Functional problems : prevalence in secondary care and perceptions of doctors

1 Abstract 1.1 Title Functional problems: prevalence in secondary care and perceptions of doctors 1.2 Aims (a) To evaluate the prevalence of functional problems in general medicine, gastroenterology, gynaecology and psychiatry outpatient specialist clinics in a hospital setting in Sri Lanka and (b) To assess the perceptions of doctors in these specialties around functional problems in the UK and in Sri Lanka. 1.3 Methodology (a) Prevalence study: Functional problems were defined as those for which a cause could not be ascertained after clinical evaluation and investigations. The prevalence of functional problems was assessed over a three month period in each specialty clinic. The patients‘ records were reviewed at three and six months to confirm the diagnosis of a functional problem. (b) Perceptions of clinicians: Qualitative methodology was used to ascertain the perceptions of doctors in the two settings covering the three specialties. A grounded theory approach was used and sixty interviews were carried out. Emphasis was placed on identifying socio-cultural implications around perceived causations and the management of these functional problems. 1.4 Results (a) Prevalence study: The prevalence study ascertained that functional problems were the commonest diagnoses in the general medicine/gastroenterology and gynaecology clinics accounting for almost a fifth of patients. In psychiatry, functional problems were the fourth common diagnosis and accounted for nearly ten percent. Patients of all consultations with functional symptoms tended to be younger; there were long delays in iv making the diagnosis and a substantial proportion of patients were subjected to iatrogenic harm from invasive investigations and inappropriate therapeutic measures. (b) Perceptions study: The perceptions study revealed divergent views by doctors about what functional problems were, how they could be categorized and how best to manage them. Socio cultural factors were thought to be intricately linked to causation and outcomes. Nonetheless, most doctors tended to isolate the clinical presentation and management from the cultural context in the way they dealt with their patients. 1.5 Conclusions Functional problems were commonly seen and diagnosed in hospital outpatient clinics. The Sri Lankan prevalence was similar to that reported from the UK. In both cultural settings the doctors who were sensitive to socio-cultural factors used tools beyond pharmacotherapy and those who held improved quality of life as the goal of treatment as opposed to cure, reported greater success in managing people with these problems. v 1.6 Acknowledgements The School of Medicine and Health, Durham University, for granting a scholarship through Project Sri Lanka for the PhD, for fulfilling research training needs and providing accommodation during my stay in the UK The Faculty of Medicine, University of Ruhuna, for granting me study leave for three years Professor Pali Hungin, my supervisor in the School of Medicine and Health, Durham University, for helping convert the research idea to a PhD thesis Professor Martyn Evans, my second supervisor in the School of Medicine and Health, Durham University, for guidance and support Professor David Petley, Deputy Head (Research), Faculty of Social Sciences and Health, Durham University, for research support To Professor Susirith Mendis, Vice Chancellor and Professor Ranjith Senaratne, former Vice Chancellor of the University of Ruhuna, Professor Thilak Weerasooriya, Dean and Professor P.L. Ariyananda, former Dean, Faculty of Medicine, University of Ruhuna, for support in obtaining study leave and a travel grant Dr Chandanie Hewage, Head, Department of Psychiatry at the Faculty of Medicine, University of Ruhuna, for constant support and encouragement over the study leave period My colleagues in the Department of Psychiatry, Faculty of Medicine, for covering the additional work during my study leave period Mrs Alex Motley, for help with correspondence and formatting Dr Simon Stockley, General Practitioner, for assistance with the pilot study Dr Amanda Gash, Consultant Psychiatrist and Dr Suresh Babu, Consultant Psychiatrist at the Tees Esk and Wear Valleys NHS Trust, Dr Deepak Dwarakanath, Consultant Gastroenterologist and Dr Anne Ryall, Consultant Gynaecologist at North Tees and Hartlepool NHS Trust, who were the co investigators for the UK arm of the qualitative study My co-investigators from Sri Lanka for the prevalence study, Dr Gamini Jayawardene, Dr Gayani Punchihewa and Dr Ajith Jayasekera, Consultant Psychiatrists, from Teaching Hospital Karapitiya Galle, Professor Thilak Weerarathna and Dr Arosha Dissanayake, Consultant Physicians from Teaching Hospital Karapitiya Galle, Professor Malik Goonawardene and Dr Dammika Jayasooriya, Consultant Obstetricians from Teaching Hospital Mahamodera, Galle vi Dr Rachel Casiday, Dr Helen Hancock, Dr Helen Close, Dr Sharyn Maxwell, Dr Eileen Scott, Durham University, for helping with the methodological aspects of the research Professor James Mason, Director of Research, School of Medicine and Health, Durham University, for advice on statistical matters Dr J. Howse, Doctoral Researcher, Durham University, for second coding of transcripts Mrs Judith Walsh, Mrs Susan Williams, Durham University, for assistance with administrative matters Members of the NHS National Research Ethics Committee, Durham and Tees Valley Research Ethics Committee 2, and Research Ethics Committee, Faculty of Medicine, University of Ruhuna, for helping conduct an ethically sound research study Staff at the North Tees and Hartlepool NHS Trust, Research and Development Office for guidance on methodological and ethical aspects of the research Directors of Teaching Hospital Karapitiya, Galle and Teaching Hospital, Mahamodera, Galle, for permitting the analysis of patient records for the prevalence study All the participants in the research Mrs Barbara Hungin for encouragement and support Sri Lankan expatriate community for assistance with logistical aspects Staff at the Keenan House, where I was accommodated during my stay in the UK My family members for their constant encouragement and support during three long years of researching