Functional somatic symptoms in youths in general practice: A ... study on prevalence, clinical management and perceived burden, 2022, Klastrup et al

[Andy]

Full title: Functional somatic symptoms in youths in general practice: A cross-sectional study on prevalence, clinical management and perceived burden

Highlights

• Youths are less often followed up in general practice compared to adults.
• 4.4% of youths are diagnosed with functional somatic symptoms in general practice.
• Youths with functional somatic symptoms are found more time consuming and burdensome.
• Management strategies directed at youths with functional somatic symptoms are relevant.

Abstract

Objective
Functional somatic symptoms (FSS) may progress into a functional disorder if poorly managed, which may have serious implications. This cross-sectional study describes the management of youths compared to adults in general practice and estimates the prevalence of FSS in youths in this setting by comparing consultation-related aspects between youths with FSS and 1) youths with a specific diagnosis and 2) adults with FSS.

Methods
We used data from a Danish survey (2008–2009), including 3295 face-to-face consultations between GPs and patients aged 15–64 years. Patients were divided into youths (15–24 years) and adults (25–64 years) and then into subgroups according to the GPs' classifications: 1) specific diagnosis, 2) resolving symptom and 3) FSS. Logistic regression analysis was used for all comparisons, and estimates were adjusted for gender, concomitant chronic disorder and GP cluster.

Results
The GPs more frequently ensured continuity of care in adults (AOR:0.75, 95%CI:0.61–0.92, p < 0.01) and perceived youths as less time consuming (AOR:0.58, 95%CI: 0.43–0.77, p < 0.01) and less burdensome (AOR:0.60; 95%CI: 0.45–0.81, p < 0.01) compared to adults. FSS prevalence was 4.4% in youths and 9.0% in adults. However, GPs perceived youths with FSS as more burdensome (AOR:7.77, 95%CI:2.93–20.04, p < 0.01) and more time consuming (AOR:3.98, 95%CI:1.42–11.12, p < 0.01) than youths with a specific diagnosis, whereas they perceived youths and adults with FSS as equally burdensome and time consuming.

Conclusion
The results indicate age-related variations in the prevalence and clinical management of FSS in general practice. The GPs perceived both youths and adults with FSS time consuming, which underlines a need for supportive management strategies.

Open access, https://www.sciencedirect.com/science/article/pii/S0022399922000502

 

[Sean]

FSS

Another one for the ever growing list of acronyms.

 

[Hutan]

I read that first as FFS @Sean, which also applies.

more 'burdensome and time consuming' than someone with a specific diagnosis. Klastrup et al, you mean the doctors have to make more effort to try to find a diagnosis when the diagnosis is not yet recorded in the person's medical notes?

Perhaps there's something lost in translation, but in English this comes across as mean-spirited. Yes, a patient with many symptoms and no diagnosis might require the doctor to make an effort above what they usually do, but surely we should be thinking about the young person? They are probably finding the whole thing of having symptoms that some people insist on calling 'functional' a good deal more time consuming and burdensome than the doctor. (And they aren't getting paid rather well to carry that burden.)

 

[Hutan]

Let's record the names of the people who are happy to put their names to this nastiness:

L.K.Klastrup a
M.Rosendal c,d
M.T.Rask c
K.S.Christensend e
C.U.Rask a,b
a Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Denmark
b Department of Clinical Medicine, Aarhus University, Denmark
c Research Clinic for Functional Disorders, Aarhus University Hospital, Denmark
d Research Unit for General Practice, Aarhus, Denmark
e Department of Public Health, Aarhus University, Denmark

 

[Hutan]

The GPs also stated their perceived burden of the consultation on a scale ranging from 1 to 10. This was based on the following instruction: “Please consider the extent to which the contact was burdensome, regardless of whether the burden was due to discomfort derived from uncertainty about the diagnosis or treatment, problems of a linguistic, cultural or cognitive nature, or if it seemed heavy/frustrating/unsatisfactory for other reasons”. For the analyses, we dichotomised burden into low [[1], [2], [3], [4], [5], [6]] or high [[7], [8], [9], [10]].

(There's an issue in the paper with the numbers of the scale turning into reference citations.)


It just boggles my mind that academics would go out of their way to ask doctors if they found contact with patients burdensome, and then not care about why they found it burdensome. I mean, how do you fix a problem if you can't tell if it is because of language difficulties or because the doctor and/or the patient are frustrated because no answer has been found?

I also find it hard to understand how 404 GPs out of 870 in the region would agree to participate in labelling their encounters with patients burdensome. I do note that the survey was done in 2007/2008. It's pretty odd to be digging out this data so long after it was collected.

87.5% of young people labelled with functional somatic symptoms were young women.

 

[Jonathan Edwards]

The GPs perceived both youths and adults with FSS time consuming, which underlines a need for supportive management strategies.

The GPs perceived both youths and adults with FSS time consuming, which underlines a need for ways to offload them onto someone else.

 

[JemPD]

Youths with functional somatic symptoms are found more time consuming and burdensome.
• Management strategies directed at youths with functional somatic symptoms are relevant.

my bolding.

Eww. Lets hope that's a tranlation issue, but 'directed at' in english is quite aggressive. Which seems in keeping with the point preceding it

 

[Hutan]

Just a few more points.

The prevalence of functional somatic symptoms 'identified' was just 4.4% in young people seen and 9% in adults seen. That's a long way short of the 30% of medical service time being taken up in a tsunami-like way by these time-consuming burdens that was put about in the UK literature. And it's very loose. GP's were supposed to estimate, at the first visit, what somebody's condition was likely to turn out to be. As such, it's probably more of a measure of doctor's prejudices, than reality.

whereas they perceived youths and adults with FSS as equally burdensome and time consuming.

Actually, Table 3 tells us that doctors found 37.50% of 'youths with FSS (n=24)' as burdensome, and 49.57% of 'adults with FSS (n=238)' as burdensome. So, they found adults more burdensome than youths by quite a big margin (and 48.44% of 'all people with FSS (n=262)' as burdensome). It seems the authors couldn't read their own table right.

Implications for research and practice
The number of youths with FSS are increasing and they are commonly encountered in general practice. Therefore, it is relevant to evaluate management and treatment strategies for this age group.

Where did that statement that the number of youths with FSS are increasing come from? It's not referenced, it's not in the study. It seems to be purely wishful thinking by these authors.

The GP-perceived burden found in the present study for patients with FSS overall suggests a need for education and implementation of supportive management strategies in general practice.

They can't really know that. We don't really know if the GP is feeling traumatised about their inadequacy, or just feeling that the consultation, where they had to make sure they had not missed a diagnosable biological cause, was more challenging than average. Do we really want GP's to stop feeling that uncertainty when faced with something they can't immediately diagnose?

Such initiative should also be directed at youths to improve the GPs' ability to help and support this potentially vulnerable young patient group.

What?! The 'youths with FSS' should be told/taught to be different in some way so that the GPs feel better about their role?

Thus, early recognition and treatment of young people with FSS may reduce the risk that the symptoms become chronic and disabling, thereby preventing FSS from having a fundamental impact on the long-term course of their life as well as reduce potential unnecessary health care use.

Again, where have the authors got this conclusion from? 'Thus' nothing. This paper tells us nothing about about how early recognition and some sort of unspecified treatment may save these troubled young people from a life of being a time-consuming burden on the health care system. It's wishful thinking, it's certainly not science.

 

[Arnie Pye]

GP's were supposed to estimate, at the first visit, what somebody's condition was likely to turn out to be.

That is appalling. At first visit from any patient with symptoms new to the patient GPs wouldn't have done any blood tests or urine tests to help them make a decision, and are unlikely to have decided whether an X-ray, CT scan, or MRI was justified (and in the UK probably wouldn't have had the authority to order CT scan or MRI anyway, which would involve a referral to a hospital or other clinic). It's unlikely the doctors would have watched the patient walk, or touched the patient, felt their glands, examined the abdomen or the joints. It's as if the profession have all decided that all patients are "icky".

To be fair to GPs though, they aren't the only ones doing this. Secondary care is often just as bad. Doctors use what I think is called "interactional resistance" on me in many appointments. Their expression is entirely blank, they don't respond to what I have to say, they don't ask questions, they don't order tests, they fob me off, and never follow up. They basically don't initiate sentences if they can avoid it. A trick I only twigged to quite recently is that a doctor, once in a blue moon might suggest I get "full bloods" done. Of course, throughout most of my life I've had no access to any results so they could do whatever they damn well wanted and then will tell me that all the results were fine and dandy, and I would never know that very little had been done. I only realised recently (since I do now have a copy of the medical records I was allowed to see) that in many cases I have had a full blood count done, and that appears to be what "full bloods" actually meant. One thing I've been plagued with all my life is symptoms of iron deficiency. I've almost never had it tested.

There are other doctors who employ the opposite - a look of barely suppressed fury that I have dared to enter their office, they employ sarcasm, threats and well-practised rudeness and insults. But they won't initiate testing of any kind, and are unlikely to follow up as well, so all treatment comes out in the wash pretty much the same.

I can almost guarantee that in any one appointment a doctor will insult my honesty, my morality, or my sanity, or some combination of the three.

Oh, and I got diagnosed with a functional bowel disease back in the day. A few years later I got an operation, instigated by a doctor at an IVF clinic based in an NHS hospital, that 90% cured my "functional" bowel problem. If it hadn't been found I would have been in frequent severe pain ever since - and the operation was 20 years ago. I'd already been in pain with the problem for nearly 30 years before that.

Edit : Missing word

 

[rvallee]

 

[alktipping]

all this is what happens to give more reasons for g p s to not do their well paid jobs . purely a method of saving health care cost. such short term thinking is extraordinary stupid since the far reaching consequences costs vastly outweigh getting the proper diagnosis and care .

 

[Hutan]

Funding

This work was supported by the Lundbeck Foundation (grant. no. R327-2019-828 ), L.F. Foght's Foundation and Sara Krabbe's Scholarship (Danish College of General Practitioners, grant. no. SK 12-2020).

Maybe someone might like to write to these funders.

Where did that statement that the number of youths with FSS are increasing come from? It's not referenced, it's not in the study. It seems to be purely wishful thinking by these authors.

Actually, although that statement in the conclusion was not referenced, an earlier statement about FSS increasing was:

Past decades have seen a rising number of adolescents with FSS in the general population, mostly in Nordic countries [7,[14], [15], [16], [17], [18]] and especially among the older adolescents [19,20] and in girls [14,17,20,21].

So, I was wrong about that.

 

[Hutan]

Checking out some of those references for an increase in psychosomatic conditions:

[7] A. Cosma, G. Stevens, G. Martin, E.L. Duinhof, S.D. Walsh, I. Garcia-Moya, et al.
Cross-national time trends in adolescent mental well-being from 2002 to 2018 and the explanatory role of schoolwork pressure
J. Adolesc. Health, 66 (6s) (2020), pp. S50-s8

Psychosomatic health complaints
Participants indicated the frequency with which they had experienced the following eight health complaints over the past 6 months: feeling low, irritability or bad temper, feeling nervous, difficulties in getting to sleep, feeling dizzy, headache, stomach ache, and backache, with the following response options: (1) “about every day,” (2) “more than once a week,” (3) “about every week,” (4) “about every month,” and (5) “rarely or never.”

A small linear increase over time in psychosomatic health complaints (B = .067; p < .001; Model 1) was found. The overall mean in psychosomatic health complaints ranged from 7.74 (SD = 6.13) in 2002 to 8.67 (SD = 6.06) in 2018 (Supplementary Table A1). Girls (B = 2.421; p < .001) and older adolescents (B = .567; p < .001) reported higher levels of psychosomatic health complaints. Adolescents from medium (B = −.609; p < .001) and high family affluence (B = −.601; p < .001) reported lower levels of psychosomatic health complaints compared with those from low affluent families.

For a start, the questions don't measure psychosomatic health complaints. They measure:

• mood (feeling low, irritability, feeling nervous);
• they measure difficulties with sleep, which could be due to a sorts of things; and
• they measure some health conditions that could also be caused by many things (feeling dizzy, headache, stomach ache, and backache).

For goodness sake, the higher incidence in girls might easily be due to the onset of menstruation in this age group. That anyone could think that those questions gives a measure of the frequency of psychosomatic health complaints strikes me as completely bizarre.

And then the increase in supposed "psychosomatic health complaints" over 10 years is pretty small. And results varied by country: Slovakia, Spain, Ukraine*, England and Romania all showed a decrease in "psychosomatic health complaints" over the ten years.

*

 

[Sean]

I find dealing with ignorant arrogant incompetent callous doctors (and health & welfare systems) more than a little burdensome.

The 'youths with FSS' should be told/taught to be different in some way so that the GPs feel better about their role?

Just an appalling attitude, isn't it.

Poor widdle medicos, having to actually earn their pay, and confront the limits of their knowledge. Must be terrible.

 

[rvallee]

Where did that statement that the number of youths with FSS are increasing come from? It's not referenced, it's not in the study. It seems to be purely wishful thinking by these authors.

The labels are used more than before. That's a real increase there. It's fake, but the increase in FSS-type diagnostic labels really is growing. Basically they're mailing themselves fan letters and using that increase in fan letters to justify being good at their job. It probably doesn't even feel like it needs to be justified from people promoting its adoption.