Is it true that more than half of medical consultations are for MUS? A look at the evidence.

Thank you for sharing this important analysis. It certainly feels as if the data is being tortured to support an ideological position.

But even if the aprox 50% figure was accurate we do not have any idea what percentage of these people are suffering from [current] medical ignorance and what percentage if any have the presumed catch-all psychiatric diagnosis of psychosomatic Medically Unexplained Symptoms syndrome.

 

Thank you for your work on this @Trish.

 

Up to ... figures can be misleading. All you need is one bad study to increase the number.

Up to 70% of ME/CFS patients have POTS, but the real figure is probably somewhere around 25%. Up to 70% of ME/CFS patients have fibromyalgia, while the community study in Chicago gave a number of only 15%. The prevalence of ME/CFS goes way up to 6% because some flawed Chinese study estimated that number. The real prevalence, however, is somewhere around 0,2-0,4%. So while it seems to correct that one study estimated the percentage of patients accessing outpatient services having MUS at 50%, the real estimate seems much lower.

Keith Geraghty recently complimented Hartman and Rosmalen (both MUS-researcher who were on the Dutch health council) for citing lower prevalence estimates of MUS in primary care:
https://twitter.com/user/status/1105415027715125248

 

It seems to me this is much easier.

Ordinary headache is medically unexplained, despite various unconvincing explanations being popular (tension etc).

Everybody gets ordinary headaches.

So the prevalence of medically unexplained symptoms is 100%.
This is, if we are defining MUS simply as medically unexplained symptoms.

But clearly that is not what is meant by MUS for those who make a living out of it. They mean symptoms that are unexplained but are due to somatisation. This is clearly a contradiction because they are now explained.

So the prevalence of MUS is 0%.

You might think this was muddled thinking, or manipulation of words. Well, at least that seems to be the standard approach for MUS. If others can muddle and manipulate, why not me?

 

It really is quite worrying, however, that documents bandy about these figures, which are clearly intended to be 'facts' without any regard for accuracy.

The Wessely figure of 52% is not the number of patients accessing outpatients services. It is a (fudged) proportion of new patient attendances. If these people are accessing multiple clinics then they will, on average, be over-represented. Virtually all old patient attendances (which are about 80% in most clinics) will have specific diagnoses. But of course they are frequent attenders at a specific clinic. So that has to be factored in too.

What I think Wessely's data claims is that somewhere 32% of 20% of outpatient visits (6.4%) involve consultations by people who admit to unexplained symptoms when sent questionnaires from researchers interested in such symptoms. As a measure of how much of resources goes on such consultations this could be a meaningful number. If we really wanted to know what proportion of people accessing outpatient services fell into this category we would need other data.

But note that admitting to o ne unexplained symptom on a questionnaire is by no means an indication that the primary reason for attending clinic was for a symptom that remained unexplained. I reckon that I had a reasonable explanation for the main symptom for 95% of patients in my clinics. But as indicated I would expect 100% of these people to have had some headaches at some time.

So the Wessely study just makes no sense to me.
I will have a look at the others.

 

Thank you, Trish, for looking into the question of where I got the 52% figure. You've found a lot of the central articles, and that's great. I wonder why you chose not to go the source, the paper I published on MUS in the #1 US bioethics journal? You'll find a great many references there, along with a discussion of the range of figures available in research (some of which you've noted here), and an assessment of what med ed and practice guidelines conclude given the astonishing range of estimates available in research.

That paper introduces MUS to the field of bioethics, so its opening is essentially a review paper - i.e. it serves the purpose of an expert literature review for those new to the area. When reviewers evaluate an article of this kind (and these are doctors, psychiatrists and bioethicists), they don't just go looking for a handful of easy access articles. Central figures are evaluated based on a reviewers' deep familiarity with all of the research in the area.

A journal of this ranking does not present controversial figures as factual. In a low ranking journal you might need to check, but in a top ranking journal you can trust that a core figure will be uncontroversial for the field. That is definitely not to say that the figure will be correct. It is only to say that it will represent typical professional understanding.

It's also helpful to note that this paper is a target article. That means it's published along with 12 other articles that consider and critique its contents. These are written by prominent experts in the field of MUS - mostly doctors and psychiatrists. This process in this journal is how bioethics considers new and important issues.

The best way to assess the validity of the 50% figure (that's the global figure I use, after noting that 52% is generally what they use in health policy in the UK), is to look and see how those 12 commentary and criticism papers respond to it. It's helpful to note that not one of those 12 critical evaluations of my article saw a need to debate the grounding figure of 50%. Again, that's not to say that it cannot be debated - but it is to say that according to the expertise of reviewers, and the 12 teams of professional experts who commented on the paper, it is correct to say that a figure of roughly 50% represents typical understanding.

Finally, to be very clear, the paper certainly does not accept that 50% of patients have MUS. It says this is a typical understanding, and then it goes on to consider in great detail what's actually happening with that portion of the patient population. All of what it says there supports your cause.

It's terrific that you guys are so astute about research, and able to explore the validity of what you read. It's very important, though, to see the difference between a non-professional looking for a handful of easy access papers and the process of peer review and commentary for the top ranked journal. That's not to say that peer review isn't faulty. Of course it is. But there's more to it than that. You need to know what kinds of things you can trust and what kinds of things you can't trust.

It is very common on s4me for objectivity to be obscured by loyalty to factions within the advocacy community. This is really not helpful to your understanding, to your cause, or to your spirits.

https://www.ncbi.nlm.nih.gov/pubmed/29697324
(There's a personal copy available at ResearchGate and on my website)

 

I am going to ignore the primary care paper because no GP can be expected to explain a whole load of symptoms that a specialist may be very familiar with and know the reason for. The idea that GPs know enough to diagnose somatoform disorder seems to me a symptom of the arrogance and laziness that has become pervasive in primary care.

 

The hospital clinic paper seems to me to provide a reasonably plausible figure of 3%. But it still looks as if it was done by people with a bias to finding more. They seem disappointed how few cases there were. Moreover, it seems that although these people had MUS not all had somatoform disorder because they distinguished this from malingering. And then the question is how do you know it is somatoform? And it is still highly likely that a significant proportion were unexplained because the physician was not skilled enough or experienced enough.

All in all though 3% looks to me to be a pretty reasonable figure.

 

Dear Diane (@Diane O'Leary). I really think you need to take on board that this group of people here on S4ME are way ahead in terms of intellectual debate than any stuffy old university department or journal whatever the impact factor. I debate here as an equal. I get caught out all the time. I am often dead wrong. Nobody cares what letters you have after your name or whether you are a professor. I find it hugely stimulating because I am constantly learning. Years ago I had a research group where we had this atmosphere but the academic environment as a whole is 95% phoney, whether medicine or philosophy.

Argument from authority ain't gonna wash here.

50% is not the 'typical understanding'. It is the bullshit that a small group of physicians and psychologists blather to each other to make each other feel important. If I suggested that 50% of patients coming to the UCH rheumatology clinic had MUS to my departmental journal club they would roar with laughter. It's fake news. Most physicians just get on with the job and ignore this sort of stuff.

 

The garbage about there being over 50% of patients with MUS and/or somatoform disorder must be compounded by the fact that there is no standard way of feeding back an accurate diagnosis to a doctor who found nothing wrong with the patient. Many cases of MUS must be solved eventually, not least because some cases of MUS must be life-threatening. But the doctors who found nothing wrong just continue on their merry way assuming that their rate of misdiagnosis or missed diagnosis is much better than it really is.

 

@Jonathan Edwards I have not made an argument from authority, as I have in no way suggested that you should believe my 50% figure based on my authority. In fact, there's not a word in there about my authority. To dispute what I've said in a credible way you'll need to take issue with the actual points I've made.

On that point it's helpful to note - as a matter of basic critical thinking - that there's a difference between a figure typically regarded as standard and a figure that doctors take seriously in practice. I have not said a word about the latter.