In secondary care about 50% of newly referred patients to outpatient clinics of Neurology, Gynecology, Rheumatology or Internal Medicine present medically unexplained physical symptoms (MUPS). Medical specialists consider patients with symptoms without underlying pathology difficult to deal with, especially when patients have invalidating symptoms. Specialists sometimes don’t understand patients’ expectations and face patients, who are not willing to accept their findings and definition of MUPS. Moreover, medical specialists feel less competent in their consultations with MUPS patients compared to patients with explained symptoms. MUPS patients in specialist care sometimes don’t feel understood, anxious and unsatisfied when expectations are not met. Contest between patients' expertise, resting on their knowledge of their symptoms and doctors' authority, based on the normal findings of tests and investigations often contribute to problems in MUPS-consultations. Providing medical specialists with MUPS-focused knowledge and communication skills could make them more comfortable and effective in consultations, which could improve patient health and reduce costs.


We performed a systematic review on MUPS-focused communication and the effects on patient health and use of care. We used the Intervention Mapping (IM) framework to systematically apply theories, empirical evidence and practice perspectives in developing a MUPS-focused communication training in specialist care. We designed a multi-center cluster-randomized trial and tested the effectiveness of this training model on doctors’ communication skills by videotaped consultations using a MUPS-focused version of the Four Habits Coding Scheme. We assessed the quality of specialists’ reply letters to the general practitioners about MUPS patients on eight digital items and studied outcomes on patient health and costs by validated patient questionnaires (Whitely Index; 4DSQ; VAS; SF-36; TiCP). Doctors evaluated the usefulness of the training program by self-report questionnaires.


We found limited research on MUPS-focused communication in specialist care. Patient outcomes and use of care were positively influenced by perceiving patients’ expectations correctly, explaining the nature of MUPS with additional information, explaining normal test results prior to investigation and a positive doctor-patient interaction. With the IM approach we developed an evidence-based, 14-hour communication training for medical specialists and residents in which they were taught to explore biopsychosocial aspects of patient’s symptoms, explain MUPS understandably, reassure patients effectively and to write appropriate reply letters to the general practitioner about MUPS patients. 123 doctors (40% medical specialists and 60% residents) and 478 MUPS patients from eleven specialties were included in the trial; 98 doctors completed the study with one or more videotaped consultation and reply letter. The training improved doctor’s exploring and information-giving skills in MUPS consultations. Specialists more often mentioned and answered patients questions in their reply letter to the general practitioner. Evaluation by self-report showed a high practical value for specialists. No effects on patient health were found. However, the trial was underpowered at patient level: recruitment of patients was lower than expected and patient non-response higher than estimated.


We developed a feasible, evidence-based and effective MUPS-focused communication training for medical specialists and residents, which provides them with optimal knowledge, skills and confidence in MUPS consultations.

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J.L.C.M. van Saase (Jan) , L.R. Arends (Lidia) , H.T. van der Molen (Henk)
Erasmus University Rotterdam
Erasmus MC: University Medical Center Rotterdam

Weiland, A. (2015, September 30). Training medical specialists in communication with patients with medically unexplained physical symptoms. Retrieved from