MUS: continuing challenges for primary care

Once upon a time in general practice patients with medically unexplained symptoms (MUS) were known as ‘heartsink’ patients: the patients who demoralise us by being difficult to treat.¹ We can’t cure them because their symptoms are not pathological, but relate to altered physiology caused by psychological distress, which they cannot consciously express, but experience as physical symptoms. MUS sounds more politically correct but is no less patronising. It also allows us to blame the patient for being difficult. In 33 years of medical practice I have not encountered genuine MUS in the patients I had long-term contact with, although it may have taken several consultations to find out what the source of psychological pain was. The death of a congenitally disabled child gave one patient chronic neck and chest pain, long before I met her. A car accident that killed a passenger caused severe back pain for years in the driver. Another patient had chronic pelvic pain caused by a celibate marriage, which she felt she could not leave.

MUS is a label that doctors can use to regard patients as untreatable. It is second to borderline personality disorder in my personal pet hates regarding labels that denigrate patients, and put blame on them for being unwell because of their perceived inadequacy. We need to acknowledge that we cannot cure everyone, but can still help by listening, by being kind, by caring about their pain, recognising it, and giving them our time. We can help by advising activities that improve health, and by challenging patients’ barriers to positive change. Do these people need a multidisciplinary approach? One caring companion to a patient’s pain can suffice. Continuity is helpful, as is consistency of advice, and a good memory of previous discussion of symptoms. If only one person provides care, it’s important to remember that any patient with MUS can go on to develop treatable illness, and be attentive to change in symptoms.