John C. Davies

Primary Care Consultations About Medically Unexplained Symptoms: Patient Presentations and Doctor Responses That Influence the Probability of Somatic Intervention

Objective: In primary care, many consultations about physical symptoms that the doctor thinks are not explained by physical disease nevertheless lead to somatic interventions. Our objective was to test the predictions that somatic intervention becomes more likely a) when doctors provide simple reassurance rather than detailed symptom explanations and do not help patients discuss psychosocial problems and b) when patients try to engage doctors by extending their symptom presentation. Methods: Consultations of 420 patients presenting physical symptoms that the doctor considered unexplained by physical disease were audio-recorded, transcribed, and coded. Analysis modeled the probability of somatic intervention as a function of the quantity of specific types of speech by patients (symptomatic and psychosocial presentations) and doctors (normalization, physical explanations, psychosocial discussion). Results: Somatic intervention was associated with the duration of consultation. Controlling for duration, it was, as predicted, associated positively with symptom presentations and inversely with patients’ and doctors’ psychosocial talk. The relationship with doctors’ psychosocial talk was accounted for by patients’ psychosocial talk. Contrary to predictions, doctors’ normalization was inversely associated with somatic intervention and physical explanations had no effect. Conclusion: Somatic intervention did not result from the demands of patients. Instead, it became more likely as patients complained about their symptoms. Facilitating patients’ psychosocial talk has the potential to divert consultations about medically unexplained symptoms from somatic interventions. To understand why such consultations often lead to somatic interventions, we must understand why patients progressively extend their symptom presentations and why doctors, in turn, apparently respond to this by providing somatic intervention. MUS = medically unexplained symptoms; GP = general practitioner.

Why do primary care physicians propose medical care to patients with medically unexplained symptoms? A new method of sequence analysis to test theories of patient pressure.

Objective: We test predictions from contrasting theories that primary care physicians offer medical care to patients with medically unexplained symptoms in response to a) patients’ attribution of symptoms to disease and demand for treatment or b) their progressive elaboration of their symptoms in the attempt to engage their physicians. Methods: Primary care physicians identified consecutive patients who consulted with symptoms that the physician considered unexplained by physical disease. Four hundred twenty consultations with 36 physicians were audio recorded and transcribed, and physician and patient speech was coded turn by turn. Hierarchical logistic regression analysis modeled the probability of the physician proposing medical care as a function of the quantity of patients’ speech of specific kinds that preceded it. Results: Whether physicians proposed medical care was unrelated to patients’ attributions to disease or demands for treatment. Proposals of explicitly somatic responses (drugs, investigation or specialist referral) became more likely after patients had elaborated their symptoms and less likely after patients indicated psychosocial difficulties. Proposals of a further primary care consultation were responses simply to lengthening consultation. Conclusions: The findings are incompatible with the influential assumption that physicians offer medical care to patients with unexplained symptoms because the patients demand treatment for a physical disease. Instead, the reason why many of these patients receive high levels of medical care should be sought by investigating the motivations behind physicians’ responses to patients’ symptom presentation. MUS = medically unexplained symptoms.

Bifocal/varifocal spectacles, lighting and missed-step accidents

Abstract Good lighting and the correct use of spectacles generally improve vision and presumably reduce the risk of accidents. However, bifocal and varifocal spectacles can increase the risk of misjudging distances when negotiating underfoot hazards. In some circumstances, the portion of the lens used for close work may inadvertently be used where accurate judgement of distance is necessary. This paper reports results from two studies of patient interviews using the Merseyside Accident Information Model; the first a study of accidents which occurred during paid employment (1504 cases) and the second of 1326 accidents mainly in domestic and leisure activities. Underfoot accidents were identified by the first unforeseen event perceived by the patient. The relationship between underfoot events and the type of spectacles worn by the patient at the time of accident was analysed. In both studies there was a significant association between accidents where the first event was ‘missed edge of’ (step) and wearing bifocal/varifocal spectacles. Corporal movements reported in both studies indicated that ‘stepping down’ when wearing bifocal/varifocal spectacles, increased the risk of ‘missed edge’ accidents. In the work environment corporal movements associated with manual handling of loads also increased the risk of ‘missed edge’ accidents when wearing bifocal/varifocal spectacles.

Understanding accident mechanisms: an analysis of the components of 2516 accidents collected in a MAIM database

MAIM is an acronym for the Merseyside Accident Information Model, the current version of which is an intelligent, knowledge-based software system. This paper describes a full scale trial using MAIM to record and categorise data on the causes of injuries. The subjects studied were 2516 patients attending the Royal Liverpool University Hospital for diagnosis and treatment of injuries between September 1992 and September 1993. The aims were to test the MAIM software, to show that it is possible to collect high quality accident information from hospital patients without writing, typing or coding, and to find methods of analysing the database to provide information that can be applied to accident prevention. Subsidiary aims were to show the extent of accidents which occur in sequences of more than one event and to confirm that it is possible to collect routinely the first and final events in accidents. No single description from the accident database could provide a perspective of how the population was injured. The database project has provided evidence on the complexity of accidents and the rare occurrence of identical combinations of all components and there were no two identical accidents. This illustrates the difficulties of preventing accidents. To assist the analysis and to focus attention on information useful for accident prevention, an analysis method has been developed to identify objects and event verbs associated with both the causes of accidents and the causes of injuries. A coefficient can be computed which links events either to the start or end of an accident. The coefficient allows accidents to be grouped so that typical or average accidents can be formulated and accidents with common features can be analysed to show the course of average or typical events reported by patients. This allows a detailed examination of common causes of similar accidents. Difficulties in classifying accidents have been highlighted; this is especially true where accident recording systems attempt to classify accidents into broad groups. The analysis method provides an insight into the mechanisms causing accidents and injuries.

An investigation of underfoot accidents in a MAIM (Merseyside Accident Information Model) database

Underfoot accidents taken from a study of patient interviews have been analysed to investigate factors that may be implicated in the causes of the accidents. Within the sample of patients in this study women holding items are more at risk than men from underfoot accidents. Carrying items such as shopping and handbags may obstruct the line of sight to underfoot hazards, affect balance and adversely affect reflex corporal movements that may help prevent injury.

Manual handling injuries and long term disability

The purpose of this study was to examine the outcome of accidents resulting in manual handling injuries (MHI) in relation to the disability caused. The Merseyside Accident Information Model (MAIM) was used to provide an event structure relating to accidents involving hospital treatment for 1504 people injured at work. Data was collected by interview; 1077 of these were followed up for details of subsequent sickness absence, return to work and impairment of normal activities. MHI accounted for 40% of the accidents and 80% of these required up to 4 weeks sickness absence. One in every five MHI cases required more than a months absence from work. The profile of time lost was similar for MHI and non-MHI. Approximately 48% returned to work on reduced duties or changed their jobs. Over 10% required hospitalisation overnight as a result of the MHI. A large number took between 4 and 8 weeks to return to work, while four out of every 257 people failed to return to work. Underfoot accidents and age were significant predictors that disability would result from a manual handling accident.

Protocol of a prospective cohort study of the effect of different methods of drainage of neuropathic bladder on occurrence of symptomatic urinary infection, and adverse events related to the urinary drainage system in spinal cord injury patients

BackgroundTo present a protocol of a prospective, cohort study in which four groups of spinal cord injury (SCI) patients will participate. (Patients with indwelling urethral catheter; patients who perform intermittent catheterisation without wearing a penile sheath; patients who perform intermittent catheterisation and wear penile sheath as well; and patients with penile sheath drainage).Objectives(1) What is the incidence of symptomatic urinary infection in men with spinal cord injury who use different types of bladder drainage? (2) Which are predisposing factors for the occurrence of symptomatic urinary infection in men with spinal cord injury who practise different methods of bladder drainage? (3) What is the incidence of catheter and urinary drainage system-related adverse events in the four groups of SCI patients?PatientsThe criteria for inclusion are as follow: (1) Male patients with neuropathic bladder due to spinal cord injury, who are registered with the Regional Spinal Injuries Centre, Southport, England. (2) Age: 18 years or above. (3) Patients who are willing to give informed consent for participation in the study. (4) Patients willing to be contacted every two weeks by a staff of the spinal unit for 36 months. (5) Patients who are willing to maintain an accurate record of adverse events related to urinary catheter and urinary drainage system and predisposing factors for the occurrence of symptomatic urinary infection. (6) Patients, who are stabilised in a particular method of bladder drainage, and therefore, unlikely to make a permanent change in the method of bladder drainage (e.g. from penile sheath drainage to the use of long-term indwelling catheter) during a foreseeable future.MethodsThe participants will be observed for a period of 36 months. A staff of the spinal injuries unit will contact the participants by telephone every two weeks on a mutually agreed day and time. The information obtained during this standardised telephonic interview conducted once in two weeks will be entered in a database. When a participant develops symptom(s) suggestive of urinary infection, he will undergo urine and blood tests, and imaging studies of the urinary tract.ConclusionThis study will provide information regarding the occurrence of symptomatic urinary infection, predisposing factors for development of urinary infection, and adverse events related to urinary catheter and urinary drainage system in SCI patients using different methods of bladder drainage.

Age and gender in underfoot accidents

The aim of this study was to investigate the effects of gender and age in the population of patients attending hospital as a result of ‘underfoot’ accidents. Patients attending hospital for the diagnosis and treatment of injuries were interviewed using a portable computer-based questionnaire, the Merseyside Accident Information Model (MAIM). Two studies were used, based on 2516 (1555 men and 961 women) and 1306 (751 men and 575 women) patients, interviewed while attending AE all P<0.001). Patients suffering underfoot accidents are increasingly likely to be female as their age increases. This is true both for ‘fracture’ and ‘non-fracture’ accidents, and in the latter at least this cannot be due to osteoporosis. We conclude that older people are increasingly likely to suffer fractures in underfoot accidents. Women are more likely to have underfoot accidents, increasingly with advancing age, and this cannot be explained by gender and ageing effects associated with fractures. We believe these data are potentially important for cost-effective targeting of preventative measures.