Normalisation of unexplained symptoms by general practitioners: a functional typology.

Abstract

BACKGROUND: Patients often present in primary care with physical symptoms that doctors cannot readily explain. The process of reassuring these patients is challenging, complex and poorly understood. AIM: To construct a typology of general practitioners' (GPs') normalising explanations, based on their effect on the process and outcome of consultations involving patients with medically unexplained symptoms. DESIGN OF STUDY: Qualitative analysis of audiotaped consultations between patients and GPs. SETTING: Seven general practices in Merseyside, United Kingdom. METHODS: Transcripts of audiotaped consultations between 21 GPs and 36 patients with medically unexplained symptoms were analysed inductively, to identify types of normalising speech used by GPs. RESULTS: Normalisation without explanation included rudimentary reassurance and the authority of a negative test result. Patients persisted in requesting explanation and elaborated or extended their symptoms, rendering somatic management more likely. Normalisation with ineffective explanation provided a tangible physical explanation for symptoms, unrelated to patient's expressed concerns. This was also counterproductive. Normalisation with effective explanation provided tangible mechanisms grounded in patients' concerns, often linking physical and psychological factors. These explanations were accepted by patients; those linking physical and psychological factors contributed to psychosocial management outcomes. CONCLUSIONS: The routine exercise of normalisation by GPs contains approaches that are ineffective and may exacerbate patients' presentation. However, it also contains types of explanation that may reduce the need for symptomatic investigation or treatment. These findings can inform the development of well-grounded educational interventions for GPs.