Published 4/1/2012
Timothy J. Birney, MD; Frederic Platt, MD

Your Most Difficult Patient: The One with Nothing Wrong

Patient A.B. has “never been the same” since her auto accident 9 years ago. While stopped at a red light, her SUV was hit from behind by a slow-moving small car. Although the SUV was equipped with high seat backs, Ms. A.B. was wearing her seat belt, and neither vehicle sustained significant damage, she has suffered from neck and thoracic spine pain ever since the accident. The constant pain, she said, is exacerbated by movement and prolonged sitting.

Ms. A.B. consulted several spine specialists. Although the examinations did not reveal any serious injuries, many diagnostic tests and therapeutic procedures—including radiographs and magnetic resonance imaging (MRI) of her spine, facet injections, medial branch blocks, steroid injections, chiropractic manipulations, and eventually a three-level fusion at C4-C7—were performed. After the surgery, she claimed she was “no better, in fact, worse.”

Although many tentative diagnoses have been offered, no doctor has been able to diagnose the cause of Ms. A.B.’s pain. Antidepressant medications have helped improve her mood but have done nothing for her pain.

Does this sound familiar? Are you plagued with similar patients?

Somatization syndrome
Although labeled many ways, these patients often are viewed as “functional” or having a more-or-less specific syndrome—somatization. A somatization diagnosis requires that all four of the following features be present:

  1. The patient experiences distressing symptoms.
  2. The patient believes that the symptoms stem from an identifiable physical illness.
  3. The doctor can find “nothing wrong.”
  4. The patient continues to return to the doctor.

Therefore, if you tell the patient that you find nothing wrong and the patient thanks you, says she is greatly comforted, and does not return soon with the same complaint, she does not have somatization syndrome.

These patients are not a new problem for the medical profession. In 1927, in the Journal of the American Medical Association, Francis Peabody, MD, wrote this about the functional patient: “Speaking medically, these are not serious cases as to the possibility of dying. But they are very serious with respect to the possibility of living. Their symptoms almost never are fatal but their lives will be long and miserable and at the end, their families and friends will no longer continue with them.”

Dr. Peabody might have added “and their medical caretakers.”

Functional patients are sitting ducks for iatrogenic injury. They line up for, even beg for, procedures—all of which have potential hazards. Ms. A.B. may already have sustained harm from all the well-intended procedures she has undergone.

It has been hypothesized that somatization is caused by emotional distress, transformed into physical symptoms, but this conception is simplistic. Psychotherapy or use of tranquilizers or antidepressants seldom reduces the chronic symptoms. Other potential causes include increased somatic awareness, memes (contagious ideas), metaphors, and worst of all, the possibility of a missed diagnosis.

Unknown diseases
Consider another patient: Mr. G.R. was a 60-year-old government executive who complained of intermittent symptoms, including pain throughout his body, weakness, and psychotic ideation and behavior (often clearly paranoid), for several years, with no diagnosis forthcoming. At times he was hospitalized and had to be restrained. When his symptoms remitted, he returned to work without disability.

Does this case ring a bell? It should. Mr. G.R. was King George III of England; at the time, his illness, now thought to be acute intermittent porphyria (AIP), had not yet been named. It is cases like Mr. G.R. that give us as physicians pause and humility. We are always afraid that we might miss something; however, we tend to do the same things over and over.

We spend a bit more time with the patient, reviewing the history and examining the patient. We order or reorder tests. We refer the patient to an expert colleague who redoes all that we have done and sends the patient back to us. All to no avail.

So what might we do? A definition of suffering by Eric J. Cassell, MD, may help: “Suffering is the experience of a person, not just minds or bodies, and that we suffer when we see the possibility of destruction of our person, or loss of whatever gives us significance in our life.”

If this is true, and our person includes our body, organs, personality and character, values and feelings, relationships inside and outside of family, work and play, past and future life, culture and communication, and even our social lives, then the clinician must come to know much more about the person of his or her patient to recognize and understand the patient’s suffering.

Taking a different approach
How do we do that? Well, first we may have to shift gears and tell the patient we are doing so. We may have to own up to our lack of a diagnosis or of a compelling case for any specific therapy. For example, we might say the following:

“Ms. A.B., I have some good news for you, as well as some not-so-good news. The good part is that my exam and our studies have not shown anything life threatening. But I believe that your symptoms will probably continue and that you and I are going to have to work on them over a long time. I do promise to stick with you, but I cannot promise a cure. I know that you are suffering and upset when doctors cannot come up with a diagnosis that explains things. I can tell you that your sort of problem is not rare and that my patients who have pain and fatigue like you do suffer a great deal. It’s no fun for you, none at all.”

Then, shift gears: “Ms. A.B., today I’d like to do something different. We’ve studied your symptoms and I realize that I know a lot more about your muscles and joints than I do about you as a person. So today I’d like to spend some time getting to know who you are as a person.”

Questions that we should consider asking include the following:

  • What do you think this illness is?
  • What do you think might have caused it?
  • What did you think we might do to help with it?
  • How is it affecting you functionally—what can you no longer do since this happened?
  • Is it affecting any important relationships in your life?
  • How do you view yourself now that this has happened?

All of these questions are not needed but the key is to step away from the patient’s recurring physical symptoms and to try to find the person buried within. Such an interview tends to differ greatly from our usual behavior and may feel strained and difficult at first. But not all patients require this approach.

Why is this so very difficult for us as physicians? Medical education is primarily the study of disease. Orthopaedists are experts in the diseases and injuries of the musculoskeletal system, and the field has made giant advances over the years. But every bone and joint we examine is in a person who is suffering, and our failure to diagnose or adequately treat those symptoms leads to more suffering.

In addition, we are not trained as nor do we want to become psychotherapists. We might find a psychotherapist who is interested in and competent with somatization patients. Then we must hope these patients would accept a referral. Unfortunately, such patients seldom follow referral recommendations and although they may feel less depressed when they go, their “physical” symptoms seldom diminish and they return.

Do we have the time to spend a whole visit learning who the patient is? Perhaps a better question is, “Do we have the time to do the same thing over and over with no hope of success?” Better to try something different.

Frederic Platt, MD, is clinical professor of medicine at the University of Colorado, a fellow of the American College of Medicine and of the American Academy on Communication in Healthcare, and regional consultant for the Institute for Healthcare Communication.

Timothy J. Birney, MD, is an orthopaedic surgeon who specializes in disorders of the spine and is in private practice in Denver, Colo.


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