Explaining the unexplainableBMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d1039 (Published 16 February 2011) Cite this as: BMJ 2011;342:d1039
All rapid responses
Dear Sir or Madam:
In this western, resource-advantaged society, 75 -80% of ambulatory
clinic visits is associated with somatic complaints which is surrogate
complaint about their life, i.e. dis-satisfaction about their job, income
In eastern Asian culture, human beings have four emotions going
through in their mind constantly: pleasure, anger, sadness, happiness. If
any one of them is overwhelmingly dominating, human beings feel the
regional change, which sometimes presents with excruciating pain or much
People are hesitant about discussing their mind set on initial
encounter but they are usually open to discussing their aches and pains
which is usual chief complaint for medical attention. These are
reflection of their struggle in their life. I like to use the acronym,
1) Myofascial Pain Syndrome, or 2) Medically Perplexing Symptomatology, or
3) Mindbody Projection Syndrome. Their implication is, as you can see,
interchangeable and we bluntly put it as Medically unexplained. In this
regard, I would like to list MPS.
Neck pain: just like expression,-pain in the neck: Mind-set of "I
want to get out of here but I am stuck here completely."
Shoulder and elbow pain: Mind-set of "I am underpaid at work or home"
Lower back pain with or without radiculopathy: Repressed anger: Mind-
set of "I want to speak out about my anger, but I need to keep it to
Esophageal reflux and postprandial epigastric discomfort: Mind-set of
"I am angry but I am not sure about what I am angry about."
Chest pain: such as in Da Costa syndrome or Hwa-byung: Unresolved
Right or Left Upper Quadrant pain: Mind-set of "I want to escape but
I have no guts to escape."
Knee pain: Mind-set of "I am lonely and sad and I don't have anyone
that I can turn to."
Plantar foot pain: mind-set of "I am underpaid even though I am on my
feet all day long."
Lateral hip pain: Emotion between anger and depression as this is
located between lower back and knees.
Calf m. Spasm: "I am lonely as I sleep alone."
Each symptomatology was evaluated so far from contemporary medical
perspective and so far we are not certain whether what we are benefiting
our patients/our fellow human beings are better off with current
Competing interests: No competing interests
Having recently returned from a Primary Health Care
(primhe)conference which held a Medically Unexplained Symptoms(MUS)summit
and being aware that there are at least two events in March where MUS is
the topic, I wanted to give a few words of encouragement to Des Spence in
his view that 'the most unexplainable and unforgivable aspect is why there
is so little research and teaching on this topic' (BMJ2011;342:d1039). I
think there is increasing research around the economic and cost
effectiveness case for addressing MUS (1) and the approach required in
primary care (2). However the learning events coming up in March and the
primhe conference are all events focussing on 'mental health' and the real
paucity of teaching about MUS is in all aspects of physical medicine.
Already I have divided up mind and body to get my meaning over.
I agree with Des that all doctors need to be able to recognise
patients with MUS and that continuity of care is crucial but even more
important is the loss of integration between mind and body, between GP's
and psychological therapists and between secondary and primary care that
we have all seen over the last few years. Looking after patients with MUS
is real whole person medicine and after all MUS is not a diagnosis but
really a critique of the medical model. I still think the best definition
of MUS is that made by an old friend who said it stood for Medically
Unexplored Stories (3). In the end doctors have to just be there for their
patients and listen to their medical stories.
1 Knapp, Martin and McDaid,David and Parsonage, Michael 2011, Health Promotion and Prevention: the economic
case p.33-35,Personal Social Services Research Unit,
LSE, London ,UK.
2 Dowrick, Christopher 2004 Medically Unexplained Symptoms in Primary Care, patients psychopathology or doctors behaviour, Atencion Primera: vol34S1 p 20-21.
3 Launer, John Medically Unexplored Stories, Postgraduate Med J. 2009; 85:503-504 doi:10.1136/pgmj.2009.087411
Competing interests: I work in a service which sees people with MUS