Thursday Review: “Multiple Symptoms and Health Anxiety in Primary Care: A Qualitative Study of Tensions and Collaboration between Patients and Family Physicians”

Difficult and ambiguous conversations are unavoidable in the practice of medicine. Looking at the most ambiguous and categorically difficult conversations helps illuminate why good communication skills are essential in all of them. Writing in BMJ Open, Le et al. give a glimpse into best practices that can be applied to any patient.

The authors derive a model from interviewing physicians and patients with unexplained physical symptoms and/or health anxiety which lists specific topics that physicians and patients often clash over. The content of the medical conversations (like what or how many tests to run, and how to medicate) isn’t the focus of the paper, though. They develop a model of collaborating with patients to focus on positive outcomes.

The four key elements in this interpersonal process are:

  1. feeling heard
  2. feeling validated
  3. respecting mutual expertise
  4. agreement on goals

The first two are specifically for the patient, but the last two are each shared between the patient and physician. The authors make it clear that feeling heard and feeling validated are interconnected:

When [patients] did not feel heard, little else could be accomplished. … When asked what it meant to be heard, patients spoke both of their physician actually listening and also of the shared understanding that resulted.

When these four key aspects of the interpersonal process are successful, the result is that two separate stories enter the medical encounter, and one shared story results from it. The patient, particularly one anxious about their health, or who exhibits undiagnosed symptoms, enters with their own lived experience. This history can be purely physical and a description of symptoms, or, as some physicians emphasized, can include psychosocial roots. The physician enters the encounter with some kind of prefigured narrative, either about this patient specifically, or generally, with their medical diagnostic expertise.

When these two narratives meet, if one or the other dominates, the result can only be finger-pointing and a power struggle. The key point of the model developed by Le et al. is the collaboration that results from the patient’s story being heard and validated as their personal experience, and a respect for the physician’s diagnostic retelling of the story as a potential way forward. As one patient said,

[A Physician can provide the best possible care by] listening and taking in all the information, and then, I think, suggesting a plan. But then, also, asking what the patient feels the next step should be.

At some level, two different people will necessarily have two different understandings of a past even and a future direction, but even if there’s tension and conflict in that difference, they need not doom the interaction to a mutually frustrating stalemate. Attention to interpersonal process rather than just the content of disagreement is helpful.

This is a cornerstone of patient experience, that the quality of the therapeutic alliance directly affects the quality of health outcomes.

Throughout the article, the authors emphasize that their findings are consistent with other studies of patient-provider interactions. They emphasize that these results are a reminder to apply familiar skills at a time of interpersonal challenge rather than a new intervention.

Every healthcare interaction, from the most complex to routine, is a call to reengage communication skills like active listening, clear communication, and professional compassion.


The article reviewed: Le, Thao Lan, Maria Mylopoulos, Erin Bearss, Rose Geist, and Robert Maunder. “Multiple Symptoms and Health Anxiety in Primary Care: A Qualitative Study of Tensions and Collaboration between Patients and Family Physicians.” BMJ Open 12, no. 4 (April 1, 2022): e050716.

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