How to learn skilled communication in primary care MUS consultations: a focus group study.

BACKGROUND: Many general practitioners (GPs) experience communication problems in medically unexplained symptoms (MUS) consultations as they are insufficiently equipped with adequate communication skills or do not apply these in MUS consultations. OBJECTIVE: To define the most important learnable communication elements during MUS consultations according to MUS patients, GPs, MUS experts and teachers and to explore how these elements should be taught to GPs and GP trainees. METHODS: Five focus groups were conducted with homogeneous groups of MUS patients, GPs, MUS experts and teachers. MUS patients and GPs formulated a list of important communication elements. MUS experts identified from this list the most important communication elements. Teachers explored how these elements could be trained to GPs and GP trainees. Two researchers independently analysed the data applying the principles of constant comparative analysis. RESULTS: MUS patients and GPs identified a list of important communication elements. From this list, MUS experts selected five important communication elements: (1) thorough somatic and psychosocial exploration, (2) communication with empathy, (3) creating a shared understanding of the problem, (4) providing a tangible explanation and (5) taking control. Teachers described three teaching methods for these communication elements: (1) awareness and reflection of GPs about their feelings towards MUS patients, (2) assessment of GPs' individual needs and (3) training and supervision in daily practice. CONCLUSION: Teachers consider a focus on personal attitudes and needs, which should be guided by opportunities to practice and receive supervision, as the best method to teach GPs about communication in MUS consultations.KEY POINTSMany GPs experience difficulties in communication with patients with MUS.There is a need to equip GPs with communication skills to manage MUS consultations more adequately.Role-playing with simulation patients, reflection on video-consultations and joint consultations with the supervisor may increase the GPs' awareness of their attitude towards MUS patients and may help GPs to identify their individual learning-points.

Which difficulties do GPs experience in consultations with patients with unexplained symptoms: a qualitative study.

BACKGROUND: Many general practitioners (GPs) struggle with the communication with patients with medically unexplained symptoms (MUS). This study aims to identify GPs' difficulties in communication during MUS consultations. METHODS: We video-recorded consultations and asked GPs immediately after the consultation whether MUS were presented. GPs and patients were then asked to reflect separately on the consultation in a semi-structured interview while watching the consultation. We selected the comments where GPs experienced difficulties or indicated they should have done something else and analysed these qualitatively according to the principles of constant comparative analysis. Next, we selected those video-recorded transcripts in which the patient also experienced difficulties; we analysed these to identify problems in the physician-patient communication. RESULTS: Twenty GPs participated, of whom two did not identify any MUS consultations. Eighteen GPs commented on 39 MUS consultations. In 11 consultations, GPs did not experience any difficulties. In the remaining 28 consultations, GPs provided 84 comments on 60 fragments where they experienced difficulties. We identified three issues for improvement in the GPs' communication: psychosocial exploration, structure of the consultation (more attention to summaries, shared agenda setting) and person-centredness (more attention to the reason for the appointment, the patient's story, the quality of the contact and sharing decisions). Analysis of the patients' views on the fragments where the GP experienced difficulties showed that in the majority of these fragments (n = 42) the patients' comments were positive. The video-recorded transcripts (n = 9) where the patient experienced problems too were characterised by the absence of a dialogue (the GP being engaged in exploring his/her own concepts, asking closed questions and interrupting the patient). CONCLUSION: GPs were aware of the importance of good communication. According to them, they could improve their communication further by paying more attention to psychosocial exploration, the structure of the consultation and communicating in a more person-centred way. The transcripts where the patient experienced problems too, were characterised by an absence of dialogue (focussing on his/her own concept, asking closed questions and frequently interrupting the patient).

Medically unexplained symptoms: the person, the symptoms and the dialogue.

Background: Many general practitioners (GPs) find the care for patients with medically unexplained symptoms (MUS) challenging. The patients themselves are often not satisfied with the care they receive. Objectives: The aim of this study is to explore what patients with MUS expect from their GP by looking at relevant communication elements in consultations as identified by patients. Methods: We video-recorded everyday consultations with GPs and asked the GPs immediately after the consultation whether MUS were presented. The patients in these MUS consultations were asked to reflect on the consultation during a semi-structured interview while watching a recording of their own MUS consultation. The interviews were analysed qualitatively according to the principles of constant comparative analysis. Results: Of the 393 video-recorded consultations, 43 concerned MUS. All MUS patients said that they wanted to be taken seriously. According to the patients, their feeling of being taken seriously is enhanced when the GP: (i) pays empathic attention to them as individuals, meaning that the GP knows their personal circumstances and has an open and empathic approach, (ii) ensures a good conversation by treating the patient as an equal partner and (iii) is attentive to their symptoms by exploring these symptoms in depth and by acting on them. Conclusion: Like chronic patients, patients with MUS value a personalised approach in which GPs pay attention to patients' personal circumstances, to proper somatic management of their symptoms and to a proper conversation in which they are treated as equal partners. Use of these basic consultation skills may greatly improve care of MUS patients.

Development of a blended communication training program for managing medically unexplained symptoms in primary care using the intervention mapping approach.

BACKGROUND: General practice (GP) training in how to communicate with patients with medically unexplained symptoms (MUS) is limited. OBJECTIVE: Development, implementation and evaluation of an evidence-based communication training program for GP residents focused on patients with MUS in primary care. METHODS: We used the intervention mapping (IM) framework to systematically develop the MUS training program. We conducted a needs assessment to formulate change objectives and identified teaching methods for a MUS communication training program. Next, we developed, implemented and evaluated the training program with 46 residents by assessing their self-efficacy and by exploring their experiences with the training. RESULTS: The resulting program is a blended training with an online course and two training days. After attending the training program, GP residents reported significantly higher self-efficacy for communication with patients with MUS at four weeks follow up compared to baseline. Furthermore, GP residents experienced the training program as useful and valued the combination of the online course and training days. CONCLUSION AND PRACTICE IMPLICATIONS: We developed an evidence-based communication training program for the management of patients with MUS in primary care. Future research should examine the effect of the training on GP residents' communication skills in MUS consultations in daily practice.

Medically unexplained symptoms: time to and triggers for diagnosis in primary care consultations.

BACKGROUND: It is currently not known when in the consultation GPs label symptoms as medically unexplained and what triggers this. AIM: To establish the moment in primary care consultations when a GP labels symptoms as medically unexplained and to explore what triggers them to do so. DESIGN AND SETTING: This was a qualitative study. Data were collected in the Netherlands in 2015. METHOD: GPs' consultations were video-recorded. GPs stated whether the consultation was about medically unexplained symptoms (MUS). The GP was asked to reflect on the video-recorded consultation and to indicate the moment when they labelled symptoms as MUS. Qualitative interviewing and analysis were performed to explore the triggers GPs perceived that caused them to label the symptoms as MUS. RESULTS: A total of 43 of the 393 video-recorded consultations (11%) were labelled as MUS. The mean time until GPs labelled symptoms as medically unexplained was about 4 minutes for newly presented symptoms and 2 minutes for symptoms for which the patients had already visited the GP before. GPs were triggered to label symptoms as MUS in the consultation by: the way patients presented their symptoms; the symptoms not fitting into a specific pattern; patients attributing the symptoms to a psychosocial context; and a discrepancy between symptom presentation and objective findings. CONCLUSION: Most GPs labelled the presented symptoms as medically unexplained soon after the start of the consultation. GPs are triggered to label symptoms as medically unexplained by patients' symptom presentation, symptom patterns, and symptom attribution. This suggests that non-analytical reasoning was a central component in their thought process.

Quantifying positive communication: Doctor's language and patient anxiety in primary care consultations.

OBJECTIVE: Positive communication is advocated for physicians during consultations with patients presenting medically unexplained symptoms (MUS), but studies generally focus on what is said rather than how it is said. This study quantified language use differences of general practitioners (GPs), and assessed their relation to patient anxiety. METHODS: Language use of 18 Dutch GPs during 82 consultations was compared for patients with MUS versus medically explained symptoms (MES). Message content (positive or negative) was differentiated from its directness (direct or indirect), and related to changes in patient's state anxiety (abbreviated State Trait Anxiety Inventory; STAI). RESULTS: In total, 2590 clauses were identified. GPs approached patients with MES with relatively more direct (vs. indirect) positive and indirect (vs. direct) negative messages (OR 1.91, 95% CI 1.42-2.59). Anxiety of both patient groups increased when GPs used more direct (vs. indirect) negative messages (b = 0.67, 95% CI 0.07-1.27) CONCLUSIONS: GPs use different language depending on the content of messages for patients with MES, but not MUS. Direct negative messages relate to an increase in patient anxiety. PRACTICE IMPLICATIONS: GPs could manage patient's state anxiety by expressing negative messages in an indirect rather than direct manner.

Improving GP communication in consultations on medically unexplained symptoms: a qualitative interview study with patients in primary care.

BACKGROUND: Many GPs find the care of patients with medically unexplained symptoms (MUS) challenging. Patients themselves are often not satisfied with the care they receive. AIM: To explore the problems patients with MUS experience in communication during consultations, with the aim of improving such consultations DESIGN AND SETTING: A qualitative analysis of semi-structured interviews. METHOD: GP consultations were videorecorded and the GPs were asked immediately afterwards whether MUS were presented. Patients in these MUS consultations were asked to reflect on the consultation in a semi-structured interview while watching a recording of their own consultation. RESULTS: Of the 393 videorecorded consultations, 43 contained MUS. Patients who did identified six categories of problems. First, they reported a mismatch between the GP's and their own agenda. Second, patients indicated that the GP evoked an uncomfortable feeling in them during the consultation. Third, they found that GPs did not provide a specific management plan for their symptoms. Fourth, patients indicated that the GP was not well prepared for the consultation. Fifth, they perceived prejudices in the GP during the consultation. Finally, one patient found that the GP did not acknowledge a limited understanding of the origin of the symptoms. CONCLUSION: According to patients, GPs can improve their consultations on MUS by making genuine contact with their patients, by paying more attention to the patient's agenda, and by avoiding evoking uncomfortable feelings and displaying prejudices. They should prepare their consultations and focus on the issues that matter to patients, for example, symptom management. GPs should be honest to patients when they do not understand the origin of symptoms.