Medically unexplained symptoms: time to and triggers for diagnosis in primary care consultations

Comparison with existing literature

As far as is known, this is the first study to look at exactly when symptoms are labelled as MUS in the consultation. By using the method of stimulated recall, more insight was gained into the moment in primary care consultations where GPs labelled symptoms as medically unexplained and what triggered them to do so.

In previous research, GPs indicated how they managed patients with MUS in daily practice.¹⁹ The researchers performed five focus groups with GPs and found that the diagnostic process of patients with MUS varied from consultation to consultation, and the patient had usually gone through a series of consultations before the GP labelled the symptoms as being MUS. The difference with the findings might be explained by the fact that this study is a more direct study where GPs were asked to reflect on their own real-life MUS consultation, whereas Hansen et al ¹⁹ studied the GPs’ view indirectly in a focus group where the results may be more prone to recall and desirability bias.

It was found that GPs labelled symptoms more quickly as medically unexplained when the symptoms had been presented previously, than when symptoms were new. This is not surprising as the GPs’ knowledge of the patient’s medical history, social background, and personal characteristics play a role in the labelling process, and GPs use this knowledge in the labelling process when there is continuity of care. The median for newly presented symptoms indicates that GPs still spend only a fairly short amount of time excluding potentially serious organic causes of disease. In most cases, GPs labelled these symptoms as medically unexplained because the patient attributed the symptoms to their psychosocial context. Additionally, GPs labelled these symptoms as MUS because they did not fit into a specific pattern, or because of their vague and unstructured presentation.

The GPs in the present study clearly indicated what triggered them in the labelling process. Similar to previous research, knowing the medical history, social background, and personal attributes of the patient,¹³ the presentation of vague and multiple symptoms,¹³ and a mismatch between symptom presentation and objective findings¹¹ triggered GPs to label symptoms as medically unexplained. Furthermore, and not reported before in the MUS literature, the present study found that GPs used symptom patterns and symptom attribution as diagnostic instruments.

Kahneman has described two models of knowing and thinking: analytical reasoning, which is controlled and relatively slow, and non-analytical reasoning, which is intuitive and fast.²⁰ As GPs mentioned that contextual knowledge, patients’ presentations, and pattern recognition played a role in diagnostic reasoning, this suggests that non-analytical reasoning (that is, clinical reasoning in which GPs do not explicitly test hypotheses) was a central component in their thought process, rather than the analytical reasoning that is dominant in the hypothetico-deduction model, wherein the GP generates hypotheses and tests these hypotheses against the findings.^21,22

GPs solve problems using a variety of strategies: they use pattern recognition for simple problems (fast), and systematic generation and testing of hypotheses for difficult problems (slow).²³ Previous research has shown that GPs encapsulate clinical knowledge in concepts and conceptualise illness scripts (causal models based on experiences) for each disease.²⁴ These ‘illness scripts’ are activated in the conversation with the patient during the consultation²⁵ and enable the GP to swiftly recognise patterns of symptoms. This diagnostic reasoning in which the non-analysing system plays a central role may be sensitive to errors and prejudices. This applies particularly for GPs who labelled symptoms, which had not been presented before, as MUS. Other research^26,27 found that GPs’ prejudices also play a role when applying the label MUS. GPs who employ prejudice as well as patients’ symptom presentation, symptom patterns, and symptom attribution as diagnostic instruments are at risk of errors; however, previous research found that the percentage of misdiagnoses in patients with MUS was relatively small.²⁸ This is in line with the present study’s findings as only one patient initially labelled with MUS was found who was later diagnosed with an underlying somatic disease. The illness scripts of MUS are often not only about symptom patterns, but may also include high frequency of healthcare use, loss of participation in daily activities, and social isolation as these are positively associated with MUS.^29,30

Previous research has described that, in contrast with biomedical disorders, in which GPs use an approach based on biochemistry, psychiatry is dependent on pattern recognition.³¹ GPs are required to use both approaches simultaneously for patients with MUS. Other researchers showed that physicians were able to reliably agree on the recognition of MUS and argued that GPs demonstrate a high level of accuracy in subjectively recognising MUS.³² For this it is helpful being aware of the factors that set up, initiate, and maintain MUS.³³ This is in line with the Dutch GP guideline on MUS, which uses a model that also involves predisposing, precipitating, and perpetuating factors.³⁴

Strengths and limitations

To the authors knowledge, this is the first study of the time to diagnosis with objective measures and minimal recall bias. The data were independently analysed by two researchers. With the qualitative approach unique to this topic, the study was able to look at the considerations of the GPs during the process of diagnosing MUS in their patients.

A possible limitation could be that the study did not have the opportunity to establish directly when the GP decided that the symptom was unexplained; this was extrapolated from the comments the GP gave during the reflections on the video-recorded consultation. Furthermore, if GPs labelled symptoms as medically unexplained before the start of the consultation, it was not possible to quantify exactly when the GPs labelled the symptoms as MUS. To pinpoint this moment in these cases, it was defined as the start of the consultation.

When selecting patients with MUS in this study, considerable variation between GPs was identified. Some GPs labelled five patients as presenting with MUS during a single day of consultations, whereas others identified none during 2 days of video-taping. This might have to do with uncertainty that some GPs have about labelling symptoms as MUS, the variation in working experience, or the result of a lack of clarity in the definition of MUS. The variation in the selection of MUS might also be accounted for by natural variation. Moreover, some GPs do not interpret symptoms as medically unexplained because they understand the biopsychosocial origin of the patients’ symptoms. Probably, these GPs use an effective communication style and know how to manage patients with MUS. Although the framing of MUS is a matter of debate, one might assume that the two GPs without any MUS consultation have a different framework about MUS. This cannot be ruled out, but it is known that most Dutch GPs comply with the Dutch multidisciplinary guideline for MUS, and this guideline for GPs about MUS explicitly explains the definition and framework of MUS.³⁴

Furthermore, the aim was to study those patients presenting with MUS according to their GP, without reference to official definitions of MUS. This is important because, it is to be assumed, that when the concept of MUS enters the mind of the physician, it evokes a certain set of cognitions that influence the physician’s behaviour. It was explicitly not the aim to have a shared and predefined understanding of the concept of MUS; however, the variation in the selection of patients with MUS does not affect the study’s conclusions. In order to increase validity, the time delay between event and recall was minimised as much as possible. Key to this validity issue is the need to ensure that the questions/prompts did not alter the cognitive process being employed at the time of the event.³⁵

Although some GPs reflected on their consultation only after a considerable amount of time, it is to be assumed that the questions did not alter the cognitive process used at the time of the reflection, and did not influence the validity of the results, since the GPs were questioned while viewing the consultation. GPs recognised their own MUS consultations very well. This is reflected in the GPs’ remarks, as almost all of the GPs were able to point out the exact moment when they believed the patient presented with MUS. Of course, it cannot be excluded entirely that the GPs had changed their mind, but this was minimised by confronting them with the actual setting. Future studies could look more specifically into the relationship between spontaneous and delayed recall sessions. Additionally, it cannot be conclusively concluded that GPs are capable of recognising MUS in patients as not enough is known about the false negatives (patients’ complaints labelled as medically explained that should be labelled as MUS).

Finally, GPs indicated in only seven MUS consultations that the symptoms had not been presented previously, which is quite a small number. Moreover, there was a large variation in the timing of labelling new symptoms as MUS. Caution is therefore to be used when interpreting the results and the findings should not be generalised.