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Physicians’ Responses to Patients’ Medically Unexplained Symptoms

From the Departments of Family Medicine (R.M.E., C.G.S., K.F., S.M., P.R.D.), Psychiatry (R.M.E., C.G.S., P.C.D.), and Community and Preventive Medicine (K.F.), University of Rochester Medical Center, Rochester, NY; the Rochester Center to Improve Communication in Health Care (R.M.E., C.G.S., K.F., S.M., P.R.D.), Rochester, NY; and the Department of Community and Family Medicine (P.A.C.), Dartmouth Medical School, Hanover, NH.

Address correspondence and reprint requests to Ronald M. Epstein, MD, 1381 South Avenue, Rochester, NY 14620. E-mail: Ronald_Epstein{at}urmc.rochester.edu

Objective: To understand how physicians communicate may contribute to the mistrust and poor clinical outcomes observed in patients who present with medically unexplained symptoms (MUS).

Methods: After providing informed consent, 100 primary care physicians in greater Rochester, New York, were visited by two unannounced covert standardized patients (actors, or SPs) portraying two chest pain roles: classic symptoms of gastroesophageal reflux disease (GERD) with nausea and insomnia (the GERD role) and poorly characterized chest pain with fatigue and dizziness (the MUS role). The visits were surreptitiously audiorecorded and analyzed using the Measure of Patient-Centered Communication (MPCC), which scores physicians on their exploration of the patients’ experience of illness (component 1) and psychosocial context (component 2), and their attempts to find common ground on diagnosis and treatment (component 3).

Results: In multivariate analyses, MUS visits yielded significantly lower scores on MPCC component 1 (p = .01). Subanalysis of component 1 scores showed that patients’ symptoms were not explored as fully and that validation was less likely to be used in response to patient concerns in the MUS than in the GERD visits. Component 2 and component 3 were unchanged.

Conclusion: Physicians’ inquiry into and validation of symptoms in patients with MUS was less common compared with more medically straightforward patient presentations. Further research should study the relationship between communication variables and poor clinical outcomes, misunderstandings, mutual distrust, and inappropriate healthcare utilization in this population, and test interventions to address this problem.

Key Words: somatization • physician–patient relations • patient-centered care • symptoms • communication • standardized patients

Abbreviations: GERD = gastrointestinal reflux disease; MPCC = Measure of Patient-Centered Communication; MUS = medically unexplained symptoms; PCC = patient-centered communication.

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