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Tuesday, 21 February 2017

Improving care for people with Medically Unexplained Symptoms

Written by Professor Carolyn Chew-Graham@PCSciences | 

As a newly qualified General Practitioner, I struggled to manage people who I thought might have medically unexplained symptoms (MUS). What would I say to the patient? Who could I refer the patient to? What could I do to support the patient, and maybe even try to improve their situation? 

 So, what are medically unexplained symptoms? 

MUS actually accounts for a considerably high proportion of NHS activity, with approximately 10% of total NHS expenditure being spent on services for the working age population in England with medically unexplained symptoms. 

MUS refers to the persistent bodily complaints, whereby adequate examination and investigation does not reveal sufficiently explanatory structural or other specified pathology. MUS are common, with a spectrum of severity, and patients are found in all areas of the healthcare system - Primary Care, the Emergency Department and Specialist Out-patient clinics. Symptoms can often include pain (muscle, headache, pelvic, facial, chest), fatigue, dizziness, shortness of breath, and may also be presented in combination. 

What impact do Medically Unexplained Symptoms have on GPs? 

Extensive literature looks into the impact on clinicians managing MUS, showing that family doctors feel less satisfied caring for patients with persistent MUS rather than patients with psychological problems. GPs have reported that they often find it stressful to work with patients with MUS, going on to describe a sense of 'powerlessness' during the consultation. These negative emotions can then go on to influence their professional judgement. 

During some of my earlier research, conducted with medical students, GPs were interviewed about their experiences of managing patients suffering from MUS. One particularly notable quite illustrated the impact that patients with MUS has on GPs; 

"Some make your stomach churn when they come in...very nervous. They make it very clear they are taking charge; and they do, they take charge, and there is nothing you can do". (GP quoted in the Wileman Paper)

As a GP, what can I do? 

As the Royal College of General Practitioners (RCGP) Clinical Champion for Mental Health (2008-12), I led the development of a number of fact sheets which aim to support GPs in their daily encounters with people with mental health problems. One of these fact sheets focuses on MUS, which makes valuable suggestions to support you, as a GP, in the identification and management of patients suffering with MUS. 

Why do GPs need to use the commissioning guidelines for MUS? 

Whilst GPs need to identify and manage many people with MUS, there are some patients who have more complex problems and need more specialist services. In view of the distress patients with MUS experience, because of the cost of managing MUS to the NHS, and to support clinicians who manage people with MUS, commissioning guidelines were needed to improve services across the NHS for people with MUS. The Joint Commissioning Panel, a joint enterprise between the RCGP and the Royal College of Psychiatrists (RCPsych), has produced a number of guidelines which advise commissioners on the current evidence-base on which to base commissioning decisions, and agree that guidance was needed for MUS. 

How were the guidelines developed? 

An expert reference group was established with myself from RCGP and Dr Simon Heyland from RCPsych acting as co-chairs. The groups membership included people with MUS, Psychiatrists and GPs with expertise in managing people with MUS and/or researching MUS, Psychologists, Nurses and Commissioners. 

The group have spent the last two years working together to agree the final content of these guidelines. 

So, what do these guidelines mean for General Practice? 

These evidence-based guidelines outline what good practice for people suffering with MUS should look like. 

The expert reference group suggest that commissioning which invests in the provision of effective and appropriate MUS services will support the delivery of the Five Year Forward View for Mental Health, and most importantly, improve care for people with MUS. 

Download the MUS Commissioning Guidelines 

About the author: 

Professor Carolyn Chew-Graham was bought up in Staffordshire, and studied Medicine at the University of Manchester. Following training to become a GP, she followed an academic career path and was awarded a personal chair in Primary Care in at the University of Manchester in 2009. In 2012, she became Chair at Keele as Professor of GP Research. Carolyn is the RCGP Curriculum Advisor for Mental Health, and the Chair of the Scientific Board for RCGP. She is the editor in chief for the journal 'Health Expectations' and section editor for 'BMC Family Practice'. 

1 comment:

  1. These MUS Commissioning Guidelines are deeply flawed and discriminate against women in particular. The references cited directly contradict what is written in the text. The Guidance claims that a risk factor is being female, but the references cited in the Guidance show that there isn't any significant gender predominance. Just as she does above, in the Guidance Professor Chew-Graham presents a wholly negative view of both MUS patients and of doctors' attitudes towards them, and she omits to include the more positive attitudes from the research cited. She also generalizes from her own non-generalizable study and the authors present a table of MUS rates in various outpatient specialties putting Gynaecology at the top of the table with a 66% rate when they should be aware that there was another very similar study that put gynaecology in the middle of the specialty table. It seems that the authors are intent on defaming women in relation to MUS when there is no evidence cited to support this. Oh, and I nearly forgot to mention....the Guidance includes patients with CFS/ME, even though this condition is classified as neurological by the WHO and not psychiatric.

    Also, Professor Chew-Graham's statement above about the cost of MUS is wrongly worded and therefore misleading to all who read it. It implies that 10% of the total NHS expenditure is being spent on MUS patients in the working age population in England......what I believe she means to say is that 10% of the NHS funds that are spent on the working age population is actually spent on MUS.....which is clearly NOT the same thing at all. Indeed the phrase seems to be deliberately designed to mislead anyway......where else do we read about funding/costs being expressed as a percentage of the NHS expenditure of the working-age population rather than as a percentage of total NHS expenditure? But even that 10% figure is in serious doubt when you look at the paper from whence it came. What is not mentioned is that the authors of that paper (Bermingham et al) said that the figure of approx. £3 billion could be out by a much as 30% so the figure could in fact be 30% lower. Yet Professor Chew-Graham fixes the £3 billion in concrete by using the 10% of NHS expenditure all smacks of gross misrepresentation to me.

    One might suppose that there could be a hidden agenda here. First brainwash doctors into believing that medically unexplained symptoms are the result of a psychiatric somatising condition.....they couldn't possibly be due/related to ADRs, misdiagnosis, testing error, admin error, Hickam's dictum, or not-yet-elucidated diseases now could they? I suspect it's far easier to get doctors and NHS commissioners to believe that MUS is the result of some neurosis rather than of a failure of current medicine if hapless women are shown to be the main defraud the reader by telling them that they are. Malign these female patients with a long string of negative comments about how dreadfully they impact on their saintly doctors, then dole out cheap CBT to them rather than sending them for the proper biomedical investigations and assessment that they deserve as paid-up members of society. Even label them with a special clinical code to make sure that these 'resource wasters' don't get investigated by any other doctors. NB This NHS Government strategy directly pits funding for physical healthcare against funding for psychiatry (IAPT- cheap CBT). (see NHS Transformation Call to Bid - IAPT).
    And there you have it,the Government's efficiency savings served up on a plate......outpatient and diagnostic secondary care services decimated and at the expense of women's health in particular.