Kroenke                          

Our expert is Kurt Kroenke, MD, MACP, Professor of Medicine, Indiana University School of Medicine, Research Scientist, Regenstrief Institute, Inc., and VA Center for Health Information and Communication

If there is a medical topic you would like to see explored here, please let me know!

Very best,

Mitzi Perdue

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COMMON SYMPTOMS OFTEN DO NOT HAVE A CLEAR-CUT DISEASE-BASED EXPLANATION

More than half of the 800 million annual outpatient visits in this country are because of symptoms. Yet in at least 1/3rd of these cases, even after examining the patient and testing, we can’t name a specific disease or cause for the presenting symptoms.  Although common in men and women across all age groups, most types of symptoms are reported by women up to 50% more often.

The most common symptom, which represents almost half of these cases, is pain. Other symptoms for which we may not have a clear-cut cause include: dizziness, trouble sleeping, fatigue, and gastrointestinal issues. In these cases, we’re left with a symptom-only diagnosis such as, “You have a headache.” or “You have fatigue.”  The symptoms may not be medically explained, but their results are nevertheless consequential:  they impair quality of life, increase health care costs, and result in work-related disability.

TREAT BOTH PHYSICAL SYMPTOMS AND ACCOMPANYING DEPRESSION OR ANXIETY

A binary approach to classifying symptoms as either physical or psychological is neither evidence-based nor patient-centered. Because there’s frequently an overlap between physical symptoms and depression or anxiety, we need to treat both. For example, when depression coexists with chronic pain, is it the cause, consequence, or product of a common pathway? Rather than a chicken–egg conundrum, longitudinal studies of pain and depression have consistently shown that their effects are reciprocal rather than unidirectional. 

THE INTERVIEW AND PHYSICAL EXAMINATION WILL PROVIDE MORE INFORMATION THAN DIAGNOSTIC TESTING

Between 73% and 94% of the information we need for a diagnosis comes from a combination of taking the patient’s history and a physical examination. Since only a relatively small proportion of what’s needed for a diagnosis comes from diagnostic testing, we may be wasting time on expensive MRIs or laboratory tests or referrals. Testing is costlier than a physical examination, which in turn is more expensive than taking a history, yet reimbursement practices in this country are in inverse proportion to their diagnostic value. Billing practices disproportionately incentivize tests and procedures. There are serious costs to unnecessary testing including: time, money, and the anxiety of false positives or the complacency of false negatives. 

TRY SYMPTOM MANAGEMENT FOR SIX WEEKS

Because the most useful diagnostic information comes from the patient’s history and from the physical exam, it often makes sense to defer testing while focusing on symptom management.  This means taking a wait-and-see attitude.  By six weeks, on average, 80% of symptoms will improve on their own.  In the case of the roughly 20% with symptoms that recur or become chronic, it’s then advisable to turn to diagnostic testing or referrals especially if symptom management has not helped. An important consideration here is that serious causes not uncovered during the initial evaluation seldom emerge later. TV shows may lead us to expect that this is a common occurrence, but in fact it’s not.

SOME TREATMENTS MAY BE EFFECTIVE ACROSS A SPECTRUM OF SYMPTOMS

Cognitive behavioral therapy and antidepressants have proven beneficial across various symptoms and symptom syndromes. Their effect is independent of the patient’s depression status. Likewise, we know that exercise can be beneficial in treating the following: pain, chronic fatigue, depression, and anxiety. Further, there is emerging evidence for the benefits of: psychotherapy; mindfulness-based stress relaxation; some types of complementary therapies; and alternative medicine therapies. Treatments that are effective for multiple types of symptoms suggest that symptoms may share a common etiologic pathway or that some treatments may have more than one mechanism of action.

COMMUNICATION HAS THERAPEUTIC VALUE

Patients may have concerns that are as important to them as the severity or duration of the symptom or symptoms that led them to seek care. For example, the real concern of a patient with headache might be, “Do I have a brain tumor?” or some consideration other than the actual symptom or symptoms. Start the office visit with a question about what is concerning the patient most. Then end the visit by asking, “Is there anything else that you were worried about or thought might be helpful?”