This study presents for the first time cross-sectional descriptive data on consultations with patients with persistent MUPS in Norwegian general practice. A consultation prevalence rate of 3% suggests that patients with persistent MUPS are common when compared to other reasons for encounter. Musculoskeletal symptoms were the most frequent symptom pattern, followed by asthenia/fatigue. Almost 45% of the patients were working. About 2/3 of the GPs offered supportive counseling at the actual consultation.
Strengths and limitations
Our study is strengthened by the naturalistic setting and the rigorous case definition, which was carefully described, also through a clinical vignette during personal meetings. Our case definition resembles definitions used in previous research
[12, 13, 15]. The prevalence in this study is on MUPS patients as perceived by Norwegian GPs and not a prevalence of MUPS in the general public, and due to the study design one patient may have been registered several times, which may influence the results. We believe however this not to be very likely and does not affect the prevalence rate, as this is still a prevalence of MUPS consultations in general practice.
Our design did not allow for inter-rater-reliability checks of the GPs’ assessments. As mean duration of a GP-patient relationship in Norway is 7.7 years
, we may assume GPs to easily recognize eligible patients due to their knowledge about their patients. Data collection based on digital patient records or interviews may represent larger sources of bias, due to lack of a specific MUPS-diagnosis, incomplete medical records or interviewer’s lack of personal knowledge of the actual patients.
Sample bias was reduced through an overall representative sample of GPs-, indicating that the results may be generalised to a comparable setting. However, more participating male GPs may underestimate the consultation prevalence since female GPs see more female patients, and, due to gender effects on communication, they may see more patients with MUPS
. GP based prevalence estimates are found to be consequently underestimated
[15, 26], but this may also indicate registration of symptoms of less clinical significance, which we did not intend to include in this study.
A response rate of 53% is modest, although higher than other surveys of GPs on MUPS
[27, 28]. Furthermore, our sample seemed to be fairly representative for Norwegian GPs.
Possible source of information bias may be due to incomplete recordings due to GPs busy workday
[29, 30] resulting in ignored eligible patients (consultation prevalence underestimated), or a non-compliant attitude to the actual instruction due to an eager to participate because of professional relationships with the first author (skewing possible for both directions). The GPs in the area received various reminders and information about the study. How this may have influenced the registration is unknown
. On the other hand, personal and extensive study information may have raised the actual quality of the collected data.
Only 32% of the patients in our sample were on sick leave. This finding seems to oppose previous research
 by suggesting that previous assumptions of high level of disability among patients with persistent MUPS needs revision. However, as loss of function was a criterion for eligibility in the study, we can only assume that that these patients met this criterion otherwise than being out of work.
Comparison with existing literature
A consultation prevalence rate of 3% suggests that patients with persistent MUPS are common in general practice when compared to other frequently occurring conditions like hypertension, atrial fibrillation, diabetes mellitus, and depression, each accounting for 1.3-4.9% of the consultations in Norwegian general practice
. A recent retrospective study from primary and secondary care in US
 presented exactly the same consultation prevalence for persistent MUPS by use of a similar case definition, and a Dutch study from primary care found a prevalence of 2.45% on persistent MUPS
More women (76%) than men in our sample suffered from MUPS, consistent with prior studies
. However, we should keep in mind that doctors tend to categorize female patients more easily as somatizers than male ones
 and that this may be the same for patients with MUPS as we do not see persistent MUPS as synonymous with ‘severe somatization disorder’
In contrast to findings from a similar study we found linearity between number of patients with persistent MUPS and total number of consultations at the individual GPs
. Musculoskeletal symptoms were the most frequent MUPS symptom pattern in our study, followed by asthenia/fatigue. These findings diverge from a recent study where asthenia/fatigue was leading among patients with persistent MUPS
. However use of different case definitions may contribute to this difference, and with knowledge of substantial co-occurrence for these symptoms, this finding may be of less clinical importance.
An important overall finding challenges the stereotypes of patients with persistent MUPS. In our study, this group of patients is heterogenous - a quarter are men, a quarter has higher education, a third is below age 40, and nearly half of them work. This highlights the need to refrain from unsubstantiated stereotyping of “MUPS-patients”.
Our finding of a scarce prescription rate complies with recommendations that medication should play a minor role in medical management of MUPS
[37, 38]. Our case definition implied prior appropriate diagnostic evaluations, but still we found that one out of five patients received further referrals. This may illustrate GPs feeling of shortcoming in managing these patients, and a lack of knowledge of what these patients’ actual want and need
[39, 40]. Furthermore, it may illustrate a limited awareness among the GPs about potentially iatrogenic harms trough additional interventions
. However, actual lab test and referrals in the registered MUPS consultations may represent adequate management of other co-existing diseases or presentation of new symptoms, which may represent new disease.
Levels of supportive counseling at the GP encounter will probably vary according to structure of health care system. In a study from US, 37% were referred to different mental health care center
, reflecting possible differences in therapeutic cultures. It seems like Norwegians GPs more often provide supportive care themselves rather referring to secondary care.