Abstract
BackgroundInternists appear to define productive interactions, key concept of the Chronic Care Model, as goal-directed, catalyzed by achieving rapport, and depending on the medical context: i.e. medically explained symptoms (MES) or medically unexplained symptoms (MUS).ObjectiveTo explore internists’ interaction strategy discourses in the context of MES and MUS.MethodsWe interviewed twenty internists working in a Dutch academic hospital, identified relevant text fragments in the interview transcripts and analyzed the data based on a discourse analysis approach.ResultsWe identified four interaction strategy discourses: relating, structuring, exploring, and influencing. Each was characterized by a dilemma: relating by ‘creating nearness versus keeping distance’; structuring by ‘giving space versus taking control’; exploring by ‘asking for physical versus psychosocial causes’; and influencing by ‘taking responsibility versus accepting a patient’s choice. The balance sought in these dilemmas depended on whether the patient’s symptoms were medically explained or unexplained (MES or MUS). Towards MUS the internists tended to maintain greater distance, take more control, ask more cautiously questions related to psychosocial causes, and take less responsibility for shared decision making.Discussion and conclusionsAdopting a basic distinction between MES and MUS, the internists in our study appeared to seek a different balance in each of four rather fundamental clinical dilemmas. Balancing these dilemmas seemed more difficult regarding MUS where the internists seemed more distancing and controlling, and tended to draw on their medical expertise. Moving in this direction is counterproductive and in contradiction to guidelines which emphasize that MUS patients warrant emotional support requiring a shift towards interpersonal, empathic communication.
Highlights
In the Chronic Care Model ‘productive interactions’ between an ‘informed, activated’ patient and a ‘prepared, proactive’ physician/practice team’ are linked to positive health outcomes [1,2]
We interviewed twenty internists working in a Dutch academic hospital, identified relevant text fragments in the interview transcripts and analyzed the data based on a discourse analysis approach
We identified four interaction strategy discourses: relating, structuring, exploring, and influencing
Summary
In the Chronic Care Model ‘productive interactions’ between an ‘informed, activated’ patient and a ‘prepared, proactive’ physician/practice team’ are linked to positive health outcomes [1,2]. To further clarify this crucial but not yet clearly defined concept, we found that internists define a productive interaction with chronically ill patients as one that is goal directed and catalyzed by achieving rapport[3]. Internists appear to define productive interactions, key concept of the Chronic Care Model, as goal-directed, catalyzed by achieving rapport, and depending on the medical context: i.e. medically explained symptoms (MES) or medically unexplained symptoms (MUS)
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