...


Parting Thoughts...


How are you going to address this with your trainees?

Think of one way you can change the way you approach MUS with your trainees

How are you going to do this (think SMART)

If that approach doesn’t work what will you do?


Questions?


1. ABC of Medically Unexplained Symptoms. Burton (Ed). 2013. Wiley-Blackwell.

2. Health Behaviour Change (2nd ed.). Mason, P. & Butler, C. (2010).

3. Overcoming Functional Neurological Disorders – A Five Systems Approach. Williams, C. (2011). Hodder Arnold

4. Deary, V., Chalder, T. And Sharpe, M. (2007). The cognitive behavioural model of medically unexplained symptoms: A theoretical and empirical review. Clinical Psychology Review, 27, 781-797.

5. Rosendal M, Blankenstein AH, Morriss R, Fink P, Sharpe M, Burton C. (2013). Enhanced care by generalists for functional somatic symptoms and disorders in primary care (Review). The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.


Contacts:David CraigNES Psychology Directorate2 Central Quay 89 Hydepark St.G3 8BW

[email protected]

Deirdre HollyNES Psychology Directorate2 Central Quay 89 Hydepark St.G3 8BW

[email protected]

Quality Education for a Healthier Scotland Medically Unexplained Symptoms: Current Thinking & Ideas...

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