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Correspondence
- Hiske J. van Ravesteijn, Peter L.B.J. Lucassen, Tim C. olde Hartman (19 December 2007)
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authors' reply to van Ravesteijn et al
- Richard Morriss, Christopher Dowrick, Peter Salmon, Sarah Peters, Graham Dunn, Anne Rogers, Linda Gask (30 January 2008)
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Hiske J. van Ravesteijn, M.D. Department of General Practice, Radboud University Nijmegen Medical Centre, the Netherlands, Peter L.B.J. Lucassen, Tim C. olde Hartman
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h.vanravesteijn{at}hag.umcn.nl Hiske J. van Ravesteijn, et al.
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Morris et al. (2007) performed a high-quality cluster randomised controlled trial in which reattribution for medically unexplained symptoms (MUS) was thought to GPs. We would like to compliment the authors on this trial. Strong points of their trial are the avoidance of selection bias by using an independent GP for inclusion, and the inclusion of patients for whom unexplained symptoms of sufficient duration were the reason for encounter. However, we have some critical comments as well. Firstly, the training of GPs took only 6 hours and was performed by non-expert trainers. Reattribution is not an easy technique to learn. Other researchers used training programs of at least 20 hours (Blankenstein, 2001; Rosendal et al, 2005). The trainers in this study were three nurses and a psychologist. Although they were prepared intensively, they might not have been familiar enough with GP consultations. Consequently, we have doubts about the thoroughness and effectiveness of the training for GPs. Secondly, the effect of reattribution training on doctor-patient communication has been evaluated in only one consultation. Reattribution usually takes more than one consultation (Goldberg et al, 1989). Making an inventory of the problems and broadening the agenda can lead to quite a disturbance of the normal flow of the consultation. Patients often need more time to make a link between their psychosocial and physical problems. In the article it seems like it was mostly the doctor who made the link. This does not fit into the original reattribution model. A negotiating style is needed in order to let the patient raise the possibility of a link him- or herself (Goldberg et al, 1989). For the purpose of effective reattribution, the patient has to come up with the link and not the doctor (Blankenstein, 2001; Rosendal et al, 2005). Thirdly, we know that the effectiveness of psychological treatments consists of specific and non-specific effects. Non-specific effects are effects caused by mutual trust, empathy and shared understanding (Stewart, 1995). The training in reattribution and applying it might have influenced the physicians’ relation with the patient negatively because of the physicians being absorbed by the application of the new intervention. Less attention for empathy and other non-specific effects might have been an additional cause for the absence of treatment effects. Finally, it is a pity that the authors did not differentiate the outcome effects for subgroups. Patients with MUS form a heterogeneous group. “Treatment effects are always moderate” due to the differences in levels of emotional and physical stress according to (Schweickhart et al, 2005). The subgroup of patients with low emotional stress before treatment might have experienced deterioration in outcome measures after reattribution due to the consequent opening up and admittance of their problems. Although this is a clinically valuable change process, by reporting the overall treatment effects, this profit might be concealed. In short, we think that yet another part of the questions around the treatment of patients with MUS has been clarified by this high-quality trial. However, there remain many questions to be solved. References Blankenstein, A. H. (2001) Somatising patients in general practice: Reattribution a Promising Approach. PhD thesis, Vrije Universiteit, Amsterdam. Goldberg, D., Gask, L., &O’Dowd, T. (1989) The treatment of somatisation: teaching techniques of reattribution. Journal of Psychosomatic Research, 33, 689-695. Rosendal, M. (2007) A randomized controlled trial of brief training in the assessment and treatment of somatization in primary care: effects on patient outcome. General Hospital Psychiatry. 29, 364-373. Schweickhart, A., Larisch, A. & Fritzsche, K. (2005) Differentiation of Somatizing Patients in Primary Care: Why the Effects of Treatment Are Always Moderate. The Journal of Nervous and Mental Disease, 193, 813-819. Stewart, M.A. (1995) Effective physician-patient communication and health outcomes: a review. Canadian Medical Association Journal, 152, 1423 -1433. |
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Richard Morriss, Professor of Psychiatry and Community Mental Health Division of Psychiatry and Institute of Mental Health, University of Nottingham, Christopher Dowrick, Peter Salmon, Sarah Peters, Graham Dunn, Anne Rogers, Linda Gask
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richard.morriss{at}nottingham.ac.uk Richard Morriss, et al.
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Thank you for the interest in our randomised controlled trial of reattribution training of practices in patients with medically unexplained symptoms (MUS). We would like to clarify some of the points that these correspondents have raised about the trial. Firstly, we conducted a six hour duration training intervention in reattribution because on the basis of a series of studies of training in primary care, this is the length of training that most general practitioners (GPs) are prepared to attend in the United Kingdom and also in many other health systems in the world. The six hour training produced the changes in communication that have been reported with a 20 hour training in reattribution (Blankenstein et al, 2002). Moreover, more extensive training in reattribution for more than 20 hours by GPs does not necessarily improve patient outcome (Rosendal et al, 2007). We used nurses and a psychologist because in practice these trainers would carry out this training in the work place if the intervention was ever implemented in routine practice in United Kingdom. We received systematic feedback from the GPs about the training on feedback forms at the time of training, in a survey carried out later and in depth qualitative interviews with a sample of GPs. The issue that the trainers might not understand the consultation was not raised as a concern by the GPs in the study. Secondly, the paper describing the reattribution model (Goldberg et al, 1989), which was written by one of our team LG, and subsequent descriptions of reattribution written by members of our team, have always promoted a model in which doctors provide the “making the link” explanation although they should do this through negotiation with the patient. In our trial (Morriss et al, 2007), the intervention group of GPs gave the “making the link” explanation in a negotiatory manner much more frequently than the treatment as usual group. We agree that reattribution may be more effective on patient outcome if patients made the link themselves between their physical symptoms and a psychosocial cause. However, GPs may need to spend much longer with patients to achieve this. Thirdly, we agree that an instrumental task-orientated consultation such as reattribution might be perceived as less empathic by patients with MUS than treatment as usual. However, in our trial the data from the patient satisfaction questionnaire suggests that compared to treatment as usual (TAU), after reattribution training (RT) twice as many patients were very satisfied with how well the GP understood the nature of their problems and their worries [RT (n=57) vs TAU (n=68): nature of the problem 34 (60%) vs 23 (34%); worry 34 (60%) vs 20 (29%); p<0.10 for both items, intention to treat analysis allowing for missing data, clustering at practice and GP level, age and gender of patient using generalised linear latent and mixed models].The data suggests that patients perceived GPs trained in reattribution to be no less empathic than GPs delivering treatment as usual. Therefore there may be other features of the reattribution intervention delivered by GPs in this way that may explain its lack of effectiveness. We have explored this in a qualitative interview study with patients in the trial that will be submitted for publication. Finally we agree that certain subgroups of patients with MUS may benefit from reattribution. However, our trial was not powered to examine this issue. References Blankenstein, A.H., van der Horst, H.E., Schilte, A.F., de Vries, D., Zaat, J.O., Andre Knotternus, J, van Eijk, J.T., de Haan, M. (2002) Development and feasibility of a modified reattribution model for somatising patients, applied by their own general practitioners. Patient Education and Counselling, 47, 229-235. Goldberg, D., Gask, L., O’Dowd, T. (1989) The treatment of somatisation: teaching techniques of reattribution. Journal of Psychosomatic Research, 33, 689-695. Morriss, R., Dowrick, C., Salmon, P., Peters, S., Dunn, G., Rogers, A., Lewis, B., Charles-Jones, H., Hogg, J., Clifford, R., Rigby, C. Gask, L.(2007) Cluster randomised controlled trial of training practices in reattribution for medically unexplained symptoms. British Journal of Psychiatry, 191, 536-542. Rosendal, M., Olesen, F., Fink, P., Toft, T., Sokolowski, I., Bro, F. (2007) A randomized controlled trial of brief training in the assessment and treatment of somatisation in primary care: effects on patient outcome. General Hospital Psychiatry, 29, 364-373. |
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