Dr Sam Wild

Medically Unexplained Symptoms

Session 27th September 2019- Bradford.

Session ran by Suzanne Heywood-Everett

Medically unexplained symptoms (or persistent physical symptoms as can be the preferred term) is a common consultation within general practice and these can be some of the most challenging cases to manage. This presentation is often more prevalent in areas of deprivation and can be exacerbated by difficult social circumstances.

This teaching day was very beneficial in discussing consulting in these cases along with management strategies. This built very nicely on previous teaching we have had regarding chronic pain. There were certainly plenty of learning points I could apply to my patients and will hopefully aid my management in these cases.

We considered potential pitfalls that general practitioners can face in managing these patients including our own unwillingness, trying lots of different treatment methods or searching for a cure, talking/persuading too much, coercion, being ‘right’/sounding smart, forgetting to observe and act curious, loosing track of own values. These are important to bear in mind when faced with patients with persistent physical symptoms as are likely to be barriers to effective management.

It was helpful discussing an approach to persistent physical symptoms (where an alternative diagnosis was felt to be ruled out). This was useful overlap with the chronic pain session; in particular breaking the initial consultation in two (the first being getting the pain story then the second considering management).

In the first session asking about the pain story, when it started, validation, how managed so far, what’s worked/not worked, what they think is going on and what they think might help, what else is going on in their life. Following this a pain/symptoms diary might be helpful (however recording what they did to help and how successful it was – rather than just the pain/symptom itself)

In the second consultation then review the diary if this has been used, build rapport and engagement. An important thing I took from this was then considering where the patient was in terms of changing and how this would change the management strategy from here. For example, if they were pre-contemplative then risk management would be sensible (ie not escalating medications if they are not going to help). If the patient is contemplative then focusing on validating, seeing what else may be going on, distracting from pain, tapping/breaths. At the preparation stage then they may be ready for more information like research (new approach to pain, excited about this), considering pain as a chronic condition in itself.

The session gave many useful examples for explanations of persistent physical symptoms. This included using danger receptors instead of pain receptors and how context changes this (e.g. nail in the hand, no pain on way to hospital then bad pain once there – stimulus hasn’t changed. Lorimer snake example. Amanda Spratt pain cycling uphill after accident when cycling uphill). As with the chronic pain teaching we discussed chronic pain as a different condition to acute pain hence not responding as acute pain to analgesia. These examples (and others) could be useful, depending on the patient – as mentioned above they are more likely to be successful with patients in the preparation stage.

The importance of giving hope about the management of symptoms was also a feature of the teaching, for example in being excited about a new way of thinking about chronic pain and giving credibility to yourself when talking about chronic pain management. Being realistic that for the patient improving symptoms and quality of life may not be quick or easy, but may be quicker and easier than they think. We also discussed the importance of the language used and to be careful with this; the classic detrimental example being crumbly spine.

The key learning points from this session will benefit my future practice in me feeling more confident and prepared to manage patients presenting with these symptoms. I recognise these will not be easy consultations but I will feel more equipped in my approach and management. In particular, considering where a patient may be in considering change; for example not trying to go into metaphors and explanations where the patient is pre-contemplative.

Notes by Dr Sam Wild (Trailblazer GP 18/19)