Abstract
We were interested in Burton et al.’s proposal of a ‘rational explanation’ framework for communication with patients after negative diagnostic tests (‘medically unexplained symptoms’). 1
We suggest that before attempting explanation it is useful to ask ‘what is it that worries you about your symptoms?’ When 86 consecutive new patients in a rheumatology back pain clinic were asked this question, only 13 (15%) denied specific fears; 55 (64%) admitted to fears about possible future disability (loss of independence or work or both, or being confined to a wheelchair); 18 (19%) were worried about the cause of their pain (cancer, arthritis, degeneration); and two (2%) had other concerns. 2
Only a minority of these concerns could possibly be alleviated by further investigation.
Furthermore, most negative diagnostic tests do not completely ‘rule out’ all serious pathology. Diagnostic uncertainty is stressful for both doctor and patient. Some responses to uncertainty, such as calling patients ‘atypical’, might alleviate the doctor’s stress more than the patient’s. To resolve diagnostic uncertainty, the patient may feel the need to offer further symptoms, or the doctor may feel the need to do more tests: the ‘cycle of anxiety and relief-seeking’ described by Burton et al. But accumulation of more and more clinical information may only serve to muddy the diagnostic waters further.
Even before the diagnostic test is ordered, the manner in which the need for the test was raised with the patient is critical, linking investigation to proposed management. For example, imaging tests for back pain might confirm that physiotherapy is appropriate. Similarly, clarity about treatment aims may help (for example, the aim of physiotherapy is to help you to ‘live with’, rather than ‘cure’, the pain). This could also help break the cycle of over-investigation for ‘medically unexplained symptoms’.