Review
Conflict, collusion or collaboration in consultations about medically unexplained symptoms: The need for a curriculum of medical explanation

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Abstract

Objective

To identify the basis of the communication problems that characterise consultations about medically unexplained symptoms (MUS) and to identify implications for clinical education.

Method

Recent research into the details of clinical communication about MUS was reviewed narratively and critically, and broader research literature was scrutinised from the perspective of a practitioner who wishes to provide patients with explanations for such symptoms.

Results

Consultations about MUS often involve contest between patients’ authority, resting on their knowledge of their symptoms, and practitioners’ authority, based on the normal findings of tests and investigations. The outcome of consultations can therefore depend on the strategies that each party uses to press their authority, rather than on clinical need.

Conclusion

Contest is a product of patients and practitioners occupying separate conceptual ‘ground’. Avoiding contest requires the practitioner to find common conceptual ground within which each party can understand and discuss the symptoms. Finding common ground by collusion with explanations that patients suggest can damage clinical relationships. Instead the practitioner needs to fashion explanation that is acceptable to both parties from available medical and lay material.

Practice implications

Although practitioners commonly fashion such explanations, this aspect of their professional role seems not to be greatly valued amongst practitioners or in medical curricula. Clinical education programmes could include curricula in symptom explanation, drawing from research in medicine, psychology and anthropology.

Section snippets

Introduction: scale and scope of the problem

Of patients presenting physical symptoms in primary care, their doctors consider that, in around 10–20%, the symptoms are not explained by physical disease [1], [2], [3]. In outpatient clinics, such as gynaecology, neurology or rheumatology, 30–70% of patients have no physical disease [4], [5], [6]. These symptoms burden patients, whose quality of life can be as poor as in patients with chronic physical diseases [5], [7], [8], and they burden health services because, despite the absence of

Consultation is part of the problem

A history of childhood abuse and associated family dysfunction, a history of illness focus in the family, and unexplained symptoms in parents are each more likely in patients with MUS than in those with physically explained symptoms [25], [26], [27], [28], [29], [30]. However, these adversities afflict many people who do not develop MUS, and include risk factors for other clinical problems, such as depression or alcohol abuse. So a purely ‘psychosomatic’ framework is incomplete. ‘Sociosomatics’

Contesting patients’ and doctors’ agendas in consultation

In several studies of patients’ perspective on consultation, one overwhelming finding emerges strongly. Patients seek legitimacy for their problems [39], [40], [41], [42], [43], [44], [45], [46]. That is, they want to feel that the doctor accepts that the symptoms are real and warrant the doctor's attention. The complaints and compliments with which patients describe their doctors are particularly informative about what they have sought from them. In a study of 68 patients, none complained

Collusion and collaboration

One way in which doctors can conduct consultations on common ground with the patient is simply to accept explanations or treatment suggestions that patients provide [60]. However, patients’ suggestions of explanations generally appear tentative and are probably intended as a way to prompt the doctor's explanation rather than impose one [40], [52], [61]. Acquiescence can therefore undermine patients’ confidence in their doctors’ expertise [60]. Moreover, it risks negating doctors’ responsibility

Crafting explanations for MUS

There is, however, an obvious paradox in arguing that doctors should provide explanations for a problem that is defined as unexplained; so criticising doctors where they neglect explanation in these consultations would be illogical. Instead, our analysis has brought us back to the starting point for this paper: that these symptoms do not fit Western medicine's ways of understanding illness and so cannot typically be explained in the ways that doctors have been trained to explain symptoms [14].

Practice implications: a curriculum of ‘medical explanation’

For medicine and associated disciplines, MUS is a ‘disconfirming case’; that is, a problem that, by definition, does not fit into current ways of explaining symptoms. In research design, disconfirming cases are recognised as a way to learn, not just about those cases, but about the limitations of the theoretical frameworks that they do not fit [107]. Therefore, by examining some of the decisions that a practitioner has to make in crafting an explanation for a ‘medically unexplained physical

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