Somatisation: a joint responsibility of doctor and patient.

Patients with medically unexplained symptoms are common in general practice, and frequently seen by various specialists.2 These patients are often portrayed as “difficult” or “heartsink”: a burden to the doctor as well as to the health-care system,3 because they show resistance to psychological explanations of their suffering and are always in quest of biomedical causes, which easily results in excessive use of health-care services and even risk of iatrogenic harm. Over the years, many empirical studies have been published about this issue, but nearly all focus on patients' characteristics and roles in the process. The possibility that doctors themselves play a part in the somatising process has been largely ignored. This possibility was explicitly examined by a research group from Liverpool University. Adele Ring and colleagues recently challenged the widespread belief of both researchers and doctors that inappropriate symptomatic treatment has to be attributed to patients' belief that symptoms are caused by physical disease, their consequent insistence on biomedical intervention, and their denial of psychosocial needs. Instead, they claim that the doctor is often responsible for the disproportionate levels of somatic interventions in this group of patients. By detailed analysis of 420 audiotaped consultations with patients with medically unexplained symptoms in general practice, the authors were able to show that physical interventions were proposed more often by doctors than by patients. Moreover, almost all patients provided cues to their psychological needs, whereas most doctors suggested that one or more physical diseases might be present. The authors conclude that the explanation for the high level of physical intervention in these patients lies in doctors' responses rather than patients' demands, and they propose that explanations for somatisation should be sought in doctor-patient interaction rather than in patients' psychopathology.