Ágoston Kecskés

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January 13, 2012

Blog Entry #9: MUPS

            Virtually all medical students encounter medically unexplained physical symptoms (MUPS)[1] at some point during their training, although they often don’t know it. MUPS is different things to different physicians. In preclerkship, I recall a lecture on some of the rheumatologist’s favourite MUPS. As I progressed through my core rotations during clerkship, my learning became necessarily more self-directed. Thus, I found myself adding more diseases to the MUPS list. In urology, MUPS was interstitial cystitis. In gynecology, MUPS was idiopathic chronic pelvic pain. In internal medicine, MUPS was irritable bowel syndrome. If the diagnostic criteria explicitly require the lack of any physical evidence of “disease,” chances are you dealing with MUPS. I never called it MUPS until recently and I suppose it doesn’t really make a difference. Still, sometimes it’s nice to be able to put a name to a disease (spectrum).

            MUPS is a good example of a topic that is taught very differently in the official versus hidden curriculum. Even mentioning MUPS to most physicians is sure to produce eye-rolling and sighing. The sight of a MUPS patient in these physicians’ waiting rooms is sure to prompt tales of past trials and tribulations in the management of said patient. In my experience, while most physicians (especially most academically affiliated physicians) will tow the party line on empathy and psychosocial awareness MUPS patients tended to test the patience of even the most invested physicians. Furthermore, MUPS patients also invariably tested the management skills of said physicians. It’s not difficult to be empathic towards a cookie-cutter, cooperative patient receiving a terminal illness diagnosis. MUPS patients, on the other hand, leave you wondering why you decided to pursue a career in medicine.

It’s precisely for these reasons that I have learned so much from MUPS patients. They had an uncanny ability to send me scrambling to dust off the cobwebs of preclerkship (e.g. effectively conveying empathy from ASCM, as well as the ninth and tenth items on the differential diagnosis of diffuse fatigue in isolation from problem-based learning cases and lectures). They routinely induced counter-transference, which routinely led to deeper introspection and reflection. They also underlined the importance of developing disease-specific scripts when educating and counselling patients. Most patients remember how their diagnoses are delivered. MUPS patients in particular have a iron-clad memories in this respect, making it all the more important to deliver information thoughtfully and effectively.

Sadly, the management of MUPS is still not well-developed. We’re not even sure if we know what MUPS is and some even question if it even really exists. Only a few RCTs have been performed on MUPS patients, but they are beginning to practice. For example, Smith et al. (2006)[2] demonstrated an improvement from baseline to 12 months of 4 or more points on the Mental Component Summary of the SF-36 in 200 subjects under the care of nurse practitioners.

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[1] Ralph D. Richardson et al., “Evaluation and management of medically unexplained physical symptoms,” The Neurologist, http://journals.lww.com/theneurologist/Abstract/2004/01000/Evaluation_and_Management_of_Medically_Unexplained.3.aspx; accessed 13 January 2012.

[2] Robert C. Smith et al., “Primary care clinicians treat patients with medically unexplained symptoms: A randomized controlled trial,” Journal of General Internal Medicine, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1924714/; accessed 13 January 2012.