Juul Houwen

Discussion

The most important communication elements during MUS consultations which should be improved according to GPs, MUS patients and MUS experts are: (1) a 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 considered the following methods as appropriate for teaching the communication elements to GPs or GP trainees: (1) stimulating 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.

Comparison with existing literature

Our findings of a thorough exploration (16-21), communication with empathy (17-19) a shared understanding of the patients’ problem (17-19), giving a tangible explanation (16-21) and shared control (19-21) have been reported before in the context of MUS and are thus far from new. This raises the question whether GPs really use these elements in consultations and why so many GPs experience MUS consultations as challenging and feel powerless during these consultations. There are indications that GPs do not use these elements in consultations with severe MUS. Or, GPs try to use the elements but do this in a negative atmosphere. The common factor here might be the negative attitude towards patients with unexplained symptoms which is already present in medical students after a few years of education. This negative attitude may be the consequence of the predominance of the biomedical model in medical education. MUS, almost by definition, do not fit into a biomedical model. MUS is therefore being perceived as complex and many students and educators struggle to understand MUS due to the ambiguity surrounding the cause. The curriculum is focused on explainable diseases, which are less complex to learn. Therefore, many students are not equipped with adequate knowledge and communication skills, leading to ineffective doctor-patient communication. This may result in negative experiences of patients and the persistence of symptoms which may enhance the negative attitude of physicians further. Furthermore, MUS are often associated with negative stereotypes, also contributing to a negative attitude. The experience of MUS as complex, the low priority of teaching MUS, the negative attitudes of tutors, the low prestige of MUS in the hierarchy of medical problems and the opinion of physicians about the relative unimportance of MUS cause barriers for the implementation of education about MUS in the medical curriculum (22-25). Instead of being focussed on a biomedical model, medical education should focus on a broader conceptualization of illness within a biopsychosocial model and should focus on the illness experience of patients. The biopsychosocial model assumes that the symptoms presented by patients always have somatic, cognitive, emotional, social and behavioural dimensions and that the experience of symptoms takes place in a constant interaction with the environment. The model is certainly fruitful for the management of MUS. Further, a focus on the implementation of teaching methods about MUS may miss the point when we do not consider the attitudes of GPs and GP trainees concerning MUS. This could also mean that a change of focus on MUS during medical education is the most important condition for improving the care for MUS patients. In this respect, it is important to know that previous research showed that a seminar about MUS was associated with a more favorable attitude towards MUS (22). Although we consider a change of attitude as most important, improvement of the GPs’ repertoire of communication skills is important to being the channel to express one’s attitude. An important example here is teaching GPs and trainees in how to provide a clear and tangible explanation of the unexplained symptom. Many GPs have problems with explaining MUS to patients, which is completely understandable in the light of the lack of attention for this topic during medical education.

Further, MUS experts said that GPs should not give an explanation too quickly as patients may reject this. When GPs label symptoms as medically unexplained, it is important that GPs do not miss a somatic underlying disease. However, Eikelboom et al described in a review that the percentage of misdiagnoses in patients with MUS was relatively small (26). Furthermore, Houwen et al analysed when and how GPs recognised MUS (27). They found that GPs labelled symptoms as medically unexplained soon after the start of the consultation and that GPs clearly pointed out what triggered them in their labelling process. This suggest that GPs do not experience uncertainty about missing a diagnosis.

Malterud et al state that in primary care there is more in diagnostic work than hypothesis testing and pattern recognition (28). Apart from these more or less objective actions, they address the importance of interpretive work which is inherently subjective. The interpretive actions from the GP are based on information such as knowing the person for a long time and, consequently, being familiar with the person’s appearance or verbal utterances. The GP may transform this information into questions for understanding, thus giving access to an alternative understanding of the problem. This approach may have potential for the implementation of education about MUS.

Furthermore, Salmon et al described that applying communication skills is not necessarily good communication because communication is always subjectively shaped (29). The concept of more or less objectively defined communication skills is inherently reductionistic. The danger of identifying communication elements as ‘skills’ is that they come to define good communication even when there is no evidence of benefit for patients. Salmon proposed that skilled communication should incorporate patients’ individuality and that practitioners should be trained in flexibility and creativity in communication (29). Therefore, learners should develop the capacity to use the elements described in our study flexibly and, if necessary, to refrain from them depending on the situation.

Strengths and limitations

This study has a number of strengths. First, participants with several backgrounds (GPs, MUS patients, MUS experts, teachers) participated which provided insights from different fields. Second, by comparing the analysis of the first two focus groups (with GPs and MUS patients) with the pre-existing list with important and relevant communicational elements based on previous research (11, 15), we concluded that the list was exhaustive. However, MUS experts expended the list with two communication elements (empowerment and meta-communication), which had not been mentioned before. Third, we used a qualitative approach with a cyclical process of gathering information and analysis performed independently by two researchers. This study has also some limitations. We performed only two focus groups with MUS experts. Although we expected that medical specialists and MUS researchers had their own specific perspective regarding communication in MUS consultations, we did not find differences with the results of the first focus group. Further, we did not match each communication element with a specific learning method as the teachers were more focused on overarching teaching methods rather than just focussing on each communication element separately. Another possible limitation could be the majority of females in all focus groups. To obtain sufficient variation of the data, we purposively approached participants with different backgrounds regarding age, clinical background, sex. Although the majority of the participants were women, we do not expect that a different distribution of sex would have led to different conclusions as we did not find new themes.

Implications for further research and daily practice

This study gave more insight on which important communication elements should to be taught to GPs and GP trainees, and how these elements can be trained. The next step will be to develop a communication training tool with the five elements found in this study. The tool should be acceptable for patients with MUS and feasible in daily general practice. The focus of this tool should be on attitude, needs assessment and training with supervision.

Conclusion

MUS experts identified five categories of communication elements that should be taught and trained to GPs: (1) a 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. 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.

Declaration

Ethical approval and consent to participate
The research ethics committee of the Radboud university medical center concluded that the study could be carried out in accordance with the applicable rules in the Netherlands (2015-1566). The authors took care that the participants could not be identified through the details of the stories. Written informed consent was obtained from all participants.

Consent for publication
Not applicable

Availability of data and materials
Additional data can be accessed via Radboudumc, department of primary and community care

Competing interests
No

Funding
This study is supported by ZonMw (Funding number 839110010)

Authors contribution
JH contributed to the conception and design of the work, collected and analysed data, drafted the work.
PL contributed to the conception and design of the work, analysed data, revised the work.
HS contributed to the conception and design of the work, collected data, revised the work.
AvD contributed to the conception and design of the work, analysed and collected data, revised the work.
KvS contributed to the conception and design of the work, collected data, revised the work.
ToH contributed to the conception and design of the work, analysed data, revised the work.
SvD contributed to the conception and design of the work, revised the work.
All authors gave their final approval of the version to be published.