Multiple Concerns or Medically Unexplained Symptoms

Medically unexplained symptoms are defined as symptoms that patients experience which impair function but do not fit characteristic patterns of disease, and persist despite normal examinations and investigations.  Most studies suggest that more than 50% of patients visiting primary care clinics with physical symptoms have no diagnosable organic disease.  As you can imagine, these scenarios can be incredibly troubling for patients and providers.

Patients with MUS often describe multiple symptoms, require frequent clinic or emergency department visits, frequently engage with the clinic outside of visit times (phone calls, electronic communication, letters, etc.), “doctor shop”,  or request multiple diagnostic tests or treatments.  With time limitations and heavy work loads, physicians may feel overwhelmed by these concerns and requests.

Patients may not feel heard or cared for if their issues are not addressed and in some cases may be harmed by unhelpful investigations, inappropriate interventions or medications.  Ensuring that the patient has received a comprehensive history and examination and reviewing past diagnostic tests and treatments is imperative to ensure that an organic cause of their symptoms has not be overlooked.   Remember to explore any attributions the patient may have regarding the cause of their symptoms. In some cases, additional testing or referrals may be appropriate.   As a physician, when we are faced with uncertainty this is the time when curiosity and further exploration is even more important.  It is also important to consider other possible reasons why a patient may present in this manner.  Acknowledging and addressing these issues when identified may help with healing.  Whether these factors may have contributed to or resulted from the illness is less important than recognizing that without support in these areas healing is more difficult.

• Received inadequate or inappropriate care in the past
• Fear of serious illness
• Feeling that unless they are “really sick” they may not be taken seriously
• Stress or comorbid anxiety, depression, personality disorders
• Inadequate social support, loneliness, isolation
• Fear of abandonment
• Intimate partner violence

Patients with MUS often feel that physicians do not believe that their symptoms are real or that they may be “all in their head.” Acknowledging and validating up front how difficult this must be for them and describing their symptoms and diagnoses with compassion can help to develop trust.  Creating a therapeutic relationship by recognizing that their symptoms are real and troubling for them even if an explanation has not and may not be found is affirming.  It is important to remember that healing can happen even if there is no cure.  Pausing to reflect on why patients may have MUS helps providers maintain empathy, prevent burnout and bring meaning to the practice of medicine.

Setting the expectation of frequent, regular visits can help the patient feel heard and supported.  Regular visits with agenda setting up front may allow patients to feel they don’t need to share everything at one visit.  It may also prevent the development (conscious or unconscious) of new symptoms in order to obtain care since they know they will have the opportunity to see you again soon.    As their physician, commit to your patient that you will continue to listen for information that requires additional medical evaluation and ensure them that you will pursue diagnostic and therapeutic interventions in those cases.  Contract with your patient that you will see them often enough that these situations should not be missed while also asking them to understand that you will not pursue unnecessary tests that are unlikely to yield more information but may cause harm.

It is important to let patients know that even if you may not be able to give them a specific diagnosis to explain their symptoms that does not mean you can not help them feel better. Focusing on improving function and quality of life is important.  Learning language that acknowledges and validates their suffering while also focusing on improving symptoms and function is helpful.

• “You and I have reviewed all of your previous tests and we have conducted many additional tests to evaluate your symptoms.  At this time, we do not have a unifying diagnosis that gives a name to the symptoms you are experiencing.  That does not mean you are not suffering. I think it is now time for us to start focusing on how to make you feel better and improve your quality of life. It is my job to keep watching out for signs and symptoms that something more serious may be going on which could require additional testing. My hope is that you can focus on healing through some of the treatments we will discuss today .” 

Treatments may be tailored to the specific symptoms they display and/or may address other underlying comorbid disorders such as stress, anxiety or depression.  A multimodal team approach involving medications, physical therapy, exercise, and mindfulness based approaches often work best.  In some cases formal cognitive behavioral therapy is needed.  Remember that health and healing is a continuum.  Remaining engaged and supportive throughout the process and being open to new and different strategies is helpful.

While considering how to care for our patients it is also important to care for ourselves.  Practicing some of the previously introduced mindfulness approaches of BREATHE-OUT and STOP are helpful in these moments.

There are many times in medical practice when we will be uncertain.  Did I get an adequate history?  Did I interpret the medical information correctly? Did I miss a diagnosis?  Am I adequately managing these complex medical conditions?  Medical uncertainty is an innate feature of medicine and medical practice and an intolerance to uncertainty increases physician’s stress, contributes to burnout and may be a potential threat to patient safety.   Medical uncertainty can be especially troubling to trainees as it is often believed that certainty is a necessary precursor for action.

Taking time to acknowledge how hard it may be to sit in a place of uncertainty is important.  Learning to become comfortable with uncertainty rather than shying away from it allows us to stay present with our patients and  to reflect on these moments as opportunities for learning and connection rather than a demonstrations of failure.  We will be discussing the concept of uncertainty further during the upcoming workshop.

RESOURCES AND REFERENCES