Fibromyalgia and the Family Doctor

The rate of correct diagnosis of fibromyalgia by family doctors, also known as primary care physicians, is reported to be steadily increasing. In a study in Israel it was found that 71% of patients that had fibromyalgia that presented symptoms to a family physician were correctly diagnosed as confirmed by a rheumatologist. However, it was also noted in the study that the rate of correct diagnosis differed based on ethnicity of the patient, which may be an important factor to consider when determining overall accuracy.1

With this being noted, there is still a great deal of ambiguity in the diagnosis of fibromyalgia within the general medical community. Many doctors use the criteria outlined by the American College of Rheumatology or ACR that was put forth in 1990. This criterion focuses in on the presence of tender points at 18 specific locations of the body. The patient, according to the ACR criteria must have experienced widespread pain over the entire body for at least three months with specific pain in 11 of the 18 possible tender points. Other doctors use symptoms only and disregard the tenderpoints. This is based on the ACR’s 2010 study that looked at alternative ways of diagnosing fibromyalgia.

Knowing How to Diagnose Fibromyalgia

The family physician that is not aware of the way to actually diagnosis fibromyalgia or that does not have an understanding of the diagnostic criteria is more likely to attempt to treat symptoms rather than look for the underlying syndrome. In a response to the study cited above specific issues were raised, such as training in medical school on clinical anatomy and rheumatic diseases as well as a better ability to provide tools to allow the patient to communicate effectively with the doctor regarding the level of pain they are experiencing.

A thorough patient history of pain and related symptoms should be completed with each patient. This includes information on the location, intensity and duration of pain, which can be assessed on a fibromyalgia pain scale. After this the doctor will actually need to complete a physical examination of the patient. If the doctor is using the original criteria, the exam would include applying uniform pressure to each of the 18 possible tender points and monitoring the patient’s level of reported pain.

There is positive information that now shows that the ACR’s modified practical diagnostic criteria can be as accurate as 88.1% without the need for a tender points examination. This survey, which includes a widespread pain index, as well as prior medical history and a physician interview of the patient, was actually more effective than a physical examination only. This criteria guide, which includes the symptom severity (SS) scale, also includes information on unrefreshed sleep, general fatigue and other symptoms. 3

One of the complications for family doctors in the diagnosis of fibromyalgia is the lack of a specific test that confirms the diagnosis. Also, patients may develop symptoms individually, and they may be treated as they occur. A family doctor that spends time looking at the history of the patient can discover a pattern of pain, muscle stiffness, irritable bowel syndrome, sleep disturbances, migraines and other symptoms, but often the pattern is missed. This can be compounded when the cost of diagnosis increases due to the request for additional tests and referrals to specialists. Patients with limited health insurance or no health insurance at all may simply be unable to access specialists or complete tests that are required to rule out other possible causes of the symptoms. However, once the diagnosis is made the cost of patient care tends to decrease dramatically, effectively saving insurance companies, patients and health care services overall.4

Changing Doctors

Unfortunately many doctors are unwilling or unable to diagnosis fibromyalgia for a variety of reasons. Although the research into this syndrome is now widely accepted and available, many medical professionals are hesitant to diagnosis syndromes since there is no specific conclusive test or any clear evidence for what causes the symptoms. There is also some indication that doctors may be under pressure from a variety of different influential groups to not accept that fibromyalgia is a syndrome and rather attribute the symptoms individually to other health issues. This may be important with private insurance companies where a diagnosis is potentially more costly to them than a non-diagnosis or simple treatment of the symptoms.5

Patients that are experiencing widespread pain, fatigue, sleep disturbances, mental fog, tender points and various other symptoms may feel that their medical professionals are not listening or don’t believe their pain and symptoms are actually present. Repeated trips to the doctor without any change in the levels, duration and severity of the presenting pain and symptoms can also cause increased anxiety as to the root cause of the symptoms. Many patients may actually begin to believe that they are exaggerating the condition or simply becoming hypersensitive to what should be “normal” pain for their age.

It is essential to get a correct diagnosis in order to limit the damage that fibromyalgia can cause physically, emotionally, socially and financially. Patients should seek out a medical professional that has experience in working with patients with chronic pain syndromes, which may be a rheumatologist or pain management specialists. Rheumatologists are often the best option as they can eliminate other types of diseases and syndromes that may mimic fibromyalgia but require a completely different treatment plan.

It is important to note that for patients with fibromyalgia, 50% of their care is done by primary care doctors. Only 16% of visits are to rheumatologists. The remaining visits are to see various other specialists such as gynecologists, psychologists, and pain specialists.

Asking your doctor for a referral to a rheumatologist or pain management specialist is an important first step. You may also be able to use online information, including searching for medical professionals in your geographic location that specialize in fibromyalgia and related syndromes. Always check with your medical licensing board before using any professional to ensure you are getting the best possible care.

References

1 Shleyfer, E., Jotkowitz, A., Karmon, A.,  et al. (2009). Accuracy of the Diagnosis of Fibromyalgia by Family Physicians: Is the Pendulum Shifting? The Journal of Rheumatology , 170-173.

2 Panchovska, M. S. (2009). Fibromyalgia and Its Diagnosis by Family Physicians . The Journal of Rheumatology , 2134.

3 Wolfe, F., Clauw, D. J., Fitzcharles, M.,  et al. (2010). The American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity. Arthritis Care & Research , 600-610.

4 Annemans, L., Wessely, S., Spaepen, E.,  et al. (2008). Health economic consequences related to the diagnosis of fibromyalgia syndrome. Arthritis & Rheumatism , 895-902

5 Wolfe, F. (2009). Fibromyalgia Wars. The Journal of Rheumatology , 671-678.

This article was originally published on July 11, 2012 and last revision and update of it was 9/7/2015