Abdominal pain, chest pain, fatigue, back pain, headache, and dyspnea are the most frequent symptoms in medical outpatients.1
In the collective patients screened for our study, abdominal pain and chest pain were the most common complaints. This case mix of outpatients compares well with general internal practitioners in the local region,17
and other regions.1
In outpatients, 40% to 85% of complaints have no discernible organic cause; i.e., they are “nonorganic” in origin.1,3,18–21
It may be crucial to diagnose a nonorganic cause of pain early in order to prevent unnecessary workup and cost.1,13
It matters whether patients can be diagnosed reliably and early with a nonorganic cause of pain, although this may be more difficult than in pain of organic origin. To appraise whether a nonorganic diagnosis can be distinguished reliably from an organic one by clinical means alone, we prospectively studied 190 consecutive general medical outpatients with abdominal or chest pain.
A clinical judgment based on patient history and physical examination alone correctly predicted final diagnosis at completion of the chart in both abdominal (72%) and chest pain (88%). When a distinction between nonorganic and organic pain, but not a precise diagnosis, was made, accuracy increased to 79% for abdominal pain and remained at 88% for chest pain. These findings match other reports on the pivotal diagnostic contribution of careful history taking and physical examination alone in various patient populations.1,4–8,11–13,22
Medical practitioners often rely on experience and feelings that are described as “probable” or “undoubted.” Here we provide some evidence concerning the adequacy of such terms in the context of nonorganic versus organic abdominal and chest pain. The preliminary diagnosis was almost completely accurate when residents, together with their supervising attending physicians, felt very confident about their preliminary diagnosis. Accuracy of an “undoubted” preliminary diagnosis was 99% compared with the final diagnosis. Conversely, the accuracy of a “probable” preliminary diagnosis of abdominal pain and chest pain compared with the final diagnosis was only 68% and 64%, respectively.
One might argue that patients with an “undoubted” preliminary diagnosis only rarely had additional investigations to dispel their initial diagnosis. However, the follow-up investigation of patients with nonorganic final diagnosis after an average of 29 months (range 18–56 months) did not identify any erroneous judgment in the subset of patients with “undoubted” diagnoses. Diagnostic accuracy for both undoubted and probable nonorganic final diagnoses after completion of the chart (gold standard) in patients with abdominal and chest pain was 93% and 98%, respectively, as compared with the follow-up investigation. This is comparable to a report of 100 patients followed for nonorganic abdominal pain who were assessed with an equally high diagnostic accuracy of 95%.14
Our study did not aim to discern whether patient history or physical examination contributed more to diagnostic accuracy. However, patient history influences diagnostic evaluation more than physical examination does, the latter revealing crucial information in approximately 20% or less of all cases.7,11–13
Our follow-up investigation revealed an improvement of nonorganic abdominal pain in approximately 50% of the patients. Similarly, nonorganic abdominal pain,3
other gastrointestinal complaints,3
and miscellaneous symptoms1
improved in approximately half of all cases after a prolonged observation period. Nonorganic chest pain in our patients improved in 64%. Similar results were reported in patients with atypical chest pain and normal coronary arteries.15
The search for low-cost and high-quality care is ongoing. Patient wishes for interventions have to be considered.23
Yet our data, as well as others’ 24
suggest that lower cost is not necessarily associated with low quality of care. We conclude that only diagnoses of nonorganic pain that are rated as “probable” need further investigations and workup.
Our study has several limitations. First, our consecutive outpatients with abdominal or chest pain are better suited for the study of nonorganic causes of pain than organic ones. The number of our patients with organic diagnoses is relatively small, heterogeneous, and represents a limited number of diseases with a low number of cases in each category of disease. This, and the high prevalence of poorly circumscribed complaints of abdominal and chest pain in daily medical practice,1,8
led us to focus on the reliability of diagnoses for nonorganic causes of pain.
Second, each patient had his or her individual workup; e.g., investigations such as treadmill ergometry or endoscopy were performed only when clinically indicated. Individualization of workup has also been described in other similar studies that reflect conditions of daily medical practice.1,3
Third, a shortcoming of any investigation like ours is the lack of a totally reliable gold standard. In our study the final diagnosis served as a gold standard to measure the quality of the preliminary diagnosis. However, standardized and more aggressive investigations may have somewhat altered the final diagnosis. To assess the gold standard, we performed a follow-up investigation of nonorganic diagnosis. It was possible to reach 71% of the patients. It appeared that our gold standard was very good, 93% for abdominal pain and 98% for chest pain.
Fourth, screening for psychiatric conditions was not performed. A number of nonorganic diagnoses in our patients could have been better circumscribed and defined with questionnaires such as the PRIME–MD patient questionnaire.25
We did not strive to make a specific diagnosis in patients with pain of nonorganic origin. Yet, further psychological workup and care are clearly necessary in these patients.25
With these limitations in mind, our study still indicates that an “undoubted” preliminary nonorganic diagnosis is highly precise and reliable. The specificity of 100% shows that no organic diagnosis was missed. Thus, watchful waiting with little or no additional laboratory or other investigations is appropriate in these cases.
In conclusion, this study demonstrates that the first judgment of experienced physicians based on careful patient history and physical examination alone is reliable in medical outpatients with abdominal or chest pain. Reliability increases with the confidence with which the diagnosis can be made. In patients that have been confidently diagnosed with a nonorganic cause of pain, there does not seem to be a need for additional workup. Avoiding unnecessary workup may contribute to high-quality and low-cost ambulatory medicine. Further studies to evaluate the appropriate investigations are required in ambulatory care patients with nonorganic complaints.