An individualized, evidence based approach to mus
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Transcript of An individualized, evidence based approach to mus
An Individualized, Evidence-Based Approach To Medically Unexplained
Symptoms
Francesca C. Dwamena, MD MSRobert C. Smith, MD ScM
Michigan State University
AACH Research and Teaching Forum, Scottsdale, Arizona
October 17, 2010
Learner Objectives
Video Presentation:
• A 34 year old female with intractable diarrhea, nausea/vomiting, abdominal pain
Workshop Objectives
Participants will be able to:1. Describe steps required to diagnose “Medically
Unexplained Symptoms” (MUS) in primary care.
2. assist MUS patients in– understanding their illnesses
– committing to participate in their care.
– setting and achieving realistic goals
3. negotiate treatment plans with patients with MUS
What do we mean by MUS?
• Symptoms that are not adequately explained by the presence of organic disease (metaphor for psychic distress)
Becomes a problem when there is high utilization
How do MUS arise?
o Often understandable in context of patient history and circumstances
o Mechanism --- patient avoids emotion
o Psychodynamic – ineffective emotional expression
o Behavioral – reinforcement of illness behaviors
o Socio-cultural – emotional suppression
o Biological – gate control theory
DSM-IV Classification of MUS
• Somatoform disorders: not used in primary care– Somatization disorder (SD) – very rare– Hypochondriasis– Chronic pain– Conversion disorder– Miscellaneous
Only SD validated; Overlapping definitions limit use for classification
Syndromes of MUS in Medicine
• Chronic Fatigue Syndrome
• Fibromyalgia
• Irritable Bowel Syndrome
• Chronic pain: back, pelvic, head, neck, abdominal, chest etc. for each specialty
Overlapping definitions limit use for classification, but useful for labeling; not useful for diagnosing mild MUS / minor acute illness
Proposed Classification
• Better to think of MUS as one entity on a continuum with 3 parameters:
–Severity
–Duration
–Co-morbidity
Normal-Mild (~80% MUS pts.)
Characterized by:
Low severity (low
utilization, few symptoms)
Acute (days –weeks)
Co-morbidity not studied
Diagnose by:
H&P + observation for weeks (e.g., eye
problem) - months (e.g., back pain).
Avoid unnecessary testing
Treatment:
Reassurance, positive PPR, symptomatic
treatment
Moderate (~15% MUS pts.)
Characterized by:
High utilization, >2 symptoms
Sub-acute (1-6 months)
20% depression, anxiety or other psych disorder. Neurotic personality
structure
Diagnose by:
H&P + observation initially; Definitive work-up with increased utilization or recurrence
• Organic disease rare after negative definitive work-up
Diagnosis of co-morbid psychiatric disease
Severe MUS (~5-6% MUS pts.)
Characterized by:
High Utilization; multiple, persistent
symptoms
Chronic (>6 months)
>67% with psychiatric disorder. 61-72% Personality
Disorder
Diagnose with:
Definitive lab and/or consultation
• MRI, or CT for chronic back pain
• CT, colonoscopy for chronic abdominal pain with altered bowel habits
• Laparoscopy for chronic pelvic pain
• Observation over time
• No need to repeat if definitive work-up was negative
Diagnose co-morbid psychiatric disease
Differential / Co-morbidity
Organic diseases• rare (e.g. Wilson’s Disease),
• vague, unusual presentations (e.g. MS, Lyme, porphyria, celiac sprue)
• prominent psych symptoms (e.g. carcinoma of pancreas, subdural hematoma or ulcerative colitis)
Factitious Disorders
• no external incentive
Malingering
• external incentive
Psychiatric• Depression, anxiety
• Panic disorder
• PTSD; also, sexual, physical abuse
• Personality disorder
• Substance abuse/dependence
Our Case – Ms G
• MUS was characterized by:
– High utilization, Multiple symptoms
– Chronic; recent acceleration
– Both medical and psychiatric co-morbidity
• Type 2 DM, OSA, depression, anxiety, dependent personality, obesity
Our Case – Ms G
To rule out organic disease,
• We reviewed med records
– CT scan abdomen (2 non-obstructing stones), EGD, colonoscopy (2 years prior), cholecystectomy
• Ordered the following in hospital
– stool studies, antiendomyseal antibodies, repeat CT (same), 240 urine VIP, 5-HIAA, ERCP with sphincterotomy, repeat colonoscopy with terminal ileum visualization (mild anemia)
• And followed her over time
Questions?
(Smith et al. JGIM, 2006;21:671-677)
206 high utilizing patients with MUS
•Primary care Nurse Practitioners
Intervention vs. Usual care
•Evidence-based Patient centered approach
•ECGN (education, commitment, goals, negotiation)
•Symptomatic treatment
•Antidepressant (usually)
Improved mental function
(OR : 1.92, CI = 1.08 – 3.40)
•Improved patient satisfaction, physical disability (p<0.001, p=0.02 respectively)
•Decreased use of narcotics and benzodiazepines (p = 0.043)
•Increased use of full dose antidepressants (p = 0.037)
Primary Care Physicians Assisted by Case Manager Can Also Treat MUS
What is the patient’s perspective?
Qualitative Methods - Sampling
Random sample of high utilizing
patients (n=103)
Purposive on spectrum of
severity
Recruited till no new themes
(n=19)
Sample - Characteristics• 16 (84%) were females• 9 (47%) married• 14 (74%) > 2 years of college• Mean age 48years (31 – 65)• >11 visits/year; 69.6% medically unexplained per
chart review• Only 7 (37%) diagnosed MUS (5 fibromyalgia, 2
IBS)
So, typical primary care patients with a lot of visits (or symptoms); many not recognized by doc as having MUS --- need to diagnose to treat.
Qualitative Methods – Long Interview (60 – 90 minutes)
Open-ended 30 – 45 minutes
Iteratively developed list of topics
• Explanatory models, locus of control, health-seeking behavior, abuse, gender effects, relationships, expectations for future
Taped and transcribed verbatim
Qualitative Methods – Grounded Theory
Read 5 transcripts
each
Prelim Themes by consensus
Tested themes
in another
5
Working themes by consensus
Tested working themes in rest
Reread all 19
transcripts
Major categories, relationships
Results• There were 3 different types of patients
• The 3 types wanted different things from their visits
Coping (n=4) Classic (n=9) Worried (n=6)
Mean age (SD) 54.5 (9.8) 47.0 (10.9) 53.2 (6.9)
# Female (% group) 3 (75) 8 (89) 5 (83)
≤ 12 years school 3 2 0
14 years 1 4 1
≥ 16 years 0 3 5
# Severe MUS (%) 1 (11) 5 (56) 3 (33)
# Moderate MUS (%) 3 (30) 4 (40) 3 (30)
Mean # visits/year (SD) 11.0 (2.7) 11.4 (3.1) 16.0 (9.6)
Mean % visits MUS (SD) 0.68 (0.24) 0.66(0.22) 0.74 (0.02)
Coping High Utilizers
Insight
Mind-body
Had therapy
Symptoms
Not disabled
Not focused on them
High utilization
Multiple tests
Follow-up visits
What they want:
to understandtheir
symptoms
Do not want unnecessary
tests, treatments
☼None had been diagnosed with MUS by their doctors
Classic Somatizers
No insight
Still raw from past trauma
Symptoms
Disability
Focus
High utilization
Symptoms
Ineffective treatments
What they want
Support
Management of symptoms, not
drugs
☼Most had been diagnosed with MUS, but no specific treatment
for MUS; patient with impression nothing could be/was done.
Worried High Utilizers
Combination
Insight
Symptoms focus
Not much disability
Worried
Knew docs make
mistakes
Not told their docs
Complained
Access to docs
Time spent with them
Healthcare system
What they want
Taken seriously
Sure
☼Only 1 had been diagnosed with MUS
Bottom Line
• Patients with MUS want and need different things from encounter– Explanation
– Support
– Treatment (not necessarily drugs)
– Respect/Reassurance
• Individualize by assessing their unique needs and meeting them.
Skills Needed To Treat MUS
1. Establish and maintain a successful doctor-patient relationship
2. Help patient to understand his/her illness (Education)
3. Help patient to Commit to actively participate in his/her care
4. Help patient to set realistic Goals
5. Negotiate and agree on pharmacologic and non-pharmacologic treatment elements
1: Establish & Maintain a Successful Doctor-Patient Relationship
• Awareness of Self
• Relationship-Building Skills
– Listen
– Ask about emotions
– Express empathy
Developing Self Awareness• Mindfulness
– paying attention, on purpose, to one's own mental and physical processes during everyday tasks, so as to act with clarity and insight
– a set of habits of mind and habits of practice in the moment
• Can be enhanced by:– Meditation
– Journaling
– Balint Groups
– Advanced Communication Training with Personal Awareness Component
• American Academy on Communication in Healthcare (AACH)– www.aachonline.org
– Finding Meaning in Medicine Groups– www.meaninginmedicine.org
Relationship-Building Skills
ASK ABOUT
EMOTION
1.Direct
2. Indirect• impact
• belief
• self-
disclosure
EXPRESS EMPATHY
1. Name
2. Understand
3. Respect
4. Support
LISTEN
1. Non-focusing
•silence
•nonverbal
encouragement
•neutral utterances
2. Focusing
•echoing
•requests
•summarizing
Express Empathy
• “NURS” often
Name: “You say being disabled by this knee pain makes you angry.”
Understand: “I can understand your feeling this way.”
Respect: “This has been a difficult time for you. You show a lot of courage.”
Support: “I want to help you to get better.”
2: Help Patients Understand
ASKWhat they fear
What do you think (fear) might be wrong?
TELLConfidently
•Good news is no life threatening disease
•We do not need any more tests
•Illness is real, “not in your head”
•It is common, it has a name, and I have experience
•We think it is caused by…
•Bad news is it cannot be cured
•But you can feel better and get on with your life
ASKIf they understand
This is a lot to throw at you. Can you tell me
what you understand so far?
What can you say to help patients understand…
• Chronic pain
• Irritable bowel syndrome
3: Help Patients to Commit
ASK for
commitment
I am committed to helping you feel better, but
I can’t do it alone. A lot of effort, especially
from you. We can go at your pace, but you
have to be on board. Are you ready?
ASK again
and again
•Are you really committed to walking? On
scale 1 to 10 where would you put yourself?
What would it take to do better?
•What 1 or 2 things can you commit to doing
by our next visit?
•You thought that walking 15 minutes 2X/week
was possible for you. What got in the way?
What would you say to following patients?
• Multiple no-shows
• Not making progress in changing unhealthy behavior
Commitment DOs and DON’TsDO
– Ask for commitment again and again; key to success
– Acknowledge patient’s plight and obstacles
– Praise small victories
– Express curiosity and be patient
– Use contracts to emphasize plan and partnership
DON‘T– Use language that blames the patient
– Give up when success is elusive or fleeting
NURS!
“You can’t keep doing the same things expecting different results…”
4: Help Patients Set Goals
ASKWhat would you be doing if you did not
have these symptoms?
e.g.,
•Better relationships
•Improved work/school record
•Improved functioning
•Improved symptoms
ASK for
Long-term goals
Even though there is no cure, you can
do/have some of these. What would
you like to have/do in the next 6 to 12
months?
Assess and celebrate progress at each visit
ASK What can you accomplish by next visit?
To Operationalize Long Term Goals
e.g.,
•Walk 3 blocks 3X/week for 2 weeks
•Meditate for 10 minutes everyday
•Swim for 30 minutes 3X/week
SUMMARIZE
and record
•You will stretch for 10min each day and
walk outside for 30 minutes on Mon,
Wed, and Fri, right?
•What will you do if it rains?
Review, revise, update goals each visit
5. Negotiate – a) Non-Pharmacologic Treatment
• Regular Visits
• Agreement not to self-refer
• Exercise
• Physical Therapy
• Relaxation techniques
• Involvement of significant other
5. Negotiate – b) Pharmacologic Treatment
1. Antidepressants
•Anyone going through this would be depressed.
•The test shows that you have major depression.
•X helps significantly to improve pain.
•We can stay away from X and try Y.
•It can help the pain and also help you to sleep.
•We can start low dose so you can get used to it.
•Would that be alright with you?
Negotiate – b) Pharmacologic Treatment
2. Wean Narcotics and benzodiazepines
•Z doesn’t work very well in the long run.
•As X builds up in your system, we can wean Z.
•Don’t worry; if we have to, we can add it right
back.
•I want to help you feel better, not worse.
•Take Z the same way everyday. Don’t skip or
take more no matter how you feel.
•Think this week about which dose you can drop.
How would you negotiate with a patient who
• Refuses to wean narcotics, instead wants to escalate use.
• Is reluctant to use antidepressants.
Demonstration: Development of Initial Plan
• Discussion (assign components)
1. How did he establish/maintain relationship? NURS (Name, Understand, Respect, Support)?
2. How did he educate (what were elements?)
3. How did he help patient to commit?
4. How did he help patient to set goals (long-term, short-term)?
5. How did he negotiate?
Our Case – Ms G
• Video• Long term goals achieved:
– Better work record (missed 63 days in 5 months vs. 5 days in 5 years)
– Successful marriage– Two beautiful babies– Able to anticipate and control exacerbations
Low utilization (from every 2 to 3 weeks to 2-3 times per year)
Consultation and Hospitalization
• Chose consultants who
– understand MUS and after appropriate evaluation are willing to tell patient - “no organic disease”
• Prepare
– consultants to prevent excessive testing and reinforcement of patient fears
– patient to avoid feelings of abandonment
• Consult psychiatrist for unstable/suicidal patients, refractory symptoms
• Hospitalize only for physical/psychiatric instability
Please fill out your evaluations!!!