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Why Do Primary Care Physicians Propose Medical Care to Patients With Medically Unexplained Symptoms? A New Method of Sequence Analysis to Test Theories of Patient Pressure

From the Divisions of Clinical Psychology (P.S., A.R.) and Primary Care (A.R., C.F.D.) and Computing Services Department (J.C.D.), University of Liverpool, Liverpool, England; Bute Medical School, University of St. Andrews, Fife, England (G.M.H.).

Address correspondence and reprint requests to Peter Salmon, Department of Clinical Psychology, University of Liverpool, Whelan Building, Brownlow Hill, Liverpool, L69 3GB England. E-mail psalmon{at}liv.ac.uk

Objective: We test predictions from contrasting theories that primary care physicians offer medical care to patients with medically unexplained symptoms in response to a) patients’ attribution of symptoms to disease and demand for treatment or b) their progressive elaboration of their symptoms in the attempt to engage their physicians.

Methods: Primary care physicians identified consecutive patients who consulted with symptoms that the physician considered unexplained by physical disease. Four hundred twenty consultations with 36 physicians were audio recorded and transcribed, and physician and patient speech was coded turn by turn. Hierarchical logistic regression analysis modeled the probability of the physician proposing medical care as a function of the quantity of patients’ speech of specific kinds that preceded it.

Results: Whether physicians proposed medical care was unrelated to patients’ attributions to disease or demands for treatment. Proposals of explicitly somatic responses (drugs, investigation or specialist referral) became more likely after patients had elaborated their symptoms and less likely after patients indicated psychosocial difficulties. Proposals of a further primary care consultation were responses simply to lengthening consultation.

Conclusions: The findings are incompatible with the influential assumption that physicians offer medical care to patients with unexplained symptoms because the patients demand treatment for a physical disease. Instead, the reason why many of these patients receive high levels of medical care should be sought by investigating the motivations behind physicians’ responses to patients’ symptom presentation.

Key Words: somatization • communication • physician-patient relations • symptoms

Abbreviations: MUS = medically unexplained symptoms.

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