Source: Medical Teacher
Vol. 30, #6, (2008), pp. 618-621
Date: May 20, 2008 (preprint)
URL: http://www.informaworld.com/smpp/content~db=all?content=10.1080/01421590801946970
Teaching medical students about medically unexplained illnesses: A preliminary
study
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Fred Friedberg(*), Stephanie J, Sohl & Peter J. Halperin
- Department of Psychiatry and Behavioral Science, Stony Brook University, New
York, USA
* Correspondence: Fred Friedberg, Ph.D., Assistant Professor, Department of
Psychiatry and Behavioral Science, Putnam Hall; South Campus, Stony Brook,
New York, 11794-8790, USA. Tel: 631-632-8252; fax: 631-632-3165; email:
Fred.Friedberg@stonybrook.edu
Abstract
Background
This study examined how an interactive seminar focusing on two medically
unexplained illnesses, chronic fatigue syndrome (CFS) and fibromyalgia,
influenced medical student attitudes toward CFS, a more strongly stigmatized
illness.
Methods
Forty-five fourth year medical students attended a 90 minute interactive
seminar on the management of medically unexplained illnesses that was
exemplified with CFS and fibromyalgia. A modified version of the CFS
attitudes test was administered immediately before and after the seminar.
Results
Pre-seminar assessment revealed neutral to slightly favorable toward CFS. At
the end of the seminar, significantly more favorable attitudes were found
toward CFS in general (t(42)=2.77; P<0.01) and for specific items that
focused on (1) supporting more CFS research funding (t(42)=4.32; P<0.001; (2)
employers providing flexible hours for people with CFS (t(42)=3.52, P<0.01);
and (3) viewing CFS as not primarily a psychological disorder (t(42)=2.87,
P<0.01). Thus, a relatively brief exposure to factual information on specific
medically unexplained illnesses was associated with more favorable attitudes
toward CFS in fourth year medical students.
Conclusion
This type of instruction may lead to potentially more receptive professional
attitudes toward providing care to these underserved patients.
Practice points
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* In contrast to practicing physicians, medical students
do not hold negative attitudes toward chronic fatigue
syndrome.
* Advanced medical students are receptive to acquiring
constructive attitudes about chronic fatigue syndrome
and fibromyalgia.
* A relatively brief exposure to factual information on two
unexplained illnesses was associated with more favor-
able attitudes toward the more highly stigmatized illness
of chronic fatigue syndrome.
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Introduction
Medically unexplained symptoms may be defined as physical symptoms that
cannot be explained by identifiable physical pathology and that distress or
impair the functioning of patients (Morriss et al. 2006). Patients who
persistently complain of these symptoms are common in primary care (Katon &
Walker 1998). Yet, we found no reports in the medical education literature
that addressed the concept of medically unexplained symptoms as part of an
undergraduate medical training curriculum. In the apparent absence of prior
training, physicians may not know how to approach these patients (Epstein et
al. 2006).
Because medically unexplained symptoms lack definitive diagnostic tests, they
are often considered psychiatric in origin or simply minor problems (Wagner &
Hendrich 1993). Yet these types of patient presentations tend to occupy a
disproportionately large share of physician time and contribute to physician
frustration (Richardson & Engel 2004). In addition, epidemiological research
suggests that medically unexplained symptoms are associated with a high
proportion of population-wide disability and health care utilization (Kroenke
& Price 1993).
Although symptom complaints may vary considerably (Katon & Walker 1998),
patients with medically unexplained symptoms often present with high levels
of psychosocial stress and psychopathology (Epstein et al. 2006). Thus
assessments and interventions that focus on identifying and managing distress
and maladaptive behavior are more likely to lead to favorable outcomes (e.g.
Morriss et al. (2006)) in comparison to standard medical care.
Chronic fatigue syndrome (CFS) and fibromyalgia (FM) represent two common
illnesses conditions that are defined by multiple unexplained symptoms and
impairments (Wolfe et al. 1990; Fukuda et al. 1994). If medical students can
be taught the fundamentals of diagnosis and management of such illnesses from
a behavioral perspective (Sharpe et al. 1997), then they will be better
equipped to help these patients.
A potential obstacle to acquiring useful clinical knowledge in this domain
may be the negative stereotypes (e.g., mental illness stigma; malingering)
that are associated with medically unexplained conditions generally, and in
particular, CFS (e.g. Looper & Kirmayer 2004). Physicians may also endorse
illness-deligitimizing views such as negative personality traits and illness
fixation (Raine et al. 2004). Such attitudes toward CFS may plausibly be
associated with patient-reported dissatisfaction with the care they receive
(e.g. David et al. 1991). It is not clear how medical students in their
clinical years view these patients.
The objectives of this study were (1) to assess medical student attitudes
toward the medically unexplained illness of chronic fatigue syndrome (CFS)
and (2) to evaluate the effects of a seminar focusing two medically
unexplained illnesses, CFS and fibromyalgia, on medical student attitudes
toward the more highly stigmatized illness of CFS.
Methods
Sample
Forty-six fourth year medical students who attended a seminar on the
management of medically unexplained illnesses from September 2005 to October
2006 were eligible to participate in the study. Only 1 student declined to
participate. The mean age was 27.8, 51.2% were female (n=21), and 22.7% were
married (n=10). The seminar in which the study was conducted was part of a
required fourth-year course, Psychiatry in Medicine (Halperin 2006), that
exposed students to common psychiatric and psychosomatic issues arising in
general medical practice. As far as we know, it is the only such required
course in the clinical years in any US medical school. This study was
approved by the Stony Brook University Institutional Review Board.
Assessment
Chronic fatigue syndrome attitudes test (CFSAT). A 14-item modified version
of the 13-item CFSAT (Shlaes et al. 1999) was used to assess attitudes toward
the medically unexplained illness of CFS. The response format was a
seven-point adjective rating scale ranging from strongly disagree (1) to
strongly agree (7). A 4 rating indicated 'neither agree nor disagree.'
Lower ratings indicated more favorable attitudes toward CFS. The test has
shown good test-retest reliability and a three factor structure
(Responsibility for CFS; Relevance of CFS; and Traits of People with CFS;
Shlaes et al. 1999).
Procedure
Subjects were administered the CFSAT immediately before and after a 90 minute
interactive seminar (taught by Friedberg) on the management of medically
unexplained illnesses that focused on CFS and fibromyalgia. In the seminar,
factual information accompanied by videotaped cases was provided with respect
to sociodemographics, clinical diagnosis, psychosocial assessment, and
behavioral management (Sharpe et al. 1997; Friedberg 2006). Subjects were
encouraged to ask critical questions and to adapt a constructive
problem-solving approach to this type of patient presentation. As future
physicians, students were told that they could provide, within the medical
visit, substantive help to these patients with empathic understanding and
straightforward behavioral management techniques, such as relaxation
training, graded exercise, and sleep scheduling (Richardson & Engel 2004).
Analyses
Descriptive statistics and paired t-tests were calculated using computer
software SPSS 14.0.
Results
Questionnaire assessments prior to the seminar revealed either slightly
favorable or neutral attitudes (neither agree nor disagree), on average,
toward CFS on most items (Table 1). However, favorable attitudes were shown
for these statements (1) 'It is important for physicians to understand CFS'
(strong agreement); and (2) 'Patients are to blame for getting sick'
(strong disagreement).
At the end of the seminar, significantly more favorable attitudes toward CFS
(t(42)=2.77; P<0.01; 95% CI (0.78 to 4.99)) were found based on total scores
on the CFSAT. Specifically, improvements were found on items that focused on
(1) favoring more CFS research funding (t(42)=4.32; P<0.001); (2) employers
providing flexible hours for people with CFS (t(42)=3.52, P<0.01); and (3)
viewing CFS as not primarily a psychological disorder (t(42)=2.87, P<0.01).
In addition, a significant difference (t(42)=2.86, P<0.01) was found in
perceptions of disability, with more agreement post-seminar that people with
CFS were disabled from working. Slight to moderate disagreement was found at
both assessments for items describing CFS patients as 'just depressed' or
'lazy' (Table 1).
Discussion
This preliminary study revealed either slightly favorable or non-committal
attitudes toward the medically unexplained and stigmatized illness of CFS
among fourth year medical students. In addition, it was found that attitudes
toward CFS were favorably changed following an interactive seminar on
medically unexplained illnesses that focused on CFS and FM. Specifically,
improvements were shown in attitudes toward research funding, flexible work
hours, and considering CFS as not primarily psychological disorder. Informal
participant feedback indicated a strong preference for the interactive format
which allowed productive discussions between the instructor and fellow
students.
An unexpected finding after the seminar was that students were more likely to
agree that 'most people with CFS are disabled from working,' which was
contrary to the instructor's message that most individuals with CFS are
employed. Teaching medical students that some patients with CFS may be
legitimately disabled, while many more patients with this illness are higher
functioning may be a complex idea to convey. The seminar presented a video of
two people with work-disabling CFS followed by a factual discussion of how
most people with CFS are able to work at least part-time. The video in
comparison to the discussion may have been more salient to the students which
in turn influenced their questionnaire response. A more balanced media
presentation that included both high and low functioning patients may have
counteracted this effect.
The absence of negative or stigmatizing attitudes toward CFS in advanced
medical students suggests that undergraduate medical institutions may provide
a desirable venue for clinical instruction about medically unexplained
symptoms. By comparison, practicing physicians often have negative views
toward patients with CFS (David et al. 1991) and to a lesser degree toward
patients with medically unexplained symptoms in general (Pridmore et al.
2004).
If medical education provides a broader conceptualization of illness within a
biopsychosocial context (Engel 1978) that recognizes the interactive
complexity of chronic conditions, then 'unexplained' symptoms can be
integrated into this model. Similar to more definitive medical illnesses,
students can be taught how to effectively and efficiently care for patients
with unexplained symptoms who are subject to the same types of environmental
and behavioral influences, e.g. stress factors, activity levels, social
relationships. For instance, training GPs to address clinical management of
medically unexplained symptoms using cognitive-behavioral and pharmacological
modalities has proved successful and cost effective in preliminary studies
(Morriss et al. 1998).
This study suggests that medical students in their clinical years are
receptive to acquiring constructive attitudes and new knowledge about
medically unexplained illnesses, such as CFS and fibromyalgia. Because this
preliminary study did not assess attitudes toward medically unexplained
illnesses in general, it is unknown to what extent the attitude change that
occurred would apply to the broad range of patients with unexplained
symptoms. This study is also limited by the absence of follow-up assessments
to determine if the more useful acquired attitudes were maintained.
This report may have important implications for a possible new dimension of
medical training. Undergraduate medical education that includes clinical
instruction on medically unexplained illness may allow a new generation of
future physicians to acquire the clinical receptivity and practical skills to
become more effective providers for these underserved populations.
Notes on contributors
Fred Friedberg, Ph.D. is an Assistant Professor in the Department of
Psychiatry and Behavioral Science at Stony Brook University.
Stephanie Sohl, M.A. is a graduate student in the Social and Health area of
the Psychology Department at Stony Brook University.
Peter Halperin, M.D. is an Associate Professor in the Department of Psychiatry
and Behavioral Science at Stony Brook University and is Director of Medical
Student Education in Psychiatry.
Table
Table 1. Chronic Fatigue Syndrome Attitudes Test: Items and Ratings Before and After Seminar.
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Item Before After (95% CI)
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Employers should provide flexible hours for people with CFS (-) 3.67 2.98 (0.29 to 1.10)**
People with CFS are just depressed 2.84 2.74 (-0.37 to 0.56)
More federal funds should be allocated for research on CFS (-) 3.88 2.98 (0.48 to 1.33)***
People with CFS are lazy 2.56 2.44 (-0.31 to 0.54)
CFS may be a medical condition (-) 1.98 1.93 (-0.18 to 0.27)
People with CFS unconsciously reject working 3.33 3.26 (-0.41 to 0.55)
Most people with CFS are disabled from working 3.53 4.42 (-1.51 to -0.26)**
It is important for physicians to understand CFS (-) 1.63 1.60 (-0.16 to 0.21)
People with CFS would get better if they really wanted to 3.67 3.28 (-0.05 to 0.84)
CFS is primarily a psychological disorder 3.63 3.09 (0.16 to 0.91)**
The majority of people with CFS have a high socio-economic status 3.88 4.05 (-0.51 to 0.19)
If people with CFS rest, then they will get better 2.79 2.44 (-0.07 to 0.77)
People with CFS are to blame for getting sick 2.23 2.00 (-0.21 to 0.68)
People with CFS could work if they really wanted to 4.02 3.56 (-0.03 to 0.96)
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(-) Items are reverse coded; 95% CI=95% confidence interval of the mean difference.
*P<0.05, **P<0.01, ***P<0.001.
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