The careful assessment tool for managing patients with medically unexplained symptoms – The experience of Slovenian family medicine trainees: A qualitative study

This was a qualitative study. We used semi-structured coursework surveys, done by Slovenian FMT, during their MUS module (part of their specialisation program).

Such a qualitative study means research determining the selection, collection, and analysis of data during the research process (21, 22, 23). The collected material was processed using qualitative content analysis (22, 24).

Coursework surveys done by 184 Slovenian FMT from seven module groups (groups 17–23) were analysed. These trainees examined a total of 702 patients with MUS between 2016 and 2018 within the MUS training module (part of the mandatory training within the family medicine specialisation). All of the 184 FMT completed their coursework, partly or in total, and responded to closed-and open-type questions in the “Feedback on Careful Assessment Use” questionnaire. The open part of the questionnaire was composed of five essay-type questions answered by the respondents in writing (Table 2).

The content and program contained in the assignments for family medicine trainees were approved by the holder of the modular part of the specialisation, the Department of Family Medicine, Faculty of Medicine, University of Ljubljana.

FMT who took part in the study came from different regions of Slovenia (Table 3), which allowed us to obtain a broad sample.

During the MUS module, FMT become familiar with the problem of identifying and recognising MUS patients, and among other skills master the practical use of the “Careful Assessment” tool for identifying and treating MUS in family medicine practice. Their assignment was to find 3 to 5 patients with MUS and to use the “Careful assessment” tool and test the newly acquired knowledge and skills in practice. The patients were identified based on the inclusion criterion for identifying patients with MNS presented in the module (Patient Health Questionnaire (PHQ-15) value ≥15 points and an additional three criteria: that the symptom is present for at least three months, that the symptom causes clinically significant problems and that symptoms cannot be explained by a known physical illness).

Manual coding (25) was used for qualitative content analysis. The respondents’ answers were analysed in accordance with the research questions, and codes were prepared and subsequently combined into categories (higher-level codes) that could be logically linked and methodically described. Coding was performed by two independent coders (V.I. and A.M.). When they failed to reach agreement on the coded text, an intercoder agreement was attempted on the differently perceived parts of the analysed text in order to match the created category (also known as the unitising process) (26).

In terms of its multi-purpose utility, the “Careful Assessment” tool was seen by the FMT as very useful for managing patients. The tool allowed them to manage the patients systematically and to gain the patients’ trust, as well as to obtain a general understanding of the patients’ histories. Below are some of their statements.

“l believe the tool was very useful. At the beginning, I felt a bit lost because I was overwhelmed by his (the patient’s) problems and medical reports. I often felt that my management was not appropriate, since I was unable to find the main problem. I improved this by using the tool.” (GP 35).

“Very useful. It helped me establish a more trusting relationship with the patient, who then opened up and we were able to slowly reach the triggers of the problems. We needed four months of consultations and the tool enabled us to finally succeed in approaching certain topics.” (GP 5).

The FMT also evaluated the experience of patients favourably, who saw the use of the “Careful Assessment” tool as positive, indicating its general usefulness both for the physician and the patient. The systematic management was considered by the FMT to be the most valuable contribution.

However, certain concerns raised by some FMT pointed to the fact that the “Careful Assessment” tool was useful for the physician, but not so much for the patients, who did not identify the potential cause of their problems during such treatment. Below are two different experiences from respondents.

“For me, “Careful Assessment” meant a structure that facilitated my in-depth dialogue with the patient. It led me to review the patient’s medical records from her childhood, to investigate her susceptibility and to reflect on and ask about the triggers and the patient’s response to them.” (GP 12).

“It was mostly useful for me in terms of understanding the patient’s feelings and problems. The tool was less useful for the patient’s better understanding of their own condition.” (GP 40).

The FMT specifically mentioned some elements of the “Careful Assessment” tool as being useful for better patient management. These included notably enhancing the physician-patient relationship, which is often called into question due to certain systemic problems in the health care system (e.g., overburdening of family physicians). Another useful element was the time available for consultations by means of the “Careful Assessment” tool.

“I was able to deal with the patient comprehensively, like all patients should be if we had the time.” (GP 55)

“In this case, I asked the patient in more detail about her current life situation and its impact on her thinking and experience. I usually do not ask this because normally I do not have the time for an in-depth medical history.” (P35)

Many respondents pointed out that they had succeeded in convincing patients with MUS to start taking better care of themselves and to change certain lifestyle practices, which contributed to the resolution of problems which had been the reason for seeing the physician.

“In this clinical case, the patient’s clinical condition definitively improved, as she started to gain weight, she was feeling better and obtained at least a partial insight into her disease.” (GP 78)

“I believe I improved patient management in this clinical case. There are changes visible, since he started doing something he likes. He feels better on a vegan diet.” (GP90)

In the opinion of the FMT, the tool proved to be generally useful for the physician to find out if the patient’s problems were associated with their psychosocial environment and mental health. Such patients most frequently present as ill, and the “Careful Assessment” tool allowed the physician to find various cognitive or psychological disorders and problems behind the patient’s physical symptoms.

“When concrete problems are manifested, the characteristics and psychological status of the patient coming to the physician’s office with the symptoms of a physical illness should be investigated.” (GP 2).

“I learned that it is highly important to understand the background, since problems also arise from the mental state.” (GP 134)

“I learned that all factors pertaining to MUS should be considered. In this case, triggers (depression, interpersonal relationships) are at the forefront.” (GP 77)

Among the new skills obtained through using the “Careful Assessment” tool for managing patients with MUS, FMT particularly stressed the following: listening to the patient; identifying symptoms and signs within the biopsychosocial model; communication skills; the ability to gain insight into the patient’s history; recognising the psychosocial environment and the patient’s social problems; and the ability to have a faster and better insight into family history. FMT usually focus on the patient’s psychophysical symptoms and often fully neglect the importance of the social environment or so-called external factors. Below are two concrete examples from this category.

“I learned that the patient’s condition and problems should be positioned into a wider context of their life and activities action, i.e., their working and living environment.” (GP 6)

“The tool really contributed to explaining the patient’s symptoms, and this module and the Careful Assessment tool made me see the bigger picture around the patient.” (GP 16)

FMT are convinced that the tool was also seen positively by the patients. The results showed that this sometimes happens during the first consultation, and sometimes later in the process when the patient and physician have built mutual trust and continue on the common path to seek solutions to the patient’s problems. Two examples of this are shown below.

“During the first consultation, the patient was upset, but came back in 10 days saying that she had reflected on her problems and started to see them from a different perspective. She acknowledged that she had many problems in her personal life that she was unable to resolve by herself.” (GP 1)

“First, the patient was surprised by the detailed questions and because new personal topics were discussed; then she opened up and explained her situation in a trusting manner.” (GP 17)

“At first, he would not hear a thing about psychological problems; he was convinced that his problems were physical in nature. Later on, he agreed to reflect on whether the cause of the problems was the family situation, he also agreed to see a psychiatrist.” (GP 19)

“The patient was highly satisfied with the consultation; when we cleared up the issue, she seemed more relaxed and came more rarely to the physician’s office and in a better mood.” (GP 88)

In some cases, the patients had reservations regarding the “Careful Assessment” tool. The FMT highlighted the patients’ lack of trust because they were used to their chosen physician (the trainee’s mentor), which resulted in denial, lack of cooperation and resentment.

“Negative response. She is convinced she is very ill and that activities she could do by herself are just a waste of time.” (GP 54)

“The patient responded very negatively, she refused to discuss her gradual work activation or professional rehabilitation.” (GP 44)

“Negative response; he had distanced himself from his psychological issues as the cause of his problems.” (GP 110) Finally, both types of experience, positive and negative, can be important in the process of improving FMT education and better management of patients with MUS.

In our study we analysed the collected data using quantitative content analysis. The advantage of such a research approach is a detailed insight into the experience of FMT in managing patients with MUS and the use of the “Careful Assessment” tool. The study constitutes the basis for future research in the learning process framework for managing patients with MUS. The findings from the study are also well-suited for improving clinical practice and conducting future studies.

The study itself has some methodological limitations. First, it was a non-random sample of 184 respondents not representative of the physician population in Slovenia. If the findings are to be generalised to all primary care physicians, a larger random sample should be included, in accordance with a pre-set sampling frame. Moreover, in such a case, a survey method would be better.

The study is also limited by the method used. It was assumed that individuals were honest (and objective) when providing their answers, which is not always true. Respondents often provide conformist answers, and it should be noted that they were not paid to participate in the study. A study bias is also often a problem when issues related to people’s health are concerned, which is particularly typical of patients with an MUS diagnosis. It should also be noted that work in primary health care, which normally follows prescribed guidelines, can significantly vary between different organisations. There are also some systemic factors (lack of physicians, overwhelming workloads in some health care sectors, etc.) and differing workloads in different regions in Slovenia, which could significantly affect the validity of the results obtained. Such limitations should be taken into account by future studies.