Patient with unexplained complaints does not 'nag' more than patient with explainable complaints

Patients with medically unexplained symptoms (MUS) are sometimes seen as nagging patients who exaggerate their complaints. Communication researcher Inge Stortenbeker investigated whether the language used by patients with MUS is indeed different from that used by patients with explained complaints. Spoiler alert: that turns out not to be the case!

Photo: Michiel Stortenbeker

Fatigue, abdominal pain, headaches, or heart palpitations. Most people occasionally have symptoms that cannot be explained. If the symptoms do not go away, people go to the doctor. If the doctor cannot find a physical explanation either, the patient is given the label MUS. MUS stands for medically unexplained symptoms. It is difficult to say exactly how many MUS patients there are in the Netherlands. The most conservative estimate is 3 to 12 percent, but GPs' estimates are between 30 and 50 percent.

There is a great deal of prejudice surrounding the label MUS. ‘In the past, patients with MUS were even called heartsink patients. A doctor's heart would sink when he saw the name of such a patient on the appointment list', says communications researcher Inge Stortenbeker. If someone comes in with a sore toe and it turns out to be broken, the medical approach is clear. If someone comes in with a persistent stomach ache and the cause cannot be found, it becomes difficult for a GP. In the case of an MUS diagnosis, doctors often talk about an exaggerating patient with vague complaints. But do these patients really describe their symptoms differently?

Linguistic characteristics

Stortenbeker and her colleagues were the first to conduct quantitative research into the language use of patients with MUS compared to patients with medically explained complaints (MES). The researchers recorded conversations of patients with their general practitioner at various general practices. After each consultation, the GP indicated whether the patient had MUS or not. In total, 41 consultations of patients with MUS were compared with 41 MES consultations. These consultations were done by 18 different GPs.

In order to compare the two groups, the researchers looked for characteristics in the patients' language use. Stortenbeker: 'We based those characteristics on the medical literature and the expectations of MUS patients. For example, the literature often describes the image of the exaggerating patient. MUS patients would use more intense language (e.g., "an immense pain") to emphasise that their visit to the GP is legitimate. We translated this into a countable marker: language intensity. In the consultations, we counted intensifiers ("it hurts a lot") and attenuators ("it's a bit sensitive").’

Negation

A second clue was the use of negation. ‘That one comes from neurology', explains Stortenbeker. ‘Research has been done in which they found that patients with unexplained epileptic seizures described a seizure in terms of what was not going on (for example, "it doesn't feel good"). We have assumed that patients with MUS also use negations more often than MES patients to describe their symptoms in GP consultations.'

In addition to these two markers, the researchers also looked at the use of a first-person or third-person perspective ("My ear is bothering me" versus "My ear keeps ringing"), because patients with MUS would be more detached from their own emotions and physical experiences and would therefore be more likely to use the third-person perspective. Subjectivity was also included in the study ("I notice I'm a bit slow"), as was abstract and concrete language as unexplained symptoms would be formulated more subjectively and vaguely. 'By counting these characteristics in the consultations, we were able to compare the two groups well', says Stortenbeker.

Stereotyped expectations

The analysis produced a surprising result: despite the prejudices against MUS patients, there was no difference between the two groups of patients. ‘We had not expected this at all!', says Stortenbeker. ‘It was actually very exciting that we found nothing. Our results indicate that GPs' ideas about how patients communicate are mainly based on stereotypical expectations and not on actual differences in their language use.’

In other words: if a patient with MES says 'It hurts a lot', a GP will not notice this, or will notice it less, than if a MUS patient says the same thing. Because the GP might expect exaggeration during a consultation with a MUS patient. Stortenbeker: 'The moment you put on those glasses, you start to see things. But as a patient, you go to the doctor and you have a complaint, regardless of whether the GP can explain it. You want to be taken seriously.’

Open mind

In previous studies, Stortenbeker and her colleagues have also examined the language used by GPs and did find differences. They do not yet know what the influence is of the GP's language use on that of the patient, but Stortenbeker thinks that it is there. ‘For example, when a doctor notes that "there is some redness". A patient might respond to this with an intensity marker such as "Well, it really hurts". We want to show GPs that stereotypical expectations about the communication of MUS patients are not correct. While the stigma surrounding MUS can affect the consultation. It is good to keep an open mind. That is sometimes difficult, but it is very important.'

The article Unexplained versus explained symptoms: The difference is not in patients' language use. A quantitative analysis of linguistic markers will appear in January 2022 in the Journal of Psychosomatic Research and can already be read online.