Constructive explanations: a taxonomy of explanation components for medically ‘unexplained' symptoms

The problem

Patients presenting with medically unexplained symptoms (MUS) are common in primary care. They are often referred for diagnostic testing, which can prove to be costly and unproductive and GPs find it difficult to explain patients' negative tests. A pilot trial of a GP with Special Interest Symptoms Clinic suggested that patients found constructive explanations to be helpful (Study 1). Subsequently, a cohort of specially trained GPs (Study 2) negotiated constructive explanations with patients and used explanations as the basis for proposing helpful symptom management plans. We developed a taxonomy of components of doctors' explanations based on these consultations which offers a framework for describing and evaluating explanations for MUS in further clinical trials.

The approach

We examined and analysed 43 transcribed consultations (16 patients) from the Multiple Symptoms Study 1 and approximately 75 consultations (23 patients) from the Multiple Symptoms Study 2. All consultations involved patients with multiple MUS and were carried out by either the intervention developer (Study 1) or 4 specially trained GPs (Study 2). We identified episodes of explanation for symptoms within Study 1 consultations and classified their core constituent components using a group sort procedure. We tested and refined the resulting classification by applying it to all symptom explanations within Study 1. We then applied the refined model to symptom explanations that were constructed within Study 2 and again refined the data-derived model.

Findings

There were 99 episodes of explanation in Study 1, each with one or more components; analysis of data from Study 2 is currently ongoing. Explanatory components clustered into three categories of Cause, Mechanism and Purpose which constitute separate steps of an explanatory pathway. The causal layer included specific adverse events such as illness and psychosocial triggers, personal dispositions, ordinary processes, and descriptions of uncertainty and complexity. The mechanism layer described physiological and psychological processes which generate or perpetuate symptoms such as central sensitisation, alarm, and avoidance. The purpose layer provides an adaptive rationale which links components, thereby forming a conceptual bridge between causes and mechanisms.Consequence This study examined extended biopsychosocial explanations for patients presenting multiple MUS within medical consultations. These explanations allow symptoms to be discussed and explained in terms of blame-free, adaptive processes which link to symptom management methods or strategies.

Credits

• LaKrista Morton, Northumbria University, Newcastle, UK
• Alison Elliott, Northumbria University, Newcastle, UK
• Jennifer Cleland, Northumbria University, Newcastle, UK
• Vincent Deary
• Ruth Thomas, Northumbria University, Newcastle, UK
• Christopher Burton, Northumbria University, Newcastle, UK