Gerry Gajadharsingh writes:
“A nice article from an urgent care physician focusing on the many patients who have chronic and so-called medically unexplained symptoms (MUS) and persistent physical symptoms (PPS) and sharing her frustrations as to what to do about it. However, the main focus of the article is on somatisation, the presentation of physical symptoms as a consequence of psychological distress. This is well recognised by clinicians (although not by patients, who in the main are reluctant to accept that psychological factors contribute towards their physical symptoms) with a cost to the NHS budget of at least 10% in 2008 and probably now much higher.
It Is common for patients not to know, that symptoms can be caused by non-pathological (disease) causes. Many patients who experience symptoms are fearful and worry about pathology/disease process. The education and practice of conventional medicine is founded on the recognition of pathology, i.e. the aim of a case history, clinical examination, laboratory testing and imaging is to see if there is an obvious underlying pathology/disease process that accounts for the patient’s symptoms.
In the majority of cases the answer is NO and this is what lead to enormous frustration in patients.
Dr Merrifield suggests that “Good doctor–patient communication is essential for the management of MUS and PPS: it is important to provide tangible explanations and support symptom management if we want patients to gain a better understanding of their symptoms.” I could not agree more.
The term functional medicine as opposed to pathological medicine is being increasingly recognised by both patients and clinicians.
It’s about the inter relationship between anatomy/structure and physiology/function in both the body and the mind.
In many of the complex patients that I tend to see there is often several and not one cause, that drives the patient’s symptoms. There is often an interplay of these functional factors which tend to influence the physical function of the body, the chemical/hormonal function of the body and how the brain and nervous system interacts with it all. The majority of our new patients receive a full diagnostic consultation and afterwards a comprehensive written report which is often at least 5 to 6 pages long. The reason for the length of the report this that patients tend to get better when they understand the nature of what drives their symptoms, and also it means treatment can be much more targeted.
It is common in my complex patient demographics, to have patients both with underlying pathology and functional disturbance. Hence why I passionately believe in an integrated approach to medicine, medication/surgery provided by conventional medicine, can often be an important part of a patient’s healthcare plan and sometimes obviously lifesaving. However, even with patients with recognised pathology, there are often functional factors which impact on their health and helping them understand these factors and giving them the tools and treatment interventions to change them can have a positive impact on their health.”
Medscape
Dr Sarah Merrifield
As I sit reviewing medical school exam questions, chuffed that I still know the answers, I ponder why it now feels increasingly rare for me to experience the reward of a clear symptom pattern and diagnosis. Despite the fact that I work mainly in urgent care, many patients I see have chronic and unexplained symptoms—they express their frustration at no one being able to tell them what is wrong and perceive this to mean that no-one cares. I see many of these grievances on social media, with people voicing their experiences as follows: ‘They said it’s all in my head!’ or ‘No-one can tell me what’s wrong with me’. Knowing that I will have to have the ‘so far, the tests haven’t found anything’ conversation again in the near future, I cannot help but feel as though I am missing something.
Most of us are familiar with the concept of somatisation, which is defined as the presentation of physical symptoms in response to psychological distress. An analysis in 2008–2009 on the cost of somatisation found that approximately 10% of NHS expenditure (£3 billion) was related to such ‘diagnoses’ in the working-age population. Based on my own experiences, I suspect that this is now a lot higher.
We are able to speak with some confidence about the impact of stress on a small range of conditions; however, our knowledge of the underlying physiological pathways and how they act seems to be where something is lacking. Hence, we sometimes use terms such as ‘medically unexplained symptoms’ (MUS) and ‘persistent physical symptoms’ (PPS) for those with symptoms we can’t explain.
Recently, I came across an interview with Dr Gabor Maté, a physician in Canada who specialises in addiction, trauma, and the impact of emotional distress. I listened with interest as he explained theories on the link between the mind and the body. Mate proposes that a number of chronic diseases, even cancer, have links with psychological trauma and emotional dysfunction. He also suggests that certain personality traits can be linked with severe physical conditions. Although I do not buy into all of his ideas, I do wonder about the contribution of trauma to a lot of the presentations I see. Further reading on psychoneuroimmunology, autoimmune disease, and the physiology of stress adds weight to this concept.
Having read a lot on this topic, I am left with the following questions: so what? What is it that we should be doing differently? Are there any practical solutions? Although I am by no means an expert, I suggest that urgent consideration of how we are explaining somatic symptoms to patients is required. Good doctor–patient communication is essential for the management of MUS and PPS: it is important to provide tangible explanations and support symptom management if we want patients to gain a better understanding of their symptoms. All medics have targeted sessions on how to break bad news, yet little or none on how to explain symptoms that arise without a clearly understood physiological pathway—it is important that we address this gap in our knowledge.
Increased research efforts are also needed in this area, particularly as it seems that the issue will only become more prevalent. Time must be allocated to educating both the public and healthcare professionals; considering the resources currently spent on somatic conditions, a small investment may have a big payoff. It would also be fantastic to have increased psychology involvement in primary care. However, given the existing barriers to the access of psychological services, this may be challenging to realise. I hope that those in charge of setting the direction for the future of healthcare will recognise the importance of increased support for patients with somatic symptoms and take action.