Review What are medical students taught about Persistent Physical Symptoms? A scoping review of the literature, 2024, Burton et al

Now published: https://bmcmededuc.biomedcentral.com/articles/10.1186/s12909-024-05610-z

Preprint: https://www.researchsquare.com/article/rs-3552374/v1

What are medical students taught about Persistent Physical Symptoms? A scoping review of the literature

Nagel Catie1

Email

Queenan Chloe1

Burton Chris1

1 University of Sheffield

https://doi.org/10.21203/rs.3.rs-3552374/v1

This work is licensed under a CC BY 4.0 License

Background
Persistent Physical Symptoms (PPS) include symptoms such as chronic pain, and syndromes such as chronic fatigue. They are common, but are often inadequately managed, causing distress and higher costs for health care systems. A lack of teaching about PPS has been recognised as a contributing factor to poor management.

Methods
The authors conducted a scoping review of the literature, including all studies published before 31 March 2023. Systematic methods were used to determine what teaching on PPS is currently taking place for medical undergraduates. Studies were restricted to publications in English and needed to include undergraduate medical students. Teaching about cancer pain was excluded. After descriptive data was extracted, a narrative synthesis was undertaken to analyse qualitative findings.

Results
A total of 1116 studies were found by 3 databases. 28 further studies were found by searching the grey literature and by citation analysis. After screening for relevance, a total of 57 studies were included in the review. There was a widespread lack of teaching and learning on PPS. Where teaching did take place, this was most commonly about chronic pain. PPS are viewed as awkward by educators and learners. Learners think that there is no science behind the symptoms. PPS is overlooked in the undergraduate teaching curriculum. The gap between the taught curriculum and learners’ experiences in practice is being addressed through informal sources and some students are taking on stigmatised attitudes towards sufferers of PPS.

Conclusions
Current suggestions for improvements in teaching are insufficient to address issues such as stigma and the poor understanding that educators and learners have about PPS. They also do not address barriers to implementation such as a lack of ownership of the topic and packed teaching curricula. Further empirical evidence is needed to demonstrate how to best teach and evaluate teaching about PPS.

 

Search terms used:

Medically Unexplained Physical Symptoms
Medically Unexplained Symptoms
Non-organic
Somatisation
Somatization
Fibromyalgia
Chronic pain
Chronic primary pain
Functional Pain
Chronic fatigue
Chronic fatigue syndrome
Chronic widespread pain
Myalgic Encephalopathy
Myalgic Enchphalomyelitis [can't even spell encephalomyelitis right]
Disorder gut brain interaction
Irritable bowel syndrome
Persistent somatic symptoms
Bodily distress disorder
Bodily distress syndrome
Functional somatic disorder
Somatic symptom disorder

So the underlying assumption is that all of these things are the same.

 

They’re collecting Chronic’s there. An unhealthy pursuit if you ask me.

 

I could've saved them the time and just shared my experience of studying - it's not taught, and where it's included in textbooks aimed at the undergrad level, a lot of these symptoms/conditions are simply lumped into categories many students don't cover or aren't interested in outside SSCs/SSUs.

Getting textbook authors to revise outdated views would be a first huge step forward, along with teaching more integrated methods of diagnosis and practice (ie - not looking purely at problems of the leg for 2 weeks, the liver for 2 weeks, but thinking about whole-body impacts and conditions that affect all areas).

I can imagine it's tough in practice to do that though as much of the curriculum as I studied was an evolution of the classic anatomy/physiology early years, going into conditions/treatment later - by which point you may already have reinforced the view that the patient is a series of parts that are to be addressed and a condition is usually the result of a single system failure, and where that link isn't clear it's not worth thinking about because it never comes up on pattern-recognition-MCQ exams.

Again, I'm not sure it required a full review to discern that - but I recognise I could have it all wrong with my anecdotal experience!

 

But surely this is the problem. These views about PPS aren't outdated they are still brand-spanking new and still being built on and expanded.

NICE produced a guideline about chronic pain and a Clinical Knowledge Summary in 2021 that tells doctors not to treat it, and recommends exercise, ACT, CBT, acupuncture, dry needling (whatever that is?), anti-depressants instead. It specifically recommends against the use of painkillers.

https://www.nice.org.uk/guidance/ng193/chapter/Recommendations

https://cks.nice.org.uk/topics/chronic-pain/management/management/

And just this week the NHS has announced that menopause symptoms shouldn't be treated with hormones but should be treated with CBT to fix their breathing and stress.

Real medicine that looks for the cause of problems and tries to fix them is disappearing down the drain at a huge rate of knots, all with the aim of saving money.

 

Not as dry as you might hope.

 

You make a good point. They're views that were recognised as incorrect (even in some textbooks as I've read) even a decade ago or more, but persist into the here and now under different labels and different books. I feel the broader issue is what I've mentioned in my later point - that doctors are trained on a systems-and-component-based approach and later divided up into specialisms that reinforce those divisions - in my view then leading to treatments that result in an either/or approach - as in, either it's physical or psychological and should be treated as one or t'other. When resources are becoming more stretched, there's even less inclination to put together holistic packages of care outside of some illnesses (eg cancer) - and even then those packages can be patchwork, covered part by NHS and part by third-sector - predominantly physical = NHS, psychological = 3S. Let's not even talk post-code lottery.

Also in an educational context, I feel I was trained on the common and the "sexy". Lots of time devoted to dementia, common colds, odd stuff with funny names that are vanishingly rare and/or devastatingly severe, but particularly where you could reel off a list of six symptoms and everyone in your class would nod and say "yes, that's definitely that". It doesn't really prepare you for variable presentations or complex conditions that require time and patience to unpick - which ultimately you probably want in a time-poor workforce, I suppose, where you wouldn't have that time or patience afforded to you. Better not waste valuable degree time on those skills you won't get to use - exactly as you say at the end. "In the name of efficiency, let's get more, shorter slots to see patients to see more, without adequately supporting most".

 

Now published:
https://bmcmededuc.biomedcentral.com/articles/10.1186/s12909-024-05610-z