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Primary Care Consultations About Medically Unexplained Symptoms: Patient Presentations and Doctor Responses That Influence the Probability of Somatic Intervention

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

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

	ABSTRACT

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Objective: In primary care, many consultations about physical symptoms that the doctor thinks are not explained by physical disease nevertheless lead to somatic interventions. Our objective was to test the predictions that somatic intervention becomes more likely a) when doctors provide simple reassurance rather than detailed symptom explanations and do not help patients discuss psychosocial problems and b) when patients try to engage doctors by extending their symptom presentation.

Methods: Consultations of 420 patients presenting physical symptoms that the doctor considered unexplained by physical disease were audio-recorded, transcribed, and coded. Analysis modeled the probability of somatic intervention as a function of the quantity of specific types of speech by patients (symptomatic and psychosocial presentations) and doctors (normalization, physical explanations, psychosocial discussion).

Results: Somatic intervention was associated with the duration of consultation. Controlling for duration, it was, as predicted, associated positively with symptom presentations and inversely with patients’ and doctors’ psychosocial talk. The relationship with doctors’ psychosocial talk was accounted for by patients’ psychosocial talk. Contrary to predictions, doctors’ normalization was inversely associated with somatic intervention and physical explanations had no effect.

Conclusion: Somatic intervention did not result from the demands of patients. Instead, it became more likely as patients complained about their symptoms. Facilitating patients’ psychosocial talk has the potential to divert consultations about medically unexplained symptoms from somatic interventions. To understand why such consultations often lead to somatic interventions, we must understand why patients progressively extend their symptom presentations and why doctors, in turn, apparently respond to this by providing somatic intervention.

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

Abbreviations: MUS = medically unexplained symptoms; GP = general practitioner.

	INTRODUCTION

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In about 10% to 20% of patients who present physical symptoms in primary care facilities, their general practitioners (GPs) consider that the symptoms are not explained by physical disease (1–3). Most patients who are told by their doctor that their symptoms do not indicate disease seek no further care (4). If the patients with medically unexplained symptoms (MUS) continue to seek medical help, their symptoms are problematic for themselves, their doctors, and the healthcare system. Patients with MUS have as poor a quality of life as those with comparable symptoms caused by disease (5,6). Many doctors find these consultations particularly challenging (7–11). Such patients consume health care disproportionately and, because there is no disease, treatment is often ineffective (6,12–14). GPs describe many reasons for providing somatic intervention for MUS, including reassurance for both the patient and the GP (15). Nevertheless, physical symptoms in primary care persist for a longer period when a disease is absent than when it is present (16). There has long been concern that inappropriate and ineffective treatment can increase dependency on medical care (17–20).

From many doctors’ perspective, the explanation for this perplexing scenario is that patients deny psychological needs and pressure physicians for somatic treatment (7,9,10,21,22). However, observation of consultations with patients presenting MUS has shown that patients requested somatic intervention less frequently than their doctors did (3). Therefore, a different explanation is needed to determine why doctors provide somatic interventions for MUS.

Recent findings have suggested that doctors can use somatic interventions to resolve contests in which patients seek engagement and support in relationship to their somatic and psychosocial problems from doctors who seek to avoid engagement (23). Doctors’ characteristic response to patients’ symptoms or requests for explanation is to normalize them, i.e., provide simple reassurance that does not address the patients’ specific concerns (24). Qualitative analysis of small samples of consultations suggested that patients respond by progressively extending their symptom presentation—reporting new symptoms and adding information about already reported symptoms—until doctors indicate engagement with the patients by providing somatic intervention (3,24,25). Qualitative analysis also suggested that more detailed explanations, while excluding disease, indicate tangible physical mechanisms that address patients’ concerns and can satisfy patients (24,26). Similarly, whereas doctors’ typical response to patients’ psychosocial cues is to disregard them or to reassert a somatic agenda, a positive response to such cues may help to avoid a somatic intervention (27).

From this analysis, we can predict that the probability of somatic intervention will be increased not, as has been thought, by the patients’ own suggestions of disease or requests for somatic intervention but by their extended symptom presentations. Correspondingly, those types of GP speech, which are thought to provoke or inhibit symptom presentation should influence the probability of a somatic intervention. Therefore, somatic intervention should be associated with normalization but inversely associated with GPs’ provision of tangible physical explanations. Where patients are given the opportunity to talk about psychosocial problems, somatic intervention should be less likely. GPs’ discussion of patients’ psychosocial concerns, which would be expected to promote patients’ disclosure, should therefore also avoid somatic interventions. The present report tests these hypotheses. By examining patients’ and GPs’ speech separately and then in a combined analysis, we were able to examine whether what GPs said had any significant influence on outcome other than that explained by its influence on what it led patients to say.

	METHOD

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Sample
Data on the frequency and variety of patient and physician speech in consultations about MUS and the interaction between the two have been reported previously (3,28). The present report is the first to examine the association between types of speech and the outcome of consultation.

After approval of this study by local research ethics committees, 50 GPs from 11 practices with research or educational affiliations to the University of Liverpool were asked to participate. Of the 50 GPs, 42 (84%; 22 males, 20 females) agreed to participate in the study and brought a combined medical experience of 5 to 42 years. Practice size ranged from one to ten physicians (mean = 4.5) and 2087 to 13,116 patients (mean = 7564). Six practices were urban, four were suburban, and one was rural. Data were collected from 2000 to 2002. Consecutive patients who sought medical advice of participating physicians were approached by a researcher before consultation and asked for written consent to audio-record their consultation. Of 5083 patients attending on study days, 1086 (21%) were excluded (<16 years or unable to consent because of visual impairment, learning disability, or extreme distress); 75 (2%) patients were missed; therefore, 3922 (77%) patients were asked for consent.

In the absence of agreed diagnostic criteria for primary care patients with unexplained symptoms, we used the criteria based on those proposed by Peveler et al. (1) to identify patients that, in the doctor’s opinion, have unexplained symptoms. Immediately after each consultation in our study, the doctor completed a checklist to indicate whether or not the consultation involved: a) presentation of a physical symptom; b) lack of explanation by a recognizable physical disease. Consultations satisfying these two criteria were retained for analysis.

Procedure
Each physician used a Sony MZ-R55 minidisk Walkman and Sony ECM-F8 Electret condenser desktop microphone to record consultations with consenting patients, and completed the checklist after each consultation. Audio-recordings of consultations meeting the research criteria were identified and anonymously transcribed. Patients’ symptoms were noted from the transcripts and categorized by the research team using the British National Formulary categorization. Treatment decisions were also noted from the transcripts and were checked by the research team against the medical records for those patients who gave their consent. The duration of consultation (in seconds) was noted from the audio-recording.

Interaction Analysis
Consultations were coded using the Liverpool Clinical Interaction Analysis Scheme (3) developed specifically for primary care consultations about MUS. It contains 25 and 30 substantive codes for the patient and physician, respectively. The unit of coding is an "utterance"; a single turn could include more than one utterance. Coding was done by A.R.; 16 transcripts were also coded by C.F.D, G.M.H., and P.S. to confirm reliability of coding (3). Speech categories relevant to the hypotheses were selected for use in the present study (Table 1). The coding scheme distinguishes two ways in which patients’ psychosocial concerns arise in patients’ and GPs’ speech—as psychosocial problems in their own right or as explanations for their physical symptoms—and both codes were included.

Response Variable
To indicate patients in whom the consultation led to a new physical intervention, a binary response variable (somatic intervention) was created to distinguish those who received new or increased drug treatment, tests, or referrals from the remainder (Table 2).

Statistical Analysis
Consultations were clustered within GP. Therefore, in multilevel analyses, we distinguished variability at the patient (consultation) and GP levels (preliminary analysis indicated little variation at the level of practice). The response variable was modeled with a logit link function and a Bernoulli sampling distribution. The amount of speech of any kind is confounded with the duration of consultation, which we therefore controlled for in all analyses. Mixed-effects models were fitted with random intercepts and, to avoid the restrictive assumption that independent variables should affect all doctors similarly, random slopes. Each analysis was therefore preceded by preliminary analyses, not shown here, in which each variable was, in turn, given a random slope and all other slopes were fixed (29). No variance component reached significance (p > .05), so all slopes were fixed in the final analysis. Patient and GP gender were included as covariates, but preliminary analyses indicated that they were unrelated to outcome and these variables were therefore excluded from subsequent analyses. Coefficients from the unit-specific model for the GP level were used to test the significance of the independent variables. We first conducted separate analyses to assess which aspects of patient and GP speech, respectively, were associated with somatic interventions. Then, to identify whether any type of GP speech remained significant after controlling for patient speech, we analyzed all variables in a single analysis.

SPSS (v12 for Windows SPSS Inc., Chicago, IL) and HLM 6.0 (Scientific Software International Inc., Lincolnwood, IL) were used for analysis. The significance criterion was p < .05.

	RESULTS

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Sample Characteristics
Of 3922 patients who were approached, 3136 (80%) consented. GPs failed to screen nine patients, but identified 508 (16%) as meeting the study criteria. After loss caused by physician error and machine failure, 446 consultations were successfully recorded and anonymously transcribed, of which 26 were discarded because no physical symptom was explicit or the patient’s companion had dominated communication. The final sample involved 36 doctors, of whom 15 (42%) were female, and 420 patients, of whom 267 (64%) were female, aged from 16 to 89 (mean = 47) years. Virtually all patients were white European (n = 413; 98%). Further details of the sample, including treatments received, have been reported previously (3). Mean (and median) duration of consultation was 10.5 (9.5) minutes; minimum and maximum were 6.9 and 36.8 minutes, respectively.

Separate Analyses of Patient and GP Speech
Results are summarized in Table 3 and Figure 1. In each analysis, somatic intervention was associated with longer consultations. In the analysis of patient speech, somatic intervention was, as predicted, associated with less talk about psychosocial problems. The predicted association of somatic intervention with increased symptom presentation did not reach significance, and the predicted association of somatic intervention with psychosocial explanations bordered on significance. As predicted, patients’ disease explanations and requests for somatic treatment were not related to somatic intervention.

View larger version (12K): [in this window] [in a new window]   Figure 1. Odds ratios and 95% confidence intervals linking unit increases in each independent variable to the probability that the consultation will lead to somatic intervention, controlling for other variables in the analysis. Separate analyses (upper panel) examine patients’ and general practitioners’ (GP) speech; the combined analysis (lower panel) examines both. Duration of consultation was included in all analyses; for clarity, this odds ratio refers to minutes.

In the analysis of GP speech, discussion of psychosocial disclosures was, as predicted, associated with reduced probability of a somatic intervention but, contrary to prediction, so was normalization. GPs’ psychosocial and physical explanations were not related to outcome.

Combined Analysis
Results are summarized in Table 3 and Figures 1 and 2. As in the separate analyses, longer consultations were more likely to lead to somatic interventions. Avoidance of somatic intervention was associated with patients’ description of psychosocial difficulties both in their own right and as explanations of their physical symptoms. The association of patients’ symptom presentation with somatic intervention reached significance in this analysis. In doctors’ speech, only normalization showed a significant association with outcome—contrary to prediction, and as in the analysis confined to doctors’ speech, consultations that avoided a somatic intervention were characterized by more normalization. Doctors’ discussion of psychosocial issues was no longer significant in this analysis, i.e., when patients’ own talk about these was controlled for.

View larger version (9K): [in this window] [in a new window]   Figure 2. Predicted relationship of probability of somatic intervention as outcome of consultation to duration of consultation (seconds) and to the number of instances of specific speech categories by patients (symptom and psychosocial presentation) and general practitioners (GPs) (normalization and psychosocial explanation). Relationships control for other variables in the regression analysis that included patients’ and GPs’ speech. Lines show values predicted by the cumulative effects of the coefficients shown in Table 3.

	DISCUSSION

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Primary care facilities therefore differ strikingly from outpatient surgery clinics, where surgical decisions in the absence of physical pathology have been associated with patients’ transparent pressure for surgery (30–32). Patients attending such clinics might have been "somatized" by successive consultations so that they seek somatic intervention (20,33,34). Alternatively, they might seek surgery as the only apparent way of engaging a surgeon with their problems whereas, in primary care facilities, patients know that GPs have many other actions available, including offering additional consultations. Whereas a patient might only have a single meeting with a surgeon about MUS, the need to maintain a continuing clinical relationship in primary care would be expected to deter overt challenges to the doctor’s authority.

As predicted, somatic intervention became less likely when patients were able to describe psychosocial problems. Although describing psychosocial problems to explain their symptoms contributed to this process, the strongest effect was seen with their description of psychosocial problems in their own right. As predicted, GPs’ own speech about patients’ psychosocial problems was associated with avoiding somatic intervention. However, this effect disappeared when patients’ psychosocial discussion was controlled for. This suggests that GPs’ psychosocial talk is not important in its own right, but only inasmuch as it helps patients to disclose and talk about psychosocial problems. A previous controlled trial of facilitating emotional disclosure by patients presenting unexplained symptoms to their GP found no effect on healthcare use or subjective health (35). However, the disclosure took place in specially arranged visits at the patient’s home, and the present findings suggest that disclosure, which is part of the routine consultation, may be more significant. GPs’ attempts to link psychosocial factors to patients’ physical symptoms were unrelated to outcome. It may be that any benefit of introducing psychosocial issues is countered by giving the impression that the doctor regards the symptoms as "psychological" and therefore not real or legitimate (26,36).

The most striking finding in GPs’ speech was, however, opposite to our prediction: consultations with most normalization were least likely to end with a somatic intervention. This contrasts with previous qualitative findings, which suggested that certain types of normalization could provoke patients to extend their symptom presentation and could thereby lead paradoxically to increased somatic intervention (24). Moreover, there was no evidence for the prediction that GPs’ explanations that included physical, but nonpathological, mechanisms helped to avoid somatic intervention.

Discrepancy between qualitative and quantitative findings might indicate that the qualitative evidence, which relies necessarily on small samples, does not generalize. Alternatively, the types of speech identified in qualitative analysis might not be identified by the formal coding that is necessary for quantitative analysis. In particular, the code that identified GPs’ physical, but nondisease, explanations probably includes some very brief explanations that are too incomplete to satisfy patients (24). In a formal coding scheme, the influence of context on understanding speech is less than in qualitative analysis. However, whether explanations are convincing and satisfying depends on the specific context. That is, explanations have no objective meaning in their own right but they depend for their meaning on the social and cultural context within which they are heard (37–40). Although the influence of context has usually been considered at the level of broad cultural or ethnic groups (39), relevant context is probably much more specific and may depend on specific characteristics of the GP, patient, and their relationship that formal coding cannot easily identify.

A consistent finding in all analyses was that, as consultations lengthened, somatic intervention became more common. It may be that GPs use somatic interventions to conclude consultations that they do not otherwise know how to manage. This finding provides an important counterpoint to the prevailing assumption that the length of consultation is a proxy measure for quality of care in general practice (41,42).

Strengths and Limitations of the Study
Although a strength of this study is that it objectively examines consultation behavior that has previously been understood mainly through the retrospective accounts of participants, it is necessarily correlational. Therefore, causation remains unclear. Speech might be associated with treatment decisions, not because it influences them but because it is associated with other factors that do so. Doctors’ psychosocial or normalizing speech might be associated with avoiding somatic intervention merely because it indicates their intentions to do so. One way to clarify this issue would be to use tape-assisted recall techniques to enable doctors to disclose their intentions in such consultations (43).

Although the coding scheme was developed specifically for consultations about MUS, any such scheme is inevitably imperfect. Individual speech codes encompass heterogeneity, and coding rules cannot fully allow for the contextual dependence of the functional significance of utterances. On the other hand, particularly in view of the absence of any evidence for significant variability across patients or GPs in the relationships that we found, such relationships represent robust properties of primary care consultations about MUS and therefore offer targets for intervention. Nevertheless, although the large sample permits generalization, this is restricted to patients identified by the definition of MUS that we used and by the demographic characteristics of the sample, which was predominantly white European.

The major limitation of the study is the absence of longer-term patient follow-up. Therefore, it is not possible to test the assumption that, in a proportion of the sample, somatic intervention would be associated with increased dependency, or to identify those in whom somatic intervention might be therapeutic, for example, where negative test results occasion effective reassurance. Although the variance components did not indicate heterogeneity among patients and GPs in the effects of patient or GP speech on somatic outcome, it is to be expected that patients will differ in the longer-term effects of the processes that we have identified.

Clinical and Research Implications
Because extended symptom complaint seems to drive somatic intervention, researchers need to identify what patients seek by such presentation. Researchers and trainers need to identify and address the specific difficulties that GPs have in responding to patients’ extended symptom presentations, why they provide somatic intervention in response, and whether and in what circumstances it is a defensive response or a strategic decision with therapeutic intent. Conversely, we need to understand how the opportunity for patients to describe or discuss their psychosocial difficulties can help to avoid consultations leading to somatic intervention. Beyond facilitating patients’ psychosocial talk, the amount of GPs’ psychosocial talk, or their ability to link psychosocial difficulties to patients’ physical symptoms, is not important. Thus, GPs’ work in managing patients with MUS may be simpler that we think or fear.

We are grateful for the enthusiastic cooperation of the participating primary care physicians.

	NOTES

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The study was funded by Grant G9900294 (P.S., G.M.H., C.F.D.) from the UK Medical Research Council.

Received for publication December 18, 2006; revision received March 26, 2007.

DOI:10.1097/PSY.0b013e3180cabc85

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