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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Unexplained symptoms or incomplete History and Physical
- Carlos A Selmonosky (1 April 2001)
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?time for a joint primary and secondary care initiative
- Rhiannon England (7 April 2001)
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An alternative view
- John Adam (8 April 2001)
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Medically unexplained vertigo
- Anonymous (9 April 2001)
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In-patients with "medically unexplained" gait disorders
- Evangeline Wassmer (10 April 2001)
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Unexplained symptoms, but not inexplicable
- B J Sweetman (12 April 2001)
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Carlos A Selmonosky Gilmer Medical Center
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If abuse,entrapment neuropathies like thoracic outlet syndrome or peroneal nerve entrapment,and tests for H.Pylori are look for in ALL patients,the number of unexplained symptoms will likely decrease. |
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Rhiannon England, GP Principal Statham Grove Surgery. London N16 9DP
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Editor- as a GP, I was pleased to read the article and editorial in this week's BMJ concerning medically unexplained symptoms in secondary care. This despite the rather patronising reference to our "considerable discomfort in managing these patients". GPs manage these patients rather better than consultants in out patient clinics, and without wasting large amounts of money in unnecessary, and often repeated investigations. However, I think it is correct to say that these patients are very difficult to manage and often GPs will refer realising that the likelihood of any organic pathology being present is small. It would be helpful if referral letters were informative about any other factors that the GP felt were relevant, and it should be routine that such patients are referred back to the GP and not referred on to the specialist in an adjoining out patient clinic. I feel GPs do look for alternative explanations such as depression, but often these patients are reluctant to look at the connection between somatic symptoms and emotional problems. The reasons for this may be complex and certainly, in my practice population, cultural factors are important. In our practice we are targeting frequent attenders, especially refugees, and inviting them to consultations where we specifically look at possible reasons for somatisation, and explore mind-body connections. It's too soon yet to say whether burn out will hit us before we get anywhere, but acknowledging the problem may help us stop concentrating too much on a medical model of disease which obviously does not work for this group. As was stated in the article by Reid et al , the cost to the NHS is enormous. Perhaps it is this fact which will ultimately drive further research. Rhiannon England |
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John Adam, Principal - Broadgate Chiropractic Clinic London England
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Backpain and headaches are quoted as two of the commonest complaints causing concern. Chiropractors have any enviable record in the treatment of both these complaints. I would draw your attention to the following:
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Anonymous
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The identity and address of the writer are known to the editorial staff. Dr. X requested anonymity to avoid the prejudice of colleagues who believe that there is no smoke without fire. I wonder just how many of the medically unexplained symptoms recorded by Reid et al reflect negligence? They claim that all cases had completed a thorough investigation but how did they define ‘thorough’? Did the patients have every routine test as well as more specialist investigations at other centers? Or was it sufficient to have all the routine tests? The authors also state that they required the suggestion of “psychosocial reasons” but did they check who made the suggestion and on what basis? I developed vertigo five years ago after a minor cold. I had countless blood tests (calcium, Hb, thyroid etc), a neurological examination plus a MRI scan of the brain. When everything came back negative, my GP and neurologist suggested that perhaps my vertigo was psychological. It wasn’t, but they did not believe me. I would have pressed for vestibular tests but I also had a lump in my breast and that took precedence. Having recovered from the various operations, I returned to the neurologist. I felt that without vestibular tests, he should not have speculated about somatisation disorder or anorexia (I’d lost weight in the acute phase). He promised to consider further testing but after three months, decided that he was satisfied with the minor improvement in my condition and discharged me. (I was still virtually unable to walk, couldn’t shop or work and was often in bed not even able to move my head). As far as he and my GP were concerned, the problem was primarily psychological and nothing I said would change their minds. Four years after onset, the Health authority allowed me to see a well-respected professor with an interest in post-viral syndromes. He repeated the neurological exam and on the basis of those findings alone, pronounced I had vestibular damage. I don’t know why the other doctors had missed the nystagmus etc. I don’t know why no one did a scan of my neck or ears. I don’t know why I was denied vestibular tests for four years. I’ve got a few clues though. One doctor told me that psychologists know how to manipulate and therefore they do. (Never quite followed the logic of that). When the suggestion of the anorexia came up, I pointed out that I’d lost the weight after the onset of the vertigo, but my GP didn’t want to discuss the matter. In fact, I didn’t fulfil any of the criteria for anorexia, I was horrified at the loss of weight and had said so at the time, I hate vomiting and anyway, middle aged shrinks with anorexia are as common as consultant neurologists caught robbing banks. Ignoring my occupation, she duly informed me that all anorexics deny their illness and that competent physicians wouldn’t trust the word of 15 year old adolescent. (I was 44 at the time and when we had this conversation, I had regained 3 kilos). Thinking back, I suspect the ‘suggestion’ of a psychological aetiology was coloured by my gender (female), my stature (short and slender) and my former occupation (psychologist\psychotherapist). So much for evidence-based medicine. The point of this letter is that if a reasonably assertive health care professional like myself can’t get anyone to investigate her symptoms thoroughly, then perhaps a less assertive layperson may encounter even greater problems. In view of my experience, I think that in a significant number of cases, ‘medically unexplained’ just means that certain routine tests were negative. Other influences which may affect how thoroughly people are assessed include sexism, racism, ageism, and the peculiar fondness by some doctors for cheap and cheerful psychiatric explanations which make Dot Cotton sound like Einstein. Finally, let me note that my breast surgeon knew more about post-infectious, chronic vertigo than either my GP or the neurologist. He and the professor reminded me that there are a lot of good doctors about; and that I was just unfortunate. However, I’m not the only one. Having talked to other sufferers, I know that there are too many neurologists in the UK who still think that everyone recovers from viral labyrinthitis within three weeks and that if it lasts a little longer and the routine tests are negative, then the patient is probably suffering from somatisation, depression or hypochondria. Four years of medically unexplained vertigo plus the suggestion of SD and anorexia greatly undermined my self-confidence as well as my trust in British neurologists. What happened to me was very distressing and totally unnecessary. I accept that the concept of medically unexplained symptoms has its uses but please resist the temptation to ascribe them to psycho-social causes. If a patient disagrees with the suggestion, he or she may actually be right! |
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Evangeline Wassmer, SpR Paediatric Neurology Birmingham Children's Hospital
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Dear Editor, We read with interest the paper on medically unexplained symptoms in secondary care1 . The authors found 21% of 971 outpatient consultations of frequent attenders were medically unexplained. Many children are admitted to our hospital with an acquired gait disorder, some have a definite underlying physical cause and some are idiopathic. We too attempted to estimate the incidence and impact of idiopathic gait disorder ("medically unexplained")in a children’s hospital providing secondary and tertiary care. We evaluated prospectively all the children admitted with a gait disorder requiring physiotherapy treatment at Birmingham Children’s Hospital, using a standardized pro-forma, during a three-month period between March and June 1999. 103 children (57 female), aged 2 to 16 years were admitted with gait disorders. Eight had an idiopathic gait disorder. All eight children exhibited significant functional impairment, pain and school absence. Idiopathic gait disorder accounted for 8% of children admitted to hospital with an acquired gait disorder. The economic and social impact of these disorders is therefore substantial, especially with regard to diagnosis, investigations, treatment and school absence. E. Wassmer
1.Reid S, Wessely S,, Crayford T., Hotopf M. Medically unexplained symptoms in frequent attenders of secondary health care: retrospective cohort study BMJ 2001:322:767-9 |
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B J Sweetman, Consultant Rheumatologist Morriston Hospital, Swansea SA6 6NL
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Editor : Half a century ago (1) it was noted that ... "patients had consulted specialists because of painful syndromes in the thorax and abdomen .. rather frequent cases in which the radiating pain (from the back) is considered as forming part of a visceral syndrome." I am sure that there must have been similar observations from earlier. Reid, et al (2) indicate that back problems continue to cause diagnostic difficulty to this day. However, they also found that chest and abdominal pains can go unexplained and I quote Forestier, et al above (1) in order to suggest that some of these problems may also emanate from the back. The leg twist test (3) can sometimes indicate involvement at the dorsolumbar junction in the spine when it is the least expected. Reid also included unexplained headaches as a cause for frequent health care attendance and it is well recognised that the neck can also be a source of such problems (4). It seems reasonable to suggest that somebody somewhere along the line should take responsibility for checking if the back or neck could explain the source of the symptoms. It is often easy to give reassurance as the preceding specialists have often excluded problems in the region where the referred pain has been projected. Where symptoms go unexplained there may also be a tendency to ascribe questionable labels such as fibromyalgia (5). Perhaps the greatest reduction in the number of "the unexplained frequent attenders" could be gained by detailed examination of the back and neck. REFERENCES: 1 Forestier J, Jacqueline F, Rotes-Querol J. La spondylarthrite ankylosante (1951) Masson & Cie. Translated as Ankylosing Spondylitis by Desjardines AU, (1956). Charles c Thomas, Springfield, Illinois; Ryerson Press, Toronto; & Blackwell Scientific, Oxford. 224-225 2 Reid S, Wessely S, Crayford T, Hotopf M. Medically unexplained symptoms in frequent attenders of secondary health care : retrospective cohort study. BMJ 2001; 322:767-769 3 Sweetman BJ. Low back pain and the leg twist test. J Orthop Med 1998; 20:3-9 4 Sweetman BJ. Whiplash : A double injury. J Roy Soc Med 2000; 93:337 5 Sweetman BJ. Fibromyalgia ... I mistake your shape. Rheumatology 2001; 40:239 |
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