Elsevier

General Hospital Psychiatry

Volume 28, Issue 4, July–August 2006, Pages 343-351
General Hospital Psychiatry

Symptom Research
More than half of all outpatient visits are trigged by physical symptoms which, in turn, are not adequately explained by medical disorders at least half of the time. Further, the presence and severity of somatic symptoms often correlate more strongly with psychological, cognitive and behavioral factors than with physiological or biological findings. Finally, our understanding of the etiology, evaluation, and management of somatic symptoms and functional syndromes is less advanced than our knowledge of many defined medical and psychiatric disorders. This special section, edited by Kurt Kroenke, M.D., will highlight original studies that advance the science and clinical care of somatic symptoms.
Turning theory into practice: rationale, feasibility and external validity of an exploratory randomized controlled trial of training family practitioners in reattribution to manage patients with medically unexplained symptoms (the MUST)

https://doi.org/10.1016/j.genhosppsych.2006.03.012Get rights and content

Abstract

Background

The evidence for the effectiveness of reattribution training are limited, and optimal service delivery is not yet established.

Objectives

The objectives of this study were to establish the feasibility and to optimize the service delivery and design of a definitive randomized controlled trial (RCT) of reattribution training for patients with medically unexplained symptoms (MUSs) in routine primary care.

Methodology

The study was of a cluster RCT design with the practice as the unit of randomization. Health facilitator (HF)-delivered reattribution training was compared with no reattribution training. The primary outcome measure used is doctor–patient communication in the consultation. Quantitative and qualitative methods identify barriers to effectiveness. The acceptability and feasibility of the intervention were established by attendance rates and postal survey after completion of training.

Results

Sixteen practices and 70 family practitioners (FPs) were recruited with representative practice and FP characteristics. Six hours of HF reattribution training to FPs in the workplace proved feasible and acceptable with all 35 FPs completing the training. Feedback from 27 (77%) FPs who received training indicated that 25 (93%) FPs believed that specific and relevant learning achievements were made, 22 (82%) felt more confident and 21 (77%) thought the training was useful.

Conclusion

HF-delivered reattribution training to whole practices is feasible and acceptable, and its effectiveness is measurable in routine primary care.

Section snippets

Background

Medically unexplained symptoms (MUSs) can be defined as physical symptoms that family practitioners (FPs) cannot explain by physical pathology and that distress or impair the functioning of patients [1]. Patients with MUSs may have a single symptom or a syndrome of symptoms such as fibromyalgia. Reattribution was developed by a member of our research group (L.G.) as a first-line treatment delivered by FPs to patients with depressive or anxiety disorders presenting with MUSs [somatized mental

Overall study design

The overall aims of the study were to maximize the effectiveness and feasibility of using reattribution in routine primary care and to identify ways to measure outcomes in a definitive RCT as precisely as possible because effect sizes are likely to be small to medium at best but still important in view of the high prevalence of MUSs in primary care consultations [5]. There are four primary sources of bias that might mimic or mask a treatment effect and that need to be minimized [15]:

Recruitment of practices and FPs

The results of the recruitment procedure for practices are shown in Table 5. In total, we approached 610 practices (1934 FPs). We recruited 16 practices that employed 70 FPs. The characteristics of the FPs are shown in Table 6. The training and control groups were well matched in terms of the key demographic characteristics of FPs and practices. Fewer FPs in the training group operated personal lists (a patient usually sees the same doctor). Personal lists are associated with more satisfaction

Discussion

The data in this article show that HF-delivered reattribution training over three 2-h sessions to FPs on a practice-wide basis in routine primary care was both feasible and acceptable in terms of full attendance rates and feedback from FPs. It is possible that the delivery of the questionnaire by the HF could have favorably influenced each FP's rating of the training (a halo effect). However, the FPs completed the questionnaire without the HF present and sent the questionnaire to an independent

Conclusion

An exploratory RCT has been designed to achieve two broad aims: (1) to refine an intervention so that it is feasible and maximally effective in routine clinical practice and (2) to collect all the information required to design a definitive multicenter RCT. The study design and preliminary results appear to meet these main aims.

Acknowledgment

This study was funded by a grant from the Medical Research Council of United Kingdom (Grant Reference Number G0100809: ISRCTN 44384258).

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    • Training tomorrow's doctors to explain ‘medically unexplained’ physical symptoms: An examination of UK medical educators’ views of barriers and solutions

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      A growing evidence-base has identified methods for supporting doctors to interact effectively with FS patients, including helping patients feel understood and believed, limiting iatrogenesis from unnecessary investigation and treatment, making timely diagnoses and helping patients engage with other care team members [18–20]. However, uptake of such training is poor [21]. Doctors that decline training hold more negative attitudes towards FS patients and dismiss their abilities to provide psychological support more than their participating counterparts [11].

    • The Expanded Four Habits Model-A teachable consultation model for encounters with patients in emotional distress

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      When applying skill 4 the clinician should build on the patient's understanding as explored in skill 3 and supplement or rephrase it in order to promote insight. Promoting insight requires a combination of psychoeducational techniques and selected, basic skills from cognitive therapy [42], reattribution therapy [43], and acceptance-commitment therapy (ACT) [44], such as encouraging acceptance and alternative thinking. There is evidence from behavior therapy that strategies of cognitive restructuring and reorientation are associated with increased mutual understanding between doctor and patient [42], but there are also examples in the literature of unsuccessful attempts to reattribute patients’ misconceptions and provide insight in patients with dysfunctional understanding of their problems [49].

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      Given the low number of participants recruitment procedures should be revised. Other similar studies have also experienced some of the same difficulties with recruitment [39]. One option is to make mental health related communication skills training mandatory for all GPs, while another is to examine what makes physicians sign up or not for such training, and make adjustments accordingly.

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      This symptom-focussed approach was confirmed by Groben and Hausteiner [25] and is in agreement with Rief and colleagues [23], who found that the number of symptoms in the SOMS showed a moderate positive correlation with the number of agreed attributions and a weak negative correlation with the number of rejected attributions. Introduced by Goldberg et al., reattribution models, are the orthodox models of care for patients who present in general medical settings with MUS and SFD [77–81]. However, as a rule, re-attribution, is by and large inefficient in terms of patients' clinical improvement [82,12,83].

    • Reattribution reconsidered: Narrative review and reflections on an educational intervention for medically unexplained symptoms in primary care settings

      2011, Journal of Psychosomatic Research
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      Only half of the studies demonstrated doctors' acquisition of the skills before determining impact on patient outcome. There is good evidence from six studies [8,9,11,14,22,30] that the skills of reattribution can be learned by both experienced GPs and trainees, although the extent to which they are used in routine practise is still limited after brief training [23,27]. Rosendal and her colleagues have clearly demonstrated that RT has a positive impact on GP attitudes and on their awareness of medically unexplained symptoms in their patients [15,16].

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