This is a group of patients that can be very challenging. Practices will vary as to the proportion of 'worried well' that present.
It is important to understand the basis for the patient's concerns. Patience and a significant degree of empathy and sensitivity are likely to be required.
Review the patients record
- Is there any significant medical history?
- How often are they presenting?
- Review the outcome of these consultations
- Are there any recurrent themes?
- Use the search facility within your clinical system to see if the patient has presented with that particular symptom before.
- Is there a past diagnosis of health anxiety?
- Is continuity of care a problem?
- What investigations (if any) have already been undertaken?
Ensure that the patient is well
Firstly ensure that the patient is clinically well. They may well have a red flag symptom suggestive of significant pathology that requires full investigation. Ensure you are happy that you have ruled anything serious out by whatever means that you need to.
Avoid over investigation
Avoid over investigation of the patient's symptoms as this can not only drive patient anxiety, it can also lead to non-specific abnormalities on blood tests, incidentalomas being discovered and means the patient is subjected to a series of unnecessary potentially harmful investigation.
The annual NHS cost for medically unexplained symptoms (MUS) in adults of working age in England was estimated to be £2.89bn in 2008-9 (approximately 10% of total NHS expenditure on these services for the working age population), while sickness absence and decreased quality of life for people with MUS was estimated to cost over £14bn per annum to the UK economy.1
Explore patients' ideas and concerns
Once (and if) red flags are excluded from presenting symptoms, it is critical that the patient's ideas, concerns and expectations are explored. A lot of patients may not be reassured by 'normal' blood parameters, imaging or secondary care opinions.
Careful exploration of patients’ ideas will allow you to establish what they think could be causing the symptom and then use those ideas to get a better understanding of their health beliefs.
What research into their symptoms has the patient undertaken? A large cohort of patients will have often reviewed the internet prior to attendance.
Identifying what patients are truly concerned about will allow you to understand what is likely to be perpetuating their anxiety. This can then be further explored.
Finding out what the patient expects of you as the professional, can allow you to meet that expectation, or alternatively reach a compromise if you feel that course of action is not necessary or appropriate at this stage.
Develop a shared management plan
Having an understanding of the patient's ideas and concerns can allow a shared management plan to be developed.
Bear in mind that fully exploring patients' health beliefs may take time and may not be possible in a single consultation – it may take many weeks or months before a true understanding of the patient's problems are uncovered.
Ensure you have a good understanding of the patient's social situation as this is likely to be relevant.
Other advice
It is important to remain calm when reviewing this group of patients – you may find that all you need to do is listen.
It may be necessary to acknowledge that you can no longer help that particular patient and then discussion with a colleague for a potential transfer of care may be appropriate.
How this might present in the CSA
This type of presentation may arise in the CSA.
Scenarios that may crop up may include those patients presenting with chronic low back pain, chronic pelvic pain, chronic facial pain, recurrent headaches, recurrent abdominal pain or symptoms suggestive of irritable bowel syndrome.
The case may provide you with information that the patient has had a series of normal investigations and that they have been see a few times for their symptoms.
Key advice
- Ensure ICE is explored fully. This will take time and potentially a few consultations.
- Be confident that the patient's symptoms do not have an underlying organic process.
- Be alert to 'transference' of anxiety during the consultation from patient to yourself. Remain calm.
- Avoid over investigation.
Dr Singh is a GP trainer in Northumberland
Reference
- Bermingham SL, Cohen A, Hague J, Parsonage M. The cost of somatisation among the working- age population in England for the year 2008– 2009. Ment Health Fam Med 2010; 7(2): 71–84.
