Medically unexplained symptoms and general practitioners: a comprehensive survey about their attitudes, experiences and management strategies

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1 Family Practice, 2017, Vol. 34, No. 2, doi: /fampra/cmw130 Advance Access publication 24 January 2017 Health Service Research Medically unexplained symptoms and general practitioners: a comprehensive survey about their attitudes, experiences and management strategies Laura Sirri a, *, Silvana Grandi a and Eliana Tossani a a Laboratory of Psychosomatics and Clinimetrics, Department of Psychology, University of Bologna, Bologna, Italy. *Correspondence to Laura Sirri, Department of Psychology, University of Bologna, viale Berti Pichat 5, Bologna, Italy. laura.sirri2@unibo.it Abstract Background. Medically unexplained symptoms (MUS) are common in primary care and are one of the most challenging clinical encounters for general practitioners (GPs). Objective. To assess GPs clinical experience with MUS and its relationship with their gender, age and length of practice. Methods. Four hundred and thirty-three Italian GPs were invited to complete a questionnaire encompassing the following MUS-related features: workload, cognitive and emotional responses, management strategies, attitudes towards psychological interventions, sources of education and educational needs. Results. A total of 347 GPs (80.1%) participated in the study. About seven out of ten physicians spent much or very much time and energy for MUS during their daily practice. Fear of neglecting a medical disease was the most frequent (59.1%) response to MUS. Providing reassurance and support (73.8%) and listening to the patient (69.2%) were the most frequent management strategies. More than half of GPs rated psychological interventions as much or very much useful for MUS. However, only a third of GPs were well informed about the role of psychologists in MUS management. The main sources of education about MUS were scientific papers and continuing medical education courses. Most of GPs (77.5%) needed further education about MUS. GPs younger age and lower length of practice were significantly associated with negative emotional responses to MUS. Conclusion. The introduction of guidelines for MUS in Italian primary care settings would promote a collaborative clinical approach to MUS and more formal training on this topic. Key words: General practice, medical education, signs and symptoms. Introduction A great amount of general practitioners (GPs) workload is concerned with medically unexplained symptoms (MUS). This descriptive term covers all those situations where patients present to physicians with physical symptoms (e.g., back pain, headache and weakness) which cannot be fully explained by a medical disease. The term MUS has been introduced to overcome the concept of somatization, which derived from the psychoanalytic theory and implied the expression of psychological distress through physical symptoms. It has been recognized that MUS frequently occur together with depressive and anxiety symptoms, yet they do not necessarily overlap with psychiatric disturbances (1). MUS result in extensive health care utilization and increased health-related direct and even much higher indirect costs (2). In The Author Published by Oxford University Press. All rights reserved. For permissions, please journals.permissions@oup.com. 201

2 202 Family Practice, 2017, Vol. 34, No. 2 some countries, GPs have the potential to reduce such costs by acting as a gatekeeper for excessive investigations and referrals (3,4). However, MUS patients are a particularly difficult-to-manage subgroup of patients, since GPs cannot easily exclude the possibility of medical disease and have to deal with patients concerns about their health status. Therefore, these patients frequently elicit frustration, sense of uncertainty and fear of missing an underlying disease in their GPs (5). Exploring GPs attitudes towards MUS deserves particular attention, since GPs responses to MUS may even reinforce patients dependence on somatic treatments. This phenomenon has been described as a somatizing effect of clinical consultation. Such an iatrogenic process has highlighted the need to shift the focus from patient s demand to doctor s response for a better management of MUS (6). However, to our knowledge, only few studies examined GPs attitudes towards MUS patients through a structured questionnaire survey method (3 5,7). Furthermore, little is known about GPs sources of education and educational needs on MUS, even though, when GPs training priorities in the area of mental health problems were examined, somatization was one of the most frequently selected topics (48% of GPs) (8). GPs knowledge about the role and usefulness of psychologists in MUS management has also been overlooked. The collaboration between primary care physicians and psychologists may improve doctor-patient communication and it has been recommended for the management of MUS patients with more severe courses (9,10). The aim of this study was to explore GPs clinical experience with MUS through a structured questionnaire survey method. Perceived workload, cognitive and emotional responses, management strategies, perceived usefulness and knowledge about psychological interventions for MUS, previous education and further educational needs on this topic were examined. We also examined whether the main features of GPs experience with MUS significantly vary according to their age, gender and length of practice. Methods Sample and procedure Four hundred and thirty-three GPs working in the Italian National Health System were invited to participate in a study on attitudes towards MUS. GPs were recruited through a convenience sampling method at scientific meetings (61% of GPs) and primary health care centres (39% of GPs) in Northern Italy (Emilia-Romagna and Veneto regions). Scientific meetings concerned with psychosomatic topics were excluded to avoid a bias in sample selection. The questionnaire survey was handed to each participating GP. Data were collected between July and December Assessment GPs were administered a self-rating questionnaire assessing the following areas: (i) Demographic features (age and gender) and professional features (length of practice as a GP and number of consultations per week). (ii) Three questions, rated on a 5-point Likert scale, were developed to assess perceived clinical workload due to MUS: (a) Approximately how many patients with medically unexplained symptoms do you see per week? (None, Less than 5, Between 6 and 10, Between 11 and 20, More than 20); (b) How much time and energy do you spend for patients with medically unexplained symptoms in your daily practice? (Not at all, A little, Somewhat, Much, Very much); and (c) How often do you have to deal with medically unexplained symptoms? (Never, Rarely, Sometimes, Often, Always). (iii) Cognitive and emotional responses elicited by MUS patients were explored through the following question: What are your most frequent reactions when you have to deal with patients with medically unexplained symptoms?. Eight response options were drafted on the basis of relevant literature (3,11 13), with particular reference to Garcia-Campayo and colleagues work (3): (a) interest/curiosity, (b) indifference, (c) anger, (d) frustration, (e) impotence, (f) inadequacy, (g) fear of failure and (h) fear of neglecting a medical disease. (iv) Management strategies adopted towards MUS patients were examined through the following question: Which management strategies do you adopt when you have to deal with patients with medically unexplained symptoms?. Six strategies were identified through literature review on this topic (4,14): (a) Listen to the patient, (b) Provide reassurance and support, (c) Provide information, (d) Order further medical tests, (e) Refer the patient to a specialist and (f) Prescribe drugs. GPs were also asked the question Where do you think patients with medically unexplained symptoms should be treated?, which was slightly adapted from Reid and colleagues Attitudes to Medically Unexplained Symptoms Questionnaire (4). The response options were taken from Reid and colleagues questionnaire (4): (a) Primary care, (b) Mental health setting, (c) Medical/surgical outpatients and (d) Outside the National Health System. (v) Two questions were developed to assess perceived usefulness of psychological interventions for MUS and knowledge about the role of psychologists in MUS management: How much do you think psychological interventions may be useful in the management of MUS patients in general practice? and How much do you think to be informed about the role of psychologists in the management of MUS patients?. Both questions were rated on a 5-point Likert scale (Not at all, A little, Somewhat, Much, Very much). (vi) GPs sources of education about MUS were examined through the following question: What does your education about medically unexplained symptoms consist in?. Response choices were as follows: (a) Undergraduate courses, (b) Scientific papers, (c) Continuing medical education courses and (d) Scientific meetings. The question Do you need further education about medically unexplained symptoms? ( yes, no and I don t know ) assessed GPs need for further education on this topic. Statistical methods Descriptive statistics were performed by means of SPSS 23.0 statistical package (SPSS Inc., Chicago, IL). Continuous variables are reported as means (standard deviation) and categorical variables as percentages, respectively. 95% confidence intervals (95% CI) for GPs cognitive and emotional responses, management strategies and sources of education about MUS are also reported. Independentsamples t-test and chi-square test were performed to examine whether GPs age, gender and length of practice were significantly associated with MUS-related perceived workload, cognitive and emotional responses, management strategies, attitudes towards psychological interventions and need for further education. A P value 0.05 was considered to be significant.

3 Medically unexplained symptoms and general practitioners 203 Results Three hundred and forty-seven (80.1%) of the 433 GPs who were invited to participate in the study completed and returned the questionnaire. Two hundred and sixty-five GPs (76.4%) were male. Participants mean age was 52.3 years (SD 7.0; range 26 67). Mean length of practice as a GP was 20.2 years (SD 9.3; range 1 42). Sixty-seven physicians (19.3%) usually saw less than 150 patients per week, 190 (54.8%) saw between 150 and 300 patients per week and 90 (25.9%) saw more than 300 patients per week. GPs response rates about perceived clinical workload due to MUS patients are shown in Table 1. More than 70% of GPs saw at least six MUS patients per week. About seven out of ten physicians spent much or very much time and energy for MUS patients during their daily practice and had to deal with MUS often or always. The most frequent cognitive and emotional responses to MUS patients were fear of neglecting a medical disease (59.1%, 95% CI ), followed by interest/curiosity (24.5%, 95% CI ) and frustration (14.7%, 95% CI ). Inadequacy, impotence and fear of failure were reported by 8.6% (95% CI ), 8.4% (95% CI ) and 5.8% (95% CI ) of participants. Feelings of anger (3.5%, 95% CI ) and indifference (1.2%, 95% CI ) were far less frequent. Table 2 displays GPs response rates about management strategies adopted towards MUS patients. Response rates suggested that most of GPs adopted different strategies, with to provide reassurance and support and to listen to the patient being the most frequent ones. Primary care was considered to be the setting where MUS patients should be treated by 64.6% of GPs. A mental health setting was chosen by 30.3% of physicians, whereas only 8.9% and 5.8% of GPs thought that it would be advisable to treat MUS patients as medical/surgical outpatients or in specialized centres outside the National Health System. Tables 3 and 4 show GPs response rates concerning attitudes towards the role of psychologists in MUS management and sources of education about MUS. More than half of GPs considered a psychological intervention to be much or very much useful for MUS management in general practice. However, only a third of GPs rated themselves as much or very much informed about the role of psychologists in MUS management and 28.9% as a little or not at all informed. Furthermore, 77.5% of GPs stated that they need further education about MUS, while 17% and 5.5% answered no and I don t know. Some significant associations between GPs experience with MUS and their age, gender and length of practice were found. GPs who had to deal with MUS patients often or always were older (53 ± 6.1 versus 50.7 ± 8.8 years, t = 2.362, P = 0.02) and had more years of practice (21.2 ± 8.8 versus 17.8 ± 10.1 years, t = 2.921, P = 0.004) than GPs dealing with MUS patients rarely or sometimes. GPs who spent much or very much time and energy for MUS patients had more years of practice than GPs spending a little or somewhat time and energy for MUS patients (20.9 ± 8.8 versus 18.4 ± 10.4 years, t = 2.096, P = 0.038). Among the responses elicited by MUS patients, only anger and frustration were significantly associated with GPs features. Younger age was associated with anger (45.9 ± 8.6 versus 52.6 ± 6.9 years, t = 3.255, P = 0.001) and frustration (49.2 ± 7.5 versus 52.9 ± 6.8 years, t = 3.498, P = 0.001). Similarly, a shorter length of practice was related to anger (13.1 ± 8.5 versus 20.5 ± 9.3 years, t = 2.724, P = 0.007) and frustration (17.1 ± 9.9 versus 20.8 ± 9.1 years, t = 2.576, P = 0.01). Anger was more likely among women than men (8.5% versus 1.9%, X 2 = 6.422, P = 0.011). As to management strategies, to provide information was more frequent among women than men (56.1% versus 41.9%, X 2 = 4.547, P = 0.033) and to refer the patient to a specialist was associated with older age (53.4 ± 5.2 versus 52 ± 7.5 years, t = 2.059, P = 0.041). Women were more likely to consider psychological interventions for MUS as at least somewhat useful than men (96.3% versus 87.9%, X 2 = 4.008, P = 0.045). Knowledge about the role of psychologists in MUS management was not significantly related to any GPs feature. GPs needing further education about MUS had fewer years of practice than those answering no or I don t know (19.6 ± 9.6 versus 22.2 ± 8.1 years, t = 2.337, P = 0.021). (See supplementary data for more information.) Discussion Table 1. Survey on 347 Italian general practitioners perceived clinical workload due to MUS patients Approximately how many patients with medically unexplained symptoms do you see per week? The present study is the first to examine GPs attitudes towards MUS patients in Italy. Other studies on this topic using a structured questionnaire survey method have been conducted in Spain, UK and Pakistan (3 5,7). Furthermore, to our knowledge, this is the first study examining GPs knowledge about the role and usefulness of psychologists in MUS management through a structured survey. However, our findings can be compared with those of other studies regarding GPs view about clinical workload, management strategies and cognitive and emotional responses to MUS. Our study confirms that MUS determine a great workload in general practice (1,3). As to GPs cognitive and emotional responses, the percentage of participants who fear to neglect an underlying disease (59.1%) was slightly higher than the one in the Spanish sample composed of 70 GPs, where 44.2% None Less than 5 Between 6 and 10 Between 11 and 20 More than 20 2 (0.6%) 89 (25.6%) 139 (40.1%) 70 (20.2%) 47 (13.5%) How much time and energy do you spend for patients with medically unexplained symptoms in your daily practice? 0 (0%) 16 (4.6%) 83 (23.9%) 195 (56.2%) 53 (15.3%) How often do you have to deal with medically unexplained symptoms? Never Rarely Sometimes Often Always 0 (0%) 8 (2.3%) 91 (26.2%) 240 (69.2%) 8 (2.3%)

4 204 Family Practice, 2017, Vol. 34, No. 2 agreed or strongly agreed that one of their main fears was to overlook an organic disease in somatisers (3). However, different sample sizes may hinder comparability between the two studies. Similarly to previous studies, response rates about MUS management suggested that GPs adopt more than one management strategy for each patient (4,7,14). This finding may reflect the clinical complexity of MUS and the need to adopt a multifaceted approach. Providing reassurance and support was the most frequently adopted management strategy by our GPs (73.8%). In a sample of Norwegian GPs, 63.7% indicated supportive counselling as the management strategy they adopt in the consultations with MUS patients (14). Furthermore, most of British and Pakistani GPs (98.9% and 80.2%, respectively) agreed or strongly agreed that the GP s role in managing MUS patients should be to provide reassurance and support (4,7). In our sample, the least frequent management strategy was to refer the patient to a specialist (25.4%). Similarly, referral was chosen only by 17.8% of Norwegian GPs (14), while 63.9% of British (4) and 76.9% of Pakistani (7) GPs agreed or strongly agreed that to refer for further investigations to identify cause should be the GP s role in MUS management. These different figures may be explained by a different question wording between studies. Our study and the Norwegian one (14) assessed actual management strategies, while the British and the Pakistani studies (4,7) examined GPs perceived role in managing MUS patients. Differences in cultural features and in health care insurance and delivery systems between countries may also explain a different GPs propensity to refer MUS patients for further investigations. A high response rate (80.1%) is a major strength of this study and it compares favourably with other studies in this field, whose response rates were 51.8%, 67%, 75% and 83.7% (3 5,7). However, we cannot exclude that GPs who refused to participate in the study had significantly different attitudes towards MUS compared to participants. As such, our sample could be representative of those GPs that are more interested in MUS. Despite this limitation, our study is the first to provide a comprehensive view of several features of GPs experience Table 2. Survey on management strategies adopted by 347 Italian general practitioners towards MUS patients Management strategies N (%) 95% CI Provide reassurance and support Listen to the patient Prescribe drugs Order further medical tests Provide information Refer the patient to a specialist with MUS patients, ranging from perceived clinical workload to education, based on a structured survey method. Important issues such as educational needs and perceived usefulness and knowledge about the role of psychologists in MUS management have been overlooked by literature. Furthermore, while previous studies focused on GPs attitudes towards their role in managing MUS patients, we explored which strategies GPs actually adopt. For example, rather than asking physicians if they should act as a gatekeeper for undue investigations, we asked them if they refer MUS patients to a specialist. As such, our data may provide a more realistic view on how GPs deal with MUS. Our study suggested a need for more formal teaching on MUS: undergraduate courses were a source of education about MUS for only one-third of GPs. Furthermore, both scientific papers and continuing medical education courses were a source of education about MUS for half of GPs, and scientific meetings concerned with MUS were attended by one out of four GPs. Postgraduate education on MUS seems to rely on GPs own initiative and, as a consequence, professional skills in MUS management may vary considerably from one GP to another. The introduction of guidelines for MUS in Italian primary care settings would both motivate GPs to include MUS in their postgraduate curricula and allow for a more homogeneous clinical practice in this domain. In our study, fear of neglecting a medical disease was the most frequent GPs response to MUS. It may be speculated that fear of neglecting a medical disease leads to fear of litigation and defensive medicine. MUS patients frequently pose some difficulties in doctor-patient relationship and GPs may fear that patients dissatisfaction with consultation increases the likelihood of malpractice litigation. However, GPs management strategies which could suggest defensive medicine (i.e., ordering further medical tests and referring the patient to a specialist) were among the less frequently reported. As such, a direct link between fear of missing an underlying disease and defensive practice cannot be suggested. Providing reassurance and support and listening to the patient were the most frequent management strategies. Generic interventions, such as explanations, adequate reassurance and education, are recommended by MUS experts (15,16) and are among the treatment principles of clinical guidelines on MUS and somatization-related disorders (9,10). Although about nine out of ten GPs rated psychological interventions as at least somewhat useful for MUS, only a third of GPs thought to be much or very much informed about the psychologist s role in MUS management. Greater GPs knowledge about psychological strategies for MUS could allow for an effective collaboration with mental health professionals. Collaborative care intervention models based on the cooperation between GPs and mental health professionals significantly improved the management of psychosomatic symptoms and doctor-patient communication (17). Clinical guidelines recommend a stepped care approach where the GP works together Table 3. Survey on 347 Italian general practitioners attitudes towards the role of the psychologist in MUS management How much do you think psychological interventions may be useful in the management of MUS patients in general practice? 4 (1.2%) 31 (8.9%) 111 (32%) 158 (45.5%) 43 (12.4%) How much do you think to be informed about the role of psychologists in the management of MUS patients? 12 (3.5%) 88 (25.4%) 130 (37.5%) 98 (28.2%) 19 (5.5%)

5 Medically unexplained symptoms and general practitioners 205 Table 4. Survey on 347 Italian general practitioners sources of education about MUS Sources of education n (%) 95% CI Scientific papers Continuing medical education courses Undergraduate courses Scientific meetings with other professionals, including psychologists, when MUS are more severe (9,10). The importance of referral to psychological treatments for MUS is also witnessed by the extension of the Improving Access to Psychological Therapies (IAPT) program to MUS patients by the UK Department of Health (18). Feasibility and acceptability of interventions based on cognitive-behavioural principles for MUS within the IAPT program have been highlighted (19,20). An inadequate knowledge about the role of psychologists in MUS treatment may both contribute to GPs difficulties in managing patients with more severe MUS and prevent adequate referral to psychological therapies. Finally, our findings highlighted that younger GPs and those with a lower length of practice were more likely to have negative emotional responses to MUS. These difficulties may explain why GPs with fewer years of practice acknowledged a higher need for further education on this topic. Conclusions MUS patients weigh a lot upon GPs clinical workload, require different management strategies and frequently elicit fear of neglecting a medical disease. However, education on MUS seems to rely on GPs own initiative and most of GPs need further education about MUS. Our study enhanced the knowledge about GPs perception of psychological interventions for MUS and highlighted the need for more information about the role of psychologists in MUS management. We hope that our findings will raise awareness about GPs difficulties in dealing with MUS, promote a more formal and tailored education on this topic according to GPs needs and encourage the development of MUS guidelines in Italian primary care settings. Supplementary material Supplementary material is available at Family Practice online. Acknowledgements We would like to thank Serena Bagli, Silvia Leardini and Nicola Tattini for their help in data collection, Maria Grazia Ricci Garotti for data entry and Alessandra Cola for linguistic consulting. We also thank all the GPs who took part in this study. Declaration Funding: none Ethical approval: the study was approved by the institutional review board of the Department of Psychology, University of Bologna. Conflict of interest: none. References 1. Burton C. Beyond somatisation: a review of the understanding and treatment of medically unexplained physical symptoms (MUPS). Br J Gen Pract 2003; 53: Konnopka A, Kaufmann C, König HH et al. 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