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UI physician outlines steps for better reassuring patients

IOWA CITY, Iowa -- Reassurance is one of the most important therapies physicians can give to patients with medically unexplained health concerns, according to a University of Iowa psychiatrist and internist who advocates a consistent, systematic approach to treating patients with unexplained symptoms.

"As many as 80 percent of the medical population have unexplained complaints and most do not have a mental illness," says Dr. Roger Kathol, professor of internal medicine and psychiatry at the UI College of Medicine. "Certainly there are some patients that have very compelling complaints -- they think and act as if they can't move their legs, or that they are blind, for example -- that may have an underlying psychiatric condition. Many other patients, however, present general stomach problems, light-headedness, headaches or fatigue, but there is no objective evidence of disease as a cause for their symptoms. These patients are not mentally ill, but concerned about bodily sensations or changes."

As a psychiatrist and a primary care physician, Kathol says he has numerous cases referred to him in which there is a question whether the patient has an organic illness or is experiencing transient, non-specific symptoms. This led him to consider approaches to treatment which help patients get beyond their symptoms and back to their normal routines without being exposed to unnecessary tests and expensive, perhaps risky procedures.

In the latest quarterly issue of the International Journal of Psychiatry in Medicine, Kathol outlines six steps primary care physicians should follow to deliver effective reassurance to patients with unexplained symptoms. They are: 1) question and examine the patient; 2) assure the patient that serious illness is not present; 3) suggest the symptom will resolve itself; 4) tell the patient to return to normal activity; 5) consider non-specific treatment; and 6) follow-up with the patient.

"For a lot of physicians, reassurance typically means telling the patient there's nothing wrong with them. That's certainly one important step," Kathol says. "In order for that step to be effective, however, the patient needs to be convinced that the doctor knows what he or she is talking about because a pertinent clinical evaluation was completed."

Giving the patient a time frame for improvement and occasionally suggesting a non-specific treatment, such as eye drops or exercise, are also important, Kathol adds. "Many physicians use two or three of the six steps, but not all of them. For consistent results, systematic use of all six steps in necessary."

The important thing for doctors to remember, Kathol notes, is that many patients complain about symptoms because they are concerned about a potentially dangerous or debilitating condition. Therefore, it is important for doctors to explain that the problem is not serious or life-threatening.

Since a physician can never be absolutely certain that unexplained symptoms are not an early manifestation of a developing illness, doctors should avoid painting themselves into a corner by saying that the symptoms are not caused by a physical illness.

"Follow-up, the final step, reassures the patient that the doctor is there for them in the event that they do not get better," Kathol says.