Discovering strengths in patients with medically unexplained symptoms – a focus group study with general practitioners 2022 Jøssang et al

Abstract

Background
When patients suffer medically unexplained symptoms, consultations can be difficult and frustrating for both patient and GP. Acknowledging the patient as a co-subject can be particularly important when the symptoms remain unexplained. One way of seeing the patient as a co-subject is by recognizing any among their strong sides.

Objectives
To explore GPs’ experiences with discovering strengths in their patients with medically unexplained symptoms and elicit GPs’ reflections on how this might be useful.

Methods
Four focus-groups with 17 GPs in Norway. Verbatim transcripts from the interviews were analyzed by systematic text condensation.

Results
Recollecting patients’ strengths was quiet challenging to the GPs. Gradually they nevertheless shared a range of examples, and many participants had experienced that knowing patients’ strong sides could make consultations less demanding, and sometimes enable the GP to provide better help. Identifying strengths in patients with unexplained symptoms required a deliberate effort on the GPs’ behalf, and this seemed to be a result of a strong focus on biomedical disease and loss of function.

Open access, https://www.tandfonline.com/doi/full/10.1080/02813432.2022.2139345

 

"A conscious effort is needed to discover patients' strengths."

Is it weird that that is exactly what I feel when evaluating most of the GP's I've come across since getting sick?

 

Imagine telling car mechanics that when they can't figure out how to fix a car, they spend time with the client going over the things that work or isn't broken in the car. And you can't even imagine that because it's too silly.

Also, this:

Is just word salad. This is publish-or-perish, completely useless papers that clearly serve no purpose other than fulfilling the obligation to publish papers. A system that does not care whether useless papers are published in such large quantities that they make up the bulk of published papers.

I have no idea what this is even supposed to be about. This is not the job. People don't go see doctors to be praised over their strengths, they go see doctors because they are the only people authorized and able to deal with medical issues. What a bunch of nonsense.

And I keep seeing this everywhere: it seems that physicians literally cannot imagine the difference that competent medical care does. This is basically being puzzled as to why people are more satisfied when a piece of technology works vs. when it doesn't work. Or they can't imagine their role in this, which is basically the same thing.

Those patients sure are experiencing life as it's happening. Hence why the low satisfaction, which takes all but half of average of intelligence to understand, it's basic common sense.

Yes, because it is demanded. You demand this. Our issues are always minimized, so we have to emphasize them, as modern medicine is unable to function without the use of technology and only treats lab results, never people. Medicine doesn't know how to deal with people. This is the system as designed and we had nothing to do with it, in fact it's very poorly designed.

And it's completely turned inward, the patients don't matter here, this is the perspective of physicians about physicians for physicians discussing what physicians see and do. The patient basically plays as much a role in this as zombies do in most zombie movies: a mere backdrop, a challenge that sometimes distract from human folly but mostly just moans around being ignored as long as they don't bother anyone.

Peak systemic dysfunction: a system completely unable to see where it's dysfunctional, perpetuating the dysfunction in a permanently locked state.

 

They want GPs to get hit with lawsuits if medically unexplained symptoms become explained.

 

Recovery Norge has a list of professionals who are officially endorsing the organisation, and one of the authors of the study, Aase Aamland, is on the list.
https://www.recoverynorge.org/om-oss-recovery-norge/fagfolk-om-recovery-norge/

In interviews and lectures she's been clear that she includes ME in her definition of MUS.

 

I like the idea of Graded Flattery Therapy as long as it starts off cautiously with compliments on the patient’s hair and builds up gradually to, say, saluting their firmness of moral purpose. We seekers of secondary gain don’t want to be overwhelmed all at once.

 

If you look at the quotes, they fall so far short of flattery it's not even funny. They sound more like things to say to someone in a suicide crisis, trying to find reasons why it's worth living, and only coming with generic platitudes of no importance that could be said of anyone. And they are mostly about past things, things that were lost, which really does the exact opposite.

For sure there have been eulogies made by people who hated the deceased and still managed not to come off as poorly. And many aristocrats have said less insulting things about the peasantry who gave them so much privilege, this is even more insulting than "let them eat cake" as at least it understands the issue is over lack of food and doesn't instead suggest a travelling band of hand puppeteers to quell discontent. Zero effort was put into those thoughts and it shows.

 

That it takes a focus group to trigger an epiphany of sorts in a small group of GP's that patients are people, too, is terrifying. And infuriating. And cartoonish.

But not surprising - at least not to any of their MUS patients, I'd wager.

 

I noticed no one ever asks the patients with MUS what they want in an open-ended manner that allows all responses to come through.

Also I wonder when the MUS theorists will grasp that the symptoms are the reality of illness or combination of illnesses and that any discrepancy between model and reality means the model is wrong.

The MUS theory also seems really outdated in a modern medical world where 7000 rare diseases are known to exist, we know that are diseases are actually common in the population (just rare individually), new ones are discovered every year, and the methods being used to diagnose complex diseases have still much room to grow. 6 out of 100 people have a rare disease according to some sources. These alleged chronic hypochodriacs and somatizers we hear about where the tests are normal might just have a rare disease that requires different diagnostic methods than the ones developed for the common diseases.

There's also a lot of other stuff we don't know about the body. There's really no reason to evoke some mysterious psychosomatic mind-body illness to explain gaps in our knowledge. Besides, psychosomatic explanations don't explain anything, they just pretend to (it's only an explanation with reasonable evidence to support it).

Medicine has dealt with the complexity of the human body and disease by creating a diagnostics and classification system that is adequate for most cases of the more common and important diseases. These works because it's a gross simplification of a very complex reality. If something doesn't fit neatly into this, it doesn't mean it's not real or some psychosomatic problem. One strategy to being able to handle more complexity is bioinformatics. I expect affordable whole genome sequencing, combined with more data and better bioinformatics tools will do a lot to help patients with currently unexplained illness. The diseases that have their origin in abnormal behaviour of the immune system might need a few other specialized tools, as will brain diseases.

 

I'd be curious to see a focus group comprised of patients from these GP's. I'd anonymize the GP's names and locations etc, but let the patients read the transcripts. Let the patients read how the doctors had to grapple with the concept that MUS patients might have strengths. Then I'd ask the patients if they'd want to hire any of those doctors. Or if they even think they should be doctors at all. Since it's a focus group, I'd encourage them to expand on their responses.

Then I'd share that, with patients' names expunged, with those GP's.

Just for the sheer moment.

But I fear it wouldn't change anything. Those GP's likely are, to a large extent, insulated from moral or any other kind of accountability, just as most of their colleagues through out the medical community are. If anything, the patient feedback would just reinforce the doctors' earlier mindset. Hubris is like that.

 

It's an odd situation - patients go to Drs for answers, treatments, cures and support, and on the face of it given that Drs are supported by State and/or commercial resources, are well paid and have a degree of positive social recognition, the Dr/patient interaction could be expected to be a fairly simple supporter/supported relationship. In reality many Drs in parts of various health systems are not well supported, are dealing with a lack of resources/burden of demand, have financial rewards reduced from historical norms and no longer enjoy previous levels of social recognition.

In these circumstances getting Drs to be both supportive and to change their perspectives requires a degree of mutual hand holding. Of course some health systems are more broken/under strain than others but frustrating as it is, pragmatically we have to have a degree of sympathy for the medics if we are to promote the most helpful conditions for change from the patient side of the equation.

 

There's quite a difference between health care systems in how GPs are incorporated within them, also the term is by no means universal. Norway, (location of the study) has only 5,400 GPs, at approximately 1 per 1000 of population, the UK has 54,000 but at a rate of only 1 per 1260 of population, while France has 94,000 at 1 per 700 of population. The US uses the broad term 'primary care physician' of which only small number class themselves as GPs. US PCP numbers are at around 1 per 1600 of population.

Population age and general health impact significantly on primary care workload so even raw numbers per population can't tell the whole story, and total numbers don't reveal age of incumbents, retirement rates or numbers in training, all of which affect how GPs/PCPs are able to interact with their patients. In England although the total GP headcount is 46,283, that equates to only 37,026 full time equivalents, with only 27,556 actually working full time.

With all these variables it's difficult to settle on what can be expected from GPs/PCPs across health systems.

Number of general practitioners practicing in Europe in 2020, by country

The Number of Practicing Primary Care Physicians in the United States

General Practice Workforce, 30 September 2022

 

Even though the proportions of GPs to patients vary a little, the.role of a GP as gatekeeper of resources (through whatever CCGs are called these days) on these shores likely has as much impact on behaviour. At least in countries where insurers play all the villainous roles, GPs have fewer structural reasons to be awkward.

 

Primary Care gatekeeping can be a feature of both Nationalised and also some Private Insurance based systems - The effects of gatekeeping: A systematic review of the literature Impact of GP gatekeeping on quality of care, and health outcomes, use, and expenditure: a systematic review

 

I was also thinking of the post-Lansley shenanigans where consortia of GPs can sometimes club up to buy community healthcare services from themselves as qualified providers. Can’t imagine that’s replicated elsewhere.