From BMJ Open, 1 December 2015.
Junior doctors’ experiences of managing patients with medically unexplained symptoms: a qualitative study
Katherine Yon(1), Sarah Nettleton(2), Kate Walters(1), Kethakie Lamahewa(1), Marta Buszewicz(1)
1) Research Department of Primary Care & Population Health, UCL, London, UK
2) Department of Sociology, University of York, York, UK
Correspondence to Dr Marta Buszewicz; email@example.com
To explore junior doctors’ knowledge about and experiences of managing patients with medically unexplained symptoms (MUS) and to seek their recommendations for improved future training on this important topic about which they currently receive little education.
Qualitative study using in-depth interviews analysed using the framework method.
Participants were recruited from three North Thames London hospitals within the UK.
Twenty-two junior doctors undertaking the UK foundation two-year training programme (FY1/FY2).
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, possible psychological comorbidities, the formulation of suitable explanations for patients’ symptoms and longer term management strategies. Many junior doctors 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.
There is 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.
From PLoS One, 14 December 2015.
Therapist effects and the impact of early therapeutic alliance on symptomatic outcome in Chronic Fatigue Syndrome
Lucy P. Goldsmith(1,2,3,*) Graham Dunn(1,2), Richard P. Bentall(4), Shon W. Lewis(2,5), Alison J. Wearden(2,6)
1) Centre for Biostatistics, Institute of Population Health, University
of Manchester, Manchester, United Kingdom.
2) Manchester Academic Health Science Centre, Manchester, United Kingdom.
3) School of Health and Human Sciences, University of Huddersfield, Huddersfield, United Kingdom.
4) Institute of Psychology, Health and Society, University of Liverpool, Liverpool, United Kingdom.
5) Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, United Kingdom.
6) School of Psychological Sciences and Manchester Centre for Health
Psychology, University of Manchester, Manchester, United Kingdom.
Few studies have examined therapist effects and therapeutic alliance (TA) in treatments for chronic fatigue syndrome (CFS). Therapist effects are the differences in outcomes achieved by different therapists. TA is the quality of the bond and level of agreement regarding the goals and tasks of therapy.
Prior research suffers the methodological problem that the allocation of therapist was not randomized, meaning therapist effects may be confounded with selection effects. We used data from a randomized controlled treatment trial of 296 people with CFS.
The trial compared pragmatic rehabilitation (PR), a nurse led, home based self-help treatment, a counselling-based treatment called supportive listening (SL), with general practitioner treatment as usual. Therapist allocation was randomized. Primary outcome measures, fatigue and physical functioning were assessed blind to treatment allocation. TA was measured in the PR and SL arms.
Regression models allowing for interactions were used to examine relationships between (i) therapist and therapeutic alliance, and (ii) therapist and average treatment effect (the difference in mean outcomes between different treatment conditions).
We found no therapist effects. We found no relationship between TA and the average treatment effect of a therapist. One therapist formed stronger alliances when delivering PR compared to when delivering SL (effect size 0.76, SE 0.33, 95% CI 0.11 to 1.41).
In these therapies for CFS, TA does not influence symptomatic outcome. The lack of significant therapist effects on outcome may result from the trial's rigorous quality control, or random therapist allocation, eliminating selection effects. Further research is needed.
From NeuroImage: Clinical, published online 10 September 2015.
Less efficient and costly processes of frontal cortex in childhood chronic fatigue syndrome
Kei Mizuno(a,b), Masaaki Tanaka( c), Hiroki C. Tanabe(d,e), Takako Joudoi(f), Junko Kawatani(f), Yoshihito Shigihara( c), Akemi Tomoda(f,g), Teruhisa Miike(f,h), Kyoko Imai-Matsumura(i), Norihiro Sadato(d), Yasuyoshi Watanabe(a,c)
a) Pathophysiological and Health Science Team, RIKEN Center for Life Science Technologies, 6-7-3 Minatojima-minamimachi, Chuo-ku, Kobe, Hyogo 650-0047, Japan
b) Department of Medical Science on Fatigue, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka City, Osaka 545-8585, Japan
c) Department of Physiology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka City, Osaka 545-8585, Japan
d) Department of Cerebral Research, Division of Cerebral Integration, National Institute for Physiological Sciences, 38 Nishigonaka, Myodaiji, Okazaki, Aichi 444-8585, Japan
e) Department of Psychology, Graduate School of Environmental Studies, Nagoya University, Furo-cho, Chikusa-ku, Nagoya, Aichi 464-8601, Japan
f) Department of Child Development, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjyo, Kumamoto City, Kumamoto 860-8556, Japan
g) Research Center for Child Mental Development, University of Fukui, 23-3 Matsuoka-shimoaiduki, Eiheiji-cho, Fukui 910-1193, Japan
h) Hyogo Children's Sleep and Development Medical Research Center, 1070 Akebono-cho, Nishi-ku, Kobe, Hyogo 651-2181, Japan
i) Department of School Psychology, Developmental Science and Health Education, Hyogo University of Teacher Education, Graduate School in Science of School Education, 942-1 Shimokume, Kato, Hyogo 673-1494, Japan
• Decrease in divided attention was related to fatigue in childhood and adolescence.
• Left frontal cortex of healthy students activated in verbal divided attention task
• Right MFG and ACG were additionally activated in CCFS patients.
• CCFS is characterized as an energy-inefficient process in frontal cortex.
The ability to divide one's attention deteriorates in patients with childhood chronic fatigue syndrome (CCFS). We conducted a study using a dual verbal task to assess allocation of attentional resources to two simultaneous activities (picking out vowels and reading for story comprehension) and functional magnetic resonance imaging.
Patients exhibited a much larger area of activation, recruiting additional frontal areas. The right middle frontal gyrus (MFG), which is included in the dorsolateral prefrontal cortex, of CCFS patients was specifically activated in both the single and dual tasks; this activation level was positively correlated with motivation scores for the tasks and accuracy of story comprehension.
In addition, in patients, the dorsal anterior cingulate gyrus (dACC) and left MFG were activated only in the dual task, and activation levels of the dACC and left MFG were positively associated with the motivation and fatigue scores, respectively.
Patients with CCFS exhibited a wider area of activated frontal regions related to attentional resources in order to increase their poorer task performance with massive mental effort.
This is likely to be less efficient and costly in terms of energy requirements. It seems to be related to the pathophysiology of patients with CCFS and to cause a vicious cycle of further increases in fatigue.