570624
research-article2015
CPJXXX10.1177/0009922815570624Clinical PediatricsBroekhuijsen-van Henten et al
Brief Report
Exploring Self-Efficacy and Attitudes Among Pediatricians in Managing Medically Unexplained Physical Symptoms
Clinical Pediatrics 2015, Vol. 54(14) 1391–1393 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922815570624 cpj.sagepub.com
Dorien M. Broekhuijsen-van Henten, MD1, Gert H. J. Luitse, MD1, Andrieke C. Knottnerus, MD2, and Meta van den Heuvel, MD3
Introduction Medically unexplained physical symptoms (MUPS) are common in pediatric practice. Children with MUPS are often functionally impaired in daily activities (school, sleep, and social behavior) and perceive their health status negatively.1 Up to 25% of children and adolescents reported chronic pain in a population study, mostly headache, abdominal pain, and limb pain.2 Fatigue was reported in 30% of a population sample of 11- to 15-yearolds.3 Patients with MUPS suffer from serious impairment in everyday life.4Factors such as deprivation, family dysfunction, family illness, and concurrent stress have all been linked to MUPS and there is evidence that recurrent somatic complaints in children are associated with increased rates of psychological morbidity.5 To physicians, treatment of patients with MUPS is often challenging. The exclusion of disease does not cure the patient: To achieve improvement, the physician needs to use specific diagnoses and treatment strategies with special demands on communication competence.1 MUPS may lead to frustration among doctors. In a study of Wileman et al,6 family physicians felt insufficiently equipped to manage youth with MUPS. Little research has been done toward perceptions and attitudes of pediatricians concerning the management of children with MUPS.7 The aim of the study was to examine self- efficacy, attitudes, and perceptions of pediatricians in the management of children with MUPS. Our hypothesis was that pediatricians with more experience had a greater exposure to children with MUPS. More exposure could have a positive effect on the self-efficacy scores and attitudes toward the management of children with MUPS.
Methods An online-distributed survey questionnaire was developed with SurveyMonkey. After pilot testing in a small group of pediatricians on clarity and ease of administration, it was
refined on the basis of their feedback. The questionnaire was addressed to all Dutch pediatricians in 2014 (n = 1306). E-mail addresses were obtained from the Dutch Society of Pediatrics (NVK, Nederlandse Vereniging Kindergeneeskunde). The survey consisted of 22 questions. Self-efficacy scores in different stages of the diagnostic and therapeutic process of MUPS were specified by the level of agreement or disagreement on a 10-point Likert-type scale. Special attention was paid to communication, investigating issues like “taking a history according to the bio-psycho-social model” and “the quality of communicating to patients and parents in cases of MUPS.” Attitudes, for example, satisfaction, were also expressed using a 10-point Likert-type scale. Data were analyzed using descriptive statistics and analysis of variance was done to compare the mean differences in Likert-type scores by years of pediatric work experience.
Results Response rate was 339 (26%) and included 70% females. Most responders (192 = 56.6%) were general pediatricians, 53 (15.6%) were pediatric subspecialists and worked in a second line hospital and 41 (12%) were pediatric subspecialists and worked in an academic medical center, in 53 responders (15.6%), this background was unknown. There was a near equal distribution over the years of experience: 0 to 5 years, n = 52 1
Amalia Children’s Centre, Isala Hospital, Zwolle, Netherlands Spaarne Hospital, Hoofddorp, Netherlands 3 Beatrix Children’s Hospital, University Medical Centre Groningen, Groningen, Netherlands 2
Corresponding Author: Dorien M. Broekhuijsen-van Henten, Amalia Children’s Centre, Isala Hospital, Dr van Heesweg 2, PO Box 10400, Zwolle, 8000GK, Netherlands. Email: [email protected]
Downloaded from cpj.sagepub.com at NANYANG TECH UNIV LIBRARY on November 16, 2015
1392
Clinical Pediatrics 54(14)
Table 1. Mean Self-Efficacy Scores in Diagnosis and Treatment of Medically Unexplained Physical Symptoms (MUPS).a Years of Pediatric Experience How competent do you feel in:
0-5
5-10
10-15
15-20
>20
P Value
Recognizing symptoms and signs of MUPS? Taking a history according to the biopsychosocial model? Diagnosing MUPS? Communicating to patients and parents in cases of MUPS? Motivating patients for treatment? In organizing treatment or referral in MUPS?
7.1 5.7 7.0 7.1 6.8 6.7
7.3 5.4 7.2 7.3 7.1 6.8
7.3 5.9 7.2 7.5 7.2 7.1
7.8 6.6 7.7 7.6 7.4 7.4
7.6 6.3 7.6 7.5 7.2 7.2
.004 .010 .003 .106 .103 .057
a
Scored on a Likert-type scale from 1 to 10 (1 = not competent at all, 10 = excellent). Values in boldface indicate statistical significance.
Table 2. Mean Likert-Type Score of Attitudes and Perceptions of Pediatricians Toward Children With Medically Unexplained Physical Symptoms (MUPS).a Years of Pediatric Experience Children With MUPS:
0-5
5-10
10-15
15-20
>20
P Value
Give me satisfaction Are causing frustration Are time consuming Are fun to work with I am afraid to miss somatic diagnosis I will refer for a second opinion
5.4 5.3 7.5 5.6 5.8 3.4
5.8 5.7 7.9 6.1 5.9 3.9
6.0 5.0 7.7 6.1 5.3 3.5
6.4 4.9 7.5 6.3 4.4 3.1
6.5 4.5 7.5 6.3 4.8 3.4
.007 .009 .452 .280 20 years, n = 67 (20%), unknown, n = 23 (7%). Mean self-efficacy scores on the different aspects of diagnosing and treating patients with MUPS, subdivided by years of experience are presented in Table 1. In general, pediatricians felt quite competent in dealing with MUPS, with mean scores just higher than 7 (scale 1-10). However, taking a history according to the biopsychosocial model scored substantially lower (lowest mean Likert-type score 5.3). There were significantly higher self-efficacy scores in more experienced pediatricians in recognizing, history taking, and diagnosing children with MUPS. The self-efficacy scores about communicating and motivating patients with MUPS did not differ according to the years of pediatric experience. The attitudes toward managing patients with MUPS varied considerably and results are presented in Table 2. More experience was significantly correlated with less frustration, more satisfaction, and less fear of missing somatic diagnoses. Pediatricians perceived MUPS as time consuming, and this did not differ according to their years of experience. Also the referral for second opinion was low among the respondents, independent of their years of experience.
Discussion Dutch pediatricians felt in general quite competent in managing children with MUPS. However, there were significant differences in less versus more experienced pediatricians. More experienced pediatricians had higher self-efficacy scores for managing children with MUPS and encountered less frustration and more satisfaction in dealing with MUPS. These perceptions are in contrast with a cross-sectional survey among pediatric health care professionals performed by Glazebrook et al,7 in whose study no relationship between years of experience and attitudes of professionals was identified. In our survey, less experienced pediatricians had more fear of missing a somatic diagnosis in children with MUPS. One explanation for this could be that families of children with MUPS often attribute symptoms to an organic cause and physicians are better trained in the assessment and differential diagnosis of physical complaints.1 In addition, pediatricians use physiological pathways to understand the way the healthy body works, and pathological pathways to explain disease. In the evaluation and treatment of MUPS multiple biopsychosocial factors are involved, which might lead to doctor’s uncertainty.1 Furthermore, it might be that more experienced
Downloaded from cpj.sagepub.com at NANYANG TECH UNIV LIBRARY on November 16, 2015
1393
Broekhuijsen-van Henten et al pediatricians make a positive diagnosis of the different types of MUPS, instead of making a diagnosis per exclusion. Positive diagnosing MUPS helps reduce additional tests to rule out somatic diagnosis and has a better starting point in communicating with patient and parents.1,5 Another finding of this study is that all pediatricians scored relatively low on the self-perceived “history taking according to the biopsychosocial model.” In medical education, there is still a dominant focus on biomedical content.8 The biopsychosocial model conceptualizes a person’s level of functioning as a dynamic interaction between his or her health conditions, personal factors, and environmental factors.9 In MUPS, which occur at the interface of mind and body, a biopsychosocial model is especially important, because the conceptual model cannot be properly understood if one continues to see those domains as separate.1,9,10 As expected, all pediatricians perceived dealing with children with MUPS as time consuming, with no significant effect of their years of experience. The time demanding nature of MUPS was also reported by other pediatric staff and general practitioners.6,7 However, in our study, the respondents felt very competent in motivating children for treatment and organizing a referral. Further research is needed to investigate the nature of time investment in MUPS. Because of the high incidence of MUPS in the pediatric office, the data of this report will be used to explore opportunities to improve early education for pediatricians about the biopsychosocial model in children with MUPS. In our survey, 260 (83%) pediatricians reported to be interested in a specific course on MUPS. Evidencebased therapy options in MUPS and using the biopsychosocial model in practice were the most mentioned subjects that pediatricians would like to learn more about. This study has some limitations. First, the response rate was 26%. Inherent in a survey design, there could have been response bias. Second, this survey was only e-mailed to Dutch pediatricians, so this may not reflect attitudes and perceptions of North American pediatricians. Third, these results reflect self-reported efficacy scores and self-reported attitudes and perceptions assessed with Likert-type scales, no qualitative study was done to explore these self-reported attitudes. In conclusion, these results suggest that years of working experience of pediatricians are important in self-efficacy, attitudes, and perceptions of managing children with MUPS. Taking a history according the
biopsychosocial model had the lowest self-efficacy score. We recommend specific education for pediatricians and pediatric residents on the biopsychosocial model in children with MUPS. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Geist R, Weinstein M, Walker L, Campo JV. Medically unexplained symptoms in young people: the doctor’s dilemma. Paediatr Child Health. 2008;13:487-491. 2. Perquin CW, Hazebroek-Kampschreur AA, Hunfeld JA, et al. Pain in children and adolescents: a common experience. Pain. 2000;87:51-58. 3. Rimes KA, Goodman R, Hotopf M, Wessely S, Meltzer H, Chalder T. Incidence, prognosis, and risk factors for fatigue and chronic fatigue syndrome in adolescents: a prospective community study. Pediatrics. 2007;119:e603-e609. 4. Konijnenberg AY, Uiterwaal CS, Kimpen JL, van der Hoeven J, Buitelaar JK, de Graeff-Meeder ER. Children with unexplained chronic pain: substantial impairment in everyday life. Arch Dis Child. 2005;90:680-686. 5. Campo JV. Annual research review: functional somatic symptoms and associated anxiety and depression—developmental psychopathology in pediatric practice. J Child Psychol Psychiatry. 2012;53:575-592. 6. Wileman L, May C, Chew-Graham CA. Medically unexplained symptoms and the problem of power in the primary care consultation: a qualitative study. Fam Pract. 2002;19:178-182. 7. Glazebrook C, Furness P, Tay J, Abbas K, Slaveska Hollis K. Development of a scale to assess the attitudes of paediatric staff to caring for children with medically unexplained symptoms: implications for the role of CAMHS in paediatric care. Child Adolesc Mental Health. 2009;14:104-108. 8. Whitehead C, Kuper A. Beyond the biomedical feedlot. Acad Med. 2012;87:1485. 9. Hyams JS, Hyman PE. Recurrent abdominal pain and the biopsychosocial model of medical practice. J Pediatr. 1998;133:473-478. 10. Kozlowska K. Functional somatic symptoms in childhood and adolescence. Curr Opin Psychiatry. 2013;26:485-492.
Downloaded from cpj.sagepub.com at NANYANG TECH UNIV LIBRARY on November 16, 2015
research-article2015
CPJXXX10.1177/0009922815570624Clinical PediatricsBroekhuijsen-van Henten et al
Brief Report
Exploring Self-Efficacy and Attitudes Among Pediatricians in Managing Medically Unexplained Physical Symptoms
Clinical Pediatrics 2015, Vol. 54(14) 1391–1393 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922815570624 cpj.sagepub.com
Dorien M. Broekhuijsen-van Henten, MD1, Gert H. J. Luitse, MD1, Andrieke C. Knottnerus, MD2, and Meta van den Heuvel, MD3
Introduction Medically unexplained physical symptoms (MUPS) are common in pediatric practice. Children with MUPS are often functionally impaired in daily activities (school, sleep, and social behavior) and perceive their health status negatively.1 Up to 25% of children and adolescents reported chronic pain in a population study, mostly headache, abdominal pain, and limb pain.2 Fatigue was reported in 30% of a population sample of 11- to 15-yearolds.3 Patients with MUPS suffer from serious impairment in everyday life.4Factors such as deprivation, family dysfunction, family illness, and concurrent stress have all been linked to MUPS and there is evidence that recurrent somatic complaints in children are associated with increased rates of psychological morbidity.5 To physicians, treatment of patients with MUPS is often challenging. The exclusion of disease does not cure the patient: To achieve improvement, the physician needs to use specific diagnoses and treatment strategies with special demands on communication competence.1 MUPS may lead to frustration among doctors. In a study of Wileman et al,6 family physicians felt insufficiently equipped to manage youth with MUPS. Little research has been done toward perceptions and attitudes of pediatricians concerning the management of children with MUPS.7 The aim of the study was to examine self- efficacy, attitudes, and perceptions of pediatricians in the management of children with MUPS. Our hypothesis was that pediatricians with more experience had a greater exposure to children with MUPS. More exposure could have a positive effect on the self-efficacy scores and attitudes toward the management of children with MUPS.
Methods An online-distributed survey questionnaire was developed with SurveyMonkey. After pilot testing in a small group of pediatricians on clarity and ease of administration, it was
refined on the basis of their feedback. The questionnaire was addressed to all Dutch pediatricians in 2014 (n = 1306). E-mail addresses were obtained from the Dutch Society of Pediatrics (NVK, Nederlandse Vereniging Kindergeneeskunde). The survey consisted of 22 questions. Self-efficacy scores in different stages of the diagnostic and therapeutic process of MUPS were specified by the level of agreement or disagreement on a 10-point Likert-type scale. Special attention was paid to communication, investigating issues like “taking a history according to the bio-psycho-social model” and “the quality of communicating to patients and parents in cases of MUPS.” Attitudes, for example, satisfaction, were also expressed using a 10-point Likert-type scale. Data were analyzed using descriptive statistics and analysis of variance was done to compare the mean differences in Likert-type scores by years of pediatric work experience.
Results Response rate was 339 (26%) and included 70% females. Most responders (192 = 56.6%) were general pediatricians, 53 (15.6%) were pediatric subspecialists and worked in a second line hospital and 41 (12%) were pediatric subspecialists and worked in an academic medical center, in 53 responders (15.6%), this background was unknown. There was a near equal distribution over the years of experience: 0 to 5 years, n = 52 1
Amalia Children’s Centre, Isala Hospital, Zwolle, Netherlands Spaarne Hospital, Hoofddorp, Netherlands 3 Beatrix Children’s Hospital, University Medical Centre Groningen, Groningen, Netherlands 2
Corresponding Author: Dorien M. Broekhuijsen-van Henten, Amalia Children’s Centre, Isala Hospital, Dr van Heesweg 2, PO Box 10400, Zwolle, 8000GK, Netherlands. Email: [email protected]
Downloaded from cpj.sagepub.com at NANYANG TECH UNIV LIBRARY on November 16, 2015
1392
Clinical Pediatrics 54(14)
Table 1. Mean Self-Efficacy Scores in Diagnosis and Treatment of Medically Unexplained Physical Symptoms (MUPS).a Years of Pediatric Experience How competent do you feel in:
0-5
5-10
10-15
15-20
>20
P Value
Recognizing symptoms and signs of MUPS? Taking a history according to the biopsychosocial model? Diagnosing MUPS? Communicating to patients and parents in cases of MUPS? Motivating patients for treatment? In organizing treatment or referral in MUPS?
7.1 5.7 7.0 7.1 6.8 6.7
7.3 5.4 7.2 7.3 7.1 6.8
7.3 5.9 7.2 7.5 7.2 7.1
7.8 6.6 7.7 7.6 7.4 7.4
7.6 6.3 7.6 7.5 7.2 7.2
.004 .010 .003 .106 .103 .057
a
Scored on a Likert-type scale from 1 to 10 (1 = not competent at all, 10 = excellent). Values in boldface indicate statistical significance.
Table 2. Mean Likert-Type Score of Attitudes and Perceptions of Pediatricians Toward Children With Medically Unexplained Physical Symptoms (MUPS).a Years of Pediatric Experience Children With MUPS:
0-5
5-10
10-15
15-20
>20
P Value
Give me satisfaction Are causing frustration Are time consuming Are fun to work with I am afraid to miss somatic diagnosis I will refer for a second opinion
5.4 5.3 7.5 5.6 5.8 3.4
5.8 5.7 7.9 6.1 5.9 3.9
6.0 5.0 7.7 6.1 5.3 3.5
6.4 4.9 7.5 6.3 4.4 3.1
6.5 4.5 7.5 6.3 4.8 3.4
.007 .009 .452 .280 20 years, n = 67 (20%), unknown, n = 23 (7%). Mean self-efficacy scores on the different aspects of diagnosing and treating patients with MUPS, subdivided by years of experience are presented in Table 1. In general, pediatricians felt quite competent in dealing with MUPS, with mean scores just higher than 7 (scale 1-10). However, taking a history according to the biopsychosocial model scored substantially lower (lowest mean Likert-type score 5.3). There were significantly higher self-efficacy scores in more experienced pediatricians in recognizing, history taking, and diagnosing children with MUPS. The self-efficacy scores about communicating and motivating patients with MUPS did not differ according to the years of pediatric experience. The attitudes toward managing patients with MUPS varied considerably and results are presented in Table 2. More experience was significantly correlated with less frustration, more satisfaction, and less fear of missing somatic diagnoses. Pediatricians perceived MUPS as time consuming, and this did not differ according to their years of experience. Also the referral for second opinion was low among the respondents, independent of their years of experience.
Discussion Dutch pediatricians felt in general quite competent in managing children with MUPS. However, there were significant differences in less versus more experienced pediatricians. More experienced pediatricians had higher self-efficacy scores for managing children with MUPS and encountered less frustration and more satisfaction in dealing with MUPS. These perceptions are in contrast with a cross-sectional survey among pediatric health care professionals performed by Glazebrook et al,7 in whose study no relationship between years of experience and attitudes of professionals was identified. In our survey, less experienced pediatricians had more fear of missing a somatic diagnosis in children with MUPS. One explanation for this could be that families of children with MUPS often attribute symptoms to an organic cause and physicians are better trained in the assessment and differential diagnosis of physical complaints.1 In addition, pediatricians use physiological pathways to understand the way the healthy body works, and pathological pathways to explain disease. In the evaluation and treatment of MUPS multiple biopsychosocial factors are involved, which might lead to doctor’s uncertainty.1 Furthermore, it might be that more experienced
Downloaded from cpj.sagepub.com at NANYANG TECH UNIV LIBRARY on November 16, 2015
1393
Broekhuijsen-van Henten et al pediatricians make a positive diagnosis of the different types of MUPS, instead of making a diagnosis per exclusion. Positive diagnosing MUPS helps reduce additional tests to rule out somatic diagnosis and has a better starting point in communicating with patient and parents.1,5 Another finding of this study is that all pediatricians scored relatively low on the self-perceived “history taking according to the biopsychosocial model.” In medical education, there is still a dominant focus on biomedical content.8 The biopsychosocial model conceptualizes a person’s level of functioning as a dynamic interaction between his or her health conditions, personal factors, and environmental factors.9 In MUPS, which occur at the interface of mind and body, a biopsychosocial model is especially important, because the conceptual model cannot be properly understood if one continues to see those domains as separate.1,9,10 As expected, all pediatricians perceived dealing with children with MUPS as time consuming, with no significant effect of their years of experience. The time demanding nature of MUPS was also reported by other pediatric staff and general practitioners.6,7 However, in our study, the respondents felt very competent in motivating children for treatment and organizing a referral. Further research is needed to investigate the nature of time investment in MUPS. Because of the high incidence of MUPS in the pediatric office, the data of this report will be used to explore opportunities to improve early education for pediatricians about the biopsychosocial model in children with MUPS. In our survey, 260 (83%) pediatricians reported to be interested in a specific course on MUPS. Evidencebased therapy options in MUPS and using the biopsychosocial model in practice were the most mentioned subjects that pediatricians would like to learn more about. This study has some limitations. First, the response rate was 26%. Inherent in a survey design, there could have been response bias. Second, this survey was only e-mailed to Dutch pediatricians, so this may not reflect attitudes and perceptions of North American pediatricians. Third, these results reflect self-reported efficacy scores and self-reported attitudes and perceptions assessed with Likert-type scales, no qualitative study was done to explore these self-reported attitudes. In conclusion, these results suggest that years of working experience of pediatricians are important in self-efficacy, attitudes, and perceptions of managing children with MUPS. Taking a history according the
biopsychosocial model had the lowest self-efficacy score. We recommend specific education for pediatricians and pediatric residents on the biopsychosocial model in children with MUPS. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Geist R, Weinstein M, Walker L, Campo JV. Medically unexplained symptoms in young people: the doctor’s dilemma. Paediatr Child Health. 2008;13:487-491. 2. Perquin CW, Hazebroek-Kampschreur AA, Hunfeld JA, et al. Pain in children and adolescents: a common experience. Pain. 2000;87:51-58. 3. Rimes KA, Goodman R, Hotopf M, Wessely S, Meltzer H, Chalder T. Incidence, prognosis, and risk factors for fatigue and chronic fatigue syndrome in adolescents: a prospective community study. Pediatrics. 2007;119:e603-e609. 4. Konijnenberg AY, Uiterwaal CS, Kimpen JL, van der Hoeven J, Buitelaar JK, de Graeff-Meeder ER. Children with unexplained chronic pain: substantial impairment in everyday life. Arch Dis Child. 2005;90:680-686. 5. Campo JV. Annual research review: functional somatic symptoms and associated anxiety and depression—developmental psychopathology in pediatric practice. J Child Psychol Psychiatry. 2012;53:575-592. 6. Wileman L, May C, Chew-Graham CA. Medically unexplained symptoms and the problem of power in the primary care consultation: a qualitative study. Fam Pract. 2002;19:178-182. 7. Glazebrook C, Furness P, Tay J, Abbas K, Slaveska Hollis K. Development of a scale to assess the attitudes of paediatric staff to caring for children with medically unexplained symptoms: implications for the role of CAMHS in paediatric care. Child Adolesc Mental Health. 2009;14:104-108. 8. Whitehead C, Kuper A. Beyond the biomedical feedlot. Acad Med. 2012;87:1485. 9. Hyams JS, Hyman PE. Recurrent abdominal pain and the biopsychosocial model of medical practice. J Pediatr. 1998;133:473-478. 10. Kozlowska K. Functional somatic symptoms in childhood and adolescence. Curr Opin Psychiatry. 2013;26:485-492.
Downloaded from cpj.sagepub.com at NANYANG TECH UNIV LIBRARY on November 16, 2015
