Peters Sarah, Rogers Anne, Salmon Peter, Gask Linda, Dowrick Chris, Towey Maria, Clifford Rebecca, Morriss Richard
School of Psychological Sciences, University of Manchester, Manchester, UK.
J Gen Intern Med. 2009 Apr;24(4):443-9. doi: 10.1007/s11606-008-0872-x. Epub 2008 Dec 17.
Despite both parties often expressing dissatisfaction with consultations, patients with medically unexplained symptoms (MUS) prefer to consult their general practitioners (GPs) rather than any other health professional. Training GPs to explain how symptoms can relate to psychosocial problems (reattribution) improves the quality of doctor-patient communication, though not necessarily patient health.
To examine patient experiences of GPs' attempts to reattribute MUS in order to identify potential barriers to primary care management of MUS and improvement in outcome.
Qualitative study.
Patients consulting with MUS whose GPs had been trained in reattribution. A secondary sample of patients of control GPs was also interviewed to ascertain if barriers identified were specific to reattribution or common to consultations about MUS in general.
Thematic analysis of in-depth interviews.
Potential barriers include the complexity of patients' problems and patients' judgements about how to manage their presentation of this complexity. Many did not trust doctors with discussion of emotional aspects of their problems and chose not to present them. The same barriers were seen amongst patients whose GPs were not trained, suggesting the barriers are not particular to reattribution.
Improving GP explanation of unexplained symptoms is insufficient to reduce patients' concerns. GPs need to (1) help patients to make sense of the complex nature of their presenting problems, (2) communicate that attention to psychosocial factors will not preclude vigilance to physical disease and (3) ensure a quality of doctor-patient relationship in which patients can perceive psychosocial enquiry as appropriate.
尽管医患双方常常对会诊表示不满，但患有医学上无法解释的症状（MUS）的患者更愿意咨询他们的全科医生（GP），而非其他任何医疗专业人员。培训全科医生解释症状如何与心理社会问题相关（重新归因）可改善医患沟通质量，不过不一定能改善患者健康状况。
研究患者对全科医生尝试对医学上无法解释的症状进行重新归因的体验，以确定对医学上无法解释的症状进行初级保健管理及改善结果的潜在障碍。
定性研究。
咨询医学上无法解释的症状且其全科医生接受过重新归因培训的患者。还对对照全科医生的患者进行了二次抽样访谈，以确定所发现的障碍是重新归因特有的，还是一般医学上无法解释的症状会诊共有的。
对深度访谈进行主题分析。
潜在障碍包括患者问题的复杂性以及患者对如何处理这种复杂性表现的判断。许多患者不信任医生讨论其问题的情感方面，选择不提及这些方面。在其全科医生未接受培训的患者中也发现了同样的障碍，这表明这些障碍并非重新归因所特有。
改善全科医生对无法解释症状的解释不足以减轻患者的担忧。全科医生需要（1）帮助患者理解其呈现问题的复杂性质，（2）传达关注心理社会因素并不排除对身体疾病的警惕，以及（3）确保医患关系的质量，使患者能够认为心理社会询问是合适的。
