The 'demanding patient' : fact or fallacy? : investigating patient influence on somatically oriented treatment decisions for medically unexplained symptoms in general practice

• Main Author: Ring, Adele
• Published: University of Liverpool 2007
• Subjects: 615.5
• Online Access: http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.439612

BACKGROUND: Patients who present physical symptoms in the absence of physical pathology are common in primary care. They are often considered by doctors to be amongst the most difficult patients to manage and their overinvestigation and treatment has been well documented. Whilst the finger is often pointed at the patient as the instigator of such treatment, there is currently little objective evidence implicating the patient directly to this potentially iatrogenic treatment process. The concept of `patient demand' largely stems from anecdotal evidence of doctors concerning their feelings of being pressurised by such patients. AIMS AND OBJECTIVES: To investigate how patients with unexplained physical symptoms talk about their symptoms during routine primary care consultations with GPs and to determine whether or not somatically oriented interventions for these patients can be attributed to patient demand for this treatment. METHODS: Initial qualitative investigation: audio recording, transcribing and thematic analysis of 36 primary care consultations between GPs and patients with unexplained physical symptoms. Second quantitative investigation: audio recording, transcribing and coding of 420 primary care consultations between GPs and patients with unexplained physical symptoms using a coding scheme developed during the qualitative phase of the study. Hypotheses generated during the qualitative phase of the study were tested with Wilcoxon or Friedman tests. RESULTS: There was little evidence from the qualitative analysis to support the suggestion that patients with unexplained physical symptoms receive somatic interventions because this is what they direct their GPs to provide. However patients presented their symptoms in characteristic ways which might conceivably pressure GPs for somatic intervention. Aspects of GP speech were also identified that had the potential to influence somatic treatment decisions. Results of the quantitative analyses showed that GPs proposed somatic treatment in more consultations than did patients. Patients requested explanation for their symptoms in a greater number of consultations than they advocated any treatment intervention. Patients criticised GPs in a substantial number of consultations in the larger quantitative sample. This type of speech may be a particularly powerful source of pressure for somatic intervention. CONCLUSIONS: The over-investigation and treatment of patients with unexplained physical symptoms can no longer be attributed to overt patient demand for such interventions. The findings of the present analyses implicate both patient and GP in the decision to provide somatically oriented treatment. Patient influence, where apparent, involves the different and complex ways that patients talk about their symptoms rather than their specific requests for intervention. The type of explanations GPs offer for patients' symptoms may prompt some patients to respond in ways that might conceivably pressure GPs for somatic intervention. The provision of somatically oriented treatment for patients with unexplained physical symptoms might therefore be more appropriately explained as the outcome of critical doctor-patient communication processes rather than patient demand for such intervention.