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Rapid Responses: Rapid Responses published:
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CMFSS in primary care
- david baker (10 August 2002)
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CMFS is an Overdiagnosed Complaint - Examine physician symptoms!
- Barbara R. Rubin (10 August 2002)
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A little honesty goes a long way.
- Gurli Bagnall (11 August 2002)
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Through the looking glass
- A. Chaudhuri (12 August 2002)
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Careful and Accurate Diagnosis Required
- Jennifer J Watkins (12 August 2002)
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Fat Files
- James F Roache (12 August 2002)
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Refiguring psychological medicine: the need for complexity and post normal science.
- Vivian S Rambihar (12 August 2002)
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Falling through the holes in holism - into the gap between head doctors and body doctors.
- David Reilly (14 August 2002)
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Frequent attenders
- James Norman Hardy (3 September 2002)
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Frequent attenders: the practitioner’s everyday life hell.
- Francesco Carelli, Ferdinando Petrazzuoli, Filippo Daddio and Alfonso Sauro (14 May 2003)
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Re: Frequent attenders: the practitioner’s everyday life hell.
- Roxana L Tiscareno (14 September 2003)
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david baker, GP
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I have just read the rapid responses to last week's article, & I'm afraid this is going to be dull in comparison! All the articles so far have been excellent in providing clear thinking in a confusing area of general practice, IMO. As regards this week's article, I'd like to ask how 4% of the general population translates into 10-15 patients per GP? We draw our lists from the general population, and a typical list for a full-time GP would be 1800. 4% of 1800 is approximately 70 patients. The outlined management plan for primary care is a good one, but difficult to deliver with currrent pressures in general practice ( for 15 patients, let alone 70). This is a shame, since it should be a more cost & time effective approach in the longer term. David Baker |
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Barbara R. Rubin, disabled by pesticide poisoning New York City, 11560 - Free Lance writer
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To the Editor, Bass and May, cite a frighteningly high percentage of persons whom they feel qualify for a diagnosis of "chronic multiple functional somatic symptoms". There is no doubt that such a diagnosis will fit certain individuals. However, the criteria used for making this determination was as follows: "Potential CMFS patients may be identified simply by the thickness of their paper notes, from records of attendance and hospital referral, and by observation of medical, nursing, or clerical staff." I suggest that in a significant number of cases, this paragraph should be rewritten to read as follows: Potential doctors of patients who will ultimately receive diagnoses of CMFS, may be identified by short attention spans for reading thick charts, heavy patient loads with brief appointment slots, a strong reluctance to write justifications for referrals to annoyed HMO organizations sending them checks and a near complete absence of scientific curiosity for the unfamiliar. The physician may have an unreasonable fear of litigation, despite the fact that some ailments have their roots in negligence on the part of employers or third parties involved in the work setting. In the U.S., where it is illegal to charge a patient for having an illness of occupational origins, charts may be surprisingly bare of certain diagnostic and historical facts. Few doctors will wait for the worker's compensation board to review a case in five years to obtain a minimal fee. This is understandable but places the patient in the position of forgoing appropriate medical care as well as justice in injury cases. ******* Perhaps this may seem harsh to the many dedicated, overworked physicians who are, after all, taking the time to read this journal for their continuing education in a terribly stressful occupation. However, no practitioner can be educated in the nearly unlimited array of illnesses and injuries that can befall the human being. Our age is littered with advanced technologies such as chlordane and phalates that do the tasks for which they were created - at a cost only counted later when the science behind the technology catches up to our marketing style. Sell first, examine later. Life is often stressful, so pointing a finger at stress can be a "saving grace" for a doctor reluctant to further investigate vague or multi-system complaints. CMFS may be an unfair assumption often leaped at prematurely to ease the burden of guilt carried by doctors who find themselves unable to help a sick individual. Some doctors, unsure of themselves, may be reluctant to contradict other doctors previously consulted. I watched one man struggle for nine years with debilitating illness only to learn he had hypoglycemia when a doctor finally prescribed a glucose tolerance test. His thick chart became bare of new entries as he enjoyed the best of health for the next twenty years with only a special diet as a prescription. Another patient developed a variety of gastro- intestinal complaints, neurological problems and respiratory symptoms which all appeared to wax and wane depending upon environmental circumstances. Five physicians later, a neurological evaluation revealed brain damage and toxicological testing indicated chronic cholinesterase inhibition - classic signs of organophosphate pesticide toxicity which should be familiar to British physicians in rural areas. She was considered a resistant patient due to her refusals to take offered medications which only exacerbated her symptoms. The statistic of 6 percent brings to mind the percentage of British and American Gulf War veterans suffering from similar, "mysterious" complaints so long denied as having a basis in organicity. No matter the findings of researchers indicating that many have CNS and immune system damage or that some belong to a class of individuals prone to toxicological insult (low paroxonase levels). No matter that peers in the French armed forces, not subjected to multiple experimental immunizations, showed a more normal rate of disability post-service. Perhaps it is immaterial that six percent of the population of California has been diagnosed with chemical sensitivities, a disorder with multiple correlates in the diagnostic codes of the ICD-9 (for example, 989.9, Toxic Effects of Chemicals). Most persons with such a diagnosis are told for years they have some form of CMFS that worsens with administration of multiple medications. Anecdotal evidence is an essential part of such diagnoses, a "test" which doctors are afraid to interpret freely. What is most important to remember is that the diagnostic criteria used by psychologists and psychiatrists are frequently anecdotal in nature. Yet when patients show patterns typical of certain complex ailments and attempt to partner their doctors in identifying an illness based upon the anecdotal experiences of other patients. they are deemed "absorbed by their illnesses". Reminder: When a patient sees a doctor, they are there for the sole purpose of discussing their health. At $200 per hour, few will show their well-rounded natures by discussing sports or politics. Doctors and patients must all be accepting of the limitations of knowledge; that no doctor is appropriate for all patients who will enter their doors and that some ailments can only be discovered over time with extensive investigation. A diagnosis must never be based upon frustration, wishful thinking or a fear of legal systems which may become involved when appropriate. This is submitted with respect for the unique partnerships required in the doctor-patient relationship. In particular, this is submitted with respect for those physicians who discuss such conclusions honestly with patients instead of making vague pacifying promises of aid that will never materialize. Sometimes the sentence, "I do not know how to help you." may be the most appropriate. Barbara Rubin
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Gurli Bagnall, Patients' Rights Campaigner
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Bass and May paint a vivid picture of the dislike and contempt many practitioners feel for their “heartsink”, “difficult” and “fat folder” patients, who evoke in them “despair, anger and frustration”. The difficulty they have in suppressing these emotions to avoid official complaints (as advised by Bass and May), is not hard to imagine. But really, whether or not Fat Folders evoke these feelings, is in the hands of the doctors themselves. The attitude that says, “Don’t argue with me! I am the expert!” does not necessarily win friends and influence patients. All that need be said, is, “I can see you are in pain, but I don’t know what is causing it.” A little honesty goes a long way. I refer, of course, to the clinical review entitled “Chronic multiple functional somatic symptoms”. It is alarming that the incidence of this newly named condition has reached epidemic proportions (over 4% of the general population), and following the very best of medical/male tradition, we were told that most of those affected, are women. Bass and May are apparently unaware that the finest example of “illness beliefs”, “perceived illness”, and “hysteria” are traditionally seen in men who have taken to their beds with the common cold. Women generally soldier on, for who else will look after the children and prepare the meals? Iatrogenic harm is a subject generally considered taboo by the profession, but it has been mentioned in articles such as “Chronic multiple functional somatic symptoms” of late. In this context, it serves to highlight two issues: (1) Quote: “It is also necessary to encourage them to concentrate on coping rather that seeking a cure.” The implication of this extraordinary statement, is that in going from doctor to doctor seeking a cure, iatrogenic harm is an almost inevitable outcome, but an outcome for which no doctor can be blamed. (Blaming the patient is, of course, another “fine” tradition.) (2) This argument serves to consolidate the notion that if an investigation for possible physical disease must be made (for the sake of appearance?), then it should be no more than superficial. From the patients’ point of view, they’re damned if the do, and damned if they don’t. If they do nothing to find explanations and relief, then they are castigated for not making an effort. If they make an effort, then they are castigated for being medical nuisances. The recommendation that patients should be reminded of “the limits of medicine” when they have “unreasonable expectations”, is so far removed from reality, it is laughable. It is the rare doctor who admits to such limitations for it destroys the illusion of medical omnipotence. The already mentioned attitude, “Don’t argue with me! I am the expert!” is the norm, and one of which the patient needs no reminding. Having admitted to the limits, however, they do raise an interesting point. How can Bass and May be so sure of their stance? There are no ifs, buts or maybes. The article is not based on anything even vaguely resembling science; at best it is opinion, and at worst, it is self- serving. I doubt an observer would be impressed with the interpretation the authors put forward to explain a patient’s comment: “It’s disgusting what doctors can do to you.” Quote: It “may suggest that the patient’s relationship with the doctor may reflect poor quality parental care or emotional deprivation in childhood.” To an observer, this definition is more likely to suggest that the doctor is trying to absolve himself from the responsibility of some dastardly deed. It is regrettable that no consideration was given to the despair, anger and frustration of patients who are affected by “the limits of medicine”. Regrettable, yes, but not surprising, for it compounds the feeling that Bass and May place the comfort and wellbeing of practitioners first, and that of the patients last. The authors established that CMFS exists in epidemic proportions, and one assumes that the included 15 year summary is an example of a typical case, yet in the conclusion they state: “Patients with multiple long- standing functional symptoms are relatively uncommon.” Apart from anything else mentioned here, I always feel uneasy about the validity of any paper that is not consistent. Gurli Bagnall, Patients’ Rights Campaigner, New Zealand |
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A. Chaudhuri, Clinical Senior Lecturer in Neurology University of Glasgow
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Bass'and May's review of "chronic multiple functional somatic symptoms" (CMFSS) deserves a few comments. The authors have essentially proposed two diagnostic criteria for CMFSS: first, the "thickness of patients' paper notes" and second, observations of the medical and non- medical health service staff (presumably overriding the observations made by patient’s own family members or his/her relatives). I congratulate the BMJ, the editors of this review series and, of course, the authors, for introducing a novel use of the measuring tape in clinical medicine. My only suggestion is that it would be very useful to know the numerical “cut -off” for the case note thickness for the purpose of referral to the psychiatry unit and perhaps the GPs ought to be advised to mention this at the time of referral of their presumed CMFSS patients to the specialist service, e.g. “Thank you for seeing this patient with case note thickness of little over three and three-quarter inches”. Am I being facetious when I say this? In my practice, the thickest case notes occasionally belonged to patients who were treated in the psychiatry units for considerable length of time for what was later discovered to be a neurological disease. To me, the statement that nearly one out of every ten patients admitted to the tertiary care have CMFSS also appears rather exaggerated. Even if there are published data to support this figure (which have not been cited), I suspect that the assessment might have been prone to selection bias. More surprisingly, however, Bass and May fail to mention that follow-up studies at the academic centres of patients diagnosed to have functional disorders did reveal a staggering misdiagnosis rate of 20-40% in the past.[1] The most common errors were failure to identify diseases like systemic lupus erythematosus (SLE), paroxysmal and demyelinating neurological disorders. Staff in most tertiary care units will be able to recount the tale of a “functional” patient in the ward who became critically ill or died all too suddenly. Could the authors please provide a statistics for this initial misdiagnosis for the sake of comparison? I have also some concerns regarding the broad stereotyping of patients (women, substance misusers and childhood abuse) in the context of applying the diagnosis of CMFSS. Epileptic seizures (with or without pseduoseizures) may arise from brain injury sustained as a result of childhood physical abuse. SLE is more common in women. Organic neurological diseases after substance abuse are too well recognised. It is also incorrect to assume that symptoms developing after a major psychological trauma is invariably due to CMFSS. For example, studies have repeatedly confirmed that there are changes in brain MRI and symptom severity in patients with central nervous system demyelination after stressful “life events”. In this review, we have been provided with the history of a single illustrative case and the picture of a single patient (Charles Darwin). Darwin might or might not have had CMFSS and I shall not comment on this example, and leave this task to the competent medical historians. Referring to the “15 year segment” in the illustrative case history of a woman with CMFSS, there appears to be a few inconsistencies. I think it would be disingenuous to question the diagnosis of acute appendicitis made by a GP and confirmed by a surgeon in this woman and the normal outcome does not contribute materially to the diagnosis of CMFSS. The second life event, an unwanted pregnancy, is certainly stressful but in itself, does not constitute a feature of CMFSS unless it was a pseudopregnancy. Thus, the record of “medically unexplained symptoms” in this case is not 15, but of 10 years duration. Without questioning the diagnosis of CMFSS here, I would humbly suggest that the excellent response of pain to a very modest dose of amitriptyline is not something I have frequently seen in patients with somatising chronic pain who, on the contrary, are invariably resistant to such a simple measure, just as patients with pseudoseizures are refractory to common anti-epileptic drug therapy. In addition, based on the history provided here, I was unable to identify the features of recurrent depressive and/or personality disorders [2] that the authors highlight as important associations of CMFSS: indeed, 50 mg of amitriptyline is a grossly subtherapeutic dose for depression. I am sure that there are far more compelling examples of somatoform disorder in everyone’s experience and I wonder if the authors and the editors wanted to be deliberately provocative with this example merely because the patient had made a self-diagnosis of myalgic encephalomyelitis and had joined a self-help group to seek assistance. In any case, I would be equally interested to know the follow up in the second 15 year segment of this patient’s life (1986-2000) because surely her response is important in evaluating the efficacy of psychiatric input in CMFSS. This commentary is already long enough and I would like to conclude with one final point. The authors have introduced an inconveniently long term and yet another new acronym (CMFSS) to describe what would be otherwise diagnosed as somatoform disorders in current clinical practice. [2] After all, the purpose of any diagnostic classification and terminology is to increase understanding of the condition for the purposes of treatment. Just as most medical and psychiatric syndromes have both organic and psychosocial aetiologies, so will most of the therapies applied. [3] I am uncertain from reading this review if the introduction of “CMFSS” offers an advancement in our current understanding or management of the somatoform disorders. Which do you think it was? [4] References: 1. Chaudhuri A. The role of neurodiagnostics in functional disorders. In: Zasler ND, Martelli MF(eds). Physical Medicine and Rehabilitation: State of the Art Reviews ,vol 16, No.1 (Functional Disorders). Philadelphia, Hanley & Belfus Inc. 2002; pp 63-75. 2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (4th ed). Washington DC: APA, 1994. 3. Miller L. What is the true spectrum of functional disorders in rehabilitation? In: Zasler ND, Martelli MF(eds). Physical Medicine and Rehabilitation: State of the Art Reviews ,vol 16, No.1 (Functional Disorders). Philadelphia, Hanley & Belfus Inc. 2002; pp 1-20. 4. Carroll L. Through the looking glass, and what Alice found there. London: McMillan & Co., 1872. |
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Jennifer J Watkins, Registered Nurse Hawkes Bay District Health Board Hastings New Zealand
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The use of terminology such as "fat folder patients", "chronic complainers" etc should not be used with people with chronic multiple functional somatic symptoms or any patient. It is misleading to suggest that just because a patient who has extensive case notes is more than likely to have CMFS. As with any patient it is important to write factual, non misleading information in order to facilitate correct diagnosis, avoid loss of faith in their doctors, and avoidance of complaints. The behaviour of the clinician is important as they must be professional at all times. It is important that clinicians actually listen to the patient and record actual comments and not preconceived ideas. If interviewing a partner or reliable informant then informed consent by the patient must be given in order not to breach privacy. It needs to be remembered that just because a patient has seen a number of doctors does not mean they have CMFS. Careful diagnosis is required. |
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James F Roache
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Any doctor, and there are many, who cannot comprehend these conditions and update their treatment/management approaches accordingly is on par with physicians of old who did not believe that "invisible" infections were responsible for deaths at child birth. Scientic method is meant, I had thought, to prove an hypothesis, not a fact - that these conditions exist and present symptoms. Or is the WHO deluded while overly consersative physicians are the repositorities of some archane way of ignoring what lies squarely in front of their noses? This situation would be laughable were it not for the fact that so much needless suffering results from medicine's inability to accept that there are some things it cannot understand which are nonetheless real. Ignorance, arrogance and cynicism make for an ugly combination in a healer. While we expect this from insurance companies, it tries one's patience to experience it from doctors. |
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Vivian S Rambihar, Cardiologist The Scarborough Hospital, Toronto, Canada.
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Refiguring psychological medicine: the need for complexity and post normal science. The article by Bass and May (ABC of psychological medicine: Chronic multiple functional somatic symptoms, BMJ 2002; 325: 323-6) raises some more fundamental issues. Our understanding of health and disease relies on the science of the day for explanations. Science is changing and so should medicine and health. Normal science, based on a mostly reductionist linear scientific method building on established evidence is further improved by a post-normal science which adds diversity, multiple perspectives and complex dynamics (1-5). Funtowicz and Ravetz have described this post- normal science as "based on the assumptions of unpredictability, incomplete control, and a plurality of legitimate perspectives." With ideas derivable from chaos and complexity science, it also throws into question the meaning of causation and hence the pathophysiologic basis for symptoms, illness and disease. (3,4). One of the reasons we have such difficulty with chronic fatigue syndrome is that we are constrained by an old science. Using ideas from post-normal science in this area of uncertainty may resolve some of this dificulty. With normal science, if a clear abnormality that can explain symptoms is not perceived, then the validity of the symptoms and any explanation of possible cause are questioned. With post-normal science, convincing symptoms with no current explanation are accepted and our ability to understand and explain is what is questioned. All of psychological medicine, as all of medicine, health and disease, should be refigured using post-normal science (2-5). In discussing this with regard to psychiatry, Laugharne and Laugharne (5) note that postnormal science, which is linked to chaos and complexity theory, requires that science expand its boundaries to include different validation processes, perspectives and types of knowledge. Integrating this newer perspective with traditional scientific thinking will retain the complexity inherent to health, illness and our everyday experiences, and may help us to offer better explanations and better care to our patients. 1. Funtowicz S, Ravetz J. Science for the post-normal age. Futures. Sept 1993;25: 739-755. 2. Kernick D, Sweeney K. Post-normal medicine. Fam Pract 2001 Aug; 18(4):356-8. 3. Rambihar VS. A new chaos based medicine: the response to evidence. Vashna Toronto 2000. 4. Rambihar VS. A new mathematical (chaos and complexity) theory of medicine, health and disease: refiguring medical thought in “A New Chaos Based Medicine: the response to evidence.” VS Rambihar, Toronto 2000 Vashna Publications. Available at http://www.complexityprimarycare.org/Rambihar.PDF 5. Laugharne R, Laugarne J. Psychiatry, postmodernism and postnormal science. J R Soc Med 2002 Apr; 95 (4); 207-210. |
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David Reilly, Consultant Physician & Honorary Senior Lecturer in Medicine Academic Departments, Glasgow Homoeopathic Hospital, 1053 Great Western Road, G12OXQ, Scotland..
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I know from experience that the sort of principles touched on by Bass and May (1) can help, and sometimes even transform patients with ‘chronic multiple functional somatic symptoms’. But I would go further and suggest that these principles are every bit as useful in people with organic problems as much as functional ones, and a failure to apply them can sometimes be the actual cause of the thick case notes, and the on going distress, be it in the person’s minds or body or some other dimension of the self. What ever the cause, distress and unwellness that persists despite medical care will lead to too many doctors (orthodox or alternative) and so too many treatments, and ever thickening case notes. In the end off course some will prove to be missed organic processes, some missed psychological processes, (and some doctors specialise in not seeing one or the other), and in many, perhaps most, there will be an interactive complexes of these. So if I could put aside that important aetiology debate for a moment, I would like to say that by what ever route they got there, by the time a patient is in this predicament, they offer us a mirror of their previous medical journey, and what is reflected is often not good. Like canarys’ fading down the mine of medicine, people in this situation confront us with our own and our systems failings, and these are often a failure to apply the many basic truths of good care that Bass and May describe: Strive to see and meet the patient as a unique individual, Establish a therapeutic relationship, Take a whole person view, Understand and take into account the patients own model of their unwellness, Relate the onset of declines in health to life events, and then Create a collaborative model and way forward. Patients are as fed up as their doctors with the absence of these elements in our rushed and fragmented health care systems. Patients are falling through the holes in the holism that should be underpinning our care, especially in pressurised general practice, and they then end up wandering between the ‘head doctors’ and ‘body doctors’ of specialist care. 1. Bass C, May S. ABC of psychological medicine: Chronic multiple functional somatic symptoms, BMJ 2002; 325: 323-6. |
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James Norman Hardy, GP principal Bethnal Green Health Centre, 60 Florida Street, London E2 6LL
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Editor, There have been a number of illuminating replies to Bass and May's article on patients who evoke "despair, anger, and frustration in doctors" (1,2,3,4). Some are angry, others questioning, and most seem to disagree with the profered diagnostic criteria. So do I. The authors make it clear that terms like "fat folder patients" are pejorative and unhelpful, but go on two paragraphs later to suggest we may identify them from the thickness of their notes. This is a facile and obsolete method in the (primary care) age of computer records. How thick is a computer record? Or a smart card for that matter? Terminologies like "chronic multiple functional symptoms" smack of DSM 4 reductionistic thinking. I prefer the term "frequent attender". It simply describes the problem: some patients attend more frequently than others, and we have to deal with it. Consider the problem. The figures would suggest it is enormous. Perhaps it is. It certainly feels as if those in secondary care share this view. Were you to ask those working worldwide in primary care for their figures they could of course effortlessly call to mind those who attend frequently (and those who are critical of uncaring doctors should consider this point; some patients will attend weekly or sometimes more frequently with variable symptoms. The problem is ubiquitous). We all have names to describe such patients and mostly they are unhelpful. They imply a certainty that there is nothing wrong, but as has been pointed out this certainty has often been punctured by subsequent diagnostic clarity (4). In fact frequent attenders consistently raise the issue of uncertainty. We spend a considerable volume of time with the uncertainty that goes cap in hand with the patient or relative who returns again and again. Frequent attenders provide the greatest challenge there iscin medical practice. Those involved have a duty to protect such patients from other doctors where therapeutic options are often limited, e.g. surgery or drug treatment, but at the same time maintain a vigilant eye for new clues. No mean undertaking. Primary care unlike secondary is not protected; no buffer here of a three month waiting list.Imagine the referral for another opinion from primary care: easy for the consultant vetting the GP letters to deflect to the SHO/SpR clinics. Another rejection for the frequent attender. But frequent attenders there are and I would suggest that the best way of helping them is by working with and acknowledging the emotions they evoke in us, be it anger, despair or frustration, to name but three. My quess is that in primary care we deal pretty well with frequent attenders who evoke positive emotions, but less effectively with those who evoke negative ones. Such emotions are generally hard to deal with. Peer support is often helpful as is undergraduate and early postgraduate training. The reality is, that what helps is the quality of the therapeutic relationship, a point well made by Balint and colleagues in the 1950s. Jim Hardy. (1) Bass, C, May, S. Chronic multiple functional symptoms. BMJ 2002:325:323-326. (2)Rubin, B. CMFS is an overdiagnosed complaint - examine physician symptoms. BMJ.com. 9.8.2002 (3) Chaudhuri, A. Through the looking glass. Bmj.com. 10.8.2002. (4) Bagnall, G. A little honesty goes a long way. Bmj.com. 10.8.2002. Competing interests none |
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Francesco Carelli, EURACT 20123 - Milan, Ferdinando Petrazzuoli, Filippo Daddio and Alfonso Sauro
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Frequent Attender’s phenomenon is one of the major discouraging problems that General Practitioners (GPs) have to face in their everyday life. Frequent Attenders (FAs) use a large amount of health care resources. However, the institutions seem not to be concerned about the problem, and the GP is left alone to deal with it. Many studies have tried to trace a stereotype of the FAs, showing a high incidence of psychiatric illness and social problems. We tried to find out other characteristics of the FAs that could help us solve the problem. From January 2001 to June 2001 the cohorts of patients of 7 GPs were investigated. These characteristics were examined: number of GP consultations, age, gender, social problems, trust in the doctors, influence of the mass media. Patients with major diseases which appropriately required a high rate of consultations were excluded. We found that between 389 FAs, these characteristics were pre- eminent: lack of trust in the doctors (23.7%), influence of the mass media (32.1 %) and conflictual relationship with their disease (48.8%). FAs’ problem is not only a social and psychiatric matter. Often the misuse and abuse of Health Care System is deliberate. The attitude and the structural bureaucracy of Health Care System towards the patients very often facilitates the occurrence of FAs’ phenomenon. A Health Care System’s policy change is required: a ticket paid by every patients for consultations, home visits and other procedures might increase the patient sense of moderation and reduce their attendance. Many studies have tried to trace a stereotype of the FAs, showing a high incidence of psychiatric illness and social problems. (1,2,3,4,5,6,7,8,9,10,11,13). Scaife (1) found that patients who were more likely to be frequent attenders included those who were divorced or widowed, who belonged to the female gender, to lower social classes or those who were unemployed. In a study set in a UK teaching general practice of 12400 patients, Heywood al (2) showed that a population of very frequent attenders, consulted five times as often as the norm, received five times as many prescriptions and were referred to hospitals five times as often. The author wonders if this represents good general practice containment of the problem or is a poor use of the resources. O’Dowd focused attention on those Frequent attenders whom GPs found to be an emotional burden : the heart sink patients (5) Common characterics among the frequent attenders are : high incidence of psychiatric illness and social problems.(1,3,7,8,10,11) Dowrick (13) postulated frequent attendance as a shared problem between doctors and patients with mutual failure in communication and comprehension. Zizzo e Carelli showed that in psychiatric illness an improvement of communication skills reduces attendance of frequent attenders.(12) We must explain what “Lack of trust in doctors” means: some patients want to have more than just one opinion on their illness so they tend to refer to a lot of physicians or consultants. “Conflictual relationship with their disease” means that some patients affected by chronic diseases such as hypertension or arthrosis are not fully convinced that their diseases are lifelong. Influenced by media: patients are continuously asking their doctors about the latest drug or the latest procedure they watched on TV or in the newspaper. These definitions are subjective but we should remember that this survey was conducted by family doctors that know their patients well. Our data confirm what other authors have already found: patients affected by multiple disease present a high incidence of psychiatric and social problems, but this doesn’t fully explain the phenomenon. As a matter of fact, there is a high percentage of patients who doesn’t show these features and, furthermore, the FAs selected in our study are only the tip of the iceberg of an excessive an widely spread frequent attendance. We try another hypotesis , we can’t fully demonstrate it because our study does have some lacks: there is no comparative group and no statistical elaboration about the significance of our variables and furthermore most of these variables are based on subjective opinion of the gp, yet we believe that we are quite near the truth. The influence of the media is important: very often they cause, in the patients who are often uneducated, and obviously without a critical eye, fears and expectations which the general practitioners are unable to face by themselves. Scientific an Medical successes, so emphasised by the media and carried from an experimental ambit of selected cases to a possible global solution of patient’s disease, very often cause these problems. (14). Nigel Edwards (14) writes about ” the growing use of guidelines, protocols, audit, regulation, and inspection that many doctors perceive as eroding their control over their professional lives”. These protocols, regulation and audit can change the “Evidence Based Medicine “ into “Bureaucracy Based Medicine” We believe that one of the main problems is the interaction among three important structural factors that we call the hellish triad: demagogy (empty promises), hypocrisy (the awareness that those promises cannot be kept) and bureaucracy (the attempt of the National Health Systems to defend themselves by the attacks often caused by their own demagogy ). Very often, the misuse of the health system is deliberate: often the FA is aware of his/her excessive consultations but he/she also feels a sense of entitlement for that. So, another possible profile for the FA is that one that we could call “Professional Martyr”. In the view of the professional martyr some things that might be useful are absolutely indispensable and he is ready to fight against everything to get them. A possible definition of the Professional Martyr is :” person that take an undue advantage from those rules and laws that tend to help people with social and physical problems”. References 1. Scaife B, Gill PS, Heywood PL, Neal RD. Socio-economic characteristics of adult frequent attenders in general practice: secondary analysis of data. Fam Pract 2000; 17: 298-304. 2. Heywood Pl, Blakie GC; Cameron IH, Dowell AC. An assessment of the attributes of frequent attenders to general practice. Fam Pract 1998; 15: 198-204. 3. Westhead JN. Frequent attenders in general practice: medica1, psychologica1 and social characteristics. J R Coll Gen Pract 1985; 35: 337 -340. 4. Schrire S. Frequent attenders-a review. Fam Pract 1986; 3: 272-275. 5. O.Dowd TC. Five years of heartsink patients in general practice. Br Med J 1988; 297: 528-530. 6. Nèal R, Heywood PL, DoweII AC, Morley SJ. Frequent attenders-who needs treatment. Br J Gen Pract 1966; 46: 131-132. 7. Karlsson H, Lehtinen V. Joukamaa M. Frequent attenders of Finnish public hea1th primary care: sociodemographic characteristics and physical morbidìty .Fam Pract 1994; 11: 424-430. 8. Von Korff M, Onnel J. Katon W et al. Disability and depression among high users of health care. Arch Gen Psych 1992; 49: 91-100. 9. Mathers N, Jones N, Hannay, D. Heartsink patients: a study of their general practitioners. Br J Gen Pract 1995; 45: 293-296. 10. McNiece R, Majeed A. Socioeconomic differences in general practice consultation rates in patients aged 65 and over: prospective cohot study. Br Med J 1999; 319: 26-28. 11. Gulbrandsen P, Fugelli P, Sandvik L, Hjortdahl P. Influence of social problems on management in general practice: multipractice questionnaire survey. Br Med J 1998; 317: 28-32. 12. Zizzo F, Carelli F.: Improvement of communication skills reduces attendance of frequent attenders). Abstr Wonca Europe Tampere Conference June 2001 . 13. Dowrick C. Why do the O’ Sheas consult so often? An exploration of complex family illness behaviour. Soc Sci Med 1992; 34:491:497. 14. Edwards N, Kornacki MJ, Silversin J. Unhappy doctors: what are the causes and what can be done?835 Br Med J 2002; 324:835–8 15. Ham C, Alberti KGMM. The medical profession, the public and the government. 835 Br Med J 2002; 324:838 Competing interests: None declared |
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Roxana L Tiscareno, none 95136
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I have MCS. I tried going to one or two doctors and that it was it. It's pointless to convince anyone I have it when tests show up negative, but then they didn't run any cholinesterace, PON1, porphyria or iron handling tests on me either. I was simply referred to a psychiatrist; therefore I have a very thin file. I hope that makes you happy because that means I have just simply given up on conventional medicine. You're fine if I have a broken or something obvious, but beyond that I don't know. Oh, I am also a female, but please forgive me for that discrepancy. In the meantime, I will wander around with worsening neurological problems, chronic severe migraines, respiratory problems, Raynaud's type of symptoms and worsening fatigue, but that's okay, I don't want to risk offending you. Competing interests: None declared |
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