General Hospital Psychiatry 29 (2007) 454–460

Symptom ResearchMore than half of all outpatient visits are trigged by physical symptoms which, in turn, are not adequately explained by medical disorders at least half of

the time. Further, the presence and severity of somatic symptoms often correlate more strongly with psychological, cognitive and behavioral factors than withphysiological or biological findings. Finally, our understanding of the etiology, evaluation, and management of somatic symptoms and functional syndromes isless advanced than our knowledge of many defined medical and psychiatric disorders. This special section, edited by Kurt Kroenke, M.D., will highlightoriginal studies that advance the science and clinical care of somatic symptoms.

Doctors' responses to patients with medically unexplained symptoms whoseek emotional support: criticism or confrontation?

Peter Salmon, M.Sc., D.Phil.a,⁎, Larry Wissow, M.D.c, Janine Carroll, B.Sc.a,Adele Ring, B.Sc., R.G.N.b, Gerry M. Humphris, M.Sc., Ph.D.d,

John C. Davies, Ph.D.e, Christopher F. Dowrick, M.D.baDivision of Clinical Psychology, University of Liverpool, Brownlow Hill, L69 3GB Liverpool, UK

bDivision of Primary Care, University of Liverpool, L69 3GB Liverpool, UKcDepartment of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA

dBute Medical School, University of St. Andrews, Fife KY16 9TS, ScotlandeComputing Services Department, University of Liverpool, Chadwick Tower, L69 3BX Liverpool, UK

Received 10 December 2006; accepted 12 June 2007

Abstract

Objective: Consultations about medically unexplained symptoms (MUSs) can resemble contests over the legitimacy of patients' demands.To understand doctors' motivations for speech appearing to be critical of patients with MUSs, we tested predictions that its frequency wouldbe related to patients' demands for emotional support and doctors' patient-centered attitudes as well as adult attachment style.Methods: Twenty-four general practitioners identified 249 consecutive patients presenting with MUSs and indicated their own patient-centered attitudes as well as adult attachment style (positive models of self and others). Before consultation, patients self-reported their desirefor emotional support. Consultations were audio recorded and coded utterance by utterance. The number of utterances coded as criticism wasthe response variable in the multilevel regression analyses.Results: Frequency of criticism was positively related to patients' demands for emotional support, to doctors' belief in sharing responsibilitywith patients and to doctors' positive model of themselves. It was inversely associated with doctors' belief that patients' feelings werelegitimate business for consultation and was unrelated to their model of others.Conclusions: From the perspective of doctors, speech that appears to be critical probably reflects therapeutic intent and might therefore bebetter described as “confrontation.” Understanding doctors' motivations for what they say to patients with MUSs will allow for moreeffective interventions to improve the quality of consultations.© 2007 Elsevier Inc. All rights reserved.

Keywords: Primary care; Medically unexplained symptoms; Communication

1. Introduction

Many patients present to their general practitioner (GP)with symptoms that the doctor thinks are medicallyunexplained (MUSs). Some doctors complain that thesesymptoms are not legitimate demands on their time or that

⁎ Corresponding author. Tel.: +44 151 794 5531; fax: +44 151 794 5537.E-mail address: psalmon@liv.ac.uk (P. Salmon).

0163-8343/$ – see front matter © 2007 Elsevier Inc. All rights reserved.doi:10.1016/j.genhosppsych.2007.06.003

these patients are impossible to help [1–5]. Patientspresenting with MUSs elicit from their doctor fewer inquiriesinto symptoms and less validation of their concerns ascompared with others [6]. Such patients often describefeeling that doctors do not believe their symptoms ordisapprove of their consulting with them [7–9]. Doctors andpatients therefore often find these consultations difficult andunsatisfying [4,7,10], and they can take on the character ofcontests between patients who seek to engage their doctor in

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addressing their problems and doctors who apparently seekto avoid involvement with demands that they regard asexcessive or illegitimate [8,11–13].

Whereas factors that influence the way that patients withMUSs present to their doctor have been researchedextensively [7,9,13–15], much less is known about thefactors that influence doctors' responses. A coding schemehas been developed and validated, based on previousqualitative analyses [16], to enable detailed quantitativeanalyses of these consultations. Patients' and doctors'utterances are categorized using a set of mutually exclusivecodes. One code is potentially particularly informative aboutthe nature of communication difficulties in these consulta-tions: “doctor criticizes patient” (D-CP). This code refers tospecific statements that could be heard by patients as criticalof something that they have said or done. It is not assumedthat such statements necessarily indicate negative feelingstoward patients. According to sociolinguistic theory,criticism is a means by which a speaker challenges theassumptions that another person seems to bemaking about thepurpose of an encounter or about participants' roles in it [17]and thus seeks to control the ground rules of communication.

Despite previous views that patients with MUSs chal-lenge doctors by seeking physical investigation or treatment,recent research suggested that a more important source ofchallenge is their demand for emotional support [12,13].Therefore, we first tested the prediction that criticism wouldbe elicited most by patients who demand emotional supportfrom their doctor the most and from doctors who believe thatpatients' feelings and emotions are not legitimate materialfor a consultation.

We next examined doctors' attitudes toward their role.Doyal [18] distinguished doctors' automatic accession topatients' requests (which he called “minimal autonomy”)from their readiness to negotiate around or even deny them(“critical autonomy”), arguing that the latter stance com-pensates for the educational, emotional or social constraintsthat prevent patients from making choices in their own bestinterest. Decisions based on critical autonomy are, as Doyal[18] suggested, particularly likely in primary care because ofits continuity of care. If GPs' criticisms reflect their wishto minimize dependence and emphasize patients' responsi-bility for managing problems that doctors cannot solve, weshould predict that doctors who most favor sharinginformation and responsibility would criticize the most.

The doctor–patient relationship is one of a family ofemotional relationships that is likely to be influenced byattachment styles [19,20], and patients' experience ofphysical symptoms and their frequency of interaction withtheir family doctor reflect their own attachment style [21,22].Therefore, our final predictions considered whether doctors'attachment styles influence their readiness to criticizepatients. The attachment theory states that adults' functioningin emotional relationships reflects enduring and generalizedstyles that arise from the experience of caring in childhood[23]. Griffin and Bartholomew [24] described how different

adult attachment styles can be resolved into two dimensionsdistinguishing how positively or negatively individualsregard themselves and others in interactions. A negativemodel of others is associated with avoidance and lack of trust,and a negative model of oneself is associated with feelinganxious about other people. Secure attachment (i.e., positivemodels of oneself and others) is thought to promote empathy,compassion and comfort with emotional closeness [25] and isrelated to parents' sensitivity to children's emotional needs[26] and to mental health workers' sensitive responses totheir patients [27]. We predicted that if criticism is motivatedby seeking patients' best interests by discouraging depen-dence, those with more positive models of themselves andothers would be more likely to make such comments. If, bycontrast, criticism is motivated by doctors' attempts at self-protection from patients' emotional demands, those withmore positive views of themselves and others would be lesslikely to criticize. Therefore, our hypotheses about relation-ships with attachment dimensions were nondirectional. Thedirection of any association will illuminate doctors' motiva-tions for criticism.

2. Methods

2.1. Sample

Fifty GPs from 11 practices with research or educationallinks to the University of Liverpool were asked to take part inthe main study. The practice size ranged from 1 to 10physicians (mean=4.5) and from 2087 to 13,116 patients(mean=7564). Six practices were urban, 4 were suburban and1 was rural. Jarman deprivation scores ranged from −11 to 56(mean=21.3), indicating that the sample was drawn from arelatively deprived section of the UK population [28]. Two to3 years after their participation, they were invited by letter toprovide additional information by completing two ques-tionnaires (see below).

There is no agreed-upon set of research diagnosticcriteria for primary care patients with unexplained symp-toms. Criteria derived from psychiatric diagnoses ofsomatization disorder are problematic because of pooragreement among them or poor discriminating capacity ascompared with psychiatric interviews [29,30], and use ofstandardized instruments can be too restrictive [31]. Ourstudy was concerned with difficulties that patients presentto doctors. Therefore, as reported previously [16], we useda procedure based on that described by Peveler et al. [32] toidentify patients who, based on a doctor's opinion, haveunexplained symptoms. Immediately after each consulta-tion, the doctor completed a checklist to indicate whether(1) the consultation involved the presentation of a physicalsymptom and (2) that physical symptom could not entirelybe explained by a recognizable physical disease. Consulta-tions satisfying these two criteria were regarded asconcerning MUSs. Although it is possible that somesymptoms identified as “unexplained” might prove to

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have a pathological cause, our procedure ensured a groupof patients who have been defined according to theirclinician's belief that their symptoms are not likely to havesuch a cause. Patients younger than 16 years and those whohad participated previously were excluded.

2.2. Recording and coding communication

Each doctor operated a Sony Walkman MZ-R55 minidiscand a Sony ECM-F8 Electret condenser desktop microphoneto record consultations with consenting patients and thencompleted the checklist (see above) after each consultation.Audio recordings of consultations meeting the researchcriteria were identified and anonymously transcribed,including all speech and noting silences exceeding 10 sand simultaneous speech.

Consultations were coded using the Liverpool ClinicalInteraction Analysis Scheme [16], which was developedspecifically for primary care consultations about MUSs. Itcontains 25 and 30 substantive codes for patients and doctors,respectively. The unit of coding is an “utterance,” definedpragmatically as a piece of speech that has sufficient meaningto be coded. Coding was carried out by A.R.; 16 transcriptswere also coded by C.D., G.H. and P.S. to confirm thereliability of coding, as reported previously [16]. Only thespeech category coded as D-CP was considered in the presentstudy. It is defined as a comment that indicates or impliescriticism or contradiction of a patient's actions or statementsor that the patient is in error; examples include the following:

“I think you're reading more into those symptoms thanyou ought to.”“There's no point talking your way round things.”“I don't think you should just get a prescription and makeyour own mind up without letting us know first.”

Its reliability was 0.71, indicated by the analysis ofvariance intraclass correlation, with the four coders regardedas a random factor. Codes are decided on from the per-spective of the listener, and the coder makes no assumptionabout a doctor's intentions. The manual providing full detailsof the coding scheme is available from the authors.

2.3. Questionnaires

Before consultation, each patient completed the 22-itemversion of the Patient Request Form [33]. It provides scoresfor three major types of help that patients seek from their GPs(i.e., the patients' intentions): medical investigation andtreatment; explanation and reassurance; and emotionalsupport (the desire to talk to their doctor about emotional orother problems). Our prediction concerns the support scale.As described previously [13], raw scores were recoded tovariables ranging from 0 to 2 and then standardized to a meanof 0 and a standard deviation of 1. Patient age, patient gender,GP gender and GP seniority (number of years since qual-ifying as a doctor) were noted as potential control variables.

GPs completed two questionnaires. The Patient–Practi-tioner Orientation Scale [34] has nine items for each of two

subscales measuring aspects of patient centeredness: beliefthat a patient should have information and be a partner indecision making (sharing) and belief that the patient'sfeelings are important in the consultation (caring). TheRelationship Questionnaire [24,35] is composed of four briefvignettes describing prototypical adult attachment styles asevidenced in peer relationships. It is brief, less susceptible toself-deceptive bias as compared with other popular measuresof adult attachment style [36], has demonstrated externalvalidity [37] and is acceptable to GPs. Respondents rated, ona scale of 1 to 7, how well they corresponded to eachvignette. Scores for positivity of models of self and otherswere calculated from these.

2.4. Analysis

We first calculated Pearson's correlations among theattachment and patient-centered attitude scales to determinewhether the constructs were independent.

Our dependent variable was the number of occurrences ofthe D-CP code within a consultation. There were threepotential levels of variability: between consultations;between groups of consultations with the same doctor; andbetween groups of doctors working in the same practice.Preliminary analyses showed little variability betweenpractices. Therefore, in the multilevel analyses, we distin-guished variability at the patient (consultation) and doctor(i.e., controlling for clustering by GP) levels. At the patientlevel, the predictor variables were patient gender andintentions. At the doctor level, the predictor variables wereGP gender and seniority, beliefs in sharing responsibility andin caring for patients' emotional feelings, positive model ofself and positive model of others.

The dependent variable was modeled with a log linkfunction and a Poisson sampling distribution assumingconstant exposure. Mixed-effects models were fitted withrandom intercepts and, to avoid the restrictive assumptionthat independent variables should affect all doctors similarly,random slopes. Coefficients from the unit-specific model forthe doctor level were used to test the significance of theindependent variables. Variance components were examinedto indicate the relative magnitude and significance ofvariability among patients and doctors in the mean (intercept)and in the influence of dependent variables (slope).

HLM 6.02a was used for analyses. Patients' and doctors'questionnaires were grand mean centered. The criterion forsignificance was Pb.05.

3. Results

3.1. Sample characteristics

Of the 50 GPs asked to take part in the main study, 42(84%) agreed (22 males and 20 females, with 5–42 years ofmedical experience), at least 1 GP from each of the11 practices from which participation was sought. All theseGPs were subsequently invited to complete the two

Table 1Details of GPs' attitude and attachment scores

Possiblescores

Mean Minimum/Maximum

S.D.

Patient–Practitioner Orientation ScaleSharing 9 to 54 43.5 37.0/47.0 2.5Caring 9 to 54 39.4 33.0/44.0 2.9Relationship QuestionnairePositive model of self −12 to 12 3.0 −2/8 3.3Positive model of other −12 to 12 0.9 −6/8 3.9

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questionnaires. Seven GPs could not be contacted (6 couldnot be traced and 1 had retired), 1 did not respond, 1 refused totake part and 33 agreed, although 4 of them did not completethe attachment scale. Therefore, questionnaires were avail-able for 29 GPs. Of 3508 patients consulting these GPs onstudy days, 98 (2.8%) could not be approached for practicalreasons, 734 (20.9%) were excluded (including 420 children,10 who were consulting for another person, 234 who hadbeen studied or had not consented previously, 30 withcommunication difficulties and 40 who were too ill or wereexcluded by the GP); 2094 (59.7%) patients consented. GPsfailed to complete checklists on 4 (0.2%) patients andidentified 308 as presenting with MUSs. Five GPs did notidentify any patient with MUSs and were therefore excludedfrom analyses. Of the patients with MUSs who wereidentified, 249, consulting 24 GPs, also completed precon-sultation questionnaires and constituted the final sample. Inthis sample, the mean age of the patients was 46.8 years(S.D.=16.7); 87 (35%) were male. Noncompletion of thepreconsultation questionnaire usually occurred when patientshad insufficient time before being called to see the GP. Thesepatients did not differ from those completing the question-naire in either age or gender. The GPs in the final sample had7–28 years of experience (mean=16.5, S.D.=6.3) and 14(58%) were male. The questionnaire scores of the GPsare summarized in Table 1.

Table 2Results of multilevel regression analyses

Coefficient P

Patient variableIntercept −1.11 .014Gender (male=0 and female=1) 0.18 .652Seeking explanationand reassurance

0.07 .701

Seeking emotional support 0.33 .014Seeking investigation and treatment 0.22 .141GP variableGender (male=0 and female=1) −0.00 .993Seniority 0.05 .033Sharing 0.21 .001Caring −0.21 .001Positive model of self 0.17 .001Positive model of other 0.00 .939

Response variable is the number of instances of speech coded as D-CP in each coa The proportionate change in the number of occurrences of speech coded as

3.2. Distribution and interrelationship of patientcenteredness and attachment variables

As might be expected in a GP sample, the doctors'responses on the patient-centeredness scales were high,indicating a predominant belief in sharing responsibility andcaring for patients' emotional needs (Table 1). While therewas a wide range of scores on both attachment scales, scoresfor the model of self were predominantly positive. Attach-ment scale scores were unrelated to patient-centered attitudes(correlations of positive model of self with caring and sharingwere −0.13 and 0.12, respectively; those of positive modelof others were 0.20 and 0.26, respectively; P N.10 for all).

3.3. Relationships with speech coded as criticism

Criticism was recorded in 67 (27.1%) consultations,with a maximum of 16 instances in a single consultation.All GPs made at least one. Results of regression analysesare shown in Table 2. Fig. 1 depicts the relationshipsdescribed in Table 2, showing the cumulative change in thepredicted frequency of criticism as scores on the significantdependent variables increased. As predicted, speech codedas criticism was more likely when patients sought moreemotional support. The corresponding event rate ratio of1.39 indicates that, per unit increase in the score on thedesire for emotional support, the number of instances ofcriticism would be expected to increase by 1.39. Asanticipated, criticism was unrelated to scores on the othertwo intentions measured by this questionnaire — seekingphysical intervention or information and reassurance. In theGP variables, the number of occurrences of criticism wasinversely related to GPs' belief that patients' feelings arelegitimate elements of a consultation (caring) and directlyrelated to GPs' belief in the need to share responsibilitywith the patients (sharing). Criticism was related to one ofthe attachment scales as well: GPs with a more positivemodel of themselves in relationships used this type of

Event rateratio a

95% confidenceinterval

Variancecomponent

P

0.33 0.14–0.77 2.24 b.0011.20 0.53–2.69 2.07 .0011.07 0.73–1.57 0.41 b.001

1.39 1.08–1.80 0.07 .0391.24 0.93–1.66 0.13 .003

1.00 0.53–1.891.05 1.01–1.091.24 1.10–1.380.81 0.72–0.911.18 1.08–1.301.00 0.93–1.07

nsultation.D-CP per-unit increase in the predictor variable.

Fig. 1. Relationship of number of expected occurrences of speech coded ascriticism to the predictor variables at the patient and GP levels. Upper panel:The effect of patients' desire for emotional support (standardized score) isshown for GPs in the lowest and highest quartiles of scores on eachcomponent of patient centeredness. Lower panel: The effect of patients'desire for emotional support is shown for GPs in the lowest and highestquartiles on the degree of positivity of their model of self. Lines show valuespredicted by the cumulative effects of the coefficients shown in Table 2.

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speech the most, whereas their model of others wasunimportant. Criticism was more common in more seniorGPs but was unrelated to GP gender and patient gender.

Variance components indicated the contribution of eachrandom effect to the variance in the number of criticisms.The relatively large and significant variance component forthe intercept was significant, indicating that GPs differ intheir use of criticism for reasons that are not controlled for bythe independent variables that we measured. Variancecomponents associated with patient gender and with theintentions to seek explanation and reassurance as well asinvestigation and treatment were also significant. Thisindicated that although, on average across all the GPs inthe study, these variables were unrelated to the amount ofcriticism, individual GPs showed varying relationshipsbetween these variables and criticism. Nevertheless, thevariance component for seeking emotional support was small

and only marginally significant, indicating that its associa-tion with increased criticism was consistent across GPs.

4. Discussion

Despite previous evidence that doctors can be negativeabout patients with MUSs and that some patients feelcriticized or rejected by their doctor, this is the first study onthe factors influencing doctors' use of speech withinconsultations that had the potential to be experienced ascritical of which we are aware. Patients differed in theamount of criticism that they elicited, with only a minorityeliciting such at all. Although all GPs criticized, they differedin their readiness to do so. The patient and GP variables thatwe measured helped explain some of this variability.

Speech coded as criticism was, as predicted, observedmost in consultations with patients who wanted emotionalsupport the most. As expected, there was no evidence that itwas elicited by their wanting physical intervention. Findingsat the patient level are therefore consistent with theprediction that criticism is a response to patients' emotionaldemands. However, Fig. 1 shows that, alone, patients'demands for support have a modest influence on the totalamount of criticism. Whereas previous work tended togeneralize across GPs about their attitudes toward MUSs,GPs differ greatly in how they experience such consultations[13] and, in the present study, doctors differed in theirreadiness to criticize. Therefore, the highest levels ofcriticism were seen when patients who sought emotionalsupport presented to doctors with specific attitudes or adultattachment styles. As we predicted, doctors who regardedpatients' feelings as outside the legitimate business ofconsultation (low caring) were more likely to criticize.Criticism was more common also in doctors who favoredgiving patients responsibility (high sharing), consistent withour prediction based on the view that doctors use this type ofspeech to reduce dependence. Doctors' belief that patients'emotional feelings are legitimate elements of consultationand their belief in the importance of sharing responsibilitywith patients are both regarded as elements of patientcenteredness [38]. Their opposite relationships with a singletype of speech are therefore consistent with the argument thatpatient centeredness is not a unitary construct [39,40].

That GPs who were least anxious in relationships (i.e.,with a positive model of themselves) criticized the most isinconsistent with arguing that criticism was motivated byself-protection. Instead, this finding is also consistent with itbeing motivated by doctors' belief that patients are bestserved by doctors who resist their dependence. Doctorsdescribe being deterred from contradicting or criticizingpatients who present with MUSs by fears that it will damagethe working relationship [41,42]. Therefore, confidencearising from a positive model of themselves would be neededfor them to do so. That more senior doctors were more likelyto criticize might reflect the greater confidence that would be

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associated with experience. This analysis suggests thatsecurely attached doctors might be suited to primary carenot, as previously suggested, because their security equipsthem for the emotional intimacy associated with long-termrelationships [43,44] but because it provides the confidenceto manage and resist patients' dependence. Indeed, in amental health setting, there is evidence that secure cliniciansare better able to avoid responding to the overt demands ofemotionally dependent patients [27].

Doctors' criticism was unrelated to their tendency to beavoidant in emotional relationships (negative model ofothers). This aspect of doctors' relationship style might notgeneralize to their relationships with patients. Alternatively,the negative finding might mask heterogeneous effects thatdepend on other variables. Precise predictions about theeffects of clinicians' attachment styles will need to be basedon an understanding of patients' styles and that of theinteraction between the two [19].

Our findings are therefore consistent with the theorythat doctors' use of speech that appears to be critical ofpatients with MUSs is elicited by their emotional demands.They are also generally consistent with this behavior beingmotivated not by self-protection in the face of patients'emotional demands but by doctors' sense of patients' bestinterests. From the doctors' perspective, therefore, behaviorthat was coded as “criticism” of patients might be betterregarded as “confrontation,” with the implication that itcan be intended therapeutically.

This study has several limitations. The participatingdoctors were necessarily self-selected as ready to take partin psychological research, and the findings are not necessarilygeneralizable to other doctors. Although we studied a largesample of patients, the sample of doctors was much smaller,and generalization about findings at the doctor level willrequire replication with larger and less self-selected samplesof doctors. There are several ways to measure attitudes towardconsultation and attachment styles, and the modest relation-ships that have sometimes been reported among them mayreflect psychometric weaknesses or situational specificity inthe instruments or definitional problems concerning theunderlying constructs that they putatively measure [45,46].Further research using other measurement procedures isneeded. Other variables that might influence doctors'reactions to patients' emotional demands, including burnout[47], should be examined. If future studies are to have powerto examine the interaction between doctors' characteristicsand patients' demands, recruitment of much larger samples ofdoctors will be needed. The type of speech that we examinedoccurred in a minority of consultations. Future researchshould examine other possible responses to patients' emo-tional demands. A study on professionals' behavior in relationto an intensely emotionally challenging issue — suspectedchild abuse — indicated several responses [48], many ofwhich, including ignoring, offering simplistic advice andoffering support in ways that trivialized patients' concerns,have been observed also in pediatric primary care [49].

It is particularly important to study doctors' conduct ofconsultations about MUSs because these are oftenunsatisfying for both doctors and patients. However, it isunlikely that the processes that we have identified arerestricted to these consultations. Indeed, the key patientcharacteristic that promoted criticism — seeking emotionalsupport from the GP — is not confined to patients withMUSs. The methods that we described could be used tofind out how doctors respond to this challenge moregenerally as compared with patients with MUSs andwhether the effects of doctors' character and attitudes thatwe demonstrated are generalizable.

This study has linked a specific aspect of doctors'behavior with patients with MUSs to characteristics of thepatients and doctors. It cannot show whether this behavioris valuable or harmful in clinical care — which will requirestudies on patients' perception of it and its effect on theprocess and outcome of consultation. However, it isprobably too simplistic to try to categorize any behaviorin consultation as intrinsically a good or bad communica-tion strategy. Since patients with MUSs seek emotionalengagement from their GP [13], our finding that criticismwas a response to such a demand and reflected doctors'unwillingness to consider patients' emotional feelings mightbe regarded as suggesting that it would be destructive toholistic clinical care. However, our proposal that suchspeech is generally deployed to negotiate with patients or toresist demands for emotional support that doctors think areexcessive or cannot be met suggests that it might beappropriate. Therefore, future research should examine notonly the communication behaviors that doctors use but alsotheir motivations for using them in specific instances.Similarly, future communication teaching will need to bedesigned not only to modify communication behaviors butalso to engage with and, if necessary, modify themotivations that doctors have for their behaviors.

Acknowledgments

This research was funded by the UK MRC.We thank the GP respondents for their enthusiastic

participation.

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