How do hospital doctors manage patients with medically unexplained symptoms: a qualitative study of physicians

OBJECTIVE: Medically unexplained symptoms are a common presentation in medical practice and are associated with significant morbidity and high levels of service use. Most research exploring the attitudes and training of doctors in treating patients with unexplained symptoms has been conducted in primary care. This study aims to explore the ways in which doctors working in secondary care approach and manage patients with medically unexplained symptoms. DESIGN: A qualitative study using in-depth interviews and thematic analysis. SETTING: Three hospitals in the North Thames area. PARTICIPANTS: Twenty consultant and training-grade physicians working in cardiology, gastroenterology, rheumatology and neurology. MAIN OUTCOME MEASURE: Physicians' approach to patients with medically unexplained symptoms and their views on managing these patients. RESULTS: There was considerable variation in how the physicians approached patients who presented with medically unexplained symptoms. Investigations were often ordered without a clear rationale and the explanations given to patients when results of investigations were normal were highly variable, both within and across specialties. The doctor's level of experience appeared to be a more important factor in their investigation and management strategies than their medical specialty. Physicians reported little or no formal training in how to manage such presentations, with no apparent consistency in how they had developed their approach. Doctors described learning from their own experience and from senior role models. Organisational barriers were identified to the effective management of these patients, particularly in terms of continuity of care. CONCLUSIONS: Given the importance of this topic, there is a need for serious consideration as to how the management of patients with medically unexplained symptoms is included in medical training and in the planning and delivery of services

Junior doctors' experiences of managing patients with medically unexplained symptoms: a qualitative study

OBJECTIVES: To explore junior doctors' knowledge about and experiences of managing patients with medically unexplained symptoms (MUS) and to seek their recommendations for improved future training on this important topic about which they currently receive little education. DESIGN: Qualitative study using in-depth interviews analysed using the framework method. SETTING: Participants were recruited from three North Thames London hospitals within the UK. PARTICIPANTS: Twenty-two junior doctors undertaking the UK foundation two-year training programme (FY1/FY2). RESULTS: The junior doctors interviewed identified a significant gap in their training on the topic of MUS, particularly in relation to their awareness of the topic, the appropriate level of investigations, possible psychological comorbidities, the formulation of suitable explanations for patients' symptoms and longer term management strategies. Many junior doctors expressed feelings of anxiety, frustration and a self-perceived lack of competency in this area, and spoke of over-investigating patients or avoiding patient contact altogether due to the challenging nature of MUS and a difficulty in managing the accompanying uncertainty. They also identified the negative attitudes of some senior clinicians and potential role models towards patients with MUS as a factor contributing to their own attitudes and management choices. Most reported a need for more training during the foundation years, and recommended interactive case-based group discussions with a focus on providing meaningful explanations to patients for their symptoms. CONCLUSIONS: There is an urgent need to improve postgraduate training about the topics of MUS and avoiding over-investigation, as current training does not equip junior doctors with the necessary knowledge and skills to effectively and confidently manage patients in these areas. Training needs to focus on practical skill development to increase clinical knowledge in areas such as delivering suitable explanations, and to incorporate individual management strategies to help junior doctors tolerate the uncertainty associated with MUS

A qualitative study exploring the difficulties influencing decision making at the end of life for people with dementia

BACKGROUND: Dementia is a progressive neurodegenerative condition characterized by declining functional and cognitive abilities. The quality of end of life care for people with dementia in the UK can be poor. Several difficult decisions may arise at the end of life, relating to the care of the person with dementia, for example management of comorbidities. OBJECTIVE: To explore difficulties in decision making for practitioners and family carers at the end of life for people with dementia. DESIGN: Qualitative methodology using focus groups and semi-structured interviews and thematic analysis methods. SETTINGS AND PARTICIPANTS: Former (n=4) and current (n=6) family carers of people with experience of end of life care for a person with dementia were recruited from an English dementia voluntary group in 2015. A further 24 health and care professionals were purposively sampled to include a broad range of expertise and experience in dementia end of life care. RESULTS: Four key themes were identified as follows: challenges of delivering coherent care in dynamic systems; uncertainty amongst decision makers; internal and external conflict amongst decision makers; and a lack of preparedness for the end of life. Overarching difficulties such as poor communication, uncertainty and conflict about the needs of the person with dementia as well as the decision maker's own role can characterize decision making at the end of life. CONCLUSIONS: This study suggests that decision making at the end of life for people with dementia has the potential to be improved. More planning earlier in the course of dementia with an on-going approach to conversation may increase preparedness and family carers' expectations of end of life

Exact pairwise error probability analysis of space-time codes in spatially correlated fading channels, Journal of Telecommunications and Information Technology, 2006, nr 1

In this paper, we derive an analytical expression for the exact pairwise error probability (PEP) of a space-time coded system operating over a spatially correlated slow fading channel using a moment-generating function-based approach. This analytical PEP expression is more realistic than previously published exact-PEP expressions as it fully accounts for antenna spacing, antenna geometries (uniform linear array, uniform grid array, uniform circular array, etc.) and scattering models (uniform, Gaussian, Laplacian, Von-Mises, etc.). Inclusion of spatial information provides valuable insights into the physical factors determining the performance of a space-time code. We demonstrate the strength of our new analytical PEP expression by evaluating the performance of two space-time trellis codes proposed in the literature for different spatial scenarios

Guiding practitioners through end of life care for people with dementia: The use of heuristics

Background: End of life care (EOLC) for people with dementia can present a multitude of challenges and difficult decisions for practitioners. These challenges may include assessment and management of difficulties with eating and swallowing, responding to agitation, treating pain, and managing recurrent infections. Practitioners sometimes lack both confidence in making end of life decisions and guidance. This study developed an alternative to lengthy guidelines, in the form of heuristics which were tested in clinical settings. The aim of this study was to test the usability and acceptability of a set of heuristics which could be used by practitioners providing EOLC for people with dementia in a variety of clinical and care settings. Methods: A three phase co-design process was adopted: 1) Synthesis of evidence and outputs from interviews and focus groups with family carers and practitioners, by a co-design group, to develop heuristics; 2) Testing of the heuristics in five clinical or care settings for six months; 3) Evaluation of the heuristics at three and six months using qualitative individual and group interviews. Results: Four heuristics were developed covering: eating and swallowing difficulties, agitation and restlessness, reviewing treatment and interventions at the end of life, and providing routine care. The five sites reported that the heuristics were simple and easy to use, comprehensive, and made implicit, tacit knowledge explicit. Four themes emerged from the qualitative evaluation: authority and permission; synthesis of best practice; providing a structure and breaking down complexity; and reassurance and instilling confidence. Conclusion: Use of heuristics is a novel approach to end of life decision making in dementia which can be useful to both experienced and junior members of staff making decisions. Heuristics are a practical tool which could overcome a lack of care pathways and direct guidance in end of life care for people with dementia

Performance Analysis of Space-Time Codes in Realistic Propagation Environments: A Moment Generating Function-Based Approach

In this paper, we derive analytical expressions for the exact pairwise error probability (PEP) of a space-time coded system operating over spatially correlated fast (constant over the duration of a symbol) and slow (constant over the length of a code word) fading channels using a moment-generating function-based approach. We discuss two analytical techniques that can be used to evaluate the exact-PEPs (and therefore, approximate the average bit error probability (BEP)) in closed form. These analytical expressions are more realistic than previously published PEP expressions as they fully account for antenna spacing, antenna geometries (uniform linear array, uniform grid array, uniform circular array, etc.) and scattering models (uniform, Gaussian, Laplacian, Von-mises, etc.). Inclusion of spatial information in these expressions provides valuable insights into the physical factors determining the performance of a space-time code. Using these new PEP expressions, we investigate the effect of antenna spacing, antenna geometries and azimuth power distribution parameters (angle of arrival/departure and angular spread) on the performance of a four-state QPSK space-time trellis code proposed by Tarokh et al. for two transmit antennas

Spatial precoder design for differential space-time coded systems: based on fixed parameters of MIMO channels

In this paper, we introduce the novel idea of linear spatial precoding based on fixed and known parameters of MIMO channels to improve the performance of differential space-time coding schemes. Antenna spacing and antenna placements (geometry) are considered as fixed parameters of MIMO channels, which are known at the transmitter. This new linear spatial precoding scheme exploits the antenna placement information at both ends of the MIMO channel to ameliorate the effect of non-ideal antenna placement on the performance of differential space-time coded systems. With this design, the precoder is fixed for fixed antenna placement and the transmitter does not require any feedback of channel state information (partial or full) from the receiver. A second precoding scheme is proposed by exploiting the non-isotropic scattering distribution parameters of the scattering channel. Unlike in the first scheme, the second scheme requires the receiver to estimate the non-isotropic distribution parameters and feed them back to the transmitter. Simulation results show that first scheme provides significant performance improvements at low SNRs and the second scheme provides significant performance improvements both at low and high SNRs