Dr. Schär Institute

Successful treatment of IBS is believed to be best achieved through a longitudinal relationship with mutual understanding between the clinician and patient at its core⁵. Yet, there is evidence of dissatisfaction and frustration amongst both patients and clinicians alike. With national guidance emphasising that the partnership between patient and healthcare professional is key to a patient-centred approach, this article summarises the challenges of this therapeutic relationship and ways to improve it⁶.
 

Clinician-Patient Perceptions & Perspectives

The majority of patients with IBS are managed within a primary care setting with the GP likely to be the most frequent point of contact. Therefore, the attitude of GPs to IBS is important. Research has shown that GPs share similar perspectives on IBS⁴. In one study using in-depth, semi-structured interviews with GPs, all participants recognised IBS as a complex condition with a biopsychosocial aetiology⁷. In a more recent study looking at GP perceptions, using Q-methodology to derive quantifiable accounts (‘factors’) and participant interviews, a clustering of views around a largely psychological account of IBS was observed⁴. However, there was some difference in views regarding the extent to which psychological or other incompletely understood pathological mechanisms account for symptoms. In comparison, a corresponding study amongst IBS patients, also using Q- methodology, generated seven different accounts which ranged from those who felt the condition was due to psychological factors to those who viewed it as more of a ‘physical disease’. The study concluded that the distinct accounts identified can be meaningfully compared to the relationship adopted to medical professionals (from negative to positive), the relationship adopted to IBS (from a physical cause/curable disease entity to a psychosocially maintained aspect of self to be managed) and the relationship to responsibility (from self as entirely non-responsible to self as responsible)⁸.
A breakdown in communication between clinicians and patients with IBS has been suggested and reasons for this proposed, specifically around the diagnostic process and treatment of IBS⁹.

Diagnosis of IBS
There appears to be unmet expectations during the diagnostic process from a patient perspective with a theme of frustration and disillusionment with medical professionals emerging amongst some. This appears to arise from uncertainties in the aetiology of the condition and the nature of the diagnosis, with ‘diagnosis by exclusion’ reported as frustrating and resulting in a sense of uncertainty for prolonged periods of time. Clinicians may also use complicated and confusing terminology without checking patient understanding.
A focus on tests by clinicians has led patients to report a lack of understanding as to how the diagnosis of IBS was reached. Interestingly, this is substantiated by GPs themselves who report reverting to past learnings and ‘diagnosis by exclusion’ rather than current guideline-led recommendations which emphasise a positive diagnosis using symptom-based criteria (Rome criteria)⁷. Even in clinicians who proactively diagnose IBS based on symptom-based criteria, many are not willing to confirm a diagnosis until additional tests have been undertaken. Previous research supports the occurrence of this reported approach further with only 19% of patients formally diagnosed with IBS on their initial GP visit and 56% after a further 1-5 visits and this leads to a ‘revolving door’ scenario¹⁰.
Ineffective treatments and a mismatch between GP and patient explanatory models may also give rise to frustration and dissatisfaction. In addition, there is a perception amongst patients that clinicians do not take them seriously and there is a failure to recognise the impact of the diagnosis on their quality of life. However, GPs with personal experience of the condition may have more empathy and consider IBS as a more acceptable diagnosis⁷. Negative stereotyping of patients with IBS by clinicians, particularly those who are frequent attenders and do not improve, may lead to a breakdown in trust and disengagement from healthcare services by the patient.

Treatment of IBS
Another area of frustration is the lack of a clear treatment plan following diagnosis for many IBS patients and a lack of guidance on what to expect⁹. Some patients are left to find out their individual triggers and develop a management plan whilst others experience a sense of frustration from the unhelpful or conflicting advice provided by healthcare professionals. A lack of, or perceived low standard of, advice in relation to IBS from healthcare professionals has also been reported which may compound negative feelings around the lack of advice some claim to have experienced¹¹. Due to the lack of a specific treatment for the condition, the approaches taken by clinicians will vary with some preferring to focus on reassurance whilst others look to find a treatment to help alleviate symptoms. Interestingly, regional variations in management behaviour have been observed with primary care clinicians in the UK prescribing medications more readily for IBS than their Dutch counterparts who were less keen to prescribe based on limited evidence for efficacy¹². The emergence of efficacious dietary treatment options for IBS may offer clinicians an alternative option to consider for the management of IBS symptoms⁶.
These insights are important to keep in mind when considering the findings from a recent survey looking to ascertain the needs of primary care healthcare professionals in the UK in relation to improving patient outcomes in those with bowel disorders¹³. The majority of survey respondents were GPs and Nurse Practitioners and over 80% of all respondents had been in their role for at least 10 years.  IBS was reported as the second most common bowel disorder treated by these healthcare professionals after constipation. The survey identified that healthcare professionals were most in need of guidance regarding referral pathways and treatment. Whilst survey responders reported feeling most at ease with first-line treatment options such as lifestyle advice and laxatives, it was in these instances most guidance was sought. Patient information was identified as being the most useful type of support and almost half of respondents viewed self-help resources as especially valuable and the key to reducing consultations. These findings appear to reflect and support the experience reported by patients with IBS when consulting with healthcare professionals.
 

Improving communication

There is a clear need for GPs to remain up-to-date with the latest research in this area as this patient group has a high level of expectation. In addition, effective management and a need for clinicians to meet patients’ need and expectations are important in overcoming any breakdown in communication. An empathic approach during consultations with IBS patients is key, including: i) perspective-taking or understanding the patient’s world; ii) remaining non-judgemental; iii) understanding patients emotions, and v) being able to share that with the patient⁹. In the absence of ‘red-flag’ symptoms, there may be a benefit to clinicians spending more time addressing any disease-specific concerns of patients as well as setting mutually-reasonable goals and expectations, teaching self-empowerment techniques, providing educational materials and empirically treating symptoms. Clinicians should provide empowering explanations and encourage patients to see IBS as a ‘legitimate’ disease. Adoption of core concepts can help to provide a framework for effective communication and can save consultation time in the long term through improved management of patient expectations and satisfactions⁹. Signposting towards support groups may enable patients to learn self-management strategies via group interaction with peers.
In summary, accounts of IBS have been found to contrast between clinicians and patients. It is important that clinicians remain mindful that their perceptions may differ to those of patients and this has the potential to undermine a constructive therapeutic relationship. Establishing and maintaining a good patient-clinician relationship is key to the successful management of IBS and clinicians should prioritise developing good communication skills to facilitate this.
 

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References

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11. Consumer Insights Research. Conducted by Planning Express on behalf of Dr Schar.
12. Casiday RE, Hungin AP, Cornford CS et al. GPs’ explanatory models for irritable bowel syndrome: a mismatch with patient models? Fam Practice 2009;26:34-9
13. Bowel Interest Group. Bowel Interest Group Member/Non-Member Survey. May 2017