BMJ  2004;328:1057 (1 May), doi:10.1136/bmj.38057.622639.EE (published 31 March 2004)

Primary care

Do patients with unexplained physical symptoms pressurise general practitioners for somatic treatment? A qualitative study

¹ Department of Clinical Psychology, University of Liverpool, Whelan Building, Brownlow Hill, Liverpool L69 3GB, ² Department of Primary Care, University of Liverpool, Liverpool L69 3GB, ³ Bute Medical School, University of St Andrews, St Andrews KY16 9ST

Abstract

Objectives To identify the ways in which patients with medically unexplained symptoms present their problems and needs to general practitioners and to identify the forms of presentation that might lead general practitioners to feel pressurised to deliver somatic interventions.

Design Qualitative analysis of audiorecorded consultations between patients and general practitioners.

Setting 7 general practices in Merseyside, England.

Participants 36 patients selected consecutively from 21 general practices, in whom doctors considered that patients' symptoms were medically unexplained.

Main outcome measures Inductive qualitative analysis of ways in which patients presented their symptoms to general practitioners.

Results Although 34 patients received somatic interventions (27 received drug prescriptions, 12 underwent investigations, and four were referred), only 10 requested them. However, patients presented in other ways that had the potential to pressurise general practitioners, including graphic and emotional language; complex patterns of symptoms that resisted explanation; description of emotional and social effects of symptoms; reference to other individuals as authority for the severity of symptoms; and biomedical explanations.

Conclusions Most patients with unexplained symptoms received somatic interventions from their general practitioners but had not requested them. Though such patients apparently seek to engage the general practitioner by conveying the reality of their suffering, general practitioners respond symptomatically.

Introduction

About a fifth of patients who consult their general practitioner present with physical symptoms that the general practitioner thinks are not explained by physical disease.¹ Nevertheless, these patients often receive extensive somatic investigation and treatment, which is largely ineffective and sometimes iatrogenic^{2 3} and which is usually attributed to pressure from patients for somatic treatment and cure.^{4 5} That general practitioners feel pressurised to offer somatic interventions helps to explain reports of their dissatisfaction with these consultations^6-9 and the widespread use of terms such as "difficult" and "heartsink"¹⁰ to describe such patients.

In this study we identified types of presentation that had the potential to lead general practitioners to feel pressurised to give somatic interventions.

Method

Sample
We wrote to general practitioners from seven practices to ask them to take part. Of 30 contacted, 28 agreed (13 women and 15 men, with experience ranging from 5 to 42 years, mean 18.4 years). Three practices were urban, three were suburban, and one was rural. List sizes ranged from 2180 to 13 116 patients, and each practice had from one to 10 doctors. The Jarman deprivation indices for the study areas were -11 to 38 (mean 17.6). Twenty one general practitioners and all participating practices were represented in the analysed transcripts.

There are several research diagnostic criteria for primary care patients with unexplained symptoms.^{11 12 13} Some of these have poor discrimination, while others are restrictive or oversimplified. Because we focused on the difficulties that patients present for doctors, we used less restrictive criteria to identify patients who, in the doctor's opinion, have unexplained symptoms. Immediately after consultation (see below), the doctor completed a checklist¹ to indicate whether or not the consultation involved: presentation of a physical symptom; symptoms that had existed for at least three months; symptoms that caused the patient clinically significant distress or impairment; and symptoms that could not be explained by a recognisable physical disease. We retained for analysis consultations that satisfied all four criteria. These criteria are strongly associated with the diagnostic criteria for abridged somatisation disorder.¹¹

Procedure
Before consultation a researcher approached 659 consecutive patients and obtained written consent for audiorecording from 420. The general practitioners completed the checklist immediately after each consultation, yielding 42 consultations for analysis. Of these, one recording failed and five transcripts contained insufficient discussion of physical symptoms. The 36 remaining consultations were anonymously transcribed.

Analysis
Analysis was inductive. Initial reading and discussion of 10 transcripts by all authors showed that overt demands for somatic intervention were rare. We therefore sought to identify more subtle ways in which patients' presentation might pressurise general practitioners.

One author (PS) carried out the preliminary analysis. This was then developed and tested by inclusion of subsequent transcripts, which were read and discussed by all authors. The analysis was unchanged by the final 16 transcripts.

Results

Sample characteristics
The most common symptoms were abdominal complaints (n = 10), pain in limbs (n = 9), or headaches (n = 7); others included chest pain, back pain, dizziness, fatigue, skin problems, and gynaecological or genitourinary symptoms (see table on bmj.com). Patients presented with between one and seven symptoms.

Patient presentations
No patient asked for investigation or medical referral. Ten asked for physical interventions of other kinds: one sought physiotherapy, four sought repeat prescriptions, and six sought a new drug prescription. Five requested sick notes.

Although direct requests for somatic intervention were few, patients presented in several ways that had the potential to pressurise general practitioners (box). All but one presented in at least one of these ways and most in several.

Potential sources of "patient pressure" Effects of symptoms on patient's life Graphic and emotive language Biomedical explanations Emotional distress caused by symptoms External authority Criticism and negation Complexity of presentation

Twenty four patients routinely reported how their symptoms impaired activities of daily living or social behaviour:

At the moment all I'm worried about is my work, problem is my sleep, I can't really sleep... if I could sort my sleep out at least I'd be able to work. (P23)

Emotive words such as "nightmare" or "horrendous" conveyed the intensity of many patients' symptoms (n = 22):

I get terrible, terrible pains in my stomach... Just terrible, really sharp, sharp pains... it's really swollen and it's absolutely solid and it's excruciatingly painful... Sometimes it'll be like somebody has literally stabbed me. (P8)

This language extended to emotive metaphors or analogies:

I just feel as though somebody's got me by the back and the shoulders and it's just really horrendous round there. This side is worse, a lot worse than that side. (P15)

Nineteen patients proposed physical explanations for their symptoms. Some, such as "wind," did not signify responsibility for the doctor. However, many, such as "pleurisy," "arthritis," or "ulcers," signified disease that the doctor would be responsible for treating. Explanations were presented as proposals for discussion, rather than firm beliefs:

I don't know where to start. I thought I took a heart attack a week last Saturday, severe chest pains. I rush myself into [hospital] and they said it wasn't the heart that was bothering me at that particular time they said "it's pleurisy in the chest." (P2)

Nineteen patients communicated emotional distress associated with their symptoms, using words including "worry," "distressing," and "bothered." They did not always attribute distress directly to the symptoms, but often attributed it to their uncertainty or fears about the cause:

I don't really know what's happening. Just worry about it all. (P27)

The other thing is I'm worried... scared... is two of my aunties, two of my uncles and my gran had all died of lung cancer which all started with a lump in my [sic] neck (P18)

Other individuals, usually family members, were cited as authority for the reality and severity of patients' symptoms and for the need for medical attention (n = 16):

With my stomach I keep thinking "oh it's probably just wind or something like that," but with it being so sharp and so regular, really because my boyfriend said "you're going to have to go to the doctors you know it's getting bad." (P8)

This included linking their symptoms to diseases of other family members:

It's exactly the same symptoms as my mum has. (P3)

No patient explicitly contradicted the doctor. Nevertheless, 17 negated in indirect ways the general practitioner's attempts to explain or manage their symptoms and, in particular, to exclude disease. Some offered additional perspectives that effectively invalidated the doctor's position:

GP: The first thing I would have checked was your gall bladder.

P7: That's what they checked.

GP: And I've seen that scan there and that was normal.

P7: But I mean at the time they took it, it was a good day so whether it's something that's flaring up.

Additional information about symptoms could also invalidate doctors' explanations:

GP: You know you talked about stress before. Are your headaches ever related to when you're feeling stressed? P8: Yes it's quite possible that it could be... You see sometimes it's at the weekend though when I'm not, I could be lying on the couch...

Patients also negated doctors' explanations by offering alternative diagnoses or by emphasising the ineffectiveness of previous treatments:

I came to see you two weeks ago and you gave me some, not quite sure, some pills to sort of hopefully take the pain away from my shoulder. It's still there, as bad as ever. (P15)

In addition, we noted complex temporal patterning of symptoms and striking complexity in the diversity of some patients' symptoms. Twenty one presented at least three somatic problems, including 11 who presented four or more. In many cases, the unfolding complexity of symptoms negated doctors' explanations. One patient introduced three distinct symptoms in the course of rejecting the doctors' attempt to attribute the first to stress.

Discussion

Main findings in relation to existing literature
Our direct examination of patients' presentations does not support the assumption that patients with unexplained symptoms pressure doctors for symptomatic intervention. General practitioners' provision of symptomatic interventions cannot be attributed to patients' overt demands.

As would be expected from previous evidence,³ all but two patients in this sample received somatic interventions. Nevertheless, none had requested investigation or specialist referral, and few asked for prescriptions.

Sources of pressure from patients
Patients had striking ways of conveying their suffering and their need for help and of constraining doctors' attempts to help. They described their suffering with graphic words and metaphors, emphasised disabling effects of their symptoms, and cited friends and family as authority for their suffering or concern. These strategies reflect the difficulty of conveying a symptom for which no objective evidence exists.¹⁴ However, unlike some strategies observed in outpatient clinics^15-18—such as explicitly requesting treatment, claiming catastrophic consequences of being untreated, and blaming doctors for making symptoms worse—these patients' strategies do not overtly challenge the authority of the doctor over management decisions. Similarly, although these patients did enter diagnosis, traditionally the doctor's preserve, they did not assert explanations but offered them as hypotheses. Patients' avoidance of overt challenge to the general practitioner's authority probably reflects the need to maintain long term relationships with general practitioners, which contrasts with the single opportunity that patients have to engage doctors in outpatient consultations.

What is already known on this topic Many patients with unexplained physical symptoms receive unnecessary somatic investigations and treatment in primary care This discrepancy has been attributed to patients pressurising doctors for somatic management What this study adds Most patients in this study did not request symptomatic interventions The ways in which patients presented their symptoms had the potential to challenge general practitioners by conveying the need for a response while constraining the general practitioner's opportunity for response The key to understanding why this group of patients receives somatic intervention lies in understanding why general practitioners respond to such challenge by offering somatic interventions

Patients offered both confirmatory and conflicting evidence about physical and psychosocial explanations and presented symptoms that defied simple explanation or reassurance. This combination of instigation for, and constraint on, engagement helps to explain the feelings of pressure, difficulty, and helplessness that such patients provoke in doctors who seek to help them.⁵

Doctors' responses to pressure from patients
However, why did so many patients receive symptomatic intervention from doctors who believed that they had no disease? The subjective feeling of pressure and helplessness might be sufficient. Emotional distress promotes habitual behaviours rather than ones that are well thought out. For general practitioners, the habitual response is to intervene symptomatically. The simplest explanation is that patients sought to engage doctors with their problems.¹⁴ Therefore they struggled to convey the reality of their symptoms and, when simple explanations threatened to end the doctor's engagement, they presented with such complexity or intensity that engagement continued. General practitioners might then have responded symptomatically either because they mistook patients' insistence on engagement as desire for intervention or because they lacked another response to evident suffering.

Strengths and limitations of this study
Because our study was a qualitative analysis in a small sample, we must be cautious in making generalisations. Moreover, our decision to use doctors' assessments of whether or not patients' symptoms were unexplained means that our results cannot be directly compared with those from studies that used external assessments of the causes of symptoms. The proportion of patients with unexplained symptoms recruited to the study was lower than anticipated, perhaps because patients with unexplained symptoms were less likely to consent to audiorecording.

Implications for research and practice
We have shown that present assumptions about patients' goals are unlikely to be correct. If unnecessary symptomatic intervention is to be avoided in patients with unexplained symptoms, general practitioners will need to understand better the influences that shape patients' presentations and doctors' responses.

---

A table of symptoms presented by patients can be found on bmj.com

This is the abridged version of an article that was posted on bmj.com on 31 March 2004: http://bmj.com/cgi/doi/10.1136/bmj.38057.622639.EE

We are grateful to T Hak for assistance in the design of the study, and for the enthusiastic participation of the anonymous general practitioners.

Contributors: See bmj.com

Funding: UK Medical Research Council.

Competing interests: None declared.

Ethical approval: Liverpool ethics committee.

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(Accepted 9 March 2004)

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