Project objectives

At least a third of primary care consultations and up to half in secondary care are for ‘medically unexplained symptoms’ or presentations where it is not possible to make a clear diagnosis of a physical disease.

Medical students currently get very little formal teaching about how best to manage such patients. This may result in them as newly qualified doctors ordering inappropriate and costly investigations or referrals in order to exclude serious diagnoses, which may cause increased anxiety in patients, frustration in clinicians and physical harm from unnecessary investigations.

A group of academic GPs at UCL run successful teaching sessions for fourth year medical students about this topic. More recently this was extended to teaching seminars for Foundation Year (FY1/FY2) junior doctors, which were very highly rated in terms of both factual knowledge and practical usefulness. This has informed this proposal which has 4 components:

1. To use qualitative in-depth interviews to explore the experiences of FY1 and FY2 junior doctors in managing patients without clear organic pathology, and their views on what influences their decision to investigate and/or refer them on and what the challenges and difficulties are in working with this group of patients;
2. To identify what training the FY1/FY2 junior doctors may have already received in this topic and how this may fit or otherwise with their perceived learning needs and what educational methods would be helpful and acceptable to them at this point in their careers;
3. To survey the Directors and Training Supervisors of the national Foundation Schools within the UK Foundation Programme responsible for training junior doctors at this level, to establish what teaching is currently being offered in this topic;
4. To convene two or three stakeholder workshops consisting of representatives from the Foundation Schools nationally, educationalists interested in the topic of medically unexplained symptoms, FY1/FY2 junior doctor and service user representatives;
5. As a result of these discussions to develop a set of course materials, a training manual and tutor training materials and pilot this during our NE Thames FY1/FY2 seminars in 2014/15. 

Changes to project objectives

The project was conducted as described in the original proposal except that due to time constraints we only conducted one half day educational workshop rather than two or three as in the original proposal. This took place on the 22nd May 2015 and was very successful, resulting in several constructive suggestions for developing a future educational intervention.

Because of a delay in approving funding and starting this project we had to deliver our spring 2015 training session to local FY1/FY2 trainees before the educational workshop held in late May to discuss the amended training materials - due to time-tabling constraints the latest available date for the local training session was the 9th April. We modified the materials for this session in light of the results of the qualitative interviews with FY1 and FY2 doctors as above, and focused more on the principles of management of patients presenting with MUS and the provision of effective explanations when no significant organic pathology has been identified. The session was very well received and highly rated by the participants, but further work is required to follow up the suggestions made at the educational workshop to produce video vignettes to demonstrate various aspects of the training. This was not budgeted for in our original proposal. 

Brief summary

(a) Qualitative Interview Study

Methods

The research assistant (RA) conducted in-depth interviews with a sample of Foundation Year (FY1/FY2) newly qualified doctors to elicit their views about the investigation and management of patients where it is not possible to make a clear diagnosis of a physical disease, and the impact which working with such patients may have on them. She purposively sampled for maximum diversity from all groups according to gender, age and ethnicity. The FY1/FY2 doctors were selected from clinicians currently working in a variety of clinical disciplines in north central London in both tertiary level Teaching Hospitals and secondary level District General Hospitals. Participants were offered a £20 book token to compensate them for their time. All participants were interviewed using a topic guide, with in-depth interviews to explore their attitudes and feelings towards patients they have seen where it was not possible to make a clear diagnosis of a physical disease.

Participants were asked what was likely to influence their decision to order investigations or refer the patient for a further opinion, as well as what might influence them to investigate and/or refer less and potential alternative strategies for managing such patients. We also investigated the emotional impact of looking after such patients. They were asked about any prior education which they had received in this field and what unmet needs they perceived as important in any further training. The RA employed the topic guide developed by the research team, with reference to outputs from previous and current work in this field and modified as required as data was collected and analysed. All interviews were digitally-recorded and transcribed. Interviews continued until data saturation – which we anticipated would happen at about 15 to 20 interviews.

The interview transcripts were analysed thematically using a ‘framework’ approach. This method of charting and analysing qualitative data was used successfully in our earlier related study with GP registrars and a more recent study with hospital clinicians. The overall interpretation of meaning and explanations was developed and the implications considered with input from the entire qualitative project team. The interpretation and analysis remained grounded in the data collected at all times.

Findings and Conclusions

Participants were recruited from three North Thames London hospitals within the UK and twenty-two junior doctors undertaking the UK foundation two-year training programme (FY1/FY2) were interviewed. The data was analysed using the Framework method and the five co-authors of the resulting publication acted as independent reviewers in both the systematic data organisation and theme identification stages of analysis.

The junior doctors interviewed identified a significant gap in their training on the topic of MUS, particularly in relation to their awareness of the topic, the appropriate level of investigations to carry out, possible psychological co-morbidities, the formulation of suitable explanations for patients’ symptoms and longer-term management strategies. Many expressed feelings of anxiety, frustration and a self-perceived lack of competency in this area, and spoke of over-investigating patients or avoiding patient contact altogether due to the challenging nature of MUS and a difficulty in managing the accompanying uncertainty. They also identified the negative attitudes of some senior clinicians and potential role models towards patients with MUS as a factor contributing to their own attitudes and management choices. Most reported a need for more training during the foundation years, and recommended interactive case-based group discussions with a focus on providing meaningful explanations to patients for their symptoms.

(b) Survey of Training Provided by Foundation Schools in This Area

Methods

Our RA obtained the names of the Directors and approved Foundation Programme Training Supervisors (FTPs) at all the Foundation Schools throughout the UK which provide protected training time for FY1/FY2 junior doctors, and sent them a questionnaire asking whether they currently provide any training for their trainees in the areas of ‘medically unexplained symptoms’ and/or ‘avoiding over investigation of patients' during the protected time offered for educational purposes. Dr Joe Rosenthal who is an approved North Central Thames Foundation School Training Supervisor has taken a leading role lead on this component.

If they provided any such training we asked them to give details about the length of time spent on these topics, a brief summary of the content of the teaching provided and teaching methods used, as well as any participant evaluation or feedback which they may have received. The RA developed this web-based questionnaire under the supervision of the research team and was responsible for sending it out by email and collating the responses Reminder questionnaires were sent after two weeks to non-responders. We also asked respondents whether they were interested in attending the workshop(s) which we planned to hold to discuss the results of both the qualitative interviews and the questionnaire survey and the content of a planned educational intervention.

Findings and Conclusions

The web-based questionnaire survey (termed an ‘expert consultation exercise’) was administered to 160 FTPs across England, Wales and Northern Ireland, with 53 sites (33%) responding. Only 6/53 (11%) of Programme Directors responding to the questionnaire reported any current provision of formal teaching about MUS within their training programmes. However, the majority recognised the importance of providing such teaching and recommended 2-3 hours of teaching per year, predominantly as case-based discussions.

(c) Workshop(s) to Develop the Intervention

Methods

We originally planned to organise a series of two or three half-day workshops involving representative stakeholders, to include members of the North Central Thames Foundation School and other interested Foundation School members throughout the UK, educationalists with an interest in MUS, interested FY1 and FY2 doctors and service user representatives. Because of time constraints we only held one workshop in May 2015, but this was very successful.

The aim of the workshop(s) was to discuss and synthesise the findings from the earlier components of this programme of work – i.e. streams (a) and (b). From the synthesis of all the evidence and the stakeholder views obtained at the workshops, we planned to determine the recommended core components of an educational intervention for FY1 and FY2 junior doctors, aiming to help them to work effectively with patients with medically unexplained symptoms and to reduce inappropriate investigations and referrals for such patients, as well as helping them to communicate effectively with such patients.

Findings and Conclusions

The expert consultation workshop was held on the afternoon of the 22nd May in central London and thirteen people attended, including two Programme Directors, six GP educationalists, one medical sociologist, two FY2 junior doctors and two research associates representing four medical schools across the UK.

The workshop attendees suggested that training about the management of patients with MUS at Foundation Year level should consist of two separate two-hour teaching sessions. The first introductory session during the first year post-qualification (FY1) should provide more factual content as a background to the topic, give definitions for the term MUS, and raise awareness about the topic from both a patient and clinician perspective, with data to illustrate the clinical and economic implications for patients, clinicians and health services. The topic should then be revisited during a second session in the second year post-qualification (FY2), with more emphasis on discussions about clinical cases or issues that participating doctors had experienced and the opportunity to discuss examples of suitable psychological and physiological explanations for common symptom presentations. Fear of litigation was also considered as a potential significant source of anxiety for new doctors, and the importance of addressing any such concerns emphasised.

It was also thought important to raise awareness about the different attitudes, both helpful and unhelpful, which junior doctors might encounter from their senior colleagues concerning patients with unexplained symptoms, with encouragement to reflect on the potential impact of these attitudes on their own views and resulting management choices. Due to its relevance to most specialties, it was suggested that some reference to MUS should be made wherever appropriate throughout the Foundation year postgraduate educational sessions, although there was recognition that this might be difficult to implement in practice.

An innovative idea proposed by workshop attendees involved the inclusion of video vignettes to illustrate various doctor-patient interactions. These could be used to show positive and negative examples of role modelling with regard to MUS, the delivery of effective explanations for common presentations, and to show the lived experience of MUS from the perspective of the patient. Case-based group discussions, role-play and one-to-one supervision sessions were also recommended. The preference was for face-to-face teaching to allow for the discussion of clinical cases, but the development of an E-learning module incorporating the various suggestions and including relevant video clips would also be possible.

(d) Development and Piloting of Training Materials

Methods

We aimed to develop full course materials, a training manual and tutor training materials for the proposed educational intervention for FY1/FY2 clinicians. We planned to use some of our existing materials from previous medical student, FY1/FY2 and GP registrar teaching sessions as a basis for this new course, but to modify them as a result of the feedback from the various components of this project. We anticipated that case based discussion is likely to be a more prominent part of the training offered to the FY1/FY2 doctors than to medical undergraduates and hoped to pilot this educational intervention with North Central Thames Foundation School FY1/FY2 trainees in the spring of 2015.

Findings and Conclusions

Because of a delay in approving funding and starting this project we had to deliver our spring 2015 training session to local FY1/FY2 trainees before the educational workshop held in late May to discuss the amended training materials - due to time-tabling constraints the latest available date for the local training session was the 9th April. We modified the materials for this session in light of the results of the qualitative interviews with FY1 and FY2 doctors as above, and focused more on the principles of management of patients presenting with MUS and the provision of effective explanations when no significant organic pathology has been identified. The session was very well received and highly rated by the participants.

Further work is however required to follow up the suggestions made at the educational workshop to produce video vignettes to show positive and negative examples of role modelling with regard to MUS, the delivery of effective explanations for common presentations, and the patient perspective. We think that these were very constructive suggestions which would be well worth pursuing, but which would require additional time and resources to that provided within this one year project. We would hope to subject the intervention when developed to an evaluation which would assess the views of both junior doctors and patients about its effectiveness, as well as more objective outcomes such as any reduction in the level of unnecessary investigations and patient re-attendances.

Our study has highlighted an urgent need to improve postgraduate training about the topics of MUS and avoiding over-investigation, as current training does not equip junior doctors with the necessary knowledge and skills to effectively and confidently manage patients in these areas. Training needs to focus on practical skill development to increase clinical knowledge in areas such as delivering suitable explanations, and to incorporate individual management strategies to help junior doctors tolerate the uncertainty associated with MUS.

Details of two resulting publications (one published and one submitted) are given below. 

Plain English summary

Medical students and junior doctors currently get very little teaching about how best to manage patients with medically unexplained symptoms (MUS) with no significant physical cause. This may lead to newly qualified doctors ordering inappropriate and costly investigations or referrals in order to exclude serious diagnoses and may cause frustration in clinicians and significant anxiety in patients, with possible harm from unnecessary investigations.

We conducted a study in several parts, aiming to develop an effective educational intervention to improve junior doctors’ knowledge and skills in this area.

The first was a qualitative study with in-depth interviews with 22 doctors in the two-year UK foundation training programme (FY1/FY2) recruited from 3 north London hospitals. Interviewees identified a significant gap in their training about MUS, particularly in relation to their general awareness of the topic, the appropriate level of investigations, possible psychological co-morbidities, provision of suitable explanations for patients’ symptoms and longer-term management strategies.

The second part was a web-based survey of Foundation Training Programme Supervisors (FTPs) responsible for training these junior doctors. The questionnaire was sent to 160 FTPs nationally, with 53 sites (33%) responding. Only 6/53 (11%) of respondents reported any formal teaching about MUS within their training programmes, but most considered such teaching important and recommended providing 2-3 hours of teaching per year.

The third was a half day expert consultation workshop to discuss these findings and how to implement them in the proposed educational intervention. It was attended by two FTPs, six GP educationalists, a medical sociologist, two FY2 junior doctors and two research associates. They suggested that training about MUS at Foundation Year level should consist of two separate teaching sessions, one in each year of the Foundation training, with specific recommendations about the content and delivery of the educational intervention.

The planned last part involved producing course materials for this intervention to be piloted during a local FY1/FY2 seminar in 2015. Because of project delays we were only able to develop the training materials with reference to the results of the qualitative interviews, but the resulting teaching was very well received. Further work is required to follow up suggestions from the workshop to produce video vignettes demonstrating various aspects of the training.

Our study highlights an urgent need to improve Foundation Year training about MUS, as currently junior doctors are unlikely to have the knowledge and skills to effectively and confidently manage patients with such presentations. 

Dissemination

Published articles

1. Yon K, Nettleton S, Walters K, Lamahewa K, Buszewicz M. Junior doctors' experiences of managing patients with medically unexplained symptoms: a qualitative study. BMJ Open. 2015;(5)12:e009593 doi:10.1136/bmjopen-2015-009593.
   http://bmjopen.bmj.com/content/5/12/e009593.full

Submitted articles

1. Yon K, Habermann S, Rosenthal J, Warner A, Walters K, Nettleton S, Lamahewa K, Buszewicz M. Medically unexplained symptoms: current and recommended teaching for newly-qualified doctors in the United Kingdom. Under review with Medical Teacher, November 2015. 

Public involvement

Our initial proposal had a fairly limited service user component as the focus of the project was the qualitative study examining the views of Foundation Year doctors about managing patients with MUS, establishing what training they currently receive about this topic and developing an educational intervention to improve their knowledge and skills in this area.

We had planned to invite service users with MUS to the stakeholder workshop(s) to discuss the format and content of the educational intervention, but decided on reflection that it would probably be very difficult for two or three service users to orientate themselves with the results of the previous research sufficiently to be able to contribute effectively at this stage and that it would make more sense to recruit service users to participate and comment from the beginning of the next stage of the proposed research – i.e. the production of the materials required for the educational intervention including video vignettes demonstrating the lived experience of MUS from the perspective of the patient.

We have identified several potential service user collaborators from a separate PhD project on the outcomes of MUS in patients identified in primary care (Kethakie Lamahewa supervised by Marta Buszewicz and Kate Walters) and would seek adequate funding for them to be properly reimbursed for their time and expertise in any future work. 

Impact

We have had one paper accepted by BMJ Open which should reach a wide general readership and another with a more educational focus under review with Medical Teacher.

The results of the qualitative research project were presented at the 2014 Annual Scientific Meeting of the Society of Academic Primary Care conference in Oxford – Yon K, Nettleton S, Walters K, Rosenthal J, Warner A, Sumathipala K, Buszewicz M, ‘Developing an educational intervention for junior doctors at FY1/FY2 level working with patients with medically unexplained symptoms (MUS) – and stimulated plenty of discussion.

The project has also been advertised via a UCL Primary Care and Population Health departmental blog: http://blogs.ucl.ac.uk/pcph-blog/2015/08/18/do-junior-doctors-at-foundation-level-receive-sufficient-training-about-patients-presenting-with-physical-symptoms-with-no-clear-organic-basis/

We have informed the Medical Director of Health Education England, Professor Wendy Reid, about the study and our conclusions. We are also planning to give a presentation to the National Foundation School Directors forum as suggested by our local Postgraduate Dean Professor Tim Swanwick, with a view to encouraging as many Foundation School Directors as possible to facilitate training in this topic within their Foundation Year programmes. 

This project was funded by the National Institute for Health Research School for Primary Care Research (project number 217)

Department of Health Disclaimer

The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR School for Primary Care Research, NIHR, NHS or the Department of Health.