Experiences of general practitioners explaining central sensitisation to patients with persistent physical symptoms:, 2022, den Boer et al

[Andy]

Abstract

Objective
Patients with persistent physical symptoms (PPS) require an explanation that is acceptable and comprehensible to them. Central sensitisation (CS) is an explanatory model for PPS and chronic pain that has been broadly applied in the context of pain medicine, but, until recently, not by general practitioners (GPs). We explored how GPs used the CS model in their consultations with patients with PPS.

Design and setting
A qualitative focus group study among GPs in the Netherlands.

Methods
We instructed 33 GPs on how to explain CS to patients with PPS. After 0.5–1.5 years of using the CS model, 26 GPs participated in focus groups and interviews to report and discuss their experiences with CS as an explanatory model. Audio recordings were transcribed and two researchers independently analysed the data. The text was coded, codes were organised into themes and discussed until consensus was reached.

Results
We identified eleven themes and grouped these into four categories.

The GPs regarded the CS model as evidence-based, credible and giving recognition to the patient. On the other hand, they found explaining the CS model difficult and time-consuming. They tailored the CS model to their patients’ needs and used multiple consultations to explain the model. The GPs reported that the use of the CS model seemed to improve the understanding and acceptance of the symptoms by the patients and seemed to reduce their need for more diagnostic tests. Furthermore, patients seemed to become more motivated to accept appropriate therapy.

Conclusion
GPs reported that they were able to provide explanations with the CS model to their patients with PPS. They regarded the model as evidence-based, credible and giving recognition to the patient, but explaining it difficult and time-consuming.

Open access, https://bmjopen.bmj.com/content/12/7/e060063

 

[Peter T]

Patients with persistent physical symptoms (PPS) require an explanation that is acceptable and comprehensible to them.

No, patients want an explanation that accurately describes their condition and if that is not possible to be told ‘we don’t know’.

 

[rvallee]

This is a twisted modern version of the Milgram experiment, except instead of random participants being asked to harm a stranger, it's physicians being asked to gaslight patients, which ultimately harms millions. They clearly have no issues with it, lying to patients is perfectly OK to them, as we can see. Which is the real alarming thing, but that's standard so not exactly a surprise.

I'm not sure things actually are any better than they were back then. They've taken all the wrong lessons out of it.

Also: an "explanatory model" sounds like religion to me, providing answers simply because it's what they do, even if that answer is made-up or unrelated to the actual questions. The Celestial sphere is an explanatory model, built on superficial observations. That's not a good thing, in fact it's explicitly bad pseudoscience.

And it's pretty ironic to pretend that the explanation is "tailored", when what they mean is exactly the way psychics use it. Medicine has grown way too comfortable with lying, and it's ruining the profession.

 

[Grigor]

My answer to her post on LinkedIn. It's in Dutch but there's a translate button on LinkedIn

https://www.linkedin.com/feed/updat...Post:6957710275487662080,6957728396051156993)

 

[Grigor]

This is also by her. Google translated.

 

[Arnie Pye]

It's in Dutch but there's a translate button on LinkedIn

Where is the translate button?

 

[Grigor]

Where is the translate button?

Hm apparently only in the app

Google translated:

the CS explanation is mainly helpful for the doctor to be able to offer something, in my view it is rather misleading for the patient.

On the basis of this review, where there are indications for a possible kind of autoimmunity, we should certainly also question mere hypersensitivity as an explanation for unexplained chronic pain.

The fact that current standard tests cannot yet explain unexplained chronic pain does not make CS directly correct.

I find the CS explanation especially premature, and quite painful for both the doctor and the patient (pun intended)...

https://lnkd.in/efVaB9wX

She normally ignores my comments so I was surprised she answered:

Thanks for sharing the interesting article Anil. Indeed, there are a number of other explanatory mechanisms, including disruption of the immune system, autonomic nervous system, and stress hormone system. I do research into the sensitization model myself, but it is a complex whole in which different mechanisms probably influence and reinforce each other.

Thanks, I certainly agree that it is a complex whole where different mechanisms influence each other. Unfortunately, I don't see that enough in the piece in GP and Science. Rather, I see there that the various mechanisms for PPS are placed in boxes quite artificially.

For example, in post-infectious (such as long COVID or in my case CMV) an explanation of the immune system and ANS is referred to. In the case of unexplained chronic pain, however, based on the review I posted about the immune system, this could also apply. Unfortunately, people with chronic pain are not told this, and they leave the office with an explanation of mere hypersensitivity that is potentially incorrect. The CS they experience could also be post-infectious, and this could be due to some form of autoimmunity.

That may not change the treatment much if effective treatments are not yet available, but it will have a major impact on how someone understands being ill. The latter is essential how someone learns to deal with the disease and the complaints. In my opinion, that is an important missed opportunity & CS too limited an explanation.

 

[Sean]

Again, if you are having to concentrate so hard on the marketing, then your product probably stinks.

 

[Snow Leopard]

GPs uncensored:

GP F2: I like it when it’s a nice person. So I can take a lot if I have a soft spot for the person in some way. And the next one, pfffff.

What a coincidence, patients think the same thing about GPs, pfffff.

GP F3: The tricky thing is, that if you say there’s something wrong with the wiring, the inhibitory wiring, it doesn’t function as it should, but it can get better, that you still call it a kind of illness. ‘O, so I have faulty wiring, so something is wrong’. That’s what people may think, now we’re talking about it, I think that’s a difficult one.

O, so the explanation you're telling your patients is just misdirection (lie)?

GPs were afraid that they might overlook somatic pathology, which has no direct bearing on using the CS model. When the GP had explained that CS was causing the symptoms that the patients was experiencing and afterward a (rare) disease was diagnosed, the GP might feel embarrassed and failing.

GP F1: So the experience at that time, it shook me that we all just couldn’t find it and it were dramatic neurological symptoms and she died, at 62 or something. So that inhibits you a little, to dare to go down that path.

A friend of mine died because of delayed diagnosis/treatment because they had a long history of mental illness (schizophrenia) and so their symptoms were simply dismissed.

 

[NelliePledge]

Yeah mate F1 go with your gut and don’t go down that BS path

 

[FMMM1]

evidence-based, credible

Surely the approach recommended by a professional here (Jonathan) would be credible - I'm sorry I don't know

giving recognition to the patient

Taking the piss --- or is the proper term gaslighting? Surely treating the patient with respect would lead you to - I'm sorry I don't know
Potentially the Doctor could point out sites like this [Science 4 ME], highlight promising research like GWAS (and encourage participation) and explain that patient participation/lobbying is needed to get the research funding to make meaningful progress --- and the BMJ is highlighting the need for research --- not!