Introduction
Both in primary and in specialist care, caregivers frequently have to
deal with or feel even confronted with patients consulting with
medically unexplained (physical) symptoms (MUS). In the literature MUS
prevalences vary between 30-50% [17, 35, 36]. MUS are categorized
into syndromes without robust evidence for these classifications. They
can be subdivided on the basis of symptom duration, number of symptoms
and their impact on life quality and daytime functioning into mild,
moderately-severe and severe.
Although the pathophysiology of MUS remains unclear, theoretical
explanatory frameworks combine and integrate biological (physiological),
psychological and social factors (e.g. in the biopsychosocial model, the
stress-vulnerability model, stress model, the perceptual-cognitive
model, the neurobiological model, vicious circles and emotions with
references in sequence of the mentioned models [3, 10, 11, 12, 18,
28]. All models are only to a limited extent based on empiric
research. Complementary to using an acceptable explanatory model, the
quality of communication is crucial in the health care provider-patient
relationship. In general and in particular in the setting of MUS, the
quality of this relationship and of the mutual communication has a
positive impact on health outcomes, patient satisfaction and therapeutic
adherence [1, 13]. MUS patients often feel not-understood and many
health care providers experience feelings of helplessness, potentially
leading to frustrations and irritation on both sides and limiting the
required patient-centeredness. This may trigger repeated consultations
and increased consumption of resources, and provoke medical shopping.
Increased use of healthcare resources is even more frequent in patients
with a different ethnic background [34]. Moreover the healthcare
sector is challenged to deal with the current issues of migration and
the presence of large groups of refugees in the European Union in a
positive way. Not only patients with immigrant backgrounds, but also
racial, ethnic, and sexual minorities experience disparities in access
to healthcare, quality of care received, and caregiver services [7].
A positive approach often is lacking in the organization of care for MUS
patients, of whatever cultural and ethnic background. This systematic
review therefore aims at a critical synthesis of the current literature
on the predefined domains of, first, syndromal definitions and
epidemiology of MUS; second, organization of care for MUS patients, in
order to define gaps as well as areas for improvement and derive
recommendations.
Methods
A systematic search was carried out on the databases PubMed, Web of
Science, Cinahl and The Cochrane Library using the keywords: ‘Medically
unexplained (physical) symptoms (MUS)’, ‘Somatoform disorder’,
‘Functional syndrome’, ‘Diversity’, ‘Migrants’, ‘Ethnicity’, ‘Care
models’, ‘Medical education’, ‘Communication skills’, ‘Health literacy’.
The keywords were internally validated by the co-authors. A framework
with two categories was predefined: syndromal definitions and
epidemiology of MUS and organization of care. In order to qualify for
this review articles needed to be 1) published between January 1, 2002
and September 30, 2019, 2) available as full text in English 3)
categorizable as original research, reviews, meta-analyses or letters to
the editor. Database screening was closed 2nd of
October 2019. Only articles in the English language were included in
order to avoid misinterpretations. Titles and abstracts were reviewed to
verify inclusion criteria. If all inclusion criteria were present or if
this remained unclear, the articles were fully read. All studies were
screened for eligibility by two independent reviewers (PV, AM) who
reviewed titles, abstracts and full text. Any disagreements were
resolved by discussion and, if necessary a third reviewer (DV) was
consulted. Additional literature was obtained through searching
references in the manuscripts (snowball method).