Doing Less, Not More, About Common Patient Complaints

October 13th, 2016

INDIANAPOLIS – Common symptoms such as fatigue and pain don’t have a definitive disease-based explanation a third of the time, and a new review suggests that physicians consider doing less in the initial visit, only responding with diagnostic tests and imaging studies if the symptoms persist after a month or so.

About half of all primary care office visits involve complaints without clear-cut causes, according to the research published recently in the Annals of Internal Medicine. The review was based on analysis of studies on common symptoms plus a quarter-century of patient care and research related to symptom management.

"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," said author Kurt Kroenke, MD, a Regenstrief Institute research scientist, Chancellor's Professor at the IU School of Medicine and an investigator at the Veterans Affairs Center for Health Information and Communication.

Kroenke noted that patients often come to see internal medicine and primary care physicians because they suffer from one or more common symptoms of unknown cause such as back pain, fatigue or sleep issues. "They may be depressed or anxious. These patients want answers,” he added.

To provide answers, physicians typically complete a medical history and do a physical examination focused on the symptoms. While diagnostic tests and imaging studies often are ordered at the initial visit, such tests are often an unnecessary expense, Kroenke said. In fact, according to the study, three-quarters of the information needed for diagnosis can be pulled 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," he conceded. "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."

Instead, Kroenke’s article 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% of the time. The patient should be advised to return in four to six weeks if symptoms don't improve, at which point, tests should be conducted.

Here is Kroenke’s reasoning on taking a wait-and-see approach in many cases:

• At least one-third of common symptoms do not have a clear-cut disease-based explanation.
• A patient's medical history alone yields 75% 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% 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 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," he 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."