patients who present physical symptoms in the absence of physical pathology: a challenge to existing...

Patient Education and Counseling 39 (2000) 105–113www.elsevier.com/ locate /pateducou

Patients who present physical symptoms in the absence of physicalpathology: a challenge to existing models of doctor–patient

interaction

*Peter Salmon

Department of Clinical Psychology, University of Liverpool, Whelan Building, Brownlow Hill, Liverpool L69 3GB, UK

Received 26 February 1999; received in revised form 25 August 1999; accepted 6 September 1999

Abstract

Many patients seek physical treatment for physical symptoms in the absence of physical pathology and incur symptomaticinterventions that are ineffective, costly and iatrogenic. It is therefore important to understand how decisions to providephysical intervention can arise in consultations in the absence of physical pathology. Existing models of doctor–patientcommunication are ill-suited to understanding these consultations. A series of studies has provided the components of analternative approach that is based on understanding consultation from the patients’ perspective. Specifically, these studieshave delineated: sources of patients’ perception of their authority over doctors; what patients seek by consulting theirdoctors; and ways that patients use their authority to influence doctors to provide what they seek. Patients’ authority reflectsprimarily their own sensory and infallible knowledge of symptoms. Their influence derives from descriptions of subjectivesymptoms and from additional strategies including descriptions of the psychosocial effects of symptoms, catastrophising andrequesting treatment. This analysis suggests directions for future research and medical training. 2000 Elsevier ScienceIreland Ltd. All rights reserved.

Keywords: Somatization; Doctor–patient communication; Conflict

1. Introduction the basis of 19% of consecutive consultations [1].These patients are recognisable in the literature on

In a significant proportion of doctor–patient inter- ‘frequent attenders’ in general practice [2] and onactions, patients seek treatment for physical symp- ‘difficult’ or ‘problem’ patients [3]. Many patients gotoms in the absence of detectable physical pathology. on to receive physical investigation and treatment,In a recent report, general practitioners (GPs) iden- including invasive procedures and prolonged treat-tified clinically significant physical symptoms of at ment which, while often being ineffective, exposeleast 3-months duration, without physical disease, as them to iatrogenic risks and incur substantial finan-

cial costs. Patients with persistent problems of thiskind are as physically disabled as patients with*Tel.: 1 44-151-794-5531; fax: 1 44-151-794-5537.

E-mail address: [email protected] (P. Salmon) chronic disease [4,5]. Economic and humanitarian

0738-3991/00/$ – see front matter 2000 Elsevier Science Ireland Ltd. All rights reserved.PI I : S0738-3991( 99 )00095-6

106 P. Salmon / Patient Education and Counseling 39 (2000) 105 –113

reasons converge on the importance of understanding psychological) matters from a body that was purelythese patients’ problems. physical and therefore amenable to highly technical

Medicine has tended to ‘explain’ these problems methods of the natural sciences. Such methodsas ‘somatisation’, with the assumption that they clearly required highly qualified experts, and layreflect underlying emotional disorder [6]. However, people lacked the expertise to understand or questionin one sample of 228 primary care patients with these experts’ behaviour. According to this view ofsymptoms persisting for a minimum of 12 months, a an inexpert patient consulting an expert professionalsignificant minority (14%) were neither depressed the role of each is defined clearly: the doctor mustnor anxious and levels of emotional disorder did not gather the necessary information, decide an appro-explain variability in impairment or health care use priate response and tell the patient what to do; the[5]. Discrete syndromes have been identified, such as patient should comply.irritable bowel or chronic fatigue, but these provide Within this framework, an important criterion ofonly the illusion of explanation because they are successful consultation is that the inexpert patientpurely descriptive. Moreover, in primary care there is should comply with the instructions of the expertlittle evidence that symptoms naturally cluster in this doctor. However, extensive research has shown that,way and, in reality, patients often have symptoms of by this criterion of success, the expert model doesmultiple syndromes [5]. Therefore the problem of not fit well with the patients’ perspective on theunexplained symptoms is unlikely to be significantly consultation. That is, patients do not reliably complyilluminated by further attempts to define properties with instructions. When patients with physical symp-of patients to which it can be attributed. An alter- toms seek physical treatment in the absence ofnative approach is to focus on how decisions for pathology, the invalidity of the expert model ofsomatic investigation and treatment emerge from the consultation is evident by definition. Patients seekinteractions of doctors with patients in the absence of treatment and investigation despite doctors’ assur-physical pathology. ances that treatable pathology is absent.

Current approaches to doctor–patient interactionreflect three broad models. According to these, the 2.2. Doctor as partnerdoctor–patient consultation is viewed as (i) a meet-ing between an inexpert (patient) and an expert Because of the limitations of an expert, authority-(doctor), (ii) a meeting of partners or equals, or (iii) based model of doctor–patient communication, ana meeting where a consumer (patient) seeks a service alternative model has been developed according tofrom a service-provider (doctor). These models cor- which doctor and patient are seen as partners withrespond to three of the types of doctor–patient different areas of expertise. From this perspective,interaction identified by Roter and Hall [7]: paternal- doctor–patient consultations are ‘meetings betweenism, mutuality and consumerism. Here, however, the experts’ [8]. According to this view, the quality ofemphasis is not on categorising interactions, but on consultation is judged according to criteria that docategorising the different assumptions that are made not arise from the ‘expert’ view. These includeabout them. It will be argued that these assumptions doctors’ sensitivity to patients’ psychosocial needs,are ill-fitted to consultations where patients seek and the amount of relevant information that thetreatment for physical symptoms without physical patient is enabled to provide. This model has there-pathology. fore led to an emphasis on improving doctors’

communication skills and to studies of the effects ofpreparing patients before consultation by encourag-

2. Models of doctor–patient communication ing and guiding them to ask questions and to tell thedoctor what they think is important [9,10]. This

2.1. Doctor as expert model has led to research showing that adherence,satisfaction, and even clinical improvement, are

The foundation of modern Western medicine was related to how well doctors elicit patients’ concernsthe dualist model which separated spiritual (and [11].

P. Salmon / Patient Education and Counseling 39 (2000) 105 –113 107

Once again, however, the problems of communi- treatment. However, to regard accession to such acation with patients who seek treatment for physical patient’s requests as adequate care, although con-symptoms in the absence of pathology expose limita- sistent with a ‘consumer’ model, would abnegate thetions of the model. In particular, the emphasis on the doctor’s duty of care.doctor’s need for sensitivity to patients’ requests andpsychosocial presentation, although superficially in-

2.4. The need for a new modelnocuous, can have unanticipated effects. As we shallsee below, patients can present psychosocial prob-

These models of the doctor’s role and of doctor–lems so as to secure, not the psychosocial help that

patient communication do not only influence re-they might need, but physical intervention [12].

search into doctor–patient interaction. They alsoTherefore, an emphasis on the need for sensitivity to

influence teaching of doctors. Therefore communica-patients’ psychosocial presentation might paradoxi-

tion skills teaching emphasises techniques to im-cally reduce doctors’ sensitivity to patients’ psycho-

prove adherence to doctors’ recommendations, tosocial needs.

facilitate patients’ disclosure and to increase satisfac-tion. However, the above analysis indicates that

2.3. Doctor as service-providerproblems of patients without physical pathology areunlikely to be addressed effectively by these ap-

Health services reflect wider social and culturalproaches. Indeed, each could make the problems

factors. An important influence on health care in theworse. Therefore a different approach is needed to

UK has therefore been the shift of responsibility forunderstanding doctor–patient communication in the

individuals’ wellbeing from the state and its agentsabsence of pathology. A series of studies has begun

to the individual during the last 15 years, as it hasto establish the main elements of a framework for

approached a USA-style view of the importance ofunderstanding this basis. The aim of this article is to

personal responsibility. In health care, this has beendraw these together and to consider the implications

reflected in consumerism, in the developing view offor research and teaching in communication.

patient autonomy over health and treatment [13] andin the growing importance of patient satisfaction as acriterion of outcome [14]. It is not clear that con-sumerism necessarily serves the patient’s interests: 3. Patients’ authority in the absence of physicalby comparison with the obligation of a doctor to a pathology‘patient’, being a ‘client’ or ‘customer’ implies noobligation upon the service provider. Nevertheless, A few studies of non-compliance with doctors’consumerism is typically seen as emphasising the treatment recommendations have examined the phe-power and authority of the patient over that of the nomenon from the patients’ perspective. They havedoctor, particularly in relation to decision-making. shown that noncompliance often reflects patients’

As with the foregoing models, interactions be- assertion of their own knowledge, beliefs, experiencetween doctors and somatising patients do not fit with or research over doctors’ [15–19]. Whether a recom-this model. Although such interactions commonly mendation is followed depends on whether it fitslead to patients receiving the somatic treatment that with what patients already believe [19,20]. Thesethey have requested, it is now widely recognised that findings show the limitation of approaching doctor–somatic treatment often does not meet these patients’ patient communication only from the viewpoint ofneeds. It can exacerbate dependency and medical the doctor. A series of studies has therefore recentlyproblems and can divert some patients from the examined doctor–patient communication from thepsychological help that they need. In the extreme, the perspective of somatising patients. In these studies,dangers of consumerism are well illustrated by the the disparity is striking between the conventionalpatient with Munchausen’s syndrome. Such a patient view (based on doctors’ perceptions and medicalis a particularly effective consumer, who can be theory) and patients’ perspective. The most impor-‘satisfied’ by being offered invasive and damaging tant difference is that, from the patients’ perspective,


it is the patients who have the greater authority and incompetent [21,22]. Even where there is no indica-expertise [12,21]. tion of incompetence in terms of professional or

The sources of doctors’ authority are well–known: ethical standards, doctors’ and associated profession-training, research and technical literature, confer- als’ competence is limited by several factors fromences, colleagues etc. However, there has been little patients’ perspective. One is that technical proce-attention to identifying sources of patients’ authority. dures might have been conducted inaccurately.Observations of, and interviews with, patients pre- Another is a perceived careless or casual approach tosenting physical symptoms without physical pathol- data-gathering. A particularly serious level of per-ogy have identified several distinct sources of pa- ceived incompetence arises in the common belieftients’ authority [12,21,22]. First, patients’ belief in amongst patients with persistent unexplained symp-the infallibility of their direct sensory experience of toms that they have been damaged by medical caretheir symptoms provides a powerful sense of authori- [12,21,22]. Finally, all patients have access toty over doctors who have to rely on indirect, and sources of information and advice about symptomstherefore fallible results of medical tests. A second and health care other than from their doctors. Indeed,source of authority derives from these patients’ doctors are typically consulted only after many otherknowledge that they carefully and thoroughly weigh sources of information have been used [17,18].up evidence and scrutinise alternative explanations – Therefore patients’ reactions to what doctors sayincluding the doctor’s. This contrasts with their view depend on how doctors’ advice concurs or conflictsof doctors’ judgements as often ill-considered. In this with what they have learned from these other sourcesway, patients can regard themselves as more open- [19,20]. Alternative sources of information aboutminded and ‘scientific’ than their doctors. problems of somatisation, specifically, are increasing

A third source of patients’ authority derives from greatly in number and persuasiveness. Populartheir common perception that doctors deny the books, newspaper articles, internet sites and suffer-reality of their symptoms [21]. It is, of course, rare ers’ support groups all claim expertise that they offerthat denial is explicit. However it is common that to patients. By the time patients consult the doctor,doctors’ explanations are perceived as denying that the nature of their problems often seems clear tothe symptoms exist or as denying that they are them, leaving the doctor with a very limited role.legitimate. Typically, this occurs where psychiatricdiagnoses or psychological explanations are pro-vided. The dualist legacy is that such statements arewidely regarded as denying legitimacy to the pa- 4. What patients seek from the doctor in thetient’s symptoms and to the suffering that is associ- absence of physical pathologyated with them. The use of diagnostic labels forsomatising syndromes has often provided the appear- The usual assumption is that patients with physicalance of legitimising them. However, while many symptoms consult doctors because they want theirpatients are content to accept that, for instance, they symptoms to be treated and removed. Although thishave bowel problems because they have irritable seems obvious, there is little evidence to support thebowel syndrome, others appreciate the circularity of assumption, at least in patients seeking treatment forsuch ‘diagnoses’: that they amount to saying that physical symptoms without pathology. In fact, therepatients have bowel problems because they have is a great deal of evidence for important reasons whybowel problems. As one patient observed, ‘IBS patients in general consult general practitioners other[irritable bowel syndrome] is what they call it when than for treatment of symptoms. In particular, pa-they don’t know what it is’ [21]. Where a patient tients seek emotional support or explanation andperceives that the doctor denies that symptoms exist, reassurance [23]. Another important reason to con-it follows that only the patient has the authority to sult is for legitimation of the sick role. Consistentcomment on them. with this picture, treatment of symptoms did not

A fourth source of patients’ authority derives from emerge from interviews with patients who hadthe surprisingly common perception that doctors are physical symptoms without physical pathology as a


significant reason why they consulted [21]. That is, ods can provide a more constructive basis fordoctors were not necessarily valued or deprecated successful treatment [25] and are considered later.according to whether they succeeded or failed todiagnose and treat the patient’s symptoms.

To understand what patients do seek in the 5. How patients’ influence doctors in theabsence of pathology, it is necessary to appreciate absence of pathologythat they tend to view symptoms as expressions ofmalign and menacing entities, separate from them- Given the authority that somatising patients feelselves. That is, symptoms are seen as having an over their doctors, and their desire for engagementexistence outside the body, invading the body and with them, it is to be expected that they seek tomoving around within it, changing form and evading influence doctors. The reality of patients’ influencecapture [21,24]. In facing this threat, patients seem to has been recognised in previous research on patients’value doctors who perform one or both of two ‘pressure’ for prescription or referral [28]. However,functions [21,25]. One is simply to name and explain this defines patients’ influence according to a subjec-the symptoms in a convincing and reassuring way. tive feeling of the doctor. It does not, therefore, helpNaming legitimises the patients’ symptoms and to understand how influence is exerted. Shorter’ssuffering. This, in turn, means that the patient is [29] historical analysis emphasised the influence thatexculpated for them. Naming also contains the a patient can exert over a doctor by presentingdegree of threat by reassuring patients that their symptoms that are subjective. The doctor is unable todisease is nothing worse. scrutinise, quantify or question such symptoms and

The second function for which patients without relies entirely on the patient for knowledge of them.pathology seek doctors is to establish an alliance As one patient commented, ‘you can’t know whatwith them against the disease entity. This is different it’s like’ [12].from the conventional view of therapeutic part- Consultations that lead to surgery have provednership, which implies a collaboration to identify and particularly interesting in this context. There istreat an illness. For the alliance it was sufficient that evidence that, in patients attending hospital clinics,the doctor was felt to be on the patient’s ‘side’, such expectations of the power of surgery exceed thosethat ‘We’re [GP and patient] in the same boat. associated with alternative treatments [30]. AlthoughNeither of us knows what it’s about’ [21]. Another surgical treatment incurs high costs to health servicespatient was specific about the nature of the alliance: and exposes the patient to risks of morbidity and‘I appreciate all the doctor’s done. Not helped mind, even mortality, many surgical procedures are carriedbut tries everything, blood levels and tests. He’s a out in the absence of any pathology [31]. It seemsgood doctor’ [21]. This patient has identified the possible that patients’ own expectations help to driveusual way in which alliances are forged in the the decision for surgery in such cases. Analysis of aabsence of physical pathology: by the doctor offering single case of a female patient who obtained surgeryrepeated investigation, symptomatic treatment and (mastectomy) in the absence of pathology supportedreferral. This process therefore feeds the problem of one further element of Shorter’s [29] analysis. Hesomatisation. Many patients, particularly those with had proposed that one source of patients’ influenceemotional or stress-related problems, do specifically over doctors in the absence of pathology was theirseek support rather than treatment [26]. However, the use of biomedical ideas to understand and describeproblem of forming an alliance in these cases is their symptoms. In the single case, the surgeoncompounded by GPs’ inaccurate perception of pa- suspected that the patient was depressed and doubtedtients’ intentions [27]. Once patients reach hospital that surgery would help [12]. In the face of thisoutpatient care, opportunities for finding more prod- psychosocial view, the patient pressed upon theuctive bases for engagement are even more limited. doctor a biomedical explanation and solution. ThatFor instance, the only way that most surgeons can is, she attributed symptoms to a specific anatomicalengage in an alliance with the patient is by offering locus [a breast lump] and sought its surgical remov-surgery. In primary care, however, alternative meth- al. (This is, of course, in contrast to the common


assumption that doctors seek to press biomedical way or, more commonly, to attest to the level of theexplanations onto patients who wish psychosocial patient’s suffering and need for treatment.issues to be addressed.)

Further understanding of patients’ capacity toinfluence surgeons emerged from analyses that fo- 6. Doctors’ counter-influence: negotiating acused on the details of doctor–patient dialogue in management decision in the absence of physicalmore routine consultations, drawn from patients who pathologypresented consecutively with menstrual problems inthe absence of pathology [22]. Some of these con- Disagreement between doctor and patient is, ofsultations led to hysterectomy; others led to more course, implicit in many instances of noncompliance.conservative responses. Contrasting these two sets of However, such instances rarely occasion overt con-consultations helped to identify strategies that were flict because the patient’s authority over his /her ownable to influence surgeons to offer surgery. Hysterec- body is final: it can be exercised by simply nottomy is of particular interest because, although it is a taking prescribed medication, or not attending anmajor procedure with a real, albeit small, level of appointment. In scientific and educational literaturepostoperative morbidity and mortality, around one about doctor–patient communication, the reality ofquarter to one third of these procedures occur in the disagreement is hidden by referring to this problemabsence of evidence of physical pathology. as the patient’s ‘failure’ to comply. Overt conflict is

That study identified several strategies that ap- to be expected where patients seek resources thatpeared to influence the surgeons to offer hysterec- doctors, as gate-keepers for valued resources includ-tomy [22]. As described by Shorter [29], patients ing treatment and also attention and the licence toemphasised their privileged knowledge of their own adopt the sick role, are unwilling or unable to give.symptoms; because these were subjective, they could Clearly, this occurs where patients seek physicalbe neither scrutinised nor questioned by the doctor’s treatment in the absence of any evidence of physicaltechnical skills. Moreover, the privileged knowledge pathology.extended to the suffering that the symptoms caused. To understand this conflict requires detailed study,Patients typically conveyed the severity of their not only of how patients influence doctors, but alsosymptoms (for instance, when asked by the surgeon of how doctors seek to influence patients in suchhow bad the symptoms were) by describing psycho- consultations. In parallel with the analysis of pa-social effects rather than their objective properties. tients’ strategies, one study has delineated surgeons’

Having established the scale of the suffering, responses in gynaecology clinics [22]. The salientpatients could then establish that the doctor had strategy whereby surgeons attempted to counterresponsibility for it. Of course, merely presenting patients’ claims was by emphasising the area oversymptoms in the context of the clinic implied that which they had privileged knowledge through theirthey were the doctor’s responsibility. However, special instruments and tests; that is, the world insidepatients could make this transfer of responsibility the patient’s body. Thus, a characteristic response ofmore explicit by showing that doctors had failed or gynaecologists reporting normal results to womenharmed the patient in the past. To clinical respon- presenting menstrual symptoms was to refer tosibility was therefore added the responsibility that having ‘looked around inside’ and confirmed thatgoes with culpability. ‘everything was normal’ [22]. The patient could not

Two further strategies offered the patient consider- dispute the conclusion. This led to consultationsable influence over the doctor [12,22]. Catastrophisa- which each party tried to resolve by drawing thetion occurred where the patient predicted that the discussion into the domain in which they, alone,doctor’s failure to act would have serious conse- were expert: the unpleasantness of the symptoms andquences for the patient or the patient’s family. the psychosocial distress that they caused (for theAnother was to refer to other people who thought patient) and the normality of the body (for thethat the doctor should act. Other doctors were cited doctor). These interactions in the absence of pathol-in support of specific treatment approaches. Family ogy were therefore a kind of ‘tug-of-war’, in whichmembers or friends can also be cited in the same each party attempted to resolve the encounter by


pulling it into their own territory. It may be this hypotheses about their influence in the consultation.tension that explained the apparently unstructured Quantification is necessary to test these hypotheses,course of some primary care interactions analysed by for instance that consultations in which specificStewart et al. [32], in which dialogue wove back and strategies are used are more likely to lead to surgery.forth between medical and psychosocial agendas. However, existing coding schemes for doctor–pa-From a decision-making point of view such tient communication emphasise the form that inter-dialogues seem chaotic and disordered. However, action takes, for example distinguishing verbal affectfrom the point of view of a power-play they make from information exchange, rather than its functionmore sense. in reaching the treatment decision [34]. Therefore a

coding scheme to quantify aspects of consultationthat were identified in the qualitative research has

7. Implications been developed [35]. Basing the procedure on priorqualitative analyses ensures that it has content va-

7.1. Conceptual framework lidity. This approach meets Inui and Carter’s [36]recommendations for consultation coding schemes in

At one level, these findings are consistent with two additional respects. It produces a coding schemewhat doctors already know: that patients can exert that is relatively simple to use because, rather thanconsiderable power over them. More than this, they attempting to describe all features of the interaction,provide an objective basis from which to understand it focuses on those that are relevant to treatmentthis power by identifying specific sources of patients’ decisions. The coding scheme is also face-valid toauthority to influence doctors in the absence of clinicians because it concerns aspects of the inter-pathology and specific strategies whereby they do so. action that matter to them. Preliminary results from

Although this kind of conflict is part of doctors’ studies of patients presenting menstrual symptoms inday-to-day experience, this is barely reflected in the absence of physical pathology indicate thattheory, research and teaching. Literature on com- strategies hypothesised to lead to surgery are, asmunicating with patients reflects the pervasive as- predicted, more common in consultations that lead tosumption that the aims of clinician and patient hysterectomy than in those leading to more conserva-coincide [8]. Sociological analyses of conflict have tive treatment [33]. Work is presently under way tofocused on power, but this has been defined in analyse the strategies used by patients and doctors insocio-cultural terms, and not in terms of the details primary care where patients present persistent symp-of treatment decisions in individual consultations toms that seem to have no pathological basis.[33]. In reality, of course, the clinician and patientare generally on the same side – the patient’s. 7.3. Teaching and trainingHowever, to refer to the clinician and patient asopponents reflects our observations of the ways in For many patients who present unexplained symp-which many interactions are conducted. A model toms, their symptoms probably reflect a heightenedbased on this view, and incorporating patients’ sensitivity to normal somatic sensations, and theseauthority and influence, offers a framework for patients need help to understand and cope with them.studying consultations with patients who present For others, symptoms reflect emotional or socialphysical symptoms in the absence of physical pathol- causes, so treatment or support should address these.ogy that can free researchers, clinicians and However, the foregoing findings indicate that pa-educators from the fundamental flaws of expert, tients often seek physical interventions and presentpartnership and consumer models. psychosocial material so as to secure these rather

than the psychosocial help that they might need.7.2. Research Therefore, the present approach contrasts with the

tendency to assume that many problems of doctor–Qualitative research has identified ways of com- patient communication can be addressed by ap-

municating (or ‘strategies’) that have not been proaches that simply enhance doctors’ responsive-previously identified, and it has provided a set of ness to patients, or that enable patients to be more


effective consumers. In the absence of physical toms without a pathological basis is to providepathology, simply increasing doctors’ sensitivity to explanations that meet the scrutiny of patients’patients’ psychosocial presentation and requests authority but avoid simply colluding with this au-might serve to bind doctors into the physical agenda thority. At present, it seems that only a smallthat patients deploy psychosocial material to support minority of medical explanations achieve this [25].[12]. This indicates an important area of need for com-

An alternative approach emerges fairly clearly munication teaching. Additional teaching needs arefrom the framework developed here. First, the indicated by the framework presented here. Doctorsadequacy of doctors’ responses must be judged from must be able to identify the strategies wherebythe patients’ perspective. Therefore a recent study patients influence their clinical decisions and theyhas used patients’ own experience of medical re- must be able to respond to these strategies in wayssponses to their symptoms to categorise doctors’ that reflect patients’ needs rather than their requests.attempts to explain symptoms in the absence ofphysical pathology [25]. Many attempts to explainsymptoms were rejected because they failed to Acknowledgementsprovide what the patients sought. Some were per-ceived as not legitimising the patients’ suffering. Preparation of this paper was supported by a grantThis arose where symptoms were (rarely) dismissed from the UK Medical Research Council.as unimportant and where they were (more common-ly) ascribed to psychological problems. Other expla-nations were rejected because they provided no Referencesname, or explanation, for the symptoms, or becausethey failed to exculpate patients for them. Explana- [1] Peveler R, Kilkennny L, Kinmonth A-L. Medically un-

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