John B. Coffey

Treating Patients with Medically Unexplained Symptoms in Primary Care

BACKGROUND: There are no proven, comprehensive treatments in primary care for patients with medically unexplained symptoms (MUS) even though these patients have high levels of psychosocial distress, medical disability, costs, and utilization. Despite extensive care, these common patients often become worse.OBJECTIVE: We sought to identify an effective, research-based treatment that can be conducted by primary care personnel.DESIGN: We used our own experiences and files, consulted with experts, and conducted an extensive review of the literature to identify two things: 1) effective treatments from randomized controlled trials for MUS patients in primary care and in specialty settings; and 2) any type of treatment study in a related area that might inform primary care treatment, for example, depression, provider-patient relationship.MAIN RESULTS: We developed a multidimensional treatment plan by integrating several areas of the literature: collaborative/stepped care, cognitive-behavioral treatment, and the provider-patient relationship. The treatment is designed for primary care personnel (physicians, physician assistants, nurse practitioners) and deployed intensively at the outset; visit intervals are progressively increased as stability and improvement occur.CONCLUSION: Providing a comprehensive treatment plan for chronic, high-utilizing MUS patients removes one barrier to treating this common problem effectively in primary care by primary care personnel.

Behaviorally Defined Patient-Centered Communication—A Narrative Review of the Literature

BACKGROUNDTouted by some as reflecting a better medical model and cited by the influential IOM report in 2000 as one of the six domains of quality care, patient-centered medicine has yet to fully establish its scientific attributes or to become mainstream. One proposed reason is failure to behaviorally define what the term ‘patient-centered’ actually means.OBJECTIVES(1) To identify patient-centered articles among all reported randomized controlled trials (RCT); (2) to identify those with specific behaviorally defined interventions; (3) to identify commonalities among the behavioral definitions; and (4) to evaluate the relationship of the well-defined RCTs to patient outcomes.DATA SOURCESMedline from April 2010 to 1975.ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONSRCTs having any specific, behaviorally defined patient-centered skill(s) in an intervention with some patient outcome involving real adult patients and providers in real clinical situations.APPRAISAL AND SYNTHESIS METHODSCritical appraisal via narrative review.RESULTSThe prevalence of any mention of patient-centeredness among 327,219 RCTs was 0.50% (1,475 studies), from which we identified only 13 studies (0.90%) where there were behaviorally-defined patient-centered skills in an intervention. Although there were too few studies to make clinical recommendations, we identified common features of the behavioral definitions used: all went well beyond identifying individual skills. Rather, skills were grouped, prioritized, and sequenced by virtually all, often describing a stepwise patient-centered approach to, variously, gather data, address emotions, or inform and motivate.LIMITATIONSThe inherent subjectivity of our method for identifying behaviorally-defined studies could under- or over-represent truly replicable such studies considerably. Also, studies were few and very heterogeneous with interventions of widely differing intensity and foci.CONCLUSIONS AND IMPLICATIONSRCTs identified as patient-centered were rare, and <1% of these were behaviorally defined and, therefore, possibly replicable. There were many common behavioral definitions in the studies reported, and these can guide us in identifying agreed-upon patient-centered interventions, the immediate next-step in advancing the field.

A Method for Rating Charts to Identify and Classify Patients with Medically Unexplained Symptoms

Background: As part of conducting a randomized control trial (RCT) to treat chronically high utilizing patients with medically unexplained symptoms (MUS), we developed the chart rating method reported here to identify and classify MUS subjects. Method: Intended at this point only as a research tool, the method is comprehensive, uses explicit guidelines, and requires clinician raters. It distinguishes primary organic disease patients from those with primary MUS, quantifies medical comorbidities in primary MUS patients, and also distinguishes subgroups among MUS patients that we call somatization (resembles DSM-IV somatoform disorders) and minor acute illness (MAI) which differs from DSM-IV somatoform definitions. Scoring rules are used to generate the diagnoses above. The rules may be set according to the investigator’s needs, from highly sensitive to highly specific. Results: We found high levels of agreement with the gold standard for MUS vs. organic disease (97.6%) and among raters for the key individual chart elements rated (92–96%). The method identified 206 MUS subjects and the extent of their medical comorbidities for entry into a RCT. It also identified somatization and MAI; the latter supports the validity of this newly reported MAI syndrome. Conclusion: We concluded that this method offered research potential for identifying MUS patients, for quantifying their medical comorbidities, and for classifying MUS subgroups.

Patient participation in clinical encounters: a systematic review to identify self‐report measures

There is evidence suggesting that active participation of patients in their health care can improve the quality of care and decrease health‐care costs. Further, patient reports of their health‐care experience are increasingly used to monitor health‐care quality.