Reattribution reconsidered: Narrative review and reflections on an educational intervention for medically unexplained symptoms in primary care settings

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Abstract

Objective

Medically unexplained symptoms (MUS) refer to bodily symptoms without a physical health explanation. In the context of MUS, reattribution is a process of attributing physical symptoms to a psychological cause. We review the use of a consultation model which employs reattribution, and which has been extensively utilised in teaching and research in primary care.

Methods

Literature search for studies utilising the reattribution model. Narrative review of the results.

Results

Data was extracted from 25 publications from 13 studies. The model has been modified over time and comparison between studies is limited by differences in methodology. The skills of the model can be acquired by training, which also improves practitioners' attitudes to MUS. However impact on clinical outcomes has been mixed and this can be explained in part from the findings of nested qualitative studies.

Conclusions

The reattribution model is too simplistic in its current form to address the needs of many people presenting with MUS in primary care. Reattribution of physical symptoms to psychological causes is often unnecessary. Further research is required into the effectiveness of stepped and collaborative care models in which education of primary care practitioners forms one part of a complex intervention. The consultation process is best seen as both a conversation and ongoing negotiation between doctor and patient in which there are no certainties about the presence or absence of organic pathology.

Section snippets

Background

Medically unexplained symptoms (MUS) refer to bodily symptoms that do not have a physical health explanation [1]. They are present in 3–19% of consultations with general practitioners [1], [2] and pose a major problem for health care systems in terms of their assessment, appropriate management and economic burden [3], [4]. In the context of MUS, the term reattribution was originally employed to denote the ascription of physical symptoms to a psychological cause. One of us (LG) co-authored a

Methods

We systematically searched the published literature with the specific objective of determining the impact that reattribution training and subsequent modifications of its original model have had on the process and outcome of care for people with medically unexplained symptoms.

Results

After removal of duplicates, 99 publications remained from which 20 were included in the review. A further 3 relevant research papers and 2 unpublished theses were added from searching of reference lists and the personal contacts/knowledge of the research team giving a total of 25 papers (Fig. 1).

These resulted from 13 different studies utilising the Reattribution model carried out in the United Kingdom (UK) [8], [9], [10], [11], [12], [22], [23], [24], [25], [26], [27], [30], [31], the

Qualitative findings

Research carried out in qualitative studies nested within trials has identified possible explanations for the mixed quantitative findings. For patients, Peters and colleagues [26] found that potential barriers to patient improvement include the perceived complexity of their problems and the difficulty experienced by patients in making judgements about how to manage their presentation of this complexity to the GP who they viewed as having a more simplistic understanding of the problem. Most

The impact of reattribution training

RT does not appear to offer a solution to the problem of managing medically unexplained symptoms in primary care in its current form. The basic skills can be acquired, but more extensive training, which would be unacceptable to most GPs in the UK (although the TERM model has now been widely disseminated in Denmark [18]), seems necessary to embed these skills and strategies. To be effective we suspect that GPs must be trained in an approach to the consultation in which they really explore

Conclusions

The reattribution model is too simplistic in its current form to address the needs of many people presenting with medically unexplained symptoms in primary care. In the broad terms of the original aims of the model set out at the beginning of this paper, we are still seeking to help patients to re-evaluate their beliefs and understanding of their problems, but we no longer consider it necessary to formally re-attribute symptoms to a psychological cause. The consultation process is best seen as

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