General practitioners' views on reattribution for patients with medically unexplained symptoms: a questionnaire and qualitative study.

BACKGROUND: The successful introduction of new methods for managing medically unexplained symptoms in primary care is dependent to a large degree on the attitudes, experiences and expectations of practitioners. As part of an exploratory randomised controlled trial of reattribution training, we sought the views of participating practitioners on patients with medically unexplained symptoms, and on the value of and barriers to the implementation of reattribution in practice. METHODS: A nested attitudinal survey and qualitative study in sixteen primary care teams in north-west England. All practitioners participating in the trial (n = 74) were invited to complete a structured survey. Semi-structured interviews were undertaken with a purposive sub-sample of survey respondents, using a structured topic guide. Interview transcripts were used to identify key issues, concepts and themes, which were grouped to construct a conceptual framework: this framework was applied systematically to the data. RESULTS: Seventy (95%) of study participants responded to the survey. Survey respondents often found it stressful to work with patients with medically unexplained symptoms, though those who had received reattribution training were more optimistic about their ability to help them. Interview participants trained in reattribution (n = 12) reported that reattribution increased their confidence to practice in a difficult area, with heightened awareness, altered perceptions of these patients, improved opportunities for team-building and transferable skills. However general practitioners also reported potential barriers to the implementation of reattribution in routine clinical practice, at the level of the patient, the doctor, the consultation, diagnosis and the healthcare context. CONCLUSION: Reattribution training increases practitioners' sense of competence in managing patients with medically unexplained symptoms. However, barriers to its implementation are considerable, and frequently lie outside the control of a group of practitioners generally sympathetic to patients with medically unexplained symptoms and the purpose of reattribution. These findings add further to the evidence of the difficulty of implementing reattribution in routine general practice.

Cluster randomised controlled trial of training practices in reattribution for medically unexplained symptoms.

BACKGROUND: Reattribution is frequently taught to general practitioners (GPs) as a structured consultation that provides a psychological explanation for medically unexplained symptoms. AIMS: To determine if practice-based training of GPs in reattribution changes doctor-patient communication, thereby improving outcomes in patients with medically unexplained symptoms of 3 months' duration. METHOD: Cluster randomised controlled trial in 16 practices, 74 GPs and 141 patients with medically unexplained symptoms of 6 hours of reattribution training v. treatment as usual. RESULTS: With training, the proportion of consultations mostly consistent with reattribution increased (31 v. 2%, P=0.002). Training was associated with decreased quality of life (health thermometer difference -0.9, 95% CI -1.6 to -0.1; P=0.027) with no other effects on patient outcome or health contacts. CONCLUSIONS: Practice-based training in reattribution changed doctor-patient communication without improving outcome of patients with medically unexplained symptoms.

Turning theory into practice: rationale, feasibility and external validity of an exploratory randomized controlled trial of training family practitioners in reattribution to manage patients with medically unexplained symptoms (the MUST).

BACKGROUND: The evidence for the effectiveness of reattribution training are limited, and optimal service delivery is not yet established. OBJECTIVES: The objectives of this study were to establish the feasibility and to optimize the service delivery and design of a definitive randomized controlled trial (RCT) of reattribution training for patients with medically unexplained symptoms (MUSs) in routine primary care. METHODOLOGY: The study was of a cluster RCT design with the practice as the unit of randomization. Health facilitator (HF)-delivered reattribution training was compared with no reattribution training. The primary outcome measure used is doctor-patient communication in the consultation. Quantitative and qualitative methods identify barriers to effectiveness. The acceptability and feasibility of the intervention were established by attendance rates and postal survey after completion of training. RESULTS: Sixteen practices and 70 family practitioners (FPs) were recruited with representative practice and FP characteristics. Six hours of HF reattribution training to FPs in the workplace proved feasible and acceptable with all 35 FPs completing the training. Feedback from 27 (77%) FPs who received training indicated that 25 (93%) FPs believed that specific and relevant learning achievements were made, 22 (82%) felt more confident and 21 (77%) thought the training was useful. CONCLUSION: HF-delivered reattribution training to whole practices is feasible and acceptable, and its effectiveness is measurable in routine primary care.

Transforming general practice: the redistribution of medical work in primary care.

The paper focuses on the redistribution of medical work within primary health care teams. It reports the results of the analysis of interviews with general practitioners, practice nurses and managers, undertaken as part of an ethnographic study of primary care organisation and practice during a period of rapid organisational change. By examining the ways in which the respondents account for how work is being redefined and redistributed, we explore how current government policy and professional discourses combine to reconfigure both the identities of those who work in primary care and the nature of patienthood. In particular, we show how general practitioners are being reconfigured as medical specialists or consultants in ways that seem to depart radically from earlier claims that general practice is a distinctive field of social or biographical medicine. Within this new discourse medical work is distributed between doctors, nurses and unqualified staff in ways which make explicit the reduction of general practice work to sets of biomedical problems or tasks. At the same time, the devolution of much general practice work to less qualified and cheaper personnel is justified by drawing on a discourse of person-centred medicine.

Telephone triage by nurses in primary care: what is it for and what are the consequences likely to be?

OBJECTIVES: To examine the perceptions that those working in primary care have about the purpose and impact that telephone triage by nurses may have on their clinical roles and identities. METHODS: Twenty-six semi-structured interviews were carried out with general practitioners (GPs), practice nurses and practice managers from a purposive sample of nine practices in one health district in the North West of England. Analysis drew on the techniques of constant comparison and discourse analysis. RESULTS: Four themes emerged from the data: justifying triage - the respondents justify the introduction of telephone triage by emphasising the managerial benefits of controlling access and by suggesting the benefits this may bring to the patient-clinician relationship; categorising patients - patients are categorised and allocated on the basis of their biomedical diagnoses to the nurses or GPs in the practice; changing roles and identities - the hierarchy of patients and conditions created by allocating patients in this way strengthens and extends the professional hierarchy within a practice; and achieving a balance between conflicting aims - there is tension between the managerial need to triage patients according to their biomedical diagnosis and the aspirations that health care professionals have to personal and patient-centred care. CONCLUSION: Telephone triage by nurses may be effective at managing patient access to GPs but the need to categorise patients according to biomedical and managerial criteria needs to be balanced against the professional roles and identities that those working in general practice aspire to.