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SOMATIC PRESENTATIONS & THE ART OF REATTRIBUTION

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1 SOMATIC PRESENTATIONS & THE ART OF REATTRIBUTION
Dr. Ramesh Mehay Programme Director, Bradford VTS based on the work of Dr. Linda Gask, Psychiatrist, Manchester

2 A & Os Aims To help you: gain a deeper understanding of patients who somatise and feel better about dealing with them Objectives At the end of this session, you will be able to: define somatisation list the 4 key stages in managing patients who somatise list some practical techniques in each stage which may aid the consultation

3 What is Somatisation? physical symptoms patient Emotional Distress
FLIPCHART “People who experience physical symptoms as a result of emotional distress”

4 Did you know…. Unexplained physical symptoms occur:
General population 80% per week Primary Care 25% Secondary Care 50% So you can’t have a diagnosis all the time! But won’t patients think you’re stupid? Surely that’s what patients want to know? Don’t worry..... You’ll feel better by the end of today’s presentation.

5 This case says it all.... A 27 year old woman had been looked after by one GP throughout her life. Her patents had separated, her father being an alcoholic, and there was some suggestion that she had been sexually abused by her step-father. She herself tended to form abusive relationships with a succession of violent males, her main outlet being frequent consultations with her doctor with bitter complaints of symptoms in a variety of body systems. Although the GP viewed her as one of her “heart sink” patients, and never felt that she was achieving much progress, she managed o contain her with only infrequent symptomatic treatments and simple investigations. Taken from chapter 9, “Somatic Presentations of Psychiatric Disorder”, Hughes Outline of Modern Psychiatry, 4th Ed, Barraclough & Gill (1996)

6 The patient then complained that her pain had actually got worse.
While her usual GP was on holiday she consulted a locum, complained of pelvic pain and in great distress. She was referred to the local gynaecologist. At the hospital, where she saw a succession of junior doctors, various medications were tried to no effect and eventually a hysterectomy was performed. The patient then complained that her pain had actually got worse. A psychiatric referral followed, and a diagnosis of somatisation disorder was made, but the patient was entirely unwilling to engage in any form of psychological treatment and spoke of suing the gynaecologist. Taken from chapter 9, “Somatic Presentations of Psychiatric Disorder”, Hughes Outline of Modern Psychiatry, 4th Ed, Barraclough & Gill (1996)

7 The usual things GPs do:
Reassure Advise Prescribe -eg analgesia, abx, antideps (symptomatic Rx) Refer (to secondary care) % no physical pathology (Bass, 1990) Investigate -eg blood tests, scans, xrays, endosc., laparosc. Operate -proportion of appendicectomies with normal histology (Fink, 1992)

8 Why Deal With Somatisation
Work out some reasons in groups – flip chart Patient reasons best interests of patient:unnecessary Ix, Rx, Tx, ↓iatrogenesis, ↓anxiety ,disability and distress, awareness and thus empowerment, Doctor reasons Hopelessness; “heartsink” emotions → framework, dr shopping/hopping, suing, maintain doctor-patient relationship Family coping with patient, other dynamics Practice/NHS/Society reasons More appointments, inappropriate Ix & Tx: cost savings (>£200 million per year!) FLIPCHART Patient Reasons Trying to do what is in the best interests of the patient Preventing unnecessary investigations, referral and treatment – and hence a reduction of the associated anxiety, disability and distress Preventing iatrogenesis (ill behaviour caused by doctors making the problem organic) Heightened awareness of symptoms and thus empowerment and ability to cope Doctor Reasons To help one avoid feeling a sense of hopelessness by having some sort of framework to work from To prevent “Dr. shopping/hopping” To prevent legal matters being pursued against other health professionals And ultimately maintaining the dr-pt relationship Practice/NHS/Society Reasons Opening up appointments for other patients (by controlling the frequency of attendance of somatisers) To keep costs down by reducing wasteful use of resources – “rationing” – with an overall benefit to practice costs, the NHS resources and Society (in terms of allocating resources where it will do the most good)

9 Let’s get stuck in.... Consultation 1 – lady with abdo pain, 27 y old, recurrent presentations with the same thing! Have a go.... let’s see how you get on Preparation Split groups into manageable sizes of 6-7 PATIENT Identify a GPSTR3 to play the patient -They will play the patient throughout the whole session Brief them about the patient (27y old female abdo pains who has had prev Ix normal) Brief them to read the rounded boxes in the patient instruction leaflet to give them a flavour of the patient they are representing. Ignore all the other instructions. Tell them to “go with the flow” on this first round; respond how they truly feel and NOT to give any clues to the doctor unless the doctor makes a specific line of enquiry FACILITATOR Must let this first round happen without interruption or discussion. Ignore the facilitator instruction sheet for this section. Brief them about the patient (27y old female abod pains who has had prev Ix normal) Explain that if the trainee says “I’d like to do such and such a test and see you again afterwards”, tell them the results were all normal and then get another trainee to carry on the subsequent consultation explaining the normal results, and carry on as they normally would. Explain to facilitator that the reason why they must not encourage discussion is because the rest of the session is based on chunking this session into the four elements of reattribution with role play to practise techniques for each element which they will then be required to facilitate. EXPLAIN TO ALL -Patient is 27y old female with recurrent abdo pains, has been umpteen times, Ix all normal -Uninterrupted consultation which they must try to complete as they normally would. -They have 30 minutes for this exercise.

10 Three Questions (optional)
In groups: How did you get on with this patient? Try also to think of a dysfunctional consultation you have had with a patient with medically unexplainable symptoms. What did you do? Why was it bad from your point of view? (DOCTOR) Why do you think it was bad from the patient’s point of view? (PATIENT) Discuss & Flipchart views By looking at the last two questions, we should be able to formulate a framework to enable us to consult with somatisers in a more comfortable way for both parties. Flip chart to map out themes “By examining negative points, which should be able to make positive themes”

11 (=Acknowledging reality of symptoms)
SKILLS THAT MAY HELP NEUTRALISE FEELINGS MAKING THE LINK BROADENING THE AGENDA (=Acknowledging reality of symptoms) FEELING UNDERSTOOD NEGOTIATING THE TREATMENT DOCTOR REASONS Negative feelings from heart sink patients in general Difficulty in trying to negotiate agendas. I know it is depression – why won’t they just accept it? I don’t believe them - “Haven’t they got anything better to do?” They don’t really have pain! PATIENT REASONS “I know what they all think of me!” Not feeling understood Doctor doesn’t believe me! Doctor decides for me without consulting me Why was it bad from your point of view (DOCTOR REASONS) Negative feelings from heart sink patients in general – exhausting (taking up too much time/resources), feeling of helplessness, waste of money which could be better spent elsewhere Difficulty in trying to negotiate agenda’s. I know it is depression – why won’t they just accept it. “Haven’t they got anything better to do?” They don’t really have pain and why should I help them if they can’t be bothered to help themselves! Why was it bad from the patient’s point of view (PATIENT REASONS) ie put yourself in their shoes Not feeling understood – I have my own health belief system which is not acknowledge or just brushed to one side by the doctor Doctor doesn’t believe me – I do have pain and headaches – they are real! They all think I’m mad or depressed or something. I can tell they (the drs’) prejudge me from their verbal and behavioural cues Doctor decides for me without consulting me

12 GROUP TASK (optional) Why are emotional problems presenting as MUS not always recognised or treated as such? Might be helpful to think in terms of doctor reasons and patient reasons

13 Why are somatic symptoms so difficult to pick up? (optional)
Doctor reasons Skill in detecting cues varies Medical training  organic approach and single diagnosis Concern about missing an organic cause Clouding by the presence of other organic disease Doctor reasons Doctors who are skilled in detection of psychiatric problems elicit twice as many cues from emotionally distressed patients Medical training emphasises an organic approach and single diagnosis Concern about missing an organic cause Medically unexplained symptoms are often missed in the presence of organic disease

14 Why are somatic symptoms so difficult to pick up? (optional)
Patient reasons Patients give little indication that there is anything psychologically wrong Patients may be unaware of psychological basis for symptoms Patients want their physical symptoms to be taken seriously Patients may feel it is inappropriate to discuss psychological difficulties Stigma of mental illness remains very powerful Patient reasons Patients with high scores on psychiatric screens give little indication that there is anything psychologically wrong Patients may be unaware of psychological basis for symptoms – but often NOT Patients want their physical symptoms to be taken seriously and therefore anticipate examination and investigation Patients may feel it is inappropriate to discuss psychological difficulties Stigma of mental illness remains very powerful

15 What doesn’t work.... (optional)
Denying the reality of the symptom Implying imaginary disorder/psychological stigmatisation “they don’t know, but they can’t tell you that. So they say it’s nothing” “it’s not bloody psychological. I’m not off my trolley. She thinks it’s all in the mind” Unresolved explanatory conflict

16 So, if u offer a bad explanation (optional)
to tell them it’s nothing doesn’t wash! they simply lose faith in you and go elsewhere. “I don’t tell her now. I think she’ll just laugh” “I’ll only see him now if it’s an emergency; like the kids or something.” Remember, patients are experts in their own bodies

17 Key Slide: Explanations that do help (optional)
Legitimising the patient’s suffering Removing blame from the patient Helping the patient to understand the problem GP sanctions patient’s own explanation “it’s interesting that you thought it might be irritable bowel when you looked stuff up on the internet. I was think that too….” Tangible mechanism “he explained about tensing myself up so the neck muscles stiffened resulting in the pain” Good explanations maintain the dr and patient link and makes sure you’re both on the same wavelength

18 (=Acknowledging reality of symptoms)
SKILLS THAT MAY HELP NEUTRALISE FEELINGS MAKING THE LINK BROADENING THE AGENDA (=Acknowledging reality of symptoms) FEELING UNDERSTOOD NEGOTIATING THE TREATMENT DOCTOR REASONS Negative feelings from heart sink patients in general Difficulty in trying to negotiate agendas. I know it is depression – why won’t they just accept it? I don’t believe them - “Haven’t they got anything better to do?” They don’t really have pain! PATIENT REASONS “I know what they all think of me!” Not feeling understood Doctor doesn’t believe me! Doctor decides for me without consulting me Why was it bad from your point of view (DOCTOR REASONS) Negative feelings from heart sink patients in general – exhausting (taking up too much time/resources), feeling of helplessness, waste of money which could be better spent elsewhere Difficulty in trying to negotiate agenda’s. I know it is depression – why won’t they just accept it. “Haven’t they got anything better to do?” They don’t really have pain and why should I help them if they can’t be bothered to help themselves! Why was it bad from the patient’s point of view (PATIENT REASONS) ie put yourself in their shoes Not feeling understood – I have my own health belief system which is not acknowledge or just brushed to one side by the doctor Doctor doesn’t believe me – I do have pain and headaches – they are real! They all think I’m mad or depressed or something. I can tell they (the drs’) prejudge me from their verbal and behavioural cues Doctor decides for me without consulting me 18

19 The Art of Reattribution
4 stages (1a) Neutralise your (Dr.) feelings then: 1. Feeling Understood 2. Broadening the Agenda 3. Making the link 4. Negotiating the treatment EXPLANATION You cant do all of this in one consultation. May even take several months of consultations before you can move onto the next stage. Remember, these patients have often had these symptoms for years! How can you expect to change that suddenly? You need to utilise skills and strategies from all stages. Must pay particular attention to ‘feeling understood’. The more info you get, the more you will understand the patient and they more they will feel rapport with you. In addition, the information elicited provides valuable info for the other stages. You need to peel enough ‘layers of the onion’ to give you a flavour of what it is like to “walk a mile” in the patient’s shoes. Don’t expect it to work in all patients. It will work in a significant proportion – much better success rate than an unstructured approach. In this session we are going to go through each of these stages and have the opportunity to practice some of the key skills. Good explanation (ie at the right depth and spiral in nature) is the key to steps 3 and 4

20 The Key Essence of Reattribution
Physical symptoms are linked to psychological issues in a way that patient and doctor find acceptable Approach is patient-led in the sense that explanations fit with the needs of the patient and their beliefs To be able to do the first one, you must do the second.

21 LET’S GO THROUGH THE STAGES

22 How to Neutralise Negative Feelings
Recognise your feelings Inner dialogue vs knee-jerk response CBT approach Actively turning your negative around into a positive Get to know the patient as a person. Focus on something that you like about that person Practising reattribution Shark vs. teddy bear vs. owl: Angry vs. “hugs n kisses” vs. wise intellectual process Recognise your feelings Inner dialogue vs knee-jerk response; awareness is the first step Remind yourself that you are a GP and this is the essence of your job CBT approach Actively turning your negative around into a positive eg “right, I know I feel down when I see them, but at least I’m controlling them from wasteful resources and reducing the anxiety for the patient” or “even though I feel like I’m not doing anything they must be getting something out of seeing me repeatedly” Or you might see them as a challenge that if successful might make you feel good Get to know the patient as a person. Focus on something that you like about that person Practising reattribution Shark vs. teddy bear vs. owl: Angry vs. “hugs n kisses” vs. wise intellectual process ?cutting off your emotional links – different state of mind

23 Feeling Understood History of the PC Respond to emotional cues
Clarification: “can you tell me a bit more about the diarrhoea” Associated symptoms: “any other symptoms when you got it yesterday morning” eg sob, shakey hands “typical day” Specific example: “could you just take me through the last time you had it. What you were doing and where you were so it gives me a sense of what was happening and how it felt” Respond to emotional cues Assess mood: “you seem a bit down in yourself” Assess severity of any depression (biological features) picks up emotional cues ?empathetic statement “so, what’s made you really worried is that….” Patient – tell them we are only dealing with the first segment and the bold black text is what the doctor has on his/her sheet. Again, do not give clues unless the doctor makes an appropriate line of enquiry Doctors – give out the doctor’s instruction sheet. Tell them that if they get stuck with any of the bold text instructions, they can find guidance for the specific case in the rounded boxes. Also tell them to hold onto the doctor’s instruction sheet as it serves the double purpose of being a good handout Facilitators – tell them the bold text is what the doctor has on their sheet. The stuff in the rounded boxes is what they are meant to be achieving and may need guidance from them if they are struggling or come to a standstill. Go through this slide first, explaining each bullet point. Then they role play – abdo pain case Then show the video clip of how it’s done – abdo pain case (Linda Gask DVD) History of the PC Clarification - “can you tell me a bit more about the diarrhoea” Associated symptoms “any other symptoms when you got it yesterday morning” eg sob, shakey hands “typical day” Specific example “could you just take me through the last time you had it. What you were doing and where you were so it gives me a sense of what was happening and how it felt” Responds to emotional cues Assess mood “you seem a bit down in yourself” Assess severity of any depression (biological features) picks up emotional cues ?empathetic statement “so, what’s made you really worried is that….” Summarise what you find Explore social and family factors Explore patient health beliefs/ patients view of the problem Clarify extent of the worry eg 1-10 scale about the cause of the symptoms Does that scale increase when you have the pain? ?previous episodes of other symptoms Brief focussed physical examination For dr reasons – to exclude physical causes For pt reason – to show them that you have taken their symptoms seriously

24 Feeling Understood Explore patient health beliefs/ patients view of the problem Clarify extent of the worry eg 1-10 scale about the cause of the symptoms Does that scale increase when you have the pain? ?previous episodes of other symptoms Explore social and family factors Brief focussed physical examination For dr reasons – to exclude physical causes For pt reasons – to show them that you have taken their symptoms seriously Summarise what you find

25 Remember, all suggestions should be TENTATIVE hypotheses
Broadening the Agenda Go through the three stages of broadening the agenda Feedback results of Ex/Ix It is important to state the abnormalities (eg tenderness) and what you think it is Rather and “all the tests were normal” say “well, we look at several things: your thyroid and blood count were normal. Your liver and sugar tests were okay too” Acknowledge reality of symptoms Even if no physical reason for their pain. Reframing the complaint ie getting them to see their symptoms in a different perspective. Start off by summarizing all their symptoms – physically, psychologically and socially. Then tentatively link them to the life events they’ve told you about. “I wonder whether………” “What do you think?” Remember, all suggestions should be TENTATIVE hypotheses Remind everyone that we are now looking at the second part of their handouts. Feedback results of Ex or Ix carried out BUT ALSO Acknowledge reality of pain or other symptoms - even if no physical reason for their pain “what I found examining you is that you certainly have got pain in the bottom of your spine but you have got good range of movements there as you probably saw yourself. I think you’ve got a fair bit of muscle tension. There are no signs of slipped disc or a trapped nerve” It is important to state the abnormalities (eg tenderness) and what you think it is Reframe the complaint: summarise all the symptoms and suggest link to life events Ie getting them to see their symptoms in a different perspective. Summaries all the symptoms – physically, psychologically and socially and then tentatively link them to the life events they have told you about “can I just go through things with you again. That you had back pain for around 3m. And it started when you were at work when you lifted something but before that you had some pressure from work . You’ve told me that on a typical day that you are not sleeping well and waking in the morning. And that as you’re about to go into work the pain becomes worse esp. at the thought of being over worked and understaffed. And that as the day goes on, the pain gets worse. I wonder whether there is a link between the pain you are feeling, the pressure under work and the fact you are feeling down. What do you think?” It is important that when you explain your ideas to the patient that you do so clearly in a tentative way. Using phrases like “I wonder if”. This gives the patient to give the opportunity to discuss this further so it doesn’t feel like you are dictating down to some one exactly what you feel their problems are about

26 Making the Link ……..between physical complaints and psychosocial problems Toolbox of Techniques How the symptoms might have occurred before during stress How depression can cause pain or lower the pain threshold How the symptoms can make you more depressed: “the vicious cycle” How tension can cause physical pain (good for neck/back pain or headaches) How symptoms can be related to life events Keeping a Record Linking in the “here and now” Significant others ALWAYS Explain: to have physical complaints when you are actually suffering from emotional problems is quite common. These are a compendium of explanations; use these tools appropriately; not all at once! Remind everyone that we are now looking at the third part of their handouts. And that we’re only going to focus on “how depression causes pain” and linking to the “here and now” Show DVD clips of each of these techniques How the symptoms might have occurred before during “stress” Use patients own words. Stress and anxiety might not be acceptable – use words the patient has used. ?pressure, mood “how would it feel if I suggested……….” How tension can cause physical pain “Do you have any idea of what might be getting tight” “?and that tightness might be causing the pain perhaps?” “What we understand is that when you get worried your muscles can get quite tight and tense and when they get quite tense for a while, they can give rise to pain. And that could give rise to your chest pains and even the headaches.” How symptoms can be related to life events “Can I just take you back to the typical day. Are there targets to be met at work? Right….i see. So it is fairly pressurised. I’m a bit concerned how pressurised each day is. Is that something you’ve been concerned about? Certainly with the day time work, that sort of pressure would get anybody's stomach churning and gurgling away and it’s not difficult to see that leading to the stomach pains and diarrhoea.” Keeping a Record “Keep a record of symptoms – times of week when they are more frequent or less frequent. What happens at night time, weekends, evenings after work It would be helpful to do this. Do you think it might be useful? Yeah it might provide us with a better idea of your symptoms and how you are feeling. So if you write down the following Note down the situation where you notice you got some body symptoms like the breathlessness. For example, the last time you had pain : The situation is what were you doing eg walking back from school Who were you with ? On my own When was it – eg in the morning Where were you – outside going up a hill Then just note down what symptoms did you notice eg pressure on chest, sweaty, sob Your mood at the time : what were you feeling eg worried, anxious, down in the dumps” Use a simple tabulated form How depression can lower the pain threshold It can be difficult and sometimes not that useful to use the term depression with patients. But esp. necessary if you feel the depression needs treatment. “looking at you in the surgery now, you seem like you’re quite down to me and that you’ve already told me that you’re not enjoying things. You have also said your concentration isn't that good and the energy is not that great. You also said you’re waking up early in the morning and that your eating is not that great and that you’ve lost around half a stone. What I wonder is therefore behind that pain is some depression which may be contributing to that pain. Have you heard of depression? What do you understand when I say depression?” – explain more as per situation. “you’re symptoms do seem to fit in with what doctors call depression and that is more than feeling just a bit down. I wonder if there is a link between the pain you are getting the depression and sometimes it can become a vicious cycle. And that depression itself can reduce your pain threshold so that pain that you would normally have and normally be able to put up with will feel a lot more severe and you experience a lot more pain” How the symptoms can make you more depressed “the vicious cycle” Might be more acceptable to pts. How the symptoms themselves can make them more depressed. “the pain can sometimes get you very low and get you in a vicious cycle. You get more low and feel more pain. Linking in the “here and now” To link exactly how they feel in the here and now with their experience of symptoms and perhaps to contrast that with how they felt earlier on in the day or some other time in the past week. “I notice that as we are talking about it that you come across as a bit agitated. How are you feeling right now? And I noticed that as we have been talking about what's been going on that you’re feeling some of these symptoms” Significant others For instance friends and family impact on the symptoms 2 strategies : 1) How symptoms and ways of responding to stress may be learned in families. It may be easier to recognise psychological mechanisms occurring in other people. “looking back on it now what sort of things were making your mother tired like that…………. (mum looked after gran etc etc). Mmm” 2) Symptoms experienced by significant others who have serious or life threatening illness may take on a special significance when they experience that symptoms themselves. “I remember that when you first came in one of your concerns was that it might be bowel cancer. Having seen what your mum went through I think you would be very aware of stomach and bowel pains” NOT TO USE ALL THESE TECHNIQUES - use certain techniques at certain times

27 CRUCIAL POINT : Making the Link
GOOD EXPLANATIONS ARE CRUCIAL TO ‘MAKING THE LINK’ they need to be contextualised to the specific case. Match what you say to what the patient has already offered to you in the consultation Use their own words as a starting point eg pressure rather than stress, mood rather than anxiety

28 Negotiating Treatment
Explore pt’s views (of what is needed) Acknowledge pt worries and concerns Amenability to -Antidepressant medication -CBT or other psychological therapies Problem solving & coping strategies Relaxation techniques/Physical Exercise Specific plans for follow up Explain to all that negotiation forms an important part of all consultations and they will get to practise this again and again when they go into GP land. So, don’t worry if they find this bit difficult or if there is not enough time to do it well today Explore patient’s views (of what is needed) “how do you feel about what we’ve talked about today………. Do you feel more relieved? What do you want to do from here then?” There is a range of different things that you can do: Acknowledge patient’s worries and concerns “How much worry do you have now about your symptoms (eg in the sob patient, the asthma). So is there something about doing some more work together to help you to manage the worry and some of the difficulties so that the symptoms become less? Does that make sense?” “one of the ways we could do that is to put a problem list together as to what you see as the main difficulties contributing to your symptoms and see what you would like to see change…..and then we can look together to see how those problems might change by looking at those problem areas” Give examples. “Do you think you would be able to do that, jot them down and bring them to the next surgery.” Problem solving and coping strategies It may be helpful to use simple problem solving strategies alternatively if it is difficult to find a solution, it might be important to look at coping strategies instead. “Can you see any ways of making things easier for yourself? Easing the pressure perhaps? ” Relaxation Esp. for muscle tension leading to pain. Introduce the idea of simple exercises “there are things that you can do in terms of relaxation exercises to help you” Appropriate treatment of depression Specific plans for follow up YOU CAN’T DO EVERYTHING IN ONE CONSULTATION AND THEREFORE FOLOW UP IS IMPT TO SEE WHERE THE PATIENT IS AT AND WHERE TO GO NEXT.

29 Does it work? Yes and no Probably essential first step in engaging the patient Much better than an unstructured approach like most GPs do Yes and no: don’t expect a 100% success rate. More like 30%; remember in some, you may be changing abnormal health behaviour that has been going on for 20+ years! ?Works better in those who haven’t been somatising xxx years.

30 Blacker’s Classification (1991)
Grouped somatisers into three categories: disguisers deniers don’t knows

31 Blacker’s Classification (1991)
Disguisers recognise that they have a psychological complaint but present to the doctor with a physical complaint as a ticket of admission. Deniers tend to resist exploration of psychological issues and often develop chronic somatic illnesses. Don’t knows are aware of emotional or psychological issues, but present with physical symptoms because they are worried they reflect physical disease.

32 Blacker’s Classification (1991)
Whilst reattribution may help with “disguisers” and “don’t knows” dealing with the deniers might prove more difficult. “Deniers” need empathy and full attention given to the possible physical reasons for their symptoms. Usually a long period of building up the relationship with the patient will be necessary, with regular appointments.

33 Managing the “fat-file patient” (optional)
What doesn’t help Blanket reassurance that nothing is wrong Patients don’t want symptom relief, but understanding Challenging the patient – try and agree there is a problem Premature explanation that symptoms are emotional Positive organic diagnosis won’t cure the patient

34 What else can help (optional)
One doctor dealing with the patient Clarifying areas you and the pt agree/disagree on Regular scheduled appointments Clear agenda setting during the consultation Limit diagnostic tests Provide clear model for the pt Involve the patient’s family Don’t expect a cure One doctor dealing with the patient - and ensuring this is communicated to all and the plan that is being proposed so that no one upsets it

35 Dealing with family (optional)
Can be central in maintaining symptoms – what do the family want? Involve family members who come with the patient by: -Reinforcing explanations -Limiting further investigations -Explore their needs (the effect the pt has on the family eg demanding etc)

36 Recent Paper on Reattribution, 2008
Reattribution training increases practitioners' sense of competence in managing patients with medically unexplained symptoms. However, barriers to its implementation are considerable, and frequently lie outside the control of a group of practitioners generally sympathetic to patients with medically unexplained symptoms and the purpose of reattribution. These findings add further to the evidence of the difficulty of implementing reattribution in routine general practice. General practitioners' views on reattribution for patients with medically unexplained symptoms: a questionnaire and qualitative study Christopher Dowrick,1 Linda Gask,2 John G Hughes,1 Huw Charles-Jones,3 Judith A Hogg,4 Sarah Peters,5 Peter Salmon,6 Anne R Rogers,2 and Richard K Morriss7 BMC Fam Pract. 2008; 9: 46.

37 – this is the best way to acquire new skills
Final Note Practise will real patients and videotape yourself Look at what you do Look at them with colleagues and get some feedback – this is the best way to acquire new skills EVALUATION Reattribution is a bit like riding a bike. The first few times you try it, it might not work well: just like the first time you try to ride a bike and fall off a few times. You then sometimes get it right: like eventually managing to ride a bike, but being still wobbly. Then finally it becomes second nature: like riding a bike without having to think consciously – and riding it well. So practise, practise and practise. It will make you working life in terms of dealing with these types of patients much easier and possibly enjoyable.


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