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General introduction   |   11



                but effect sizes were small (35). This is probably an overestimation of the usefulness of
                CBT as many patients do not accept CBT because they consider their complaint to be
                of physical origin. Further, other forms of psychological and activating therapies—from   1
                hypnotherapy to mindfulness-based therapy and yoga—have demonstrated low-to-
                moderate efficacy in treating patients with MUS, such as irritable bowel syndrome (36).

                Non-specific strategies Previous research showed positive effects of the clinical assessment
                of the symptoms (history taking, attentive physical examination, paying attention to
                psychosocial aspects, explanation, giving reassurance) on health outcomes. As an example,
                in patients with headache, the main predictor in a favourable outcome at one year was
                the patient’s perception that (s)he had had the opportunity to discuss the problem fully at
                the first visit with the GP (37). Another study described the therapeutic effect of a positive
                explanation on the outcome in MUS patients (38), while still other research found positive
                therapeutic effects of an enhanced patient-practitioner relationship in patients with
                irritable bowel syndrome (39). Non-specific therapeutic elements, such as those resulting
                from effective doctor-patient communication and the doctor-patient relationship, have
                positive effects on patients’ health outcomes as well (40). Clinical encounters in which GPs
                pay attention to patient-centredness, empathic communication and positive suggestions
                (e.g. by raising positive outcome expectations), lead to less stress about symptoms,
                improvement of complaints and reduced levels of anxiety (41, 42). These findings indicate
                that improving GPs’ communication skills and focusing on the therapeutic potential of the
                consultation itself, will improve patients’ health outcomes. Given the limited number of
                studies focusing on the improvement of communication in MUS consultations, the high
                number of problems experienced by GPs in the communication with MUS patients, and
                the positive effects of high-quality doctor-patient communication and a good doctor-
                patient relationship, this thesis will focus on the consultation process itself.

                Rationale for this thesis
                Currently available, specific MUS intervention strategies, e.g. CBT, are not effective or do
                not fit well within the everyday primary care setting. Therefore, an intervention for patients
                with MUS should be an integral part of the consultation process itself. Our hypothesis is
                that the clinical assessment of the symptoms and the non-specific therapeutic elements,
                such as doctor-patient communication and the doctor-patient relationship, comprise an
                effective therapeutic tool for patients with MUS.

                Objectives of this thesis
                The aim of this thesis is to develop a communication training program for GPs and GP
                residents, which focusses on (enhancing) communication strategies that are an integral
                part of the consultation process and focusses on the clinical assessment of symptoms
                and non-specific elements. This communication strategy is theory- and evidence-based,
                acceptable for patients with MUS and feasible to apply in daily general practice. This
                strategy is potentially relevant for the secondary care setting too and will focus on the
                therapeutic benefits of the consultation process itself. We hypothesize that improving
                the clinical assessment (history taking, physical examination, request of additional
                testing, explanation of what is wrong, and advice) of symptoms in combination with
                improvement of non-specific therapeutic elements (such as patients’ expectations,
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