Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Ill considered criticism from editor
- David J Maconochie (1 May 2004)
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Not as easy as you seem to think
- Mark Oliver (1 May 2004)
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Unexplained Symptoms
- John Caldwell (1 May 2004)
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Funny how easy a GP's job looks to those who don't have to do it.
- Melanie L Wynne-Jones (3 May 2004)
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Trying to fix a car by talking to it
- Richard Smith (3 May 2004)
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Poverty of Rich Medicine
- Vikas Dhikav (3 May 2004)
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Consulting with heartsinks
- Gwion Rhys (4 May 2004)
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Removal of research warts
- William T Hamilton, David Kessler (6 May 2004)
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David J Maconochie, locum GP Somerset
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Dear Sir, The editor needs taking to task for his broad generalisation that GPs practice "poor medicine" when it comes to dealing with patients with "unexplained physical symptoms". I would be very surprised to hear that he had ever practised as a GP because he should have more insight. The behaviour that comes in for the blanket criticism is the prescription of medicines to treat symptomatically those unexplained symptoms, and the performance of investigations under circumstances where the likelihood of discovering an abnormality is low. The three questions I ask myself when presented with a patient with UPS are: 1) might there be an underlying disease that I am missing? 2) is the patient worried that there might be a serious diagnosis? or 3) is it the symptoms that are the main cause for concern? If the main concern is 1), I will advise investigations even if the patient does not appear to be asking for them. If it is 2) I will offer investigations for the patient's reassurance. If it is 3) I will offer to treat the symptoms if the patients wishes. My experience is that my colleagues do likewise. So in what way exactly can this be considered to be "bad medicine"? Yours etc Competing interests: None declared |
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Mark Oliver, GP Stafford ST17
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Looking after this demanding cohort is not as easy as Smith seems to feel with his broad brush condemnation of general practitioners in their struggle to manage these very difficult cases. We have very limited time, and these patients in practice often do demand lots of time and investigations, as any GP in day to day practice could tell you. In practice it is very difficult to exclude organic pathology, protect them from medical interventions that may be harmful, and address the underlying psychopathology (if acknowledged) in the time deficient resource-depleted environment of the NHS, where the GP is often the only outlet available for these patients to unload their frustrations with their life. Competing interests: A GP in NHS practice |
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John Caldwell, GP Principal Liverpool L25 3PA
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Richard Smith's editorial gives the impression that this group of patients is particularly badly managed in a primary care setting. It is recognised that care of these patients is difficult, but there is little evidence that they are better treated by hospital consultants, even in specialist settings such as pain clinics. The authors of the original article should be commended for their willingness to consider the treatment of such a difficult group rather than berated for a failure to deliver better outcomes and accused of practising "poor medicine". In the time and resource limited modern NHS, there is little hope of rapid access to the psychological interventions that could make a difference to those patients in this group that have no readily identifiable organic pathology, and they must first be differentiated from those that do have conditions where medical intervention is appropriate. Better results for this group depends critically on the time their General Practitioner can spend with them, so I suspect that there will be a fall in the quality of care delivered to them in the next few years, as doctors' priorities are shifted in line with Government expectations. Competing interests: GMS GP Principal |
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Melanie L Wynne-Jones, GP Partner Marple Medical Practice, Marple, SK6 6AB
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Just adding my support for the cogent and accurate comments made by my GP colleagues above. GPs are now simultaneously lambasted for failing to investigate patients yet referring patients unnecessarily, for being patient-centred yet treating symptoms that may not have an organic basis, for treating conditions with medication when the alternatives are not available for 12 months or even never. I could go on and on and on....... Competing interests: GP Principal |
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Richard Smith, Editor BMJ
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Several general practitioners have objected to me criticising the way that patients with medically unexplained symptoms are dealt with in general practice. I’m entirely happy that they should take a different view from me, but I’m less happy with the suggestion of some that my views are irrelevant because I’m not a general practitioner. These comments reminded me of the English cricketer Geoffrey Boycott, who told Anthony Clare in a radio interview that he was interested only in the views of those who could bat. Unless you had had the experience of facing a cricket ball coming you at 100 miles an hour and could hit it to the boundary, then your views counted for nothing. My memory is that Boycott applied this philosophy to a person’s views on everything not just cricket. My critics are not so severe, but is it right to insist that only general practitioners can have legitimate views on how patients are managed in general practice? It seems to me an extreme idea—and one that will block progress in general practice. I didn’t intend to suggest that the management of patients with medically unexplained symptoms is easy. I know that it’s not only intellectually hard but also emotionally draining. I remember Simon Wessely, an expert on managing these patients, saying that the tragedy of medicine is that doctors learn a great deal at medical school learning about how to treat patients with medically explained symptoms and then spend most of their professional lives treating patients with medically unexplained symptoms. Much of the time that they are applying the wrong model and using the wrong tools. It’s like trying to fix a broken car by talking to it, a very frustrating experience. My main intention in my brief piece was to suggest that the interaction between general practitioners and patients with medically unexplained symptoms described in the research on which I was commenting was not very helpful for either the patient or the doctor. There are better ways, and these were discussed extensively in the ABC of psychological medicine that we published in 2002. Richard Smith, Editor, BMJ Competing interests: I'm the editor of the BMJ and accountable for all it contains. |
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Vikas Dhikav, Resident All India Institute of Medical Sciences, New Delhi-110029, INDIA
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We can criticize the GPs for their overzealous use of investigations, patients and society for their unrealistic expectations so on and so forth; I believe, one truth which all of us cant evade is that contemporary medicine is crippled when it comes to the treatment some of the functional conditions such as erectile dysfunction (ED). Now, it goes without saying that ED can have devastating effect on the patients and those who do not improve with PD5 inhibitors such as sildenafil or any other drug feel utterly dissatisfied. And one may even ask, why not? It’s because of the stigma the problem has. Now, is media the only culprit? No, we all are! Media seems to be the obvious culprit but then how many pharmaceutical companies, non- governmental organizations, or institutes and universities have made an active effort to educate patients about ED which may affect any forth male in their lifetime? Isn’t ED one of the most common disorders that has potential to destroy personal, family and social life? Ill-informed patients; destroyed mentally by the condition with their 'male ego' find it hard to cope up with the pressures it generates often go to quacks, body shoppers and 'self-proclaimed' doctors. In India, although there are laid norms for the specification the hording a qualified practitioner can make but these quacks have the largest of all signboards and they make tallest of all medical claims-of course, they can never be substatiated-thats cheating! The need for better drugs cannot of course be overemphasized but patients should be educated that having ED doesn’t mean the end of life. It is a general feeling among patients over here in India that allopathic physicians can’t treat impotence but quacks can! That’s why; self- proclaimed doctors have the most exuberant of all practices Competing interests: None declared |
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Gwion Rhys, GP Principal Ty Doctor, Nefyn, Gwynell LL53 6EA
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Finding efficacious ways forward when dealing with patients without easily explainable symptoms is a part of a GP's daily routine. As is noted, a fifth of our consultations deal with such matters. To label all such patients as being "heartsinks" is a mistake, and I believe the term is increasingly used too loosely. Groves 1 in his original article defining heartsinks is also careful to point out that a doctor's negative reactions should be interpreted and used to facilitate better understanding. But this takes us away from the important issue; that consultation techniques, and strategies about how to look after difficult patients is a part of every GP in training's core curriculum. Knowing our goals and limitations, especially when dealing with patients without simple pathology is our bread and butter. It's not surprising therefore that many GP's feel aggrieved when it's said that we deal with 20% of our consultations poorly. I certainly believe that General practitioners are in the speciality most adept and aware of the issues that surround heartsink patients; with all of us having videoed and analysed such consultations in detail. There is the conundrum of why "none of the 36 patients asked for investigation or medical referral;" one reason, as the author says is that "patients presented in several ways that had the potential to pressurise general practitioners." Another is that GP's are taught about non-verbal communication, and are skilled at identifying what patients seek over and above what they say; that sometimes makes our decisions hard to explain. Us GP's do indeed get tetchy when we’re told week after week that the care of this, that the other that we do is poor; but our consultation skills is one area in medicine where our speciality feels that we do have an edge. 1 Groves JE: Taking care of the hateful patient. N Engl J Med 296:883 -887, 1978 Competing interests: None declared |
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William T Hamilton, Research fellow University of Bristol BS6 6JL, David Kessler
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Dear Sir, The BMJ includes a small box with each paper, summarising the prior knowledge and what the study adds. This is laudable, but inevitably overlaps with the abstract. We suggest an alternative use for a box. We are torn between calling it an honesty box or a confessional box. The idea is that all research has warts, some ugly, others less so. The ugly ones should be picked up by peer-review. The less ugly ones are never seen, remaining only as a twinge of guilt in the researcher’s conscience. Possible examples are: “our power calculation – though justified by the literature- was optimistic”….. “Reference 13 covers similar ground to our study, and we did not know it was in progress when we planned ours”….. “We didn’t expect finding B, and did the literature search on it after it was discovered.” Declaration of competing interests does not serve this purpose. We believe the box is in the spirit of genuine scientific enquiry, and may act as an antidote to spin. It may even contribute to restoring public faith in science. Confessional/ honesty box. This letter may improve our CVs Yours sincerely, William Hamilton, FRCP FRCGP
David Kessler, MD, MRCPsych, MRCGP Research Fellows, Division of Primary care, University of Bristol, BS6 6JL Competing interests: None declared |
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