Persistent Physical Symptoms—Healthcare Workers’ Experiences of Current Models of Care

Abstract

Persistent physical symptoms (PPS) are frequently seen in most medical specialties. Healthcare provision for PPS patients has been largely ineffective due to an outdated biomedical approach and failure to encompass the multifaceted nature of PPS, despite the guidelines recommending multidisciplinary care involving medical, social and psychological provision for the management of PPS. There are unresolved challenges and associated costs with PPS, suggesting needs are not being met. The aim of this research was to explore the current management of PPS patients, to provide insights into the opportunities for interventions to better manage PPS. A qualitative study was used, applying semi-structured interviews with sixteen healthcare practitioners including ten General Practitioners in the primary care network (PCN) and six secondary care practitioners in the National Health Service. The findings generated from the thematic analysis included three themes: (1) challenges of the early identification and management of PPS, (2) moving away from search and fix to support and manage and (3) moving care from hospitals to the community. Healthcare practitioners working with patients with PPS continue to experience a range of challenges. Addressing these challenges through better training, improved communication and systemic changes can enhance care for both patients and practitioners. There is a role for community-based initiatives, social prescribers and specialist PPS clinicians, and PPS should be taught in the medical curriculum.

1. Introduction

Persistent physical symptoms (PPS) is the term used to describe recurring bodily complaints for which adequate examination and investigation does not reveal an obvious pathology (Deary et al., 2007; Chalder & Willis, 2017). PPS was previously termed medically unexplained symptoms (MUS) or medically unexplained physical symptoms (MUPS); however, this term has been argued to be misleading, and unhelpful to patients with PPS (Creed et al., 2010). PPS are frequently seen in most medical specialties (Chalder & Willis, 2017; Bermingham et al., 2010; Jadhakhan et al., 2019). Although PPS are many and varied, frequently reported responses to symptoms of PPS include lower levels of physical activity, disrupted sleep routines, catastrophizing thoughts and working days lost (Chalder & Willis, 2017).

PPS are an increasing global burden, particularly across Western primary care (Löwe et al., 2024). The fragmentation of organisational structures enables a discordant assessment of multimorbidity, leading to suboptimal care and pathways ill-defined and complex (Swainston et al., 2023). Patients and healthcare practitioners are dissatisfied with healthcare services and some of this frustration is attributed to the diagnostic uncertainty that can add to clinicians’ professional uncertainty. Fear of missing serious pathology subsequently contributes to the high hospital care referral rates (Chew-Graham et al., 2017; Greco, 2012). Inconsistency leaves many patients unsure of what to do or where to seek further help (Watts, 2017).

Guidelines recommend multidisciplinary care involving medical, social and psychological provision for the management of PPS; however, interventions have only had some successes in managing symptoms (Henningsen et al., 2018; Kroenke, 2007; Löwe et al., 2024; Olde Hartman et al., 2017; Swainston et al., 2023). A holistic assessment of symptoms, including aetiologically relevant psychological factors such as depression, anxiety, traumatic experiences and stressful life events, are imperative for formulating patients’ treatment trajectory (Jones et al., 2009; Reuber et al., 2005). Basic care consists of addressing underlying pathophysiology and using person-centred communication techniques with validation, appropriate reassurance and biopsychosocial explanation (Löwe et al., 2024), while also considering the cultural diversity of PPS and intercultural communication (Mariman et al., 2023). However, pursuing existing models that involve examining psychosocial factors concurrent with somatic symptoms have limited acceptability (Morriss et al., 2010), despite understanding of the importance of good communication in exploring psychosocial cues and engaging in a more patient-centred approach (Houwen et al., 2019). Moving away from the biomedical model of healthcare to a biopsychosocial model would be useful to guide holistic consultations (Thursby et al., 2024).

Creating a safe therapeutic environment, generic interventions and good doctor-patient communication and relationships are important elements in the treatment of PPS (Heijmans et al., 2011). Identifying barriers of acceptance of holistic therapies, incorporating interactions between the mind and body, is key to facilitating the development of services offered to patients with PPS. The therapeutic alliance is commonly perceived as problematic due to a breakdown in communication, which can be characterised by differing opinions. Patients often seek biomedical explanations for their symptoms in line with pre-existing health beliefs and assumptions (Wileman et al., 2002), and are often reluctant to acknowledge therapy as an alternative treatment when deemed appropriate (Kleinstäuber et al., 2017). The support patients expect from clinicians often places greater demand on their skills, which elicits negative feelings towards patients (Czachowski et al., 2012). Such emotional responses may be fuelled by frustrations around ill-defined concepts and lack of policy guidelines, as both primary and secondary care clinicians have reported a lack of confidence in diagnosing and treating PPS (Czachowski et al., 2012; Maatz et al., 2016; Murray et al., 2016).

Despite the vast evidence in the recommended management strategies of PPS, PPS continues to pose unresolved challenges and associated costs, suggesting needs are not being met and costly resources are being used ineffectively (Chew-Graham et al., 2017; Greco, 2012). Provision for PPS patients is failing to meet the expectations and needs of both the people living with the symptoms and the healthcare professionals working with them (Swainston et al., 2023). Further research was therefore invaluable to explore the current management of PPS patients, to provide insights into the opportunities for interventions to better manage PPS.

This qualitative research was part of a multi-workstream project examining the potential for closer multi-disciplinary and inter-sector working, with expert-by-experience knowledge at the centre. The project involved a clinical workstream and research workstream. Interdisciplinary training and service delivery approaches were examined, focussing on optimising practice across existing pathways, and not setting up a standalone PPS service. The team were involved in the design and implementation of PPS skills development training, a collaboration with a United Kingdom (UK) Primary Care Network (PCN) and secondary care National Health Service (NHS). The training included an increased awareness of PPS and knowledge and the development of skills in recognising PPS, strategies for not missing life threatening or structural disorders, and delivering the idea or ‘diagnosis’ of PPS and management strategies through a combination of pre-workshop materials and three face-to-face sessions. The research included two systematic reviews (Swainston et al., 2023; Thursby et al., 2024) and two qualitative studies to interview (i) patients with PPS and (ii) healthcare practitioners.

2. Materials and Methods

2.1. Method

An interpretivist paradigm with subjectivist ontology was applied. An interpretivist paradigm enabled us to facilitate understandings of how and why and allowed for complexity and contextual factors of the phenomenon (Everest, 2014). A qualitative method was applied to seek experiences, understandings and perceptions of individuals to uncover reality within their natural settings (Creswell, 2003; Thanh & Thanh, 2015). Semi-structured interviews were applied to gain a deeper appreciation and greater understanding of PPS in practice.

2.2. Design and Participants

A qualitative methodology employed semi-structured interviews and opportunity sampling with sixteen healthcare practitioners within the PCN and secondary care service in the UK. Ten general practitioners (GPs) and six secondary care clinicians (gastroenterologist nurse, gastroenterologist consultant, orthopaedic surgeon, physiotherapist in older people’s medicine, physiotherapist in rheumatology and cardiology nurse) were interviewed. Ethical approval was granted from Wales Research Ethics Committee (REC) two (314998) 11 July 2022.

2.3. Recruitment

GPs were invited to participate via email by a member of the research team (DT) who was the Clinical Director for the North-East and Cumbria PCN. The GPs were provided with a participant information sheet and those willing to be interviewed responded to the researcher (LD) and an interview was scheduled to take place online. Secondary Care Practitioners were recruited from Northumbria Healthcare NHS Foundation Trust (NHFT) through opportunity sampling. The researchers (LD and ST) emailed the participants with a participant information sheet and invited them to participate in the interview. One interview took place face-to-face, and fifteen interviews were conducted virtually. Study eligibility included varying experience of working with patients with PPS.

2.4. Interviews

In-depth semi-structured interviews were performed between October 2022 and April 2023. All interviewees provided informed consent prior to the interview and the interviews lasted on average thirty minutes. The interviewees discussed their experiences/attitudes of working with PPS, current models of care, the therapeutic relationship, barriers to effective management and development of care pathways and potential interventions. The interview schedule was developed based on the existing literature and the team’s clinical expertise in PPS and can be found in Appendix A. The first author (LD) conducted all interviews, transcriptions and analysis. All interview transcripts were anonymised, and participants were assigned a pseudonym.

2.5. Data Analysis

Data were analysed using Reflexive Thematic Analysis (Braun & Clarke, 2006, 2019), a theoretically flexible generic method whereby the researchers’ subjectivity was central to the analysis with an organic and recursive coding process. This involved becoming familiar with the data by reading and re-reading the data transcripts. Initial codes were developed by identifying interesting aspects of the data, and codes were reviewed and refined. Codes were clustered together with relevant quotations and organised into potential themes. Themes were generated that represented patterns of shared meaning, underpinned by a central meaning-based concept. Regular meetings were held to review codes and collaborate on the production, reviewing and defining of themes to develop a richer more nuanced reading of the data, rather than seeking a consensus on meaning. During the research process, the researcher maintained a reflexive diary documenting their thinking, methodology decisions, and observations. The researcher (LD) was a female health psychologist and experienced qualitative researcher supported by a team with a specialist interest in PPS.

3. Results

In the interviews, three themes were identified, including challenges of the early identification and management of PPS, moving away from search and fix to support and manage and moving care from hospitals to the community.

3.1. Challenges of the Early Identification and Management of PPS

There were challenges identified as influencing the early identification of people with PPS. As part of the qualitative study within the overall project workstream, GPs were asked to identify patients presenting with PPS to invite them to an interview. GPs were familiar with MUS/MUPS, and the terminology PPS was not commonly used, and recruitment was therefore challenging. Some of the secondary care clinicians had participated in the training workshops delivered as part of the clinical workstream and were familiar with PPS.

I don’t think I have used it with patients at all… I mean I think probably knowing more about it and learning more about it, I might be more inclined to use it

(GP 01)

Early identification of PPS patients was associated with the challenges in managing patients with PPS successfully. This was due to the time constraints in being able to have lengthy patient-centred discussions, and PPS conversations taking place alongside exhausting medical tests and investigations. There were concerns that no specific PPS service existed to refer patients to for extra support, and earlier conversations about PPS were therefore unlikely.

I think it was not knowing what happens next, if it gets beyond me what am I supposed to do with it? I don’t want to open that can of worms, and then have no were to go…you can go and speak to your GP about it’

(HCP 01)

The system was described as the problem due to the medicalisation of PPS and services continuing to work in silo. There was often poor communication between specialities and between primary and secondary care services and therefore missed opportunities for early identification. The management of PPS was expressed as currently being reliant on primary care but only following repeated tests and investigations in secondary care. GPs therefore required better ways to communicate about PPS, as this was rarely discussed with patients.

3.2. Moving Away from Search and Fix to Support and Manage

Due to the unresolved challenges, earlier conversations about PPS were unlikely to take place. The interviewees raised various alternative management strategies including a PPS specialist, as patients appreciate advice about receiving patient-centred care along with interventions proportionate to the complexity of patients’ problems. Some healthcare professionals suggested an individual approach may be needed, as patients experience a broad spectrum of symptoms and issues, as well as group treatment and peer support within a multidisciplinary approach.

These people need to be grouped and supported and they should be a physio, an OT, a psychologist, and a doctor working in a group setting…whereby they recognise that there’s more people in the world with this and there is a way out and talking about the pathways of what they can do…good self-care, what makes you feel better…and if GPs could refer in that would be really helpful to them because it’s going to cut the visits down

(HCP 03)

Although PPS training was offered to the interviewees, the GPs required training to be conducted during continued professional development events to allow them time to undertake the training. It was suggested for PPS training to be taught during medical training and opportunities for training need to be promoted across multi-sector organisations.

We do a multidisciplinary team meeting every week and this morning one of the surgeons was scratching his head about a guy whose got ongoing abdominal pain and nothing to show for it, and myself and one of the other specialist nurses chipped in and said have you heard of PPS…and he was like how do I refer into this? How do I get more involved with that?

(HCP 01)

Training needs to be offered across multi-sector providers to build a sustainable working alliance. There needs to be an increased awareness of PPS, improved communication to minimise working in silo and peer support for clinicians to better support one another.

3.3. Moving Care from Hospitals to the Community

A joined-up approach between multi-sector providers was needed, as well as a shift in the management of PPS outside of the hospital to the community. Community-based initiatives, for example supervised exercise, peer support groups and a multi-disciplinary well-being hub, were recommended.

Having a GP and a social prescriber working together with the various community services… its only for an afternoon, but if you could have like a couple of them…working together collectively…and they get that sort of overall holistic care

(GP 09)

Interviewees emphasised how they required an increased awareness of available resources outside of the hospital that are available for improving the management of PPS. Multidisciplinary team working and collaboration to raise awareness of other services that professionals can signpost to patients would be advantageous, and the management of PPS could be supported by a social prescriber.

I would certainly think about social prescribers because we as GPs we cannot really keep our heads across all community services that are there

(GP 10)

A PPS service gap existed, and a PPS service with a PPS specialist, such as ‘living well with long term symptoms’, would be welcomed; however, it may become overwhelmed due to the number of people living with PPS and would require patient selection. Lifestyle medicine could play an important role as a possible self-management strategy for patients with PPS and may avoid transactional consultation.

4. Discussion

This qualitative study aimed to explore healthcare practitioners’ experiences of the current healthcare provision for PPS patients. The themes offer important insights into the ongoing challenges that healthcare practitioners experience in the management of PPS, and recommendations for the better management of PPS through community-based initiatives.

Three themes were generated that provide useful data for healthcare professionals and service providers for the better management of PPS. There were ongoing unresolved challenges with the early identification of patients with PPS that were associated with successful management of PPS. This finding is consistent with previous research on clinicians’ diagnostic and professional uncertainty (Chew-Graham et al., 2017; Greco, 2012), and the requirement that patients with serious physical disease are excluded before GPs bring PPS into play at an earlier time in their symptom trajectory (Rask et al., 2021). Therefore, earlier conversations about PPS are unlikely to take place. The pursuit of inappropriate investigations to find the cause of patients’ symptoms or avoid litigation can cause significant harm to the patient. Such procedures can exacerbate anxiety, lead to further investigation of incidental findings, and have the potential for over-treatment and unnecessary interventions, including medication that can lead to side effects and addiction (Chew-Graham et al., 2017). Understanding the underlying mechanisms of these challenges is imperative to improving clinical practice, as early recognition of PPS both reduces the healthcare burden and improves prognosis.

The use of the terminology posed further challenges to early recognition, as many clinicians were using MUS/MUPs. This is important because it can hamper communication and developments. All clinicians need to be aware of ‘PPS’ to avoid stigmatising patients or overlooking patients with relevant diagnoses that fall within the umbrella term. Increasing healthcare practitioners’ knowledge around PPS can improve patient and healthcare practitioner outcomes, including healthcare practitioners’ confidence and self-efficacy when working with PPS (Thursby et al., 2024). Health practitioners should receive training and supervision to address their lack of confidence and improve their knowledge of PPS, and biopsychosocial models should be integrated into the education of healthcare professionals (Scope et al., 2021; Thursby et al., 2024; Toussaint et al., 2025), for example, the use of consultation-based interventions with mind–body explanations in conjunction with a PPS diagnosis (Burton et al., 2020; den Boeft et al., 2017; Morton et al., 2016; Thursby et al., 2024; van Ravenzwaaij et al., 2010). There is a role for specialist clinicians who have additional competencies and capacity to support the management of patients with complex problems, delivering training and liaising with more generalist clinicians (Chew-Graham et al., 2017). Improving communication about PPS across multi-sector providers may help with systematic changes and may reduce the medicalisation of PPS.

The interviewees were in support of moving away from search and fix to support and manage and alternative management strategies were proposed, including moving care from hospitals to the community. Diagnosing and treating PPS can be complicated due to the failure of diagnostic classifications that appreciate the complexity and individual nature of presentation (Burton et al., 2020; Dwamena et al., 2009). When clinicians ignore psychosocial cues and focus on alleviating symptoms, this may inadvertently promote somatisation and consequently lead to multiple consultations and repeat referrals (Dwamena et al., 2009). However, there is a common view that contact with secondary care is unhelpful. Shifting models of care from hospitals into the community may be advantageous. Increasing public knowledge about symptoms, genesis and treatment options is recommended (Toussaint et al., 2025). The optimisation of community/non-clinical resources, such as social prescribing, community groups and health trainers (Mossabir et al., 2015), may provide broader forms of support and can lead to proactive health behaviours and self-efficacy (McGowan et al., 2021). Patients have tried various strategies in search of symptom relief, including making use of various community-based initiatives or public mental health services such as psychologists, physiotherapists, massage therapists, osteopaths, acupuncturists or chiropractors, mindfulness classes or yoga sessions, but they need help to navigate the ‘jungle of management strategies’ (Rask et al., 2021). As addressed in this current study, GPs required an increased awareness of the available community-based resources available for patients with PPS to signpost or prescribe community-based support. Social prescribers may therefore play a role in navigating the potential community-based initiatives. However, Cochrane reviews have found that the PPS evidence base is separated into specialisms and syndromes and lacking in rigour (Bidonde et al., 2019; Nunan et al., 2022), and further research is needed to support community-based approaches (Nunan et al., 2022).

A collaborative approach between multi-sector services was suggested by the interviewees. This is reflected in a gap across training programmes in that healthcare practitioners were not encouraged to work with colleagues across services or specialities (Thursby et al., 2024). Early intervention is needed, including the sharing of information between clinicians that will support properly integrated holistic care for PPS, based on systems that enable close liaison from a broad range of clinicians (Chew-Graham et al., 2017). Deary and colleagues have suggested to identify, improve, and create effective pathways and integrated interfaces between secondary care, psychological services, community-based and voluntary sector provision, to develop more efficient new ways of working (Deary et al., 2014). Multi-sector organisations are collaborating to empower their local communities through community-centred approaches to improve well-being and health (Morgan, 2018) and services are transforming to improve access to psychological therapies for people with PPS (NHS England & NHS Improvement, 2018). Sharing knowledge about effective healthcare practices across countries is needed to improve patient care (Kustra-Mulder et al., 2024). One example is the expert consensus on the recommendations of health services for people with chronic fatigue syndrome across Europe. The expert group encourages countries and regions to plan services, training and educational needs according to the specific needs and characteristics of their population, organisational structures and resources, and they recommend a national champion (Nacul et al., 2021).

An international group have provided an evidence-driven review on the clinical management of PPS and recommend the development of personalised treatment models, stepped care and collaborative care models, including the promotion of transdisciplinary collaboration and the establishment of multimodal treatment settings (Löwe et al., 2024). There is a call for action in European healthcare, and public health initiatives should raise awareness and support a biopsychosocial perspective in the general population. By prioritising PPS and fostering collaboration, Europe can enhance outcomes and quality of life for those affected (Toussaint et al., 2025). It is required that asset-based approaches become an important part of the public health offer.

Strengths and Limitations

A strength of this study is the extensive and wide-ranging years of experience of the healthcare practitioners interviewed. Data sufficiency was reached, and meaning was generated through the interpretation of data, and the judgement of saturation was therefore subjective. However, we acknowledge that most interviewees were recruited from primary care. The findings provide useful insights into the use of community initiatives for the management of PPS. Further research could explore the available support and improve the way services work together. The views of social prescribers would be invaluable. Some of the interviewees had attended the PPS training or were aware of the training, and this may have influenced their decision to participate in the research. However, the interviewer did not deliver the PPS training. A copy of the manuscript was emailed to the interviewees for member checking prior to publication. Only one interviewee responded and was in agreement with the findings.

5. Conclusions

Healthcare practitioners working with patients with PPS experience a range of challenges, including diagnostic uncertainty, emotional strain, communication difficulties and a lack of systemic support or training. Biopsychosocial and patient-centred approaches and focus on building strong relationships (i.e., focusing on working alliance) are core recommendations in several clinical guidelines and are well established in the research. Addressing these challenges through better training, improved communication and systemic changes can enhance care for both patients and practitioners. There is a role for community-based initiatives, social prescribers and specialist PPS clinicians.