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found that about 40% of the veterans who reported themselves as being unwell in Phase I of the study report that they are better in Phase II.

MEDICALLY UNEXPLAINED PHYSICAL SYMPTOMS

A recent article by Craig Hyams, M.D., reviewed the medical literature from the U.S. Civil War through the present. He found that concern about medically unexplained physical symptoms (MUPS) has occurred following every war. According to Dr. Engel, disease is something that is identified by biological indices or exam findings. When we find symptoms but no biological indices or examination findings, then these symptoms are unexplained. This does not, however, mean that they do not have an explanation. But it is not necessary to know the cause of symptoms to treat them.

Dr. Engel stated that a problem in caring for patients with MUPS is “medicine as usual,” that is, the physician takes a history, listens to how the patient feels, examines the patient, then does some laboratory testing with the idea of identifying a diagnosis and a treatment. If the physician is unable to diagnose the problem, several things might happen—treatment may end; there may be further testing, retesting, and referral; the patient may be given pills; or there is surgical intervention. For patients with MUPS, this may result in more harm than good. Certain diagnostic tests have important morbidities associated with them. Additionally, overtesting conveys to the patient the message that he or she has to prove his or her illness, that it is necessary for a test to show something to validate the patient's problem.

It is also possible that if symptoms are unexplained, many physicians will describe them as somatization or psychological in nature. However, according to Dr. Engel, the first step in caring for patients with MUPS is to legitimize the patient's illness. Disability already exists; it only becomes worse if it is not acknowledged. Acknowledging the illness allows the patient and the physician to proceed to devising strategies for treating the symptoms. There are multiple levels at which intervention can occur, ranging from the intensive kind of program at Walter Reed for those with severe disability, to much less intensive strategies at the primary care level aimed at preventing patients from developing such severe problems that they require the specialty care approach.

At Walter Reed's intensive program, the goal for treating MUPS is to improve outcomes through structured care targeting behavior and knowledge, to prevent disability in people with MUPS. The approach advocated is collaborative; that is, the patient and the physician collaborate and negotiate exact and explicit behavioral goals. Many patients are defeated by symptoms they view as out of control. It is the job of the health professional to help the patient become more activated, both physically



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