Changing how primary-care doctors treat pain, fatigue and other common symptoms
Common symptoms such as pain or fatigue account for over half of all doctor's office appointments in the United States, translating into more than 400 million visits annually.
A new study from the Regenstrief Institute and Indiana University School of Medicine reports that one in three common symptoms do not have a clear-cut disease-based explanation. The study also offers suggestions on how doctors can help patients deal more effectively with both physical and psychological symptoms.
The peer-reviewed study, "A Practical and Evidence-Based Approach to Common Symptoms," is based on a review of studies on common symptoms plus a quarter-century of patient care and research related to symptom management by study author Kurt Kroenke. M.D. He is a Regenstrief Institute research scientist, Chancellor's Professor at the IU School of Medicine and a Veterans Affairs Center for Health Information and Communication investigator. The study appears in the Oct. 21 issue of the Annals of Internal Medicine.
"Many patients come to see primary care doctors like myself because [the patient] has been suffering from one or more common symptoms and don't know the cause," Dr. Kroenke said. "They may have back pain, fatigue, sleep complaints. They may be depressed or anxious. These patients want answers."
To find the cause of a symptom, physicians typically complete a medical history and do a physical examination focused on the symptoms. They frequently order diagnostic tests and imaging studies at the initial visit; but such tests are often an unnecessary expense, according to Dr. Kroenke, whose study found that three-quarters of the information needed for diagnosis can be culled from the patient's medical history.
"But it's counterproductive for the doctor to say to the patient that they shouldn't worry as everything is normal," Dr. Kroenke said. "Studies that we and others have conducted show that there is an unmet patient need to know what a symptom is and how long it might last."
Dr. Kroenke recommends that the physician talk with the patient about how symptoms are common, may improve gradually, often are responsive to symptom-specific treatments including self-management and are not cause for concern about 75 percent of the time. The patient should be advised to return in four to six weeks if symptoms don't improve.
"Only if there are red flags for serious problems like cardiovascular disease or cancer should the doctor typically do more at the initial visit. Testing can be reserved until a follow-up appointment for the subgroup of patients whose symptoms haven't diminished," Dr. Kroenke said.
Key findings of the study:
- At least one-third of common symptoms do not have a clear-cut disease-based explanation.
- A patient's medical history alone yields 75 percent of diagnostic information.
- Physical and psychological symptoms commonly co-occur.
- Most patients have multiple symptoms rather than a single symptom.
- Symptoms become chronic or recurrent in 20 to 25 percent of patients.
- Serious causes that are not apparent after initial evaluation seldom emerge later.
- Some medications and behavioral interventions are effective for multiple types of symptoms.
- Measuring treatment response with valid scales (for example: PHQ-9, the so-called blood pressure cuff for depression co-developed by Dr. Kroenke) can be helpful.
- Communication has therapeutic value, including providing an explanation and likely prognosis but not "normalizing" the symptom.
"Changing how doctors treat symptoms regardless of underlying cause won't be easy," Dr. Kroenke said. "Physicians are better reimbursed for tests and procedures than for taking medical histories and having conversations with patients. As we evaluate what is best for patients with common symptoms, we also need to reconsider how health care dollars are allocated."