When Symptoms Remain Difficult: A Clinician’s Guide to Communication

Doctor and patient talking together in a calm consultation — Open, respectful conversations can help patients and clinicians agree what to do when symptoms remain difficult.

Ideas for clinicians when a patient has a diagnosis, but symptoms remain distressing or difficult to manage. This article grew out of an online meeting where people living with aspergillosis discussed how difficult it can be when symptoms remain troublesome and they feel their experience is not fully understood. The suggestions below draw on that patient discussion and published guidance; they are intended to support reflection, not to judge individual clinicians.

A patient may continue to struggle even when their diagnosis is known, investigations have been completed, or treatment has been tried. Sometimes there is no clearer explanation to offer, or no new treatment likely to make the symptoms go away.

That can be a difficult moment in a consultation. A patient may worry that they are not believed. A clinician may worry that discussing stress or mood will sound dismissive—or feel pressure to provide an answer that medicine does not yet have.

The conversation can still be useful. It can acknowledge the impact of symptoms, explain what is known and uncertain, and agree what happens next.

Start with the impact

Symptoms are only part of the patient’s experience. It also matters what they prevent, what they make harder, and what it costs the person to keep going.

A patient may still be working, socialising or caring for others, but need to rest afterwards or be unable to repeat the activity the following day. They may look well in the consultation while describing symptoms that disrupt sleep, concentration, relationships or daily routines.

Questions such as “What is hardest to manage at the moment?”, “What happens after you’ve pushed through?” or “What would you most like me to understand?” can help bring that impact into the conversation.

Acknowledging the impact does not require certainty about its cause. It shows the patient that their account has been heard.

Explain what is known and what remains uncertain

When tests do not reveal a new cause, patients may need a clear explanation of what has been considered, what the results show, and what they cannot tell us. Saying “I don’t have a better explanation today” can be more reassuring than offering a tentative explanation as if it were certain.

“I can see these symptoms are still affecting you. We haven’t found a new explanation in the tests we’ve done. That doesn’t mean I think nothing is wrong. Let’s talk about what we can do now and what should prompt us to review things.”

The wording will depend on the patient and the clinical situation. The aim is to make sure uncertainty does not sound like disbelief.

The General Medical Council’s Good medical practice asks doctors to listen, acknowledge patients’ concerns and experience, explain uncertainty, and encourage open dialogue about health. It also recognises the lasting impact a medical professional’s approach can have on a patient. NICE guidance on patient experience in adult NHS services similarly emphasises involving people in discussions about their care and respecting their needs and preferences.

Discuss mind–body effects without blame

Stress, sleep, mood and the demands of living with a long-term condition may affect how symptoms are experienced and managed. Physical symptoms can also cause stress, disrupt sleep and affect mood. These influences can interact.

Raising them need not suggest that symptoms are imaginary or “all in the mind.” A clinician might ask permission and explain why the topic could be relevant:

“Would it be okay if we also talked about sleep, stress and mood? These can interact with physical symptoms, and understanding that may give us more ways to support you.”

Patients may welcome this conversation, feel uncertain about it, or have previously felt dismissed when psychological factors were raised. Making space for their response—and continuing to consider their physical health—can help preserve trust.

Agree what happens next

Even when there is no new treatment to offer, the appointment can end with a shared plan. Depending on the situation, that might include:

practical support for managing symptoms and their impact
whether treatment, medication or other support should be reviewed
what changes the patient should report or seek help for
when to review the situation
who the patient should contact if things change

A plan does not have to promise that symptoms will resolve. It gives both people a way to keep responding if they do not.

What does the research say about communication?

Research on persistent physical symptoms and symptoms without a complete medical explanation is relevant to these conversations, but it does not map perfectly onto every patient with an established diagnosis. It should inform the discussion, not define the person.

A 2022 systematic review examined communication interventions for symptoms often described in the literature as “medically unexplained.” It found the evidence was mixed and limited by differences in the interventions and the quality of studies. The authors recommended further development of communication approaches before more trials are undertaken. This means a conversation aid such as a patient-completed appointment note may be worth developing and evaluating, but should not be presented as a proven intervention. Read the review.

In a qualitative study, patients identified acknowledgement and validation, along with specific recommendations, as helpful parts of communication about persistent symptoms. Read the study. A clinical review by Husain and Chalder discusses assessment and management of persistent physical symptoms and emphasises that symptoms are real and can be distressing. Read the review.

Keep listening

Clinicians work within real limits, including short appointments, complex records and uncertainty about what might help. Patients may also find it hard to describe fluctuating or invisible symptoms, particularly if they have felt dismissed before.

Listening carefully, explaining decisions and making the next step clear cannot guarantee agreement or solve every problem. But they can help keep the relationship intact when there is no easy answer. The aim is for the patient to leave knowing that their concerns have been taken seriously, what remains uncertain, and what will happen next.

This article offers general communication ideas, not clinical guidance. It draws on patient discussion and published resources; it should be reviewed by a clinician before publication.