HOW TO TREAT 41 patient ’ s needs and the condition they are managing as non-specific treatments can be inappropriate and unhelpful . 112
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HOW TO TREAT 41 patient ’ s needs and the condition they are managing as non-specific treatments can be inappropriate and unhelpful . 112
All have strong advocacy groups of patients worldwide that argue for greater recognition for the suffering of those experiencing these constellations of symptoms . Recognising the psychosocial status of a disease compared with a syndrome helps clinicians understand why there is conflict between patients who believe they are experiencing a disease and clinicians who do not agree .
These communities clearly demonstrate the stigma and discrimination experienced by those who do not have a ‘ credible ’ medical diagnosis . It seems unjust that medical support should be predicated on the ability of health professionals to make a disease diagnosis .
SYSTEMIC BARRIERS TO MANAGEMENT
MANAGING medically unexplained symptoms takes time , patience , diagnostic acumen and deep interpersonal skills .
At present , there are substantial disincentives to do this work . GPs have been financially penalised when providing long consultations , and the availability of GPs
Figure 7 . There is no invisible ribbon day for medically unexplained symptoms .
is falling rapidly . 113 GPs are less able to access the investigations they need to detect rare diseases , with the removal of Medicare rebates for many investigations , including MRI ,
How to Treat Quiz . which creates financial barriers for many patients . At the same time , litigation is rising , leading GPs to fear “ missing something ” and driving over-investigation .
MEDICALLY UNEXPLAINED SYMPTOMS
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There are fewer generalist physicians available for consultation and fewer hospital resources available to support them . 114 Multidisciplinary teams focusing on the management of medically unexplained symptoms — including defined disorders like functional neurological symptoms — are rare .
If we are to improve our management of these complex conditions , it is necessary to have the resources to do so . We are expecting to shift away from GPs to more focused primary care services , using multidisciplinary teams . Although this may be advantageous in some conditions , there is a risk that the loss of generalism in the primary care sector will reduce the chance of managing these diagnostically and relationally challenging patients .
THE FUTURE
CURRENT research into the connections between the mind and body are likely to improve our understanding of the cause . In time , we may discover specific diagnostic tests and therapeutic agents to address the needs of many of these patients . In the meantime , we need more evidence to support specific consultation skills .
Clinicians need evidence-based explanatory frameworks to assist in strengthening the doctor – patient relationship and techniques to help them explore patients ’ ideas , concerns and expectations . This is even more challenging when working with patients who live with diversity , marginalisation and disadvantage .
We also need more evidence to support specific physical and psychological techniques and the resources to develop and utilise multidisciplinary teams skilled in working with these complex patients .
1 . Which THREE statements regarding medically unexplained symptoms are correct ? a They are associated with a history of childhood abuse or trauma . b They are frequently seen in patients who also have anxiety or depression . c They can cause significant morbidity . d They are more common in men .
2 . Which THREE may occur in patients in the absence of a diagnosis ? a Loneliness , isolation , marginalisation and invalidation . b Easier access to care through public health services . c Iatrogenic harm from over-investigation , overdiagnosis and overtreatment . d Seeking validation from other individuals and communities , including virtual communities .
3 . What TWO statements are correct ? a Medically unexplained symptoms commonly originate in either the mind or the body . b Medically unexplained symptoms have been classified in psychiatric taxonomies for centuries . c Most medically unexplained symptoms are caused by psychosocial problems . d Physical symptoms may arise from a psychological cause , particularly in children .
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4 . Which THREE strategies may help cope with managing heartsink feelings ? a Shift the focus from curing to coping . b Accept that the patients are suffering , and communicate that you recognise the symptoms are real and distressing . c Practise harm minimisation . d Refuse to order any further investigations when new symptoms arise .
5 . Which TWO statements regarding the elusive illness are correct ? a Ordering multiple investigations will ensure that the correct diagnosis is ultimately made . b Patients may present early in their illness when investigations may be negative and examination normal . c Patients with elusive illness rarely experience mental health disorders . d It is important to periodically revisit assessment and take a full history .
6 . Which THREE statements regarding the contested illness are correct ? a These patients invest significant work , time and energy to earn their status as credible patients . b There is the potential for significant conflict in the consultation . c Organise a regular physical health assessment to help screen for unexpected comorbidity . d Agree with the explanation offered by the patient so they feel understood .
7 . Which TWO may be features of the chaotic illness ? a Patients with chaotic illnesses usually have deep psychosocial needs that cannot be met . b Utilising social supports in the community usually resolves the chaotic illness . c Many of these patients are survivors of childhood trauma . d Patients usually have a strong therapeutic relationship with their primary healthcare provider .
8 . Which THREE statements regarding mental illness are correct ? a Frank somatisation is more common in children . b Patients with mental health needs experience internalised
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• RACGP points are uploaded every six weeks and ACRRM points quarterly . stigma and shame and may not feel comfortable expressing these . c Patients with mental illness seldom present with physical symptoms . d In Western culture , psychiatric illnesses are often seen as less real or legitimate than physical illness .
9 . Which TWO strategies may be useful in managing medically unexplained symptoms ? a Validate the patient ’ s experience by acknowledging that the symptoms are real and distressing . b Avoid giving the symptoms a name as this will imply that a cure is possible . c Do not offer symptomatic relief as this reinforces the idea the condition is real . d Limit iatrogenic harm by minimising unnecessary investigation .
10 . Which THREE are barriers to treating medically unexplained symptoms ? a The stigma and shame associated with having no name for an illness . b The recent emphasis on the mind – body connection and the importance of mindfulness . c Financial disincentives for the GP managing complex care . d Lack of multidisciplinary teams focusing on the management of medically unexplained symptoms .
CONCLUSION
THE advantage of general practice is that GPs can cross the boundaries between disease categories , systems and disciplines to look at a presentation from multiple points of view .
GPs also see patients over time , so when symptoms emerge , we can shift our focus to revisit the diagnosis . And we are in the unique position of caring for many patients where the diagnosis is elusive , the presentation is complex and the patient is unable to obtain a diagnosis that will make sense of their suffering .
The ability to tolerate uncertainty , negotiate the balance between potential benefit and harm of interventions , and care for the patient regardless is a core skill of GPs .
Patients with medically unexplained symptoms deserve care . This care should not be predicated on whether we are able to provide a clear diagnostic explanation for their illness . Unfortunately , healthcare is not structured well for patients who do not have categorical diagnoses .
If GPs are to continue this important work , we need to continue to advocate for better systems of care for patients who need additional support in the absence of a clear biomedical diagnosis .
FURTHER READING
• Dr Louise Stone . Medically unexplained symptoms : bit . ly / 3nnwUiu
• BJGP Open 2017 ; 5 Oct : bit . ly / 40DmkSP
References Available on request from howtotreat @ adg . com . au