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APPENDIX A Population and Need-Based Prevention of Unexplained Physical Symptoms in the Community CharIes C. Engel, Jr., and Wayne ]. Katon SYNOPSIS How might military medicine respond to existing research on the epide- miology, burden, natural history, and management of medically unexplained physical symptoms (MUPS) in primary care and the general population? This review of extensive published research suggests that MUPS are pervasive and contribute substantially to physical, social, occupational, and organizational im- pairment, psychosocial distress, unnecessary health care utilization and expen- ditures, and adverse health care outcomes. These studies suggest that the natural history of MUPS is influenced by a number of predisposing, precipitating, and perpetuating factors and that certain prognostic factors may help clinicians and policy makers estimate the outcomes and population needs. We use the epidemiology of MUPS and the basic principles of population- based health care to construct an efficient MUPS prevention strategy that em- phasizes a continuum of care. In the absence of randomized trial evidence of efficacy for any single multifaceted continuum of MUPS care, the prevention program suggested is conservative and reasonably achievable, lends itself to subsequent evaluation and improvement, and calls for a multifaceted, well- inte~rated stenned care management anoroach involving ~7 , ~ ~ ~7 ~ ~ Charles C. Engel, Jr., M.D., M.P.H., is Chief of the Gulf War Health Center at Walter Reed Army Medical Center in Washington, D.C., and Assistant Professor of Psy- chiatry at the Department of Psychiatry of the Uniformed Services University in Be- thesda, Maryland. Wayne J. Katon, M.D., is Professor and Vice-Chair, Department of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine. The views expressed by Doctor Engel in this article are his own and do not reflect the official policy or position of the Department of the Army, the Department of Defense, or the U.S. Government. 173
174 STRATEGIESTOPROTECTTHEHEALTHOFDEPLOYED U.S. FORCES . broad-based and low-intensity educational interventions delivered to every member of the military services and perhaps their family members; . primary care-based collaborative and interdisciplinary practice teams that aim to improve short- and long-term health behaviors using a variety of behav- ioral strategies including education; . information systems that use expert systems to process and feed back data obtained by using a health care-based health information system and a popula- tion survey-based health data monitoring system; . specialized, multimodal services available for the intensive multidisci- plinary management of disabling and otherwise treatment-refractory MUPS; and . development of a "center of excellence" to lead clinical, research, and educational efforts related to MUPS in the military. We suggest that future improvement efforts target military clinicians, military health care delivery, the military work environment, and existing methods for compensating and returning ill personnel to work. No matter the overall process and structure of care provided for individuals with MUPS, physicians are urged to practice "person-centered" rather than "dis- ease-centered" care. They cannot ignore their place as consultants to real people in real predicaments who are attempting to make difficult decisions potentially affecting their future health, career, relationships, and status. Hadler has stated that the role of physicians, "should be more than that of concerned citizens or even of patients' advocates; tto that] we can add the perspective of students of the human predicament."58 The expanded notion of ill health as a human pre- dicament is especially apropos in occupational and military medicine settings. Occupational and military physicians treat diseases, but of equal import is their obligation to study and prepare the workplace so those workers with illness- related work limitations can eventually make a successful return to productivity. Eventually, we are impressed that military medicine's innovations in this area may provide an important model for civilian health care organizations seeking solutions to the difficult challenge of MUPS. UNDERSTANDING MEDICALLY UNEXPLAINED PHYSICAL SYMPTOMS The absence of a discerned cause for physical symptoms is best viewed through the lens of the scientific uncertainty necessarily involved in any one-to- one doctor-patient visit. We will use "MUPS" in reference to health care use for physical symptoms that are not clinically explained by a medical etiology. MUPS can be broken down into a four-part process. First, an individual must experience the symptom. In a simplified way, this might be viewed as the bio- logical part of the process. Presumably, for one to perceive a symptom, some neurophysiological event must bring it to awareness. The second step is cogni- tive, or related to how we think about the symptom. The person perceiving a
APPENDIX A 175 symptom overlays some knowledge, biases, or beliefs that he or she has about the symptom and its cause, assigning it a level of medical importance. We do not seek care for most of the symptoms we experience, partly because we assign them some relatively low level of medical significance. When we seek care, we are taking a third and behavioral step that is mediated by our belief in the symptom's significance. The fourth and final step is the purview of the clinician: he or she must de- cide the extent to which symptoms are explained by the patient's medical diag- noses. This is one of the most problematic aspects of MUPS. There is a clear potential for doctor-patient conflict in this formulation. Differing clinician and patient explanations for MUPS may be one of the most important contributors to the frustration that these symptoms create for clinicians 97 ~54 and the dissatis- faction with care that many affected patients describe. Add some reason for doctor-patient mistrust, and the relationship can become outwardly adversarial and result in mutual rejection. In occupational settings like the military, clinicians must provide care within the context of competing and sometimes unacknowledged obligations. The clinician is committed to the welfare of the employer, who is both paying the clinician's salary and providing medical benefits for the patient. This same clinician has a simultaneous duty to the health and well-being of the patient. Under these circumstances, the patient may fear that the clinician is being co- erced to deny the reality of the medical problem in service to the employer's financial or political interests. The patient may feel that the clinician is more interested in keeping the patient on the job than in providing treatment. Alterna- tively, the clinician may suspect that the patient is exaggerating health concerns to obtain benefits. Conflicts such as these heighten doctor-patient mistrust, dampen rapport, and diminish the chance of a productive clinical encounter. Symptom-based disorders are diagnoses based upon patient-reported physical symptoms rather than specific findings on clinical examination or diagnostic test- ing. Symptom-based disorders seldom offer clinicians and patients more than a label. In most instances, the prognosis, treatment, and factors that determine dis- ability are remarkably similar across different symptom-based disorders. Observed differences are typically small and are attributable to differences in severity, the number of other symptoms involved with the syndrome, or differences in loss of functioning due to symptom location (e.g., lower-extremity joint pain impedes walking, whereas headache pain does not). The names of symptom-based disor- ders are usually based on hypothesized etiology (e.g., chronic Lyme disease), pu- tative triggers (e.g., multiple chemical sensitivity), a central descriptive feature (e.g., chronic fatigue syndrome), or body region (e.g., temporomandibular disor- der). Labels often use complicated terminology (e.g., fibromyalgia or myalgic encephalomyelitis) that suggests to patients, doctors, and the public that the syn- drome is better understood than it actually is. Therefore, we will use the term symptom-based disorder to signify syndromes that are clinically diagnosed almost exclusively by using patients' verbal descriptions. Table A-1 displays some com- mon examples of symptom-based disorders and illustrates that clinicians in nearly
176 STRATEGIESTOPROTECTTHEHEALTHOFDEPLOYED U.S. FORCES every specialty encounter them. Symptom-based disorders overlap extensively, manifest remarkably similar pathophysiology, risk factors, clinical course, and prognosis, and respond to similar rehabilitative treatment approaches.~723 54 67 ~8 ~58 Historically, physicians have tended to categorize MUPS and symptom-based disorders as psychiatric symptoms on the basis of exclusion. It seems most logical that only some MUPS are psychiatric in their origin. TABLE A-1 Some Symptom-Based Diagnoses and the Specialties that Commonly Diagnose and Encounter Them Specialty Clinical Syndrome Specialty Clinical Syndrome Orthopedics Low back pain Patellofemoral syndrome Dentistry Temporomandibular dysfunction Gynecology Chronic pelvic pain Rheumatology Fibromyalgia Premenstrual syndrome Myofascial syndrome Siliconosis Ear-Nose- Idiopathictinnitus InternalMedicine Chronic fatigue syn Throat drome Neurology Idiopathic dizziness Infectious Diseases Chronic Lyme disease Chronic headache Chronic Epstein-Barr virus Chronic brucellosis Chronic candidiasis Urology Chronic prostatitis Gastroenterology Irritable bowel syn Interstitial cystitis drome Urethral syndrome Gastroesophageal reflux Anesthesiology Chronic pain syndromes Physical Medicine Mild closed head in Jury Cardiology Atypical chess pain Occupational Multiple chemical Idiopathic syncope Medicine sensitivity Mitral valve prolapse Sick building syn drome Pulmonary Hyperventilation syn- Military Medicine Gulf War Syndrome drome Endocrinology Hypoglycemia Psychiatry Somatoform disorders
APPENDIX A 177 EPIDEMIOLOGY OF SYMPTOMS AND SYMPTOM-BASED DISORDERS Prevalence in the Community and Primary Care Review of the epidemiology of unexplained physical symptoms necessarily involves discussion of the epidemiological literature on somatization and the somatoform disorders (e.g., conversion disorder, somatization disorder, or pain disorder). The central feature in the somatoform disorders, however, is the pres- ence of MUPS. The absence of test abnormalities or objective physical exami- nation findings means that a psychiatric etiology is presumed but that the actual etiology is a matter of debate. We advocate an Theoretical, nonetiological, and phenomenological understanding of MUPS since this formulation is intellectu- ally honest and maximally acceptable to those affected. Population-based surveys have shown that 85 to 95 percent of community respondents experience at least one physical symptom every 2 to 4 weeks al- though relatively few of these symptoms are reported to physicians. The population-based Epidemiologic Catchment Area Study examined 13,538 re- spondents from four U.S. communities and found that 25 percent reported chest pain, 24 percent reported abdominal pain, 23 percent reported dizziness, 25 per- cent reported headache, 32 percent reported back pain, and 25 percent reported fatigue.9~ Thirty-one percent of symptoms were medically unexplained, and the type of symptom was unrelated to the absence of explanation. Eighty-four per- cent of symptoms caused respondents to seek health care, take a medicine, or curtail activities.9~ Over 4 percent of people had a lifetime history of multiple, chronic, unexplained symptoms and an exacerbation within the past year.38 ~42 Other studies have shown that MUPS are associated with a high proportion of populationwide disability and health care utilization, largely because they are so common.3974 For example, the 1989 National Ambulatory Medical Care Sur- vey estimated that physical symptoms account for 57 percent of all U.S. ambu- latory care visits including some 400 million clinic visits per annum.~27 Kroenke and Mangelsdorff90 reviewed the medical records of 1,000 primary care-internal medicine patients over a 3-year period and determined the incidence, diagnostic findings, and outcomes of 14 common symptoms. At least one common symp- tom was present in 38 percent of patients, and only 16 percent of symptoms were felt to have an organic cause. Symptomatic patients were monitored for an average of 11 months, and for 47 percent of patients the symptom persisted throughout the follow-up period. Two-thirds of symptoms were evaluated be- yond the initial history and physical examination, but only approximately 1 in 10 evaluations resulted in an organic diagnosis not apparent at the index visit. Subsequently, Kroenke et alps completed an off~ce-based survey of 410 primary care-internal medicine patients to determine the prevalence and adequacy of therapy for 15 common symptoms. Eighty-two percent of patients had one or more symptoms, and in 77 percent one or more of these symptoms had been reported to patients' physicians. However, only 39 percent of patients with fa
178 STRATEGIESTOPROTECTTHEHEALTHOFDEPLOYED U.S. FORCES fugue, dyspnea, dizziness, insomnia, sexual dysfunction, depression, and anxiety reported any noticeable response to treatment. Most other primary care research suggests that etiologies are unknown for at least 25 to 30 percent of patients with either painful or nonpainful physical symptoms.87 92 93 An extensive scientific literature has shown that MUPS are strongly and consistently associated with psychosocial distress, psychiatric disorders, de- creased quality of life, and increased health care utilizations ~8 25 38 39 56 76 90 92 ~29 ~35 Depression and anxiety are consistently associated with MUPS across many studies that have used wide-ranging methodologies including cross- sectional ~35 case-control,73 82 ~40 ~52 ~56 and longitudinal designs35° Some evi- dence suggests that associated high health care utilization leads to more harm and patient dissatisfaction than benefit.86 ~45 Natural History of MUPS MUPS are characteristically chronic and intermittently relapsing, although the natural history is reasonably variable in severity and periodicity. Factors responsible for variability in clinical outcomes may be classified as predispos- ing, precipitating, and perpetuating factors. Predisposing factors are characteristics of individuals that render them more vulnerable to MUPS and related morbidity. Important predisposing factors are heredity;~36 ~62 neurophysiological, neurotransmitter, and autonomic nervous system factors;4 3~ 44 52 55 83 ~44 early life adversity (e.g., child maltreatment);3 26 68 8598~52~53~55 chronic medical illness;2~266~2~47 or chronic distress or mental illness.3470 Predisposing factors may be either intrinsic (i.e., innate to the indi- vidual) or acquired (i.e., obtained during lifetime exposure or experience). A precipitating factor is essentially a "straw that breaks the camel's back," initiating an acute episode of MUPS and related morbidity. Factors that precipi- tate MUPS include biological stressors,~5 ~34 psychosocial stressors,27-29 acute psychiatric disorders, and epidemic health concerns.~4 2~ 24 62 69 ~39 Perpetuating factors are those that maintain, exacerbate, or prolong symp- toms, distress, and disability after they occur. Perpetuating factors may occur independently of the original precipitants. They include harmful illness beliefs (beliefs that lead to a maladaptive response to the symptoms),~32 labeling effects (i.e., the adverse effects associated with viewing oneself as ill),406063 ~06 misin- formation,~ 7 ~6 ~00 ~30 ~33 workplace and compensation factors, 59 ~28 ~4~ and social support factors.~07 Prognostic Factors: Prediction of Outcomes and Assessment of Future Needs MUPS occur along a spectrum of severity and prognosis74 ranging from mild and transient to chronic and disabling. Prognostic factors are individual, environ
APPENDIX A 179 mental, or population characteristics that may be used to predict symptom out- comes and estimate future treatment and resource needs. The prognostic spectrum of MUPS includes acute, recurrent, and chronic subtypes. Acute MUPS occurs in the absence of a previous pattern or history of MUPS and lasts a few months at most, and associated disability is often temporally associated with an acutely stressful life event. Recurrent MUPS is characterized by alternating symptomatic, asymptomatic, and mildly symptomatic periods. Chronic MUPS is a pattern of persistent unexplained physical symptoms associated with chronic disability, high health care utilization, and persistent problems with coping. Empirically evaluated prognostic indicators for MUPS include (1) prior level of health care use, (2) psychiatric factors, (3) physical symptom factors, and (4) factors related to functioning. A high level of previous health care use suggests that a poor long-term outcome characterized by chronic MUPS is rela- tively likely.78 ~36 A large number of prospective studies have consistently found that the presence of stressors, distress, and psychiatric disorders, especially when they are chronic, predict persistent MUPS and related disability.9 ~3 22 29 57 65~05~09~9~26 A higher number of comorbid physical symptoms ("symptom count"~53 and longer symptom durational 22 89 95 ~48 also predict a poor outcome. Past poor functioning including occupational functioning suggests a poor prog- nosis.37 50 94 A patient's historical level of functioning can serve as a marker for a myriad of issues that diminish the amount of reserve that an individual can muster when symptoms worsen. PREVENTION OF SYMPTOMS AND SYMPTOM-BASED DISORDERS The epidemiology of MUPS suggests that those individuals afflicted with the mysterious "Gulf War Syndrome" may represent only the most disabled, symptomatic, and distressed of ill Gulf War veterans. For each veteran who seeks care for Gulf War-related health concerns, there may be several others with fewer physical symptoms. In a less protean manner, perhaps, these indi- viduals' symptoms are reducing their capacity to function, increasing their use of health care, and heightening their health-related worries. Left unmanaged, these milder syndromes may become subject to the adverse influences of the previously described predisposing, precipitating, and perpetuating factors. Is it possible to prevent MUPS? Resources are limited, and the scope of the problem is wide. The success of any program of prevention will depend on the degree of effectiveness of existing interventions and the resources required to deliver them. It may be feasible to significantly reduce the organizational impact of MUPS among military personnel by using a coordinated combination of population-based and need-based strategies. We recommend the adoption of a "population-based health care" model that uses a stepped-care approach (Figure A-1) to achieve maximum overall efficiency and effectiveness.
180 Preevent Prevention Postevent Prevention Workplace risk communica tion Workplace screening ~ \ Workplace edu- . Workplace cation education Family educat Family edu- . ion cation Public service announce- meets .^ STRATEGIESTOPROTECTTHEHEALTHOFDEPLOYED U.S. FORCES Intensive Programs Multispecialty care: 1 ) 1 0- to 1 5- week outpati- ent <2) 3-week in- patient Collaborative Primary Care '' Integrated pat- tern of care Clinical risk communicat Primary Care on ~ ~ Care-based: Care-based . 1 ) education screening . 2) physical re Clinical risk . activation communicat- . 3) problem ion . solving Tracking Tracking Tracking Tracking Tracking Vulnerability Precipitating Symptoms and Chronicity Disability Factors Health Concerns FIGURE A-1 A stepped-care approach to the population management of medically unexplained physical symptoms. Advantages of Population-Based Intervention Rosen has noted, "a large number of people exposed to a small risk may generate many more cases than a small number exposed to a high risk" (p. 24~. Similarly, a large number of people exposed to a low-intensity preventive inter- vention can have a very large population effect (i.e., the effect of prevention summed across every person experiencing the intervention). Figure A-2 uses
APPENDIX A 25 20 au Q ~15 En 10 5 O EMPHASIS: EMPHASIS: POPULATION UNMET NEEDS .~ - - ~ - Before After - 20 A cr '\` ~Disability _. ~t ' At/' do-- ~- - 10 Q _~~ ~,y~ ~-5 ~ ~ '; ;'' i ~'2"~ I- ~ 1 1 my, ..... 0 1 2 3 4 5 6 181 7 8 9 10 11 12 13 14 15 16 Symptom Count - lo FIGURE A-2 Contrasting the population-based and needs-based approaches to reducing morbidity related to medically unexplained physical symptoms. Since disability (right vertical axis) is closely related to symptom count, population interventions that reduce symptoms a small amount per individual ("Before" = before intervention; "After" = after intervention) can prevent extensive disability when benefits are summed across the population. More intensive needs-based interventions can assist the relatively few indi- viduals with repeated health care visits, multiple symptoms, and high levels of disability. Units of disability are hypothetical. hypothetical data to illustrate that there is a graded and threshold-free relation- ship between symptom count and disability. Therefore, even among relatively healthy individuals, a small intervention benefit results in a small average indi- vidual improvement in functional status. Figure A-2 also shows that most of the population experiences relatively few symptoms and consequently little disabil- ity related to MUPS. When small reductions in individual disability occur across an entire population, the resulting societal benefits may be large and meaningful. For the majority of people, MUPS come and go, usually without so much as a physician consultation. If these people are encouraged to seek health care for MUPS, it may increase the chance of long-term disability. This increase in dis- ability may occur via mechanisms such as unnecessary worry, unnecessary avoid- ance of physical and social activities, unnecessary treatment, adverse effects of treatment, and provider errors.42 "Medicalization" of otherwise minor and transient symptoms may also occur. This is a process similar to labeling, wherein the act of visiting a doctor for a symptom imbues the symptom with catastrophic meaning, thereby setting up a self-fulf~lling expectation of future disability.
182 STRATEGIES TO PROTECT THE HEALTH OF DEPLOYED U.S. FORCES In sum, population-based approaches to MUPS have the advantages of uni- versal exposure to an intervention and summation of the benefit per individual across an entire population. Since many individuals who would never have be- come ill necessarily receive intervention, population-based interventions must have a lower potential for harm than most interventions employed for the sick. Advantages of Need-Based Intervention Interventions that target the whole population can seldom address the unmet needs of the important minority suffering from many symptoms and extensive disability. Rosen described health care-based preventive approaches as "the high risk strategy" because the effort is to identify individuals at especially high health risk or with especially great need for health care. The time-limited nature of clinical practice requires that providers rapidly recognize patients who require special attention. In essence, the clinician must identify and dichotomously de- lineate people lying along the continuum of disability severity as either ill or not ill. The point at which people are deemed ill is more or less arbitrary but neces- sary to operationalize so that the process of care can proceed unhindered. Using the hypothetical data from Figure A-2, for example, the "cutoff point" for identi- f~cation of individuals in need of clinical care is set at 10 symptoms. This artificial dichotomy leads to the specific advantages and disadvantages of health care-based prevention strategies. The primary advantage is that inter- vention can be matched to the unique needs of a relatively few seriously ill indi- viduals, an approach that is attractive and sensible to both ill patients and their providers. Another advantage is that intervention aimed at the ill is minimally intrusive or harmful for those who are not ill. Riskier, more intensive, or more invasive interventions may be justified for "high risk" or ill individuals because of the comparatively large potential for individual benefit and the reduced so- cietal cost conferred by limiting the intervention to a few. On the other hand, clinical strategies contribute disappointingly little to any overall reduction of population disability. This is because only a very small pro- portion of society is ever exposed to a clinically based intervention that targets an ill or needy population. For example, Figure A-2 suggests that relatively few individuals have 10 or more symptoms, and many who have fewer than 10 symptoms will manifest significant disability and unmet needs that would not be addressed by a clinical intervention. In sum, the population-based and need-based prevention approaches both offer important advantages and suffer from unique limitations. The best ap- proach to the prevention of MUPS therefore involves some combination of population-based and need-based prevention, intervention, and management.
APPENDIX A 183 Population-Based Care: Matching Resources to Needs Population-based care aims to improve health outcomes through carefully structured clinical services linked through primary care to a population-based prevention plan. Population-based care is the development and implementation of a detailed plan that covers all people in a defined population who, despite population-based prevention, have developed a chronic or recurrent health con- dition or concern. Important symptoms are identified, a mechanism to track out- comes is devised, and a deliberate matching of appropriate resources to patients with unmet needs occurs.~5~ Katon and colleagues have described how population-based care can re- duce the prevalence of depression, and we advocate an analogous approach for MUPS. Critical is an understanding that various health care settings see different clinical populations with contrasting levels of MUPS severity and duration. More severely ill populations are encountered as the setting shifts from the community into higher levels of health care (e.g., tertiary care and inpatient hospital). This is clearer when one considers the dynamics of illness in populations. Consider that the point prevalence (P) of some illness (i) is roughly equal to its incidence (Ii) times its average duration (Di): Pi _ Ii ~ Di.~25 For intermittently relapsing illnesses such as MUPS, the duration of symptomatic illness can be approximated as the number of symptom episodes (N) times the average dura- tion per symptom episode (De) Given some assumptions (beyond the scope of this discussion), the following can be shown: Pi Ii * De * Ni This equation predicts that groups with more frequently episodic MUPS or MUPS of longer episode duration are overrepresented in populations because these characteristics elevate prevalence. The incidence of brief, nonrecurrent MUPS (e.g., acute back pain with a rapid resolution) may be relatively high compared with that of chronic MUPS. Even so, the long symptom duration and large number of episodes among those few individuals with an incident case of MUPS who develop chronic MUPS ensure that those with chronic MUPS are disproportionately represented in the population at any point in time. This over- representation of those with chronic and recurrent MUPS versus those with brief and acute MUPS is greater in specialty care than primary care and greater in referral facilities than local facilities. This occurs because local care and lower- intensity levels of care serve to "filter out" healthy and transiently ill individu- als. Hence, the prevalence of chronic and recurrent illness is least in the general population, the greatest in specialty and tertiary referral settings, and intermedi- ate in local and primary care settings. The equation presented above suggests that the societal or organizational burden of MUPS may be reduced in at least three ways: . incidence reduction or prevention of illness onset (primary prevention),
184 STRATEGIES TO PROTECT THE HEALTH OF DEPLOYED U.S. FORCES . duration reduction (secondary prevention), and . relapse prevention (secondary prevention). A fourth method of MUPS prevention (tertiary) targets the important morbid con- sequences of chronic MUPS: psychosocial distress, psychiatric disorders, and dis- ability. From the equation, we would expect that the first three strategies might reduce the population prevalence of MUPS. The fourth approach may not alter the prevalence of MUPS but may still reduce the population burden of MUPS. Implementing and Improving Population-Based Care Wagner and coworkers have described how to implement and improve population-based care. They describe three distinct organizational thrusts: in- formation systems, practice design, and patient education. Information Systems Information systems (ISs) are computer-based systems used to capture data that can be used to inform clinicians regarding patient status, assist clinicians and medical executives interested in monitoring and improving the quality of care, and guide policy makers attempting to assess population needs and deter- mine appropriate staffing levels. An IS for MUPS should use three components: a health information system (HIS) (a passive automated health surveillance sys- tem), a survey-based health monitoring system (HMS) (an active health surveil- lance system), and expert computer systems (ESs) (automated systems that gen- erate useful reports for the identification of high-risk patients and evaluation of care, population health status, and clinical outcomes). The schematic in Figure A-3 shows the interrelationship of IS components to various tools that may enhance the population-based care of MUPS. The HIS can record medical problem lists and measures of health care utilization (out- patient, inpatient, and pharmacy services and various procedures), health care costs, and presenting symptoms. These data, combined with HMS-based data on patient-reported physical symptoms, may be used to define MUPS for tracking purposes and to identify high-, intermediate-, and low-risk groups. Katon and colleagues have suggested that the following elements are integral to any HIS that supports evidence-based interventions within a population- based health care system: . regularly updated information on patients' primary care physician, place of care, and other contact information; . current information on health care use including medication fills, proce- dures, laboratory results, primary care visits, and specialty care visits; . a prioritized medical problem list; and
APPENDIX A / HMS (Population Survey) Past and current symptoms Risk factors Exposures 185 MUPS (Case Definition) Low risk Intermediate risk High risk . .. POPULATIONS... . . . EPIDEMIOLOGIC MAPS . . . . . . PRACTICE GUIDELINES . . . . . . REGISTRIES . . . ES _ ~ ES HIS (Care-Based) Problem list and symptoms Visits and admissions Pharmacy use Orders and procedures Health care costs FIGURE A-3 Components of an IS used in population-based health care for MUPS and their relationship to one another. ES = expert computer systems, HIS = health informa- tion system, and HMS = health monitoring system . other information relevant to establishing condition-specific patient reg- istries for tracking and monitoring. The IS uses ESs to process raw data obtained with HMS and HIS, prepare these data for various uses, and deliver cleaned and collated data to appropriate users. ESs are programmed to generate tools that aid clinical management, patient follow-up, and treatment and policy decisions. Examples of ES tools include re- ports, reminders, clinical indicators, feedback systems, and guideline recommen- dations. ESs may be used to create registries, identify from a practice team panel patients who are likely to meet case criteria or who require intervention, monitor outcomes, compare outcomes for individual patients to those for groups of similar patients, and track the progress and relative prognosis of particular high-risk pa- tients. An appropriate ES for MUPS might identify high-risk MUPS patients (for example, those with frequent visits or certain diagnostic codes from the Interna- tional Classification of Diseases), remind clinicians of applicable guidelines and algorithms, identify relevant patient and family education tools, and implement screening scales or standard questions for consistent outcomes monitoring. Eventually, it will become possible to compare the relative impact of primary care, specialty care, and quality of care on MUPS outcomes. In the future, linking of the HIS and HMS with administrative information systems (AISs) (e.g., military personnel files containing dates of promotion, disci
186 STRATEGIESTOPROTECTTHEHEALTHOFDEPLOYED U.S. FORCES plinary actions, awards, deployments, and evaluations of performance) may allow careful empirical evaluation of whether risk factors and interventions alter militar- ily relevant MUPS outcomes. The combined use of ESs, HISs, HMSs, and AISs may provide for careful longitudinal tracking of the health status of individuals with MUPS who have recently deployed. Eventually, extensive empirical experi- ence and understanding regarding the course of MUPS after deployments may be gained. IS data may be used to create population-based case registries and epide- miological maps showing the population distribution of people meeting case crite- ria. These individuals may be tracked for outcomes of potential interest such as long-term health care costs and service utilization, absenteeism, activity limita- tions recorded on military medical profiles, length of military career, rates of ac- tive duty reenlistment, promotion rates, and misconduct rates. Over time, refine- ments may be made to the existing case definition of MUPS so that it identifies individuals and groups at low, intermediate, and high risk of poor outcomes from MUPS. These data may also inform efforts to generate, implement, and evaluate pertinent clinical practice guidelines and best clinical practices. Practice Design Many have argued that the biggest barrier to quality clinical practice is the manner in which medical care is delivered Ambulatory care involves patients seeking care for a myriad of poorly understood psychosocial and medical rea- sons. In the traditional acute care approach, a physician quickly narrows to an often oversimplified "chief complaint," assesses only the most urgent medical needs, and then triages the patient to an appropriate level of care. Physicians managing acute medical problems are seldom practiced, skilled, or inclined to deliver preventive behavioral measures (e.g., dietary counseling, smoking ces- sation, and exercise prescription). This approach fails to address the broad and often behaviorally based needs of people with chronic health conditions like MUPS. These individuals require systematic assessments, effective and targeted education, and sustained psycho- social support and follow-up aimed at maximizing long-term health and well- being. Their medical status may not become life threatening or severe enough to require acute medical attention until late in life or course of illness. By then, the opportunity to provide effective preventive measures has largely been lost. The following are other barriers to the primary care management of MUPS: . time restrictions and patient defensiveness;~3 . high level of concern and low level of patient trust of military health care providers potentially responding to an organizational allegiance when caring for patients with MUPS after a deployment; . reimbursement approaches that favor the use of invasive medical proce- dures over more behaviorally oriented rehabilitative care;33
APPENDIX A 187 . clinician perceptions of MUPS patients as frustrating, noncompliant, and U n d e S i r a b l e ; 6 l , 9 7 , ~ 1 2 , ~ 5 4 inadequate coordination of care between primary and specialty care;~3 . excessive reliance on physicians as the primary clinical facilitators of medical and behavioral change; . disproportionate physician and media interest in disease-centered care featuring new technologies rather than patient-centered care stressing health behavior change; and . an unwillingness or inability on the part of physicians to delegate crucial behavioral and educational aspects of the patient encounter that are best ad- dressed by clinicians from nonmedical disciplines (e.g., nurses, psychologists, social workers, nutritionists, exercise physiologists, physical therapists)35~ Improving primary care management of patients with MUPS requires far- reaching alterations in the culture, incentives, structure, and process of medical care as it is currently delivered. Given the demands on primary care, it seems unrealistic to expect that primary care physicians alone will comprehensively and intensively meet the diverse medical, educational, behavioral, and psycho- social needs of all MUPS patients. A more achievable goal is to develop a proximate, structured, collaborative, interdisciplinary, and multimodal process of primary care capable of reducing the burden of MUPS on primary care physi- cians. If primary care physicians can achieve success within the context of a reorganized clinic process, they may eventually find that behavioral manage- ment of MUPS and related distress and disability is rewarding and worthwhile. Therefore, we recommend the development, implementation, and use of structured and carefully monitored health care programs that use primary care practice teams. Practice teams employ a wide range of nonphysician and physi- cian providers collaborating together in a coordinated process of care. The team meets regularly to improve clinical coordination and intensify care-based efforts to inform patients about MUPS, prevent relapse of MUPS, increase physical activation, improve treatment adherence, respond to patient support needs, and hasten return to work. Patient Education and Clinical Risk Communication The range of patient education options is rapidly expanding. Carefully de- signed patient education materials are particularly important for those experi- encing MUPS after deployments. Appropriate education materials can address harmful illness beliefs, the health effects of individual deployments, self-help strategies, the importance of managing disability and distress, the risks and limitations of extended diagnostic testing in "low-yield" clinical situations, and the ubiquitous nature of MUPS. Modalities available for disseminating patient information include brochures, mailings, books, videotapes, audiotapes, and waiting-room computers using self-guided learning approaches, as well as Inter
188 STRATEGIES TO PROTECT THE HEALTH OF DEPLOYED U.S. FORCES net-based learning technologies. Nonphysician specialists trained in patient edu- cation strategies and information technologies may assist patients with their questions in a manner that fosters trust and reduces distress regarding unlikely causes of symptoms. They may help patients troubleshoot attempts to initiate regimens of regular physical activity, take their medicines regularly, and so on. Health risk communication is a discipline that addresses methods of en- hancing bilateral communication in "low-trust, high-concern" situations. We have already described the insidious impact of the physician's competing and frequently unacknowledged obligation to the employer on the provider-patient encounter in occupational and military medicine. To date, risk communications experts have focused primarily on community-based methods of disseminating information and keeping communication constructive. However, risk communi- cation approaches may be modified and applied to the low-trust, high-concern clinical encounter that occurs in occupational and military medicine settings. Risk communication imperatives are to carefully design and empirically test the impact of health risk messages. In clinical settings, we might ask: (1) Does a particular waiting room brochure foster patient trust in their physician? (2) Is there a way to restructure the clinical encounter that enhances communication between providers and patients under these tense situations? (3) What is the most effective way for a military physician to tell someone postdeployment that the person's symptoms are medically unexplained without fostering fear of a progressive illness due to some poorly understood military-related toxic expo- sure? Clinical risk communication might be defined as the application of health risk communication approaches in the interest of enhancing the overall effec- tiveness of occupational, military, and analogous medical encounters. Stepped-Care Approach to Population MUPS Management A critical focus of population-based care involves matching intervention intensity to the severity, duration, disability, and psychosocial needs of patients. The stepped administration of specific interventions (i.e., administration from least to most intensive) ensures that the individuals with the greatest need re- ceive the most intensive and costly treatments. Figure A-1 summarizes the stepped approach that we currently envision. It employs five basic steps: preevent prevention, postevent prevention, routine primary care, collaborative primary care, and intensive multidisciplinary care. Note that a high level of clinical certainty and rigorous empirical evidence is not required to initiate this care model. The approach that we describe may be and should be incrementally updated and revised as necessary research is completed.
APPENDIX A Step One: Preevent Primary Prevention 189 Currently, the primary prevention of MUPS is poorly understood, and re- source-intensive attempts to implement unproven primary prevention strategies seem premature and unnecessarily costly. Nonetheless, populationwide primary preventive efforts to prevent the onset of MUPS as well as associated distress and disability are deserving of further attention and research. For example, "step one" approaches such as organizational policies and regulations or community- or workplace-level education involving literature, television, or other media segments require study and may have significant value. Unfortunately, the ef- fectiveness of such efforts for MUPS is anecdotal and largely unknown. The routine administration of high-intensity step one prevention is likely to overex- tend costly resources to the majority of individuals who will never develop health concerns, making feasibility a major concern. Therefore, large resource expenditures may be difficult for policy makers to justify in the absence of ex- perimental evidence supporting the efficacy of preevent prevention. One promising primary prevention modality is education and related pro- grams. For example, Symonds and colleagues~43 found that a low-intensity workplace intervention for back pain prevented subsequent sick leave. The in- tervention involved reattribution of back pain by use of an educational program. Pamphlets were distributed to all workers regardless of back pain history. The pamphlet highlighted the benign nature of low back pain and the importance of activity maintenance and early return to work as ways to successfully reduce morbidity. The investigators also found the program shifted worker beliefs about the causes of back pain. Similarly, military personnel, their families and signif~- cant others, their leaders, and health care personnel may benefit from brief, sim- ple, education-oriented efforts that provide appropriate information regarding MUPS and their relationship to distress and treatable psychiatric disorders. One potential way of narrowing the scope, increasing the feasibility, and re- ducing the cost of intensified step one prevention is to inform them by using IS technology. For example, smaller groups with predisposing MUPS factors may respond to a targeted intervention. ISs may help narrow the focus of intensified efforts to mitigate the impacts of these factors on subsequent development of MUPS and related morbidity. Step Two: Postevent Primary Prevention We suggest narrowing the focus of postevent prevention to specific units and associated families that have recently deployed or faced other events that might precipitate subsequent health concerns. Within these units smaller groups at especially elevated risk of MUPS may be identified on the basis of the pres- ence or absence of past MUPS or other predisposing factors. The "real-time" availability of IS data has the potential to focus preventive efforts at identified points of organizational vulnerability.
190 STRATEGIESTOPROTECTTHEHEALTHOFDEPLOYED U.S. FORCES Several candidates for postevent preventive efforts deserve further attention and evaluation. Workplace-based briefings may teach recently deployed person- nel the associated possible or known health risks. Leadership efforts to normal- ize the workplace through an early return to work routines and previously scheduled activities may maximize postevent productivity. A feeling of chaos and loss of control are common immediately after a tactical deployment or a catastrophic event. A rapid return to routines may provide personnel with a fa- miliar and predictable environment and a feeling of productivity. The availabil- ity of support meetings and meetings open to some larger community (so-called town hall meetings) may provide a forum for military and community leaders to learn of event-related community and family concerns. Similarly, town hall meetings offer opportunities for personnel and significant others to articulate and even ventilate important event-related health concerns. If the event or de- ployment involved sufficiently large numbers, telephone hot lines may be use- ful, too, providing personalized contact for people with questions, concerns, or previously undiscovered events or exposures. A large anecdotal literature often promotes large-scale postevent debrief- ings. However, randomized trials of critical incident debriefings (CIDs) have shown limited efficacy, and at least one study has suggested that CIDs may ac- tually increase the risk of postevent psychological distress.~59 A CID uses a structured debriefing format often led by mental health professionals with vari- ous levels of experience and expertise. Those exposed to the "critical incident" are encouraged to review the event in detail, focusing on current emotions and emotions during the incident. Efforts are made to inform people of the signs and symptoms of psychological trauma. CID is difficult and costly to successfully implement on any wide scale, may set up self-fulf~lling expectations of subse- quent psychological symptoms and disability, and is empirically unsupported from the experimental trials completed to date. As in step one, caution is necessary when considering relatively high- intensity preventive measures for people who have yet to develop MUPS. A commonly considered step two approach is populationwide postevent screening. These efforts may positively reinforce or "medicalize" what are otherwise nor- mal transient symptoms following such events. Even given IS data regarding predisposing and precipitating factors, it may be difficult to accurately predict who will develop MUPS and even harder to know who among individuals with MUPS will then develop disability and distress. Singling high-risk individuals out for a psychosocial intervention before the onset of symptoms and disability may unnecessarily and unfairly stigmatize or prematurely label many individu- als. Most of those labeled immediately postdeployment will not develop symp- toms or their symptoms will be time limited. Therefore, primary care-based screening for MUPS, tracking of outcomes of MUPS, and intensification of treatment for those with suboptimal outcomes is the most practical and least costly approach.
APPENDIX A Step Three: Routine Primary Care 191 As noted, feasible primary prevention strategies for MUPS are, unfortu- nately, of a low intensity; therefore, we can expect that new cases of MUPS will regularly occur even after relatively successful population-based prevention programs. Virtually all individuals with MUPS will encounter primary health care. Therefore, a key to secondary prevention may involve early primary care recognition and timely management of MUPS to reduce the impact of precipi- tating and perpetuating factors on physical symptoms, emotional distress, and disability. IS technologies may remind primary care physicians which of their patients are most symptomatic, most concerned about their health, and most distressed regarding undiagnosed illness. Once these patients are identified, there are several ways that clinicians may mitigate the impacts of precipitating and perpetuating factors in an effort to prevent a chronic course. These are now . revlewe Routine Primary Care Physician Management First, do no harm. Most pa- tients with MUPS have had extensive diagnostic evaluations. Often, clinicians are aware at the time of initial history and physical that diagnostic testing offers a low yield or that anxiety or depression are important exacerbating factors. Studies sug- gest, however, that for patients with MUPS, clinical awareness is not well inte- grated into physicians' diagnostic and treatment practiced As we have described, "shotgun" diagnostic testing under these circumstances can be harmful. Ordering unnecessary tests sends the wrong message to patients and promotes a passive patient mindset (e.g., "the doctor's in charge" and will "find it and fix it") that is counter to achieving behavioral activation goals and shifting some responsibility for wellness to the patient. Physicians are notoriously poor at making patients aware of the tests that they order, the rationale for ordering them, and the eventual results. One alternative to running new tests is for doctor and patient to carefully review past testing together, an approach that promotes clinician-patient collabo- ration and patient understanding. Sometimes, however, new diagnostic testing is necessary. A good rule of thumb for testing in patients with MUPS is to test only for classic constellations of symptoms or new objective signs. Clinicians must take care not to present medications as a substitute for per- son-centered care for MUPS aimed at addressing health concerns and reducing disability. Although medical explanations for physical symptoms are often lacking, physicians often still place the patient on medications, even though medications are a relatively small part of the overall management of MUPS and unintended adverse effects often outweigh medication benefits. Sedatives are usually inappropriate unless insomnia is acute, stress related, and expected to abate within a short time. Narcotic analgesics usually do more harm than good, since they slow thinking, cause sedation, and reduce overall functioning. Both of these medication groups usually have adverse impacts on efforts to activate pa- tients. Chronic administration of other central nervous system depressants such as so-called muscle relaxants is unadvised for similar reasons. Antidepressants,
192 STRATEGIESTOPROTECTTHEHEALTHOFDEPLOYED U.S. FORCES however, reduce the occurrence of MUPS among patients with chronic pain, panic disorder, dysthymic disorder, and major depressive disorder. In addition, reductions in depression and anxiety are critical to behavioral activation. It is important to carefully explain the rationale for antidepressants, or else patients will assume they were prescribed because the doctor thinks that the symptoms are "in the head," causing the patients to discontinue the medicine or see another doctor. All patients with MUPS should receive a complete and careful explana- tion of medication side effects, so that if they occur the clinician's credibility is enhanced and the chances of continued adherence is maximized. Cure rarely; comfort always. Seldom is it possible to cure any chronic ill- ness, and MUPS are no exception. Setting symptom eradication as a treatment goal will only lead to clinician and patient dissatisfaction. Clinicians intent on cures often feel as though they have nothing to offer patients with MUPS. They may devalue their role with patients with MUPS as "doing nothing" or "hand- holding." The importance of a supportive, empathic, and person-centered (rather than disease-centered) approach cannot be overemphasized. Comforting patients with MUPS often entails reassurance. This means more than simply telling them that their symptoms are not serious. It involves eluci- dating harmful illness beliefs and directing education and advice to those beliefs. The following are common examples of harmful beliefs: "My symptoms are a sign of disease." . "When I hurt it means I am seriously injuring myself" (e.g., "pinching a nerved. . "When I have symptoms I can't make it without rest and a break from my responsibilities." Clinicians can also learn the phrases that people with MUPS find belittling and avoid them. Similarly, they can learn some phrases that "join" the clinician and patient in a collaborative dialogue. For example, most individuals with MUPS describe their distress as secondary to symptoms. Although research is clear that distress increases the risk of subsequent physical symptoms and vice versa, it is best to adopt the patient's words and views regarding causation, no matter how faulty the clinician may think they are. Patients understandably react negatively to physician statements such as, "There's nothing physiologically wrong." Per- haps most physicians suffer from a good deal of overconfidence in their own clinical conclusions and would benefit from allowing their patients to have more input than they currently do. Comforting involves off~ce-based patient education and often centers on the health effects of adverse life events and toxic exposures, the impacts of anxiety and mood on physiology, symptoms, and functioning, the limits of medical testing, and the impacts of medication side effects on functioning. Self-help materials such as audiotapes and books about physical activation, relaxation
APPENDIX A 193 techniques, and coping with chronic pain and similar symptom-based disorders are widely available. Negotiate behavioral goals targeting illness and disability. Reducing dis- ability requires specific changes in patient behavior. It requires patients to take an active, collaborative role in their treatment rather than a more traditional pas- sive role ("fix me dock. Provider-patient collaboration and negotiation of be- havioral goals will usually prove to be more rewarding than striving for an elu- sive cure. Goals must be specific, incremental, realistic, and achievable, and they should center on observable or reportable behaviors. First and foremost, goals must be negotiated with the patient such that the patient "owns" the goals. If goals are simply clinician imposed, the patient may have no investment in them, view them as impossible, or covertly oppose them. It is often useful to have patients graph their incremental progress toward their goals and review the graphs with them at their follow-up appointments. Examples of good areas for goal formulation are occupational, household, or social task performance, physi- cal activation, sleep hygiene, or medication adherence. Hold the patient responsible for change, but avoid "the blame game. " In disease-centered care, the patient is a passive participant. The patient is to "comply" with the doctor's "orders." The patient visits the doctor in search of answers, and the doctor is responsible for providing them. In person-centered care, the clinician must move out of the "answer man" role and join with the patient as a facilitator of behavioral change. The clinician negotiates the goals of treatment with the patient, helps him or her solve the problems "they" encounter, and carefully addresses the patient's expectations for quick or magical solutions. Simply acting as an "idea generator" for the obstacles that patients describe helps to facilitate behavioral gains. Clinicians must shift the responsibility for change to the patient, but they must also remain vigilant not to blame the patient for their lack of progress or their illness predicament. Encourage physical and role reactivation. Regular exercise in tolerable doses helps patients with MUPS discharge distress, increase stamina, and im- prove functioning. Physical therapy programs of gradually increasing physical activity are sometimes useful for overcoming the deactivation and weight gain that occurs for many patients with MUPS. Usually, a physical therapist is not necessary to initiate reactivation strategies; these can be negotiated in the physi- cian's office. Similarly, patients need encouragement to remain gainfully em- ployed and active in supportive relationship roles. This reduces dependence and improves morale, self-confidence, and ability to meet expectations. In most oc- cupational settings and especially in the military, reactivation strategies require careful coordination with employers or supervisors. The best reactivation plan will go awry if workplace supervisors are unaware of it or do not support it.
194 STRATEGIESTOPROTECTTHEHEALTHOFDEPLOYED U.S. FORCES Involve social supports. Social supports may include family or close friends. Clinicians should encourage participation of support systems in nearly all aspects of care, provided that the patient approves of this. Family or friends can help clarify concerns, illness beliefs, symptoms, and deficits in functioning. Often, the patient's most important concerns are related to those closest to the patient, and their involvement in care can make or break the clinician's ability to successfully engage the patient in a constructive dialogue about the patient's health concerns. In occupational settings, the extent of involvement of the su- pervisor or employer must be similarly considered. "Collaboration" with the employer should seldom occur without the expressed (and usually written) per- mission and direct involvement of the patient. If organizational conditions, rules, or regulations pertain to employer or supervisor involvement, these should be clear and available to the patient from the time of the initial clinical contact or whenever it becomes apparent to either the patient or the clinician that employer involvement may occur. Coordinate care with one designated clinician. Proper management of the delivery of care is both cost-effective and in the best interest of the patient. This is especially important for patients with many MUPS and those with chronic symptoms. In the absence of well-coordinated and centralized care, patients with multiple MUPS are likely to bounce from specialist to specialist, receive many unnecessary diagnostic procedures, and end up on multiple unnecessary medi- cations. The key elements of coordinated care include (1) establishment of a relationship with a single primary care provider, (2) appointments at regular, time-contingent intervals of about every 4 to 6 weeks, (3) a brief physical ex- amination at each visit to address new physical concerns, and (4) limits on pa- tient-initiated visits for an exacerbation of otherwise chronic symptoms. When- ever possible negotiate an advance plan as to how symptom-contingent visits will be handled. If it is anticipated that this may become a problem, it is often sensible for clinician and patient to negotiate a written plan that both can refer to if limits become necessary. Some patients may fear that these limits mean that the doctor is angry with them or going to reject them. If the plan was previously negotiated and drafted in writing, these patient concerns may be tactfully ad- dressed when they arise with minimal damage to the doctor-patient relationship. Consultants to the primary care physician must understand that they are to rec- ommend care rather than assume it. Similarly, primary care clinicians should present consultants with a focused question. Consultants must understand their role and the key aspects of caring for patients with MUPS. Anticipated andjudicious mental health care referral. Psychiatric referral is frequently appropriate for those with MUPS, especially for patients who request it, have suffered a recent stressor, have a treatment-refractory psychiatric disor- der, or describe suicidal or other clinically worrisome issues. However, most patients with MUPS do not require psychiatric treatment or psychological test- ing. Evidence suggests that a surprisingly large proportion of patients with
APPENDIX A 195 MUPS receive mental health referrals without an adequate explanation as to why they are needed.86 In some cases, there is little doubt that a clinician desires primarily to "turf,' (i.e., reject) a difficult patient. Not surprisingly, this message is seldom lost on the patient. Clinicians should not wait until the entire biomedi- cal evaluation is complete and then obtain a referral because "potential medical causes are 'ruled out' and therefore the patient needs a psychiatrist." To prevent patients from experiencing mental health referral as rejection, it is usually best for clinicians to anticipate the potential need and introduce it early in a non- threatening way. Patients are best told that a frequent consequence of MUPS is disabling distress and that appropriate care can mitigate the impacts of their symptoms on their quality of life. It is important that primary care clinicians see patients after completion of the mental health referral to reduce the patient con- cerns that the doctor is rejecting or abandoning them. Primary care clinicians should ask patients how they experienced the consultation and contact the con- sultant directly for recommendations if possible. Unfortunately, most mental health professionals have only infrequent expo- sure to patients with MUPS, are not skilled in their management, and do not readily appreciate the need to collaborate closely with primary care. Even when done under ideal conditions, less than half of referred patients ever obtain men- tal health evaluation. Patient defensiveness, excessive rejection fears, and social stigma associated with having a psychiatric disorder are among the significant obstacles to effective mental health consultation for patients with MUPS3~3 Clinicians often obtain psychological tests such as the Minnesota Multipha- sic Personality Inventory with the expectation that it will provide them with hard-and-fast evidence that MUPS are psychological rather than physical in ori- gin. These tests can offer information regarding the relative style, quality, and success of patient coping and distress. However, they are not effective for diag- nosing a psychological etiology for physical symptoms. Extensive psychological testing is not a panacea and may be quite threatening to patients when adminis- tered under any clinical circumstance, especially when the assessment may have occupational or military ramifications. Teaching MUPS Management to Primary Care Physicians One reason that physicians minimize the importance of MUPS is their lack of awareness of and comfort with appropriate management strategies. Naturally, they focus on things they know how to treat, and most think there is nothing they can do about MUPS. It is important to enable them through proper educational experiences that focus on the basic primary care strategies described earlier. MUPS-related clinical training experiences may add to the overall quality of patient care by improving the routine primary care management of associated, frequently unrecognized, and treatable psychiatric disorders. Research suggests that an excessively biomedical approach to MUPS or coexisting chronic medical illness markedly diminishes physician attention to psychosocial aspects of care such as recognition of treatable anxiety and depressive disorders. Kirmayer and Robbins84 studied 685 patients presenting to a primary care clinic and found that
196 STRATEGIESTOPROTECTTHEHEALTHOFDEPLOYED U.S. FORCES approximately three-fourths of those with major depression or anxiety disorders complained exclusively of physical symptoms. Studies have shown that men- tally ill patients with emotional complaints are usually detected, whereas those with only physical complaints are generally missed.5~ Providers in medical settings may sometimes collude with patients in ways that undermine effective health care. For example, the provider may detect mental illness in a patient but fail to offer treatment because he or she senses that the patient might be unreceptive. Some clinicians are better than others at identifying treatable psychiatric disorders in their patients.~°~ Conversely, dis- tressed patients will more readily share their emotional concerns with those cli- nicians who are best at addressing them.5~ Appropriate medical education em- phasizing communication skills, MUPS, and the recognition and treatment of anxiety and depressive disorders by primary care providers may improve clinical outcomes and provider confidence in addressing patients' psychosocial issues. Efforts to improve physicians' communication skills are critical to improving the routine primary care management of MUPS. Too often clinicians fail to ac- knowledge to themselves and to their patients the high degree of uncertainty in- herent in all clinical practice, perhaps especially for those patients in whom no explanation is found for physical symptoms. Clinicians must learn and relearn that the "absence of an explanation" is not synonymous with a "psychological expla- nation." A fundamental tenet in the art of caring for MUPS is to acknowledge the centrality of aversive symptoms to the patient's life before asking the patient to take responsibility for overcoming those symptoms. Often physicians admonish their patients to actively seek a state of health, and some even equip their patients with tools for seeking that health. However, unless they first validate, empathize, and even immerse themselves in the patient's physical symptoms and their sense of personal damage, sacrifice, and suffering, most patients will feel misunder- stood. Some will feel that the physician is blaming them for their illness. A few patients will experience an unspoken challenge, the challenge to prove the reality of their suffering. In short, physicians must make it their routine clinical mission to develop an appreciation for the extent that each patient constructs his or her life around symptoms, suffering, and limitations, whether or not medical explanations are available. For example, Marple and colleagues found that when physicians addressed patients' health worries and fears and understood the rationale behind their fears, their physical symptoms and functioning improved faster and the pa- tient was more satisfied with care. Physicians must develop strategies and experience explaining the limits of diagnostic testing and clinical treatments to their patients. Gallagher and co- workers49 illustrated this in a recent study. Those investigators explored 39 in- ternists' responses to a patient request for an expensive, unindicated diagnostic test. An actor was used to play out a standardized and blinded clinical scenario. Participating internists practiced in a health maintenance organization, and each encountered a young woman presenting with only chronic fatigue and no neu- rological symptoms. The patient desired magnetic resonance imaging (MRI) to rule out multiple sclerosis because of a friend's recent experience with the dis
APPENDIX A 197 ease. Only 10 percent of internists asked about the friend's illness, but 8 percent ordered the MRI and 22 percent said they might in the future. Fifty-three percent referred the patient for a neurology consultation on the day of the visit, and all but 13 percent of internists said they might refer the patient in the future.49 This study is but one of many that illustrate the need for greater clinician education regarding strategies for addressing patients who press for unnecessary diagnostic testing or treatments. Step Four: Collaborative Interventions in Primary Care To benefit patients, specialists and primary care providers need to learn and respect each others' ideas, share resources, and learn ways of successfully working together to develop consensus around common goals like the popula- tion-based care of patients with MUPS. Particularly important is the need to develop collaborative on-site programs of behavioral health care for primary care providers. Such programs can enhance patient adherence to behavioral ap- proaches initiated in primary care. In addition, on-site consultation reduces stigma by presenting it as a routine part of the primary care experience rather than something mysterious and remote. On-site collaboration also provides pri- mary care providers with satisfying opportunities to interface with and learn from specialists from the other disciplines rather than the more traditional ap- proach of referring complex primary care patients to specialists "right when they get interesting." Several groups have looked at primary care-based psychosocial interven- tions for persons with MUPS, distress, or both. Strategies have most commonly involved screening,~4-~6 physician and patient education,5 primary care-based mental health consultation,72 interdisciplinary treatment teams,~°8 and psycho- therapy techniques adapted for primary care use.20 Smith and colleagues ~24 ~37 have found replicable reductions in the cost of care and even small improve- ments in health-related quality of life for patients with the most severe forms of MUPS (i.e., patients with somatization disorder) simply by sending a set of short, codified recommendations to patients' primary care providers advising them on how to manage them. Katon and colleagues79 completed a randomized trial of psychiatric consul- tation for "distressed high utilizers of primary care" at Group Health Coopera- tive of Puget Sound, a health maintenance organization serving over 350,000 enrollees in Washington State. Distressed high utilizers were defined as the top 10 percent of ambulatory care utilizers over the year prior to study who were identified as distressed either by their primary care physician or by high scores on a validated paper-and-pencil measure. This 10 percent of patients utilized approximately one-third of all outpatient visits, 26 percent of all prescriptions, and one-half of all inpatient hospital days. The intervention consisted of a structured psychiatric research interview followed by a 30-minute collaborative patient interview and treatment planning session involving the generalist, psy
198 STRATEGIESTOPROTECTTHEHEALTHOFDEPLOYED U.S. FORCES chiatrist, and patient. Patients in the control group received usual primary care. Improvements in mental status or service utilization of intervention patients over that of controls could not be demonstrated. In retrospect, the intensity of the intervention was low, perhaps serving notice that MUPS involve many complex factors that are not responsive to a brief, one-time intervention that targets mainly psychiatric disorders. Prescription practices were marginally better for the intervention group, but subsequent antidepressant regimen adherence was generally poor for patients in both groups. There was no formalized mechanism for interdisciplinary collaboration after the initial consultation and no way of subsequently enhancing primary care clinicians' effectiveness or their adherence to the original collaborative care plan.77 More recently, primary care approaches to physically symptomatic and dis- tressed primary care patients have focused on "multimodal" or "multifaceted" interventions. These are best administered in steps, so that the most intensive, expensive, or burdensome treatments are held in reserve for those who are oth- erwise treatment refractory. Components have included screening; on-site men- tal health consultation; cognitive-behavioral and problem-solving therapies aimed at medication adherence, depression, MUPS, physical activation, and relapse prevention; videotapes, pamphlets, and other education materials on self- care; structured follow-up strategies; and standardized written primary care in- structions. Other efforts to enhance primary care clinicians' ability to tackle the multiple needs of their patients have employed "academic detailing," feedback to clinicians from their patients' automated pharmacy or health care utilization records, and case management. Katon and colleagues75 80 used a multifaceted approach to assist depressed primary care patients, an approach that can serve as a model for similar primary care-based MUPS interventions. Elements of their intervention targeted the patient, the physician, and the process of health care delivery. Elements that targeted patients were reading materials on depression, antidepressants, simple self-administered cognitive-behavioral techniques for managing depression, and a videotape on similar topics for viewing with spouses. Elements that targeted primary care physicians were didactics on antidepressants and behavioral treat- ment of depression, case-based consultation for each depressed patient, and on- going interaction and feedback between the psychologist and primary care phy- sicians. Elements that targeted the process of care were extensive and manualized. These included behavioral therapy done in the primary care setting. Behavioral therapy aimed at teaching patients depression self-management skills, improving medication regimen adherence, and preventing future relapses. Psychologist contacts were scheduled and occurred in the primary care setting. These contacts involved skills training, education, and homework. Relaxation training, assertiveness training, problem-solving training, and collaborative psy- chologist-patient development of a relapse prevention plan were done. Addi- tional telephone contacts with the psychologist occurred after completion of primary care-setting contacts. Symptom monitoring occurred by a standardized measure and a checklist. The psychologist screened and documented antidepres
APPENDIX A 199 s ant side effects, dosing, and adherence. During weekly interdisciplinary team meetings, a psychiatrist reviewed antidepressant-related information and overall treatment progress. The psychiatrist would advise medication alterations as indi- cated, and the psychologist communicated these recommendations to the pri- mary care physician, who would carry them out. This integrated process of care was carefully monitored for integrity by using a numeric rating system. These integrity ratings were monitored and used to provide regular clinician feedback. Katon and coworkers75 compared this collaborative interdisciplinary inter- vention to usual care for depressed primary care patients using a randomized controlled design. As long as 4 months after completion of the intervention, in- tervention patients with major depression reported greater satisfaction with care, adherence to the medication regimen, and improvement in depressive symptoms than major depression patients receiving usual care. The results of the interven- tion were less clearly favorable among patients with minor depression (signif~- cantly improved antidepressant regimen adherence and perceived antidepressant helpfulness, but there were no significant differences between the groups re- garding depression symptoms or satisfaction with depression care).75 Other analyses of these data have found evidence of improvements in physical symp- toms. Analyses of cost-effectiveness found that the intervention was more costly than usual care for patients with both major and minor depression. However, for the major depression patients, the multifaceted intervention offered significantly greater cost-effectiveness than usual primary care349 Given the added expense associated with collaborative models, we suggest that they be held in reserve for patients for whom routine primary care manage- ment strategies for MUPS fail. Symptom duration is a key step four indicator to monitor using IS-generated reports. When a patient's symptoms reach some threshold of extended duration, more intensive collaborative efforts may be pro- actively introduced. Step Five: Specialized Intensive Multimodal Care There are several excellent examples on which to model tertiary prevention programs for patients with MUPS who fail to improve in response to collabora- tive primary care approaches. These programs are multimodal and multidisci- plinary, occur in specialized (i.e., non-primary care) settings, and involve either a 3- to 4-week inpatient or intensive outpatient program or a 10- to 15-week program of weekly or biweekly individual or group visits. These programs em- phasize carefully planned psychosocial elements that address the chronic nature of reduced functioning and the factors that reinforce it. Usually, psychosocial and medical care is combined with a highly struc- tured and generally supervised physical activation or exercise plan. These pro- grams view disability as a behavior amenable to modification regardless of its biomedical etiology. Engel and colleagues36 have described such a program for veterans with MUPS after service in the Gulf War. The intervention, called the
200 STRATEGIESTOPROTECTTHEHEALTHOFDEPLOYED U.S. FORCES Specialized Care Program (SCP), is a 3-week intensive outpatient program modeled directly after the University of Washington's Multidisciplinary Pain Center.99 Their preliminary data suggest that treated patients make mild to mod- erate gains in multiple domains including functional status and health-related quality of life, psychosocial distress, physical symptoms, and physical health concerns. 5 Bonica at the University of Washington was among the first to apply a mul- tidisciplinary approach to the treatment of chronic pain patients in the late 1950s.99 Since then, the approach has gained relatively wide acceptance for work-impaired chronic pain patients, especially those with back pain and fibro- myalgia. A recent meta-analysis of 65 controlled studies of multidisciplinary interventions for chronic pain patients noted improvements in return to work rates, pain, mood, and health care utilization.43 The authors were cautious in their conclusions, noting that the level of methodological rigor for most studies was low. lS-generated reports may monitor the patient population for individuals who develop chronic MUPS-related disability. If patients are recognized early and enrolled in specialized intensive multimodal care for MUPS, the chances of sat- isfactorily returning them to work may be maximized. Components of Specialized Services The following sections review the common components of most intensive programs and the research that supports their efficacy. Cognitive-behavioral therapy. Until recently, most approaches to patients with treatment-refractory chronic pain or other persistent disabling MUPS have involved an intensive burst of multimodal care delivered over several weeks, usually in an inpatient setting. Perhaps not surprisingly, given the general shift in emphasis from inpatient care to less expensive outpatient approaches, recent studies have evaluated less intensive but more longitudinal treatment strategies. The best studied of these involve combined cognitive-behavioral therapy (CBT) and physical reactivation. CBT used in this context aims to help patients test and appropriately adjust harmful beliefs that they may have regarding the cause of their symptoms and the ways of treating their symptoms. Empirical trials have shown the benefits of CBT for a range of MUPS including chronic fatigue,~3~ irritable bowel syndrome,~7 ~46 temporomandibular disorders,32 burning mouth syndrome,~° hypochondriasis,~57 and multiple MUPS.64 96 ~38 Wessely's group30 in London found that 63 percent of patients with chronic fa- tigue syndrome (CFS) showed significant improvement in their physical functioning after random assignment to CBT and physical activation, whereas only 19 percent assigned to relaxation training showed significant improvement. Improvements were enhanced over the 6 months following treatment. Significant improvements among CBT-physical activation recipients over those among the relaxation group were also noted in work and social adjustment, symptoms of fatigue, fatigue-related problems, and progress toward individualized long-term goals. Of note, improvements in dis
APPENDIX A 201 tress and depression were only slightly better in the CBT-physical activation group, and the differences were not statistically significant. Sharpe and colleagues completed a randomized trial of CBT for patients with CFS by comparing it with usual medical care. They found that 73 percent of patients assigned to CBT rated their outcome as satisfactory or better, whereas only 27 percent of the usual care group gave such a rating, a difference that was highly statistically significant. Sixty-three percent of the CBT group improved in their work functioning, whereas only 20 percent of the usual care group improved in their work functioning. Functioning, fatigue, and depression but not anxiety were also significantly improved. As one would hypothesize under a model of treatment with CBT, illness beliefs and coping were more positively altered for those assigned to CBT than for those assigned to usual care. As was observed in the previously described CBT-physical activation trial, outcomes continued to improve for months after the completion of the intervention.~3~ Physical activation and exercise. Exercise is known to have important physical and psychological impacts upon health and well-being.~04 ~60 Using a randomized design, Fulcher and Whiten examined the impact of a gradually increasing program of supervised aerobic exercise for patients with CFS, com- paring this approach to stretching and relaxation. After 12 weekly sessions, 51 percent of those assigned to exercise rated themselves globally as "much better" or "very much better," whereas 27 percent of the stretching and relaxation group gave such a rating, a statistically significant difference, and improvements were stable over the subsequent several months. Fatigue, physical functioning, and fitness were also significantly better in the exercise group.48 Similar findings after exercise programs have been noted for other chronic or symptom-based disorders such as post-polio syndrome,4~ chronic low back pain,4647 depressive disorders, fibromyalgia,~03 and "effort syndrome."~° Return-to-work strategies. Challenges exist around when and how to return workers with MUPS to work. There is general agreement that an early return to work is important to maintain role functioning and reduce chronic disability. There is evidence in the low back pain literature that a return to modified work can be successful.45 Currently, the Army employs a profiling system of tempo- rary or permanent work restrictions for those with diminished occupational functioning because of illness. Unfortunately, this approach may actually rein- force disability unless it is used in combination with a carefully supervised and graduated but relatively rapid return-to-work plan that is introduced to the worker very early in the rehabilitation process. For example, a 1-year follow-up of the use of work restrictions for nonspecific low back pain indicated they actu- ally diminished the likelihood of return to work and did not reduce subsequent work absence or recurrences of back pain.~9 A supervised and graduated return- to-work approach may be especially important in the military when aerobic physical conditioning such as long-distance running is required. A "profile" brands the worker as a problem to supervisors and coworkers. The loss of physi
202 STRATEGIES TO PROTECT THE HEALTH OF DEPLOYED U.S. FORCES cat conditioning and endurance that occurs in response to persistent physical symptoms and resulting deactivation requires time and a graduated program to reverse. Abrupt and haphazard return of personnel to full physical duties and the expectation that they will immediately perform at the same levels as others in their unit will commonly produce failure and an increased sense of defeat for the worker. In contrast, a rapid return of workers to their full levels of supervisory and other nonphysical roles is indicated to reinforce organizational expectations that a rapid return to productivity is expected. Likewise, worker productivity helps bolster self-esteem and a sense of accomplishment. Obstacles to Specialized Services The greatest obstacle to the development of specialized care for patients with MUPS is the perception on the part of adminis- trators, policy makers, and clinicians that MUPS are neither disabling nor impor- tant. Although explanations of"stress" or "somatization" for unexplained physical symptoms serve an important clinical purpose for many MUPS patients, they are often used to minimize the needs of affected patients. Another barrier at present is the lack of an institutionalized niche for specialized care for MUPS, especially after combat and deployments. Both primary and tertiary care of MUPS is, as we have shown, interdisciplinary and requires the collaboration of many clinicians such as generalists, psychiatrists, psychologists, physiatrists, anesthesiologists, nurses, social workers, physical therapists, occupational therapists, and dietitians. In the current health care environment, each of these clinicians is responsible to a department head, and departments are demarcated along specialty lines. Interdis- ciplinary care of MUPS is a lesser priority for each of these departments than ill- nesses that fall more clearly within their specialty purview. When competing clini- cal demands are high, the argument that patients with MUPS suffer more from "nothing" than "something" seems compelling organizationally. Another important obstacle to intensive models of MUPS care is the con- ventional sense that such care is too costly. Currently, it is not known whether the extra costs associated with appropriate intervention are offset by longer-term decreases in health care use and improvements in occupational functioning. Most patients referred to intensive MUPS care, however, are using unusually large amounts of health care and are functioning poorly, so the potential for gains appears to be great. Left untreated, patients with MUPS remain costly to society. For the military, MUPS seem certain to occur after future wars, and excellence in this aspect of patient care may pay public relations dividends as well as improve the care of affected veterans. Further research on the cost- effectiveness of specialized services for patients with treatment-refractory MUPS is needed to rigorously examine these issues. CONCLUSIONS Hadler58 has described four major areas in which occupational physicians might contribute to the care of workers: clinical, educational, research, and pol
APPENDIX A 203 icy making. We adhere to his comprehensive outline and offer our own thoughts and a few of his in concluding this review of MUPS and their relevance for the military and perhaps other employers. First, physicians caring for workers with MUPS must foster improved worker adaptation to illness as the worker experiences it. Hadler has urged physicians to try to understand the "sociopolitical arena" in which illness occurs. We urge clini- cians to go several steps further and design a system of care that is responsive to people and their subjective health concerns rather than diseases per se. Second, physicians caring for workers with MUPS must develop appropri- ate educational experiences for other providers and for affected workers and their significant others. Clinician education should emphasize the psychosocial and behavioral contexts of illness and disability rather than only simplistic bio- medical perspectives. Providers must become more sophisticated regarding the ways that environmental factors may shape behavioral responses to symptoms and to ill health. Third, physicians caring for workers with MUPS must develop short-, in- termediate-, and long-term clinical research and policy research agendas with explicit goals and objectives. These research agendas must address important military health practice and policy questions. Research into biological mecha- nisms, although important for understanding one basis of unexplained symp- toms, is costly. History suggests that mechanistic research is slow to yield im- mediate answers of importance to workers, patients, and organizations. Rather, epidemiological research is necessary to aid policy makers' attempts to compre- hend the societal and military burdens of MUPS and the historical relevance of MUPS to diverse deployments. Hadler has recommended research on the im- pact of job demands on physical and emotional health and workers' health per- ceptions, and this remains an area of need. Where, how, and why veterans with postdeployment health concerns seek their care and their satisfaction with that care is currently completely unknown within the military and is of great impor- tance to prevention, treatment, and risk communication efforts. Fourth, we suggest that physicians and policy makers move as rapidly as possible toward population-based models of health care and create system in- centives for local-level development of novel interdisciplinary approaches to MUPS, interventions that span the spectrum of precare, primary care, collabora- tive primary care, and intensive specialty care. Physicians and policy makers must consider human factors whenever they are engaged in workplace structure and task design, since in the end, new technologies are effective only if the peo- ple who operate them are functioning well. Physicians and policy makers should carefully consider the impact of the prevailing military and U.S. Department of Veterans Affairs disability compensation system on incentives for workers to improve their health. Given the necessary breadth of efforts to prevent MUPS in the military, we suggest the development of a "center of excellence" to lead clinical, research, and educational efforts related to MUPS in the military. A center of excellence could initiate and monitor efforts to implement clinical, educational, and re
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