1. Quality Education for a Healthier Scotland Medically Unexplained Symptoms: Current Thinking & Ideas for Teaching Dr. Deirdre Holly Research & Training Officer (Health Psychology) Psychology Directorate

2. Quality Education for a Healthier Scotland

3. “Persistent and distressing somatic symptoms for which adequate somatic explanation does not reveal sufficient explanatory organic pathology” -Shaefert et al, 2013

4. Quality Education for a Healthier Scotland Vague symptoms, polypharmacology, high distress, insistent and frequent attendees. Irritable Bowel Syndrome, Chronic Fatigue Syndrome, Fibromyalgia.

5. Quality Education for a Healthier Scotland What problems as GPs and trainers do you see?

6. Quality Education for a Healthier Scotland Key Figures

7. Quality Education for a Healthier Scotland 20% of Primary Care consultations Up to 50% in Secondary Care High levels of distress and disability 60% also have a diagnosed Long Term Condition 2% of Primary Care patients attend persistently £3.1 billion cost annually in UK

8. Quality Education for a Healthier Scotland What works and what doesn’t?

9. Quality Education for a Healthier Scotland Most health professional encounters involve “expert” and “patient” Problems arise when explanations don’t sit well Tendency for many health professionals to push the same message Frustration when the patient resists explanations Presumption that patient has heard what you’ve said

10. Quality Education for a Healthier Scotland Evidence to support CBT-based interventions (Van Dessel et al 2014) Enhanced generalist care may be helpful (Rosendal et al 2013) Reassurance/Psychosomatic ideas may not be helpful Biopsychosocial perpetuation…(formulation vs diagnosis) Personally relevant, mechanical explanations best (Burton (Ed) 2014)

11. Quality Education for a Healthier Scotland Initial Thoughts

12. Quality Education for a Healthier Scotland Full physical examination Physiological aspects of the explanation: Pain Mechanisms (sensitisation) Gut Motility Vestibular aspects of dizziness

13. Quality Education for a Healthier Scotland What not to say...and why

14. Quality Education for a Healthier Scotland “Good news, there’s nothing wrong with you!” “The results of the tests have ruled out anything bad” “There is not much we can do with these symptoms” “There could be psychological reasons for all this” “I’m not sure your symptoms are as bad as you say” “I’m going to refer you one more time for reassurance” “You’re absolutely fine, it’s going to be ok”

15. Quality Education for a Healthier Scotland How do we avoid this?

16. Quality Education for a Healthier Scotland Perpetuating Factors

17. Quality Education for a Healthier Scotland Perpetuating factors - Cause vs Perpetuation Consequence of how symptoms are interpreted: Avoidance of activity Low mood and anxiety Create “vicious cycle” – not a cause, but maintenance Consequences add to the suffering of the patient

18. Quality Education for a Healthier Scotland

19. “So what do you notice when you’re doing less?” “How hard is it to cope when you feel down?” “How can you end up feeling with these worries?” “What’s happened to your motivation?” “So one thing affects another, affects another?”

20. Quality Education for a Healthier Scotland Good way to validate the patient experience Can be used to identify intervention strategies Reflect on success of trying to look for cause

21. Quality Education for a Healthier Scotland Move away from psychological cause Don’t expect to do it all in one session Personally relevant explanations including physiological elements Recognise the difference between cause and perpetuation Reject, collude or empower?

22. Quality Education for a Healthier Scotland “...complex interactions of physiological and cognitive processes...” Neither simple disease syndromes nor a general somatisation disorder are adequate to describe the diversity seen in primary care. Somatisation is too restrictive a label; ‘functional somatic symptoms’ is a more appropriate term.” -Burton, 2003

23. Quality Education for a Healthier Scotland Core Communication Skills

24. Quality Education for a Healthier Scotland Demonstrating genuine empathy Checking you understand the patient Summarising the information provided Reflecting on what has been said Validating what the patient has said Checking the patient has picked you up correctly Getting personally relevant information to use

25. Quality Education for a Healthier Scotland How can we enable GP trainees to do this?

26. Quality Education for a Healthier Scotland Mapping to RCGP Curriculum

27. Quality Education for a Healthier Scotland CompetenceComponentRationale 1. Primary Care Management 1.2.3 Develop the clinical skills you need in history-taking, physical examination and the use of ancillary tests for diagnosis 1.2.4 Develop the skills you need in therapeutics, including drug and non-drug approaches to treatment 1.5.1 Develop your communication skills for counselling, teaching and treating patients and their families/carers 1.6.1 Develop and maintain a relationship and style of communication that does not patronise but treats your patients as equals The purpose of the MUS Toolkit is to provide users with the skills to enable them to develop a shared understanding with their patient to provide them insight into their patient’s experience of their condition and ultimately manage their symptoms within primary care/enable the patient to self- manage appropriately. 2. Person-centred care2.1.3 Master patient illness, sickness and disease concepts 2.2.1 Adopt a patient-centred consultation model that explores your patient’s ideas, concerns and expectations, integrates your agenda as a doctor, finds common ground and negotiates a mutual plan for the future 2.3 Use your skills and attitude to establish a partnership The Toolkit promotes a patient-centred approach through the use of approaches such as person-centred statements and open questions which should help the GP and their patient establish a partnership. This approach should also assist the co- development of a management plan.

28. Quality Education for a Healthier Scotland SectionStatementsLink to MUS Toolkit 3.01 Healthy people: Promoting health and preventing disease 2.5 Negotiate a shared understanding of problems and their management (including self-management), so that patients are empowered to look after their own health and have a commitment to health promotion and self- care 2.6 Encourage patients, their carers (and family when appropriate) to access further information and use patient support groups The MUS toolkit seems to fit well with aspects of person-centred care outlined in these clinical statements due to its emphasis on the use of a shared understanding of symptoms. In addition, the toolkit encourages GPs to support their patients to self-manage their conditions. 3.05 Care of Older Adults1.9 Have an organisational approach that allows easy access to the primary healthcare team for older people, appropriate timing of appointments and the systematic management of chronic conditions and co-morbidities 2.5 Have appropriate communication skills for counselling, teaching and treating patients, their families and carers, recognising the difficulties of communicating with older patients including the slower tempo, possible unreliability or having to rely on the evidence of third parties The toolkit may have special relevance for elderly patients who tend to present with more LTCs.

29. Quality Education for a Healthier Scotland COT Performance Criteria

30. Quality Education for a Healthier Scotland PC1 The doctor is seen to demonstrate empathy, warmth and genuineness towards the patient PC3 The doctor is seen to explicitly elicit the emotional, cognitive and behavioural effects of physical symptoms PC5 The doctor is seen to bring information about the consequences of persistent symptoms together to demonstrate a “vicious cycle” PC6 The doctor is seen to help the patient draw conclusions about the “vicious cycle”, exploring the likelihood of further investigations being effective, and the rationale for self management

31. Quality Education for a Healthier Scotland Barriers to Implementation

32. Quality Education for a Healthier Scotland Believing that referral is a good way of providing reassurance Believing that referral is an effective management strategy when under pressure

33. Quality Education for a Healthier Scotland How can you address these barriers?

34. Quality Education for a Healthier Scotland Provide opportunities to master core communication skills Highlight benefits of being able to manage people with MUS within primary care Encourage use of approaches suggested within practice in manageable bite size chunks -use additional resources, where necessary Use of videos embedded within PESTO Observation of other’s consultations

35. Quality Education for a Healthier Scotland Key Points to Emphasise

36. Quality Education for a Healthier Scotland You can’t do everything Personally relevant explanations can be therapeutic Providing physiological pathways may help Keeping and re-appointing the patient can help No one is advocating the “T” in CBT… The trials of moving from “diagnosis” to “formulation” Without core communication skills there’s little point...

37. Quality Education for a Healthier Scotland Parting Thoughts...

38. Quality Education for a Healthier Scotland How are you going to address this with your trainees? Think of one way you can change the way you approach MUS with your trainees How are you going to do this (think SMART) If that approach doesn’t work what will you do?

39. Quality Education for a Healthier Scotland Questions?

40. Quality Education for a Healthier Scotland

41. 1. ABC of Medically Unexplained Symptoms. Burton (Ed). 2013. Wiley-Blackwell. 2. Health Behaviour Change (2 nd ed.). Mason, P. & Butler, C. (2010). 3. Overcoming Functional Neurological Disorders – A Five Systems Approach. Williams, C. (2011). Hodder Arnold 4. Deary, V., Chalder, T. And Sharpe, M. (2007). The cognitive behavioural model of medically unexplained symptoms: A theoretical and empirical review. Clinical Psychology Review, 27, 781- 797. 5. Rosendal M, Blankenstein AH, Morriss R, Fink P, Sharpe M, Burton C. (2013). Enhanced care by generalists for functional somatic symptoms and disorders in primary care (Review). The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

42. Quality Education for a Healthier Scotland Contacts: David Craig NES Psychology Directorate 2 Central Quay 89 Hydepark St. G3 8BW david.craig@nes.scot.nhs.uk Deirdre Holly NES Psychology Directorate 2 Central Quay 89 Hydepark St. G3 8BW deirdre.holly@nes.scot.nhs.uk