Abstract
Medically unexplained symptoms (MUS) are symptoms for which the origin remains unclear despite adequate history taking, physical examination, and additional investigations.1 An estimated 3–11% of patients visiting general practice repeatedly consult their GP for MUS.2,3 MUS exist along a continuum ranging from self-limiting symptoms, to recurrent and persistent symptoms, through to symptom disorders.4 Although there are various terms for the condition, for example unexplained physical symptoms, functional symptoms, or somatoform symptoms, we have chosen to use MUS in this article because this is the most frequently used term. This review aims to address current problems with the management of undifferentiated MUS; specific syndromes within the MUS spectrum, such as chronic fatigue syndrome and irritable bowel syndrome, are excluded from discussion. Patients with persistent MUS suffer from their symptoms, are functionally impaired, and are at risk of potentially harmful additional testing and treatment.5 Furthermore, these patients commonly express dissatisfaction with the medical care they receive during their illness.6 They feel stigmatised and not taken seriously.7 GPs often experience patients with persistent MUS as difficult and frustrating to manage.8 In addition, MUS are associated with reduced health-related quality of life, higher healthcare and social costs, and costs associated with lost productivity.9,10 The effects of many treatment strategies have been studied in recent decades. However, not all interventions are acceptable or feasible in routine primary care. In the light of the central role of the GP in managing MUS, we will discuss the importance of consultation skills and the effects of specific treatments in primary care. We will do this by way of a narrative review using available national guidelines and Cochrane Reviews in this field. ### Clinical guidelines on MUS in primary care In recent years several guidelines on MUS have been published: a Dutch multidisciplinary guideline (2010);11 a German multidisciplinary guideline (2012);12 Dutch13 and Danish14 general practice guidelines (2013); and …
Highlights
The available Cochrane Reviews provide some guidance for the management of patients with MUS in primary care
The following were found with regard to patient outcomes: 1. the effectiveness of enhanced care by primary care professionals is currently limited; 2. the efficacy of psychological treatment provided by specialists is well documented and cognitive behavioural therapy (CBT) is the psychological treatment with the strongest current evidence; 3. the role of pharmacotherapy is very limited; 4. evidence for physical treatment is absent; and 5. the effectiveness of consultation letters is limited
The following specific communication skills are recommended: systematically exploring patient’s ideas, concerns, and expectations, and providing a targeted and tangible explanation for their symptoms
Summary
In recent years several guidelines on MUS have been published: a Dutch multidisciplinary guideline (2010);[11] a German multidisciplinary guideline (2012);[12]. Danish[14] general practice guidelines (2013); and multidisciplinary UK guidance for health professionals (2014).[15] The Dutch and German multidisciplinary guidelines and the Danish GP guideline make use of the Grading of Recommendations Assessment, Development and Evaluation. There is high-quality evidence that good doctor–patient communication in the consultation is essential for the treatment of MUS as patients seek a shared understanding of their symptoms.[12] Guidelines recommend using standard approaches to exploring symptoms, such as the ideas, concerns, and expectations model, employing open questions. Based on lower levels of evidence, the Dutch GP guideline and the German and UK guidelines pay attention to the provision of a summary by the GP as a communication tool.[12,13] Such a summary should include the topics that have been discussed in the consultation. The guidelines state that explicit communication about expected results of biomedical investigations is essential.[11,12,13,14,15] When discussing treatment, the Danish guideline states that the GP should communicate with the patient in an open and accommodating manner, in which the advantages and disadvantages of further testing and treatment can be discussed.[14]
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