The consultation as a liminal space – understanding what happens in extended role GP consultations for persistent physical symptoms

Problem

GP consultations normally fit a pattern which is appropriate for diagnosing common diseases, but may fall short of fulfilling the needs of patients presenting with persistent physical symptoms (PPS). Evidence suggests that patients with PPS make repeated GP visits, the outcome of which are unsatisfactory to both the patient and the GP.

Approach

The Symptoms Clinic is an extended-role GP intervention, comprising an initial 45 minute consultation and 3 further 15 minute consultations, based on 4 elements: Recognition; Explanation; Action; and Learning (REAL). It is being tested in an ongoing randomised controlled trial: Multiple Symptoms Study 3.

A process evaluation is embedded within the trial, to examine how the intervention works in practice, and what processes and mechanisms appear to lead to better outcomes. 68 consultations (17 sets), 17 patient interviews and 6 GP interviews have been analysed, using an inductive qualitative approach.

Findings

Here, we use the idea of liminal space, “betwixt and between” worlds (such as daily life and a conventional GP appointment), to understand what happens in the Symptoms Clinic. Our findings suggest that by breaking conventional norms, the extended consultation becomes a liminal space, where customary roles are put aside and transformations are made possible.

In the recognition phase of the intervention, GPs established the possibility of a liminal space. Extended time and active listening allowed the patient’s story to be recognised and their experiences validated. Explanation then used this space to create something new. The GPs worked with patients to construct an acceptable, recognisably medical explanation, usually in terms of somatic and neuro-psychological function. By explaining “unexplained” symptoms in appropriate language the GPs appeared to free patients from the responsibility for causing, or finding the cause of, their symptoms. These explanations were offered as possible, even speculative, rather than definitive, as the GP invited the patient to negotiate or co-construct the explanation. Actions and learning followed from the explanation, and again, were co-constructed with the patient.

The liminal space observed within these consultations appears important in allowing patients to explore new ways of thinking and doing, without the risk of failure. While all patients described the consultations as giving them time, those who perceived a benefit described a process that had given them new understandings of, and “tools” to manage, their symptoms as they moved forward.

Consequences

By bending the rules of normal GP consultations, and applying the REAL elements, extended role GPs are able to create a liminal space in which to reframe their symptoms. While it is tempting to think patients are looking for certainty, it appears that indefinite but plausible explanations in this liminal space are both possible and possibly therapeutic.