The latest evidence of the woeful state of care for Medically Unexplained Symptoms (MUS aka Psychophysiologic Disorders or PPD) comes from my local newspaper. In a Health column, we find the following question from a reader:
"I have severe back pain but my MRI appears to be normal. What are my options? Can you help?”
The "answer” is provided by the physician director of an "Advanced Pain Management Center.” The doctor begins by reporting a study that found herniated discs in about 30% of MRIs done in people who had no pain (the converse of the questioner’s problem). The logical conclusion from this research is that herniated discs do not always cause pain. A further inference is that in some patients with both pain and a herniated disc, the pain is not caused by the disc but by some other cause. The doctor could then have pointed out that this "other cause” (most commonly unrecognized life stress) might be responsible for the questioner’s pain.
Unfortunately, instead of explaining this, the doctor perseverates on the concept that there must be a diseased structure responsible for the questioner’s pain. Outrageously, with no mention of the statistically most likely cause of unresolved psychosocial issues, he suggests a plan of additional tests including specialized x-ray studies and/or diagnostic nerve blocks. These are uncomfortable (they involve long needles), risky, unlikely to be of any benefit and generate generous fees for the physicians who perform them. The doctor concludes by inviting the questioner to call his office for an appointment.
The old expression that "when your only tool is a hammer, every problem looks like a nail” applies here, particularly when you are well paid for hammering. By teaching medical clinicians to screen for psychosocial causes of MUS, teaching mental health professionals techniques for managing physical symptoms with psychosocial causes and teaching both how to collaborate we can reduce the frequency of diagnostic travesties like that above.