Medical disengagement Christopher Dowrick Professor of Primary Medical

Medical disengagement Christopher Dowrick Professor of Primary Medical Care University of Liverpool, UK

Themes n n n Medically unexplained symptoms (MUS) in primary care Mismatch between help seeking and care received Medical disengagement

MUS are a problem n n Health care Doctors Patients Nosologists

Do doctors help, or hinder?

Research Team n n n Peter Salmon Chris Dowrick Adele Ring John Davies Gerry Humphris Larry Wissow n Liverpool n Dundee Johns Hopkins n

Principal Question n What strategies do patients with unexplained physical symptoms, and their doctors, use to influence treatment decisions? ¡ ¡ Somatic Psychosocial

Study summary n n 9 primary care sites on Merseyside, UK 42 general practitioners transcripts of 420 MUS consultations Liverpool Clinical Interaction Analysis Scheme n Ring et al, Soc Sci Med 2005

Key findings (1) n Patient presentations perceived as pressure ¡ n Normalisation by GPs common, but counterproductive ¡ n Ring et al, BMJ 2004 Dowrick et al, Br J Gen Pract 2004 Patients less dualistic than previously assumed ¡ Salmon et al, Br J Gen Pract 2004

Key findings (2) n Patients seek support > treatment ¡ n Salmon et al, J Psychosom Res 2005 Mismatch between help seeking and care n ‘Medical somatisation’ ¡ Ring et al, Soc Sci Med 2005

Psychosocial agendas voiced…. n 61% (of 420) referred to emotional or social problems ¡ ¡ n 41% by direct disclosure 41% by suggesting psychosocial explanations 70% requested explanations for their symptoms ¡ Only 9% did neither

…. but often unheard n n n In 67% consultations, doctors indicated physical disease could be present In only 16% did doctors make empathic statements Doctors more likely than patients to propose symptomatic management

Symptomatic management % Z=12. 19, P<0. 001

Why this mismatch? Examining the role of doctors

Hypotheses n n Medical role Skill deficits Cognitive errors Disengagement

Emotional disengagement? n n Criticism in 88 (27%) consultations GPs most likely to criticise patients who seek emotional support ¡ Patient seeks n Explanation: Management: Support: n NB doctor variability n n ¡ OR 1. 09 (0. 76, 1. 56) OR 1. 15 (0. 94, 1. 42) OR 1. 38 (1. 08, 1. 77) Salmon et al, Psychosom Med 2006

Physical disengagement? n Somatic outcomes directly associated with ¡ length of consultation n ¡ t 2. 742, p 0. 007 patient elaboration of symptoms n t 1. 990, p 0. 047 n NB not associated with ¡ ¡ Patients’ reference to physical disease Patients’ proposal for somatic management

Interpretation n Doctors’ strategies for disengagement contribute to somatic outcomes in consultations about MUS in primary care

Possible solutions n Somatic outcome less likely if GPs ¡ normalise n ¡ t -3. 134, p 0. 002 or prompt for psychosocial disclosure n t -3. 339, p 0. 002

Next steps n Doctor variability ¡ ¡ n attachment style patient-centredness Direct hypothesis testing ¡ TAR interviews with doctors and patients

Watch this space… n cfd@liv. ac. uk