Medically unexplained symptoms: (Letter 1 of 2)

Abstract

Dr Page and Professor Wessely should be congratulated on their exploration of medically unexplained symptoms and the doctor-patient encounter (May 2003 JRSM1). We wish to add some comments from the standpoint of a rheumatology chronic back pain clinic. ‘Medically unexplained’ implies a dualistic view, separating biomedical from psychosocial models. As physicians, our social role is fundamentally biomedical, and this still has value: in our clinic, 8% of a series of 657 consecutive referrals received an alternative diagnosis.2 In many cases, the biomedical model appears insufficient to fully ‘explain’ a patient's symptoms. This, if perceived as a failure to fulfil the physician's proper role, can cause negative feelings in both doctor and patient. Conversely, an explanation that involves a physical mechanism appears useful in maintaining a positive doctor-patient relationship.3 In our clinic we avoid labels such as ‘fibromyalgia’, which can contribute to social iatrogenesis.4 Instead we try to provide patients with an explanatory model for their symptoms that is based on the interdependence of mind and body, with the aim of acknowledging the reality of the patient's suffering but breaking the loop of multiple unnecessary investigations. Patient satisfaction was found in our clinic to relate as much to communication—the opportunity to discuss personal worries and future prognosis—as to the investigations performed.5 Reassurance is not simply a matter of ‘ruling out sinister causes’6 but of directly addressing a patient's fears, particularly regarding the future.7 The consultation can then move on to take a pragmatic patient-centred approach to management. Guidelines developed for our clinic recommend that, to avoid engendering unrealistic hopes, doctors explain to patients that physiotherapy will not cure their pain but will help them to achieve more despite this pain. Likewise, when referring for magnetic resonance imaging, we tell the patient why—for example, explaining that we want to make sure that there is no contraindication to aggressive rehabilitation. In this way, we try to use consultation techniques that directly address the patient's hopes, fears and expectations as well as addressing the physician's agenda of excluding other organic disease and recommending appropriate treatments.