WB05 TREATING MEDICALLY UNEXPLAINED SYMPTOMS: AN EVIDENCE-BASED METHOD

Transcription

1 WB05 TREATING MEDICALLY UNEXPLAINED SYMPTOMS: AN EVIDENCE-BASED METHOD Francesca C. Dwamena, MD, Associate Professor, Michigan State University; Auguste H. Fortin VI, MD, MPH, FACP Associate Professor, Yale University; Robert C. Smith, MD, ScM, FACP Professor, Michigan State University Sheraton Centre Toronto Conference Room E, Mezzanine Level (April 26, :00PM 3:30PM) ANNOUNCEMENTS 1. There will be no break during session. Please feel free to step out if you have to and join us when you are done. 2. American Academy on Communication in healthcare (AACH) (formerly American Academy on Physician and Patient (AAPP)): Summer Faculty Development Course June 18 22, 2007, Michigan State University. Visit for more information. 3. Please fill out evaluation before you leave (even if you have to leave early) AGENDA 2:00pm 2:05pm 2:10pm 2:15pm 2:20pm 2:30pm 2:35pm 2:55pm 3:25pm Introductions, announcements (Dr. Dwamena); Learner objectives (Dr. Fortin) Workshop objectives, video Part I Mechanisms, Classification and Diagnosis (Dr. Smith) Video Part II Treatment of MUS (Dr. Dwamena) Consultation and Hospitalization (Dr. Fortin) Faculty demonstration: developing the initial plan Participant role-plays Feedback and evaluations

2 SCENARIO A PATIENT Development of Initial MUS Management Plan You have headaches, abdominal pain, and constipation. Headaches started just about the time you started working 18 years ago and abdominal pain started just before you got married about 15 years ago. Increased fiber in diet does not help. You use an enema occasionally with some relief. The headaches are the hardest to deal with. They come on suddenly for no apparent reason and sometimes become so severe that you do not want to do anything. Your previous physician gave you Propoxyphene for pain. You have been depressed on and off for about 18 years. When you are depressed, you lose motivation, sleep a lot, and become impatient with your children when they want you to spend time with them. You have tried antidepressants but you did not tolerate them. They made you feel weird. Besides, you are tired of physicians suggesting that all your symptoms are from depression. Sometimes you think they believe it is all in your head. You have been to the emergency room 10 times in the last 6 months. You sometimes feel like your spouse and children are too much work. You have two sons (8 and 10 yrs) and one of them is having a lot of trouble at school. Your spouse is too irresponsible to help raise the children. He/She is addicted to pornography and smokes marijuana. You blame this for your lack of intimacy. Your father, who was the most important person in your life died when you were 10 years old. After that, you shut off your feelings. Because of this, you do not believe you will benefit from counseling. You went through a father lost thing when you were a teenager, that made you drink and use drugs for 5 years in your early 20s. You are overweight, and you would like to lose some weight. The doctor has reviewed your previous records, performed several tests, and referred you to some specialists for evaluation. You are here for a follow-up visit. You are anxious to learn of the results of the tests and to finally get some help. SCENARIO B PATIENT Follow-up visit You have a new co-morbid condition You learned about a month ago that you have tension headaches and irritable bowel disease, both of which are exacerbated by stress and depression. You agreed to try a new antidepressant and start an exercise program. You hope to eventually be able to go back to work and to have better relationships with your family and friends. You are here today for follow-up of tension headache, IBS, and depression. During a health fair this past week, you were told that your blood pressure was high. That worried you because you know high blood pressure can give you a stroke. You stopped taking your new antidepressant medication because you thought it might have caused the high blood pressure. You stopped the daily exercise (walking) because you just did not feel well. Do not volunteer feelings or reasons for your actions with the physician unless he or she specifically asks or unless it flows naturally from your conversation. SCENARIO C PATIENT Follow-up visit You are non-committal or not improving You have been diagnosed with tension headaches, irritable bowel syndrome, and depression. Today, you are back for a scheduled visit. You do not feel that much better and you have not lost any weight. You feel you have no control when it comes to eating. You joined Weight Watchers but you have not been consistent. You quit taking your new antidepressant after one week because you did not think it was helping. You still worry that the doctor is missing something serious. Do not volunteer feelings or reasons for your actions with the physician unless he or she specifically asks or unless it flows naturally from your conversation. 2

3 OBSERVER (CHECKLIST) Critique the interview for a negotiated, empathic approach and for use of all 4 points of ECGN ECGN Treatment Plan Elicit an emotion Use NURS (name, understand, respect, support) Educate the patient Indicate problem is real Indicate thorough work-up is negative Use a specific name Demonstrate confidence diagnosis is correct Indicate that stress, depression and anxiety are important contributors Stress improvement, not cure Obtain commitment Give an overview of the planned treatment Get the patient to commit to work in a new, different way Facilitate realistic goals Facilitate Long-term goal(s) Facilitate short-term goal(s) Negotiate individual plan Antidepressant (full dose) for depressed patients SSRI for anxiety disorders Non-addicting symptomatic medications Individualized physical therapy, physical or relaxation exercise program without consultation Establish agreement for no self-referral and to take only medications prescribed by you (written contract when necessary Involve significant family member SCENARIO A - PHYSICIAN Development of Initial MUS Management Plan Patient complains of headaches, abdominal pain, and constipation. Headaches started just about the time she started working 18 years ago and abdominal pain started just before she got married about 15 years ago. However, headache and abdominal pain have intensified in the last 7 months. She uses Propoxyphene for pain. She has been depressed on and off for about 18 years but cannot tolerate antidepressants because they make her feel weird. She has refused counseling in the past and does not believe her symptoms are from depression. She has been to the emergency room 10 times in the last 6 months. She has two sons (8 and 10 yrs) and one of them is having a lot of trouble at school. Her husband is too irresponsible to help raise the children and they are having trouble with intimacy. She is also struggling with excessive weight. After a thorough work-up, including a complete history and physical exam, review of old records, referrals and any other lab and radiological tests (e.g. MRI of the brain) you think are necessary, you decide there is no organic disease basis for the patient s symptoms. You make a diagnosis of tension headaches, irritable bowel syndrome and co-morbid depression, i.e. your diagnosis is severe MUS. The patient is here for a scheduled follow-up visit to discuss her results and to begin treatment. Use empathic, open-ended questioning to learn of new symptoms and to maintain and monitor the doctor-patient relationship (DPR). Use ECGN to develop the initial treatment plan with the patient. 3

4 OBSERVER (CHECKLIST) Critique the interview for a negotiated, empathic approach and for use of all 4 points of ECGN Update history Use open-ended skills to obtain history Elicit emotion Use NURS to address emotion (name, understand, respect, support) ECGN Treatment Plan Educate the patient Correct misconceptions while avoiding blame Suggest/review diary in refractory or severe patients Obtain commitment SCENARIO B - PHYSICIAN Subsequent visit The patient has new co-morbid condition Patient is here for follow-up. About a month ago, you made a diagnosis of tension headaches, irritable bowel syndrome and co-morbid depression, i.e. your diagnosis was severe MUS. You negotiated a treatment plan with the patient, who agreed to start antidepressant medication and to walk for 30 minutes 3 times a week. Use open-ended questions to learn about the patient s progress and about any new concerns. Elicit the patient s emotions and use NURS at least once to address emotions. Then use ECGN to develop subsequent plans with the patient. Re-emphasize need to take responsibility for negotiated plans Address expectations to improve without effort Encourage questions SCENARIO C PHYSICIAN Facilitate realistic goals Review previous visit s homework Revise long-term goals Facilitate new short-term goals (homework) Negotiate individualized plan Antidepressant (full dose) for depressed patients and/or anxious patients Wean addicting medications Non-addicting symptomatic medications Individualized physical therapy, physical or relaxation exercise program without consultation Establish agreement for no self-referral and to take only medications prescribed by you (written contract when necessary Involve significant family member Subsequent visit The patient is noncommittal or not improving Patient is here for a scheduled follow-up visit for tension headaches, irritable bowel syndrome, and co-morbid depression. With your help, the patient decided over several visits to take an antidepressant walk 3 times a week and join Weight Watchers. She hopes to eventually be able to return to work and to have better relationships with her family. Use open-ended questions to learn of the patient s progress and any new concerns and use NURS to address any expressed emotions. Then use ECGN to review and revise treatment plans with the patient. 4

5 ANNOTATED BIBLIOGRAPHY 1. Smith RC. Patient Centered Interviewing. 2 nd ed. Philadelphia: Lippincott Williams & Wilkins, This book presents the patient-centered interviewing model in a step-by-step fashion, with an ongoing vignette that gives suggestions of words to say. It also discusses how to circumvent common physician and patient barriers. 2. Smith RC. Videotapes: (1) Patient-Centered interviewing and (2) Doctor-Centered Interviewing. Marketing Division, Instructional Media Center, Michigan State University. Contact information: P.O. Box 710, East Lansing, MI 48824; (phone); (fax); 3. Smith RC, Lyles JS, Mettler BE et al. The effectiveness of intensive training for residents in interviewing: A randomized, controlled study. Annals of Internal Medicine 1998;128(2): In this randomized, controlled study, residents using the patient-centered interviewing model showed greater skill and confidence in interviewing all types of patients. 4. Putnam SM, Lipkin M, Lazare A, Personality styles. In: Lipkin M, Putnam SM, Lazare A, eds. The Medical Interview. New York: Springer-Verlag, 1995: This chapter presents how certain personality types, usually within the range of normal, can affect the DPR. 5. Novack DH, Suchman AL, Clark W, Epstein RM, Najberg E, Kaplan C: Calibrating the physician: personal awareness and effective patient care. JAMA 1997; 278: This paper discusses common physician attitudes, emotional responses, and present examples of organized activities that can promote personal awareness. 6. Smith RC. Somatization Disorder: defining its role in clinical medicine. J Gen Intern Med 1991; 6: This paper discusses the diagnosis and treatment of MUS. 7. Smith RC, and Dwamena FC. Classification and Diagnosis of patients with Medically Unexplained Symptoms J Gen Intern Med, In press 2007 (published online Jan 17, 2007 by Springer New York) This paper discusses the MUS diagnostic scheme discussed in this workshop. 8. Smith RC, Lein C, Collins C, Lyles JS, Given B, Dwamena FC, Coffey J, Gardiner JC, Goddeeris J, Givens CW. Treating Patients with Medically Unexplained Symptoms in Primary Care. Journal of General Internal Medicine, 2003;18: This article describes the MUS intervention used in this workshop. 9. Smith RC, Lyles J, Gardiner J, Sirbu C, Hodges A, Collins C, Dwamena FC, Lein C, Given B, Godeeris J. Primary Care Clinicians Employ the Provider-Patient relationship to Treat Patients with Medically Unexplained Symptoms. J Gen Intern Med.2006;21: This article used the classification system discussed in this workshop to identify primary care patients with moderate to severe MUS. We demonstrated that primary care clinicians could effectively treat these difficult patients. 5

6 Faculty contact information: Francesca C. Dwamena, MD B331 Clinical Center 138 Service Road East Lansing, MI Phone: Fax: Robert C. Smith, MD, ScM B306 Clinical Center 138 Service Road East Lansing, MI Phone: Fax: Auguste H Fortin VI, MD, MPH Waterbury Hospital 64 Robbins St. Waterbury, CT Phone Fax auguste.fortin@yale.edu 6

7 Disclosure of Financial Relationships Francesca C. Dwamena, MD Auguste H. Fortin VI, MD, MPH, FACP Robert C. Smith, MD, ScM, FACP Have no relationships with any proprietary entity producing health care goods or services consumed by or used on patients.

8 Management of Medically Unexplained Symptoms Society of General Internal Medicine annual national meeting Toronto, Canada April 26, 2007 Francesca C. Dwamena, MD Michigan State University Robert C. Smith, MD, ScM, FACP Michigan State university Auguste H. Fortin VI, MD, MPH, FACP Yale University

9 Objectives Participants will: 1. Understand the principles of diagnosis in medically unexplained symptoms (MUS). 2. Understand an evidence-based treatment (Education, Commitment, Goals, Negotiation: ECGN) for primary care patients with MUS 3. Have experience with ECGN in role-plays using tested case scenarios

10 Case Presentation A 34 year old female with low grade RUQ pain, diarrhea for 15 years. S/P cholecystectomy. Much worse in October, 02 work stress Hospitalized March 03 exacerbation while visiting family CTs, HIDA, ERCP, EGD, colonoscopy with terminal ileum visualization all unremarkable Video presentation of patient interview

11 Definition and Proposed Mechanisms Definition: No known organic disease, Psychiatric symptoms (metaphor for psychic distress) plus high utilization (the problem) Mechanisms: Patient avoids emotion Psychodynamic ineffective emotional expression Behavioral reinforcement of illness behaviors Socio-cultural emotional suppression Biological gate control theory

12 DSM-IV Classification of MUS Somatoform disorders: not used in primary care Somatization disorder (SD) very rare Hypochondriasis Chronic pain Conversion disorder Miscellaneous Only SD validated; Overlapping definitions All require prior exclusion of organic disease

13 Syndromes of MUS in Medicine Chronic Fatigue Syndrome Fibromyalgia Irritable Bowel Syndrome Chronic pain: back, pelvic, head, neck, abdominal, chest etc. for each specialty Lack validity: overlapping definitions; require prior exclusion of organic disease

14 Proposed Classification Better to think of MUS as one entity on a continuum with 3 parameters: Severity Duration Co-morbidity

15 Normal to Mild MUS (~80% of all MUS) Low utilization, few # of symptoms Duration: days to weeks duration ( acute ) Co-morbidity: not studied Diagnosed by: appropriately detailed H&P and observation over time (e.g., 2 weeks for eye problems, to 3 months for back pain). ***Avoid unnecessary testing Treatment: Reassurance, positive PPR, symptomatic treatment

16 Moderate MUS High utilization (for recurrent or different symptoms) Duration: 1-6 months ( subacute ) Co-morbidity: 20% have depression, anxiety or other psychiatric disorder. Neurotic personality structure Diagnosis H&P + observation initially, rule out organic disease with definitive work-up (+/- consultation) with increased utilization/recurrence Rarely find disease after negative definitive work-up Diagnose co-morbid psychiatric disease

17 Severe MUS (~5-6%) High Utilization for persistent symptoms Duration: >6 months Co-morbidity: >67% or meet criteria for psychiatric disorder. Personality disorder (61-72%) Diagnosis Rule out significant organic disease with definitive lab and/or consultatative investigation, e.g., MRI, or CT for chronic back pain CT and colonoscopy for chronic abdominal pain with altered bowel habits Laparoscopy for chronic pelvic pain No need to repeat if definitive work-up was negative Diagnose co-morbid psychiatric disease

18 Differential Diagnosis of MUS 1. Organic diseases a. rare (e.g. Wilson s Disease), b. diffuse, vague, unusual presentations (e.g. MS, Lyme disease, porphyria, celiac sprue) c. prominent psychological symptoms (e.g. carcinoma of pancreas, subdural hematoma or ulcerative colitis) 2. Factitious Disorders (no external incentive) 3. Malingering (external incentive) 4. Co-morbidity a. Depression, anxiety b. Panic disorder c. PTSD; also, sexual, physical abuse d. Personality disorder e. Substance abuse/dependence

19 Treatment of moderate to severe MUS Positive PPR + ECGN and medications. Randomized controlled trial (JGIM, 2006;21: ) 206 high utilizing patients with moderate to severe MUS Primary care personnel (nurse practitioners) Intervention vs. usual care Results Improved mental function (OR = 1.92, CI = ) Improved patient satisfaction, physical disability (p<0.001, p=0.02 respectively) Decreased use of narcotics and benzodiazepines (p = 0.043) Increased use of full dose antidepressants (p = 0.037) Videotape Part II: patient s experience of treatment

20 Moderate to Severe MUS Treatment Effective DPR is key Elicit emotions, e.g., How does that make you feel? NURS emotions, e.g., Name Understand You feel frustrated. I can see how you would feel that way. You certainly have been through a lot. I will work with you to Respect Support make it better Negotiate rather than prescribe Recognize/address emotional barriers

21 Treatment Plan: Principles Address ECGN at each visit Dissociate symptoms from treatment by scheduling visits and medications and avoiding p.r.n treatment or visits. Weekly visits (~1 month) prolong interval when patient is ready. Supplement with 3-5 minute phone calls in between visits if necessary. Monitor for co-morbid disease; brief limited physical exam at each visit.

22 Education: at every visit: Address patient s explanatory model Correct misconceptions, avoid blame Serious disease ruled out, further testing not needed Problem is real, not in the head Name, proposed mechanism Stress can aggravate or precipitate symptoms Anti-depressants better than narcotics and tranquilizers Cure unlikely but symptoms can be managed

23 Education Initial plan: Good news is you do not have a life threatening disease. We do not need to do anymore tests. You have (Label). It is real, not in your head. I have treated a lot of patients with this. It is caused by (e.g. abnormal wiring or abnormal contraction). Stress can cause or worsen symptoms (e.g diarrhea when anticipating bad news). We are probably not going to cure it, but we can work together to move it from the center of your life Patient understands and is not just reassured Most patients are not faking or seeking drugs Follow-up visits: Correct misconceptions while avoiding blame; review diary.

24 Commitment Get patient to commit to work in a new, different way (negotiate) Re-emphasize need to take responsibility for negotiated plans Encourage questions Address expectations to improve without effort

25 Commitment Initial plan: We have treatment that works, but we have to work on it together. It s going to be a lot of work, probably harder than you have ever worked on your health, but it will be worth it. Are you ready? Follow-up visits: Re-emphasize commitment; address expectations to improve without effort

26 Goals Initial plan: What are some of the things you would be doing if you weren t feeling so bad? What 2 3 things will you commit to doing over the next week? Follow- visits: Review previous visit s homework. Review and/or revise long term goals. Facilitate new short term goals (homework)

27 Negotiation (individual plan) Antidepressants for depression and anxiety -- full dose Taper addicting medications Non-addicting symptomatic medications Negotiate the following without consultation Individualized physical therapy Individualized physical exercise program relaxation exercise program Establish agreement for no self-referral and to take only medications prescribed by you -- written contract if necessary Involve significant family member.

28 Negotiation Initial plan: We have to treat the depression and anxiety along with other symptoms switch addicting medicines for more effective meds Antidepressants are very effective pain medications important to titrate to full dose I will go over some specific exercises with you Don t go to ER, see other doctors, change doses or take other medicines without you and I first discussing Bring family member to next visit Follow-up visits: Review / renegotiate individualized behavioral plan. Use written contract if necessary.

29 Markers of success Early Markers Understands (Education) Commits Sets goals Follows negotiated plan Late Markers Expresses emotion Positively engages provider Decreased symptoms Solves problems, negotiates solutions Makes progress at work and at home

30 Consultation and Hospitalization Chose consultants who understand MUS, will curtail investigations and convey to patient: no organic disease Consult psychiatrist for suicidal/homicidal patients, refractory symptoms, special subsets, e.g. conversion disorder, psychosis Prepare consultants to prevent excessive testing, reinforcement of organic disease concerns Prepare patient to avoid feelings of abandonment Hospitalize only patients with documented organic disease, psychiatric instability

31 Faculty Demonstration: Development of Initial Plan

32 Role Plays 1. Development of initial plan 2. Subsequent visit: A patient with a new comorbid medical condition 3. Subsequent visit: The non-committed or not improved patient

33 Objectives Participants will: 1. Understand the principles of diagnosis in medically unexplained symptoms (MUS). 2. Understand an evidence-based treatment (Education, Commitment, Goals, Negotiation: ECGN) for primary care MUS patients 3. Have experience with ECGN in role-plays using tested case scenarios

34 Please fill out your evaluations!!!