Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
ARE YOU A BIT NAIVE?
- graeme mackenzie (30 April 2004)
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Join me at the coal face
- John Hopkins (30 April 2004)
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Psychological dissection of unexplained physical symptoms!
- Dr. Naseem A. Qureshi (30 April 2004)
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Richard Smith - not qualified to comment
- david baker (1 May 2004)
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Sorting the wheat from the chaff
- Trefor J Roscoe (1 May 2004)
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Re: Sorting the wheat from the chaff
- Lisa C Blakemore-Brown (2 May 2004)
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Re: Re: Sorting the wheat from the chaff
- Ellen Goudsmit (4 May 2004)
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Study GPs let down by authors and editor
- Graham Wheatley (5 May 2004)
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Treatments unexplained, why not symptoms
- Joan T McClusky (6 May 2004)
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Second opinion
- Phillip J. Colquitt (6 May 2004)
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Second opinions prevented in this draconian system
- Lisa C Blakemore-Brown (6 May 2004)
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Re: Study GPs let down by authors and editor
- Mark Struthers (7 May 2004)
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Re: Study GPs let down by authors and editor
- Graham Wheatley (8 May 2004)
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Medically Unexplained - so blame the patient.
- Charles Pragnell (10 May 2004)
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It's not just patients who make things up
- Jenny L Robertson, Peter Robertson (10 May 2004)
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Re: Re: Sorting the wheat from the chaff
- Gurli Bagnall (17 May 2004)
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Point of information
- Sharon Davies (8 July 2004)
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Unexplained Symptoms Require Appropriate Investigation
- Michael D Innis (9 July 2004)
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The Freudian Fallacy (or the need to be cautious about diagnosis)
- susanne McCabe (9 July 2004)
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graeme mackenzie, GP Whitehaven CA28 7RG
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I note this paper and the editorial. Why is it the patients account to the authors is treated as the last word? Are you aware of the games some patients play with their symptoms and the well known concept of manipulative help rejection? Will you support us when we miss pathology because we have allowed them to express their suffering and then not picked up the key symptoms that do need investigation? Competing interests: None declared |
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John Hopkins, GP Jubilee Medical Group Newton Aycliffe DL5 4SE
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Dear Dr Smith, Implicit in this piece of research is the view that GPs should do more to support people with medically unexplained symptoms. It's perhaps worth saying that, by taking active steps in response to such syptoms, for example investigation, prescription or referral, the GP is acknowledging the impact the symptoms have on the patient. Usually the process of following up the outcome of these steps allows the opportunity for further discussion and support. However, there is no getting away from the fact that these practical steps fall short of a full response. Such a response would consist of the GP embracing, perhaps literally, the patient and their problems. One could quite easily spend half an hour or longer with each patient, empathising with them and sharing their difficulties and anxieties. Which leads me to put a challenge to the team that wrote this paper. One of them is medically qualified and the others are psychologists so it would be entirely appropriate for them to devote, shall we say, three hours a week for the next twelve months talking to patients in depth about their medically unexplained symptoms. This would certainly teach them a great deal about the reality of of non-academic general practice and would give welcome authority to any conclusions they might reach. Yours sincerely, John Hopkins Competing interests: None declared |
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Dr. Naseem A. Qureshi, Medical Director [A], Director, CME&R Buraidah Mental Health Hospital, Postcode.2292, Saudi Arabia
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Dear Sir: There is a converging evidence that mostly female patients with unexplained physical symptoms [UPSs], also better called somatic symptoms [SSs], are known to overutilize medical services together with extensive investigations and each consultation often ends by drug prescribing by the general practitioners [GPs] or physicians. Whether somatic prescribing is governed by internal drives of the GPs or pressure from such patients is an interesting avenue for research and the study by Ring et al (2004) judiciously clarifies this conundrum. Reportedly, the UPSs are mostly symbolic of some sorts of moderate to severe distress that these patients tend to express through body language, i.e. by somatization process. The expression of overwhelming distress by psychological ways is probably underdeveloped in this particular population of patients. Or they are likely to have negative attitudes or stigma against psychological symptoms or mental diseases and hence not seeking proper help from mental health professionals. Therefore, they tend to medicalize or physicalize or somatize their distresses rather than psychologizing them. Evidently, the dynamic process of somatization is known to vary across cultures of the world, possibly more common among developing countries. What is actually underpinning the gamut of UPSs is a group of psychiatric disorders, which according to Diagnostic and Statistical Manual of Mental disorders (DSM-IV) are better known as somatoform disorders. These disorders commonly include conversion disorder, somatization disorder, undifferentiated somatoform disorder, hypochondriacal disorder, pain disorder, body dysmorphic disorder and somatoform disorders not otherwise specified. The differential diagnosis of somatoform disorders usually include general medical conditions, depressions with somatic symptoms (masked depression), several types of anxieties such as panic, factitious disorders, malingering, adjustment disorder, and schizophrenia with somatic delusions. Notably, UPSs may also convey subsyndromal diagnoses of these somatoform disorders. Therefore, the patients with UPSs need proper diagnosis (which is often difficult in such patients), relevant neuropsycholgical investigations and proper treatment in order to enahnce the quality of life of such patients and also reduce unnecessary overuse of medical services coupled with huge costs. Psychiatric consultation-liaison services at primary health care level may effectively address both the diagnostic and therapeutic dilemmas of such patients. Reference: Adele Ring, Christopher Dowrick, Gerry Humphris, and Peter Salmon. Do patients with unexplained physical symptoms pressurise general practitioners for somatic treatment? A qualitative study. BMJ 2004; 328: 1057-0 Competing interests: None declared |
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david baker, GP Principal Dorset
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I liked this article. I think it's message is summed up in the second "what this study adds" point: "The ways in which patients presented their symptoms had the potential to challenge general practitioners by conveying the need for a response while constraining the general practitioner's opportunity for response" - in other words, these patients are playing (TA) games. Resolution, treatment, cure - nope, not interested. The problem we have is how to avoid being part of the game, but getting them out of the door in 10 minutes. Good comment from the researchers, & it conveys why these patients are so difficult to manage. In steps Richard Smith (Editor's choice): "Why then do doctors habitually treat the patients symptomatically? The authors believe that the patients try to engage the doctors, but when they respond with simple explanations and threaten to end the engagement the patients try harder to transmit the intensity and complexity of their symptoms. The doctors then offer treatment either because they mistake the patients' attempts at engagement for insistence on treatment or because they've run out of explanations. Either way, it's poor medicine." OK, it's a wind up, I accept that, & I'm wound up. But what a load of ill-informed nonsense. Ever seen these patients, Richard? Ever had them through your door on a daily basis? Ever dealt with 10 of their symptoms only to be told about the next 10 ( or the same 10 again, but with increased severity)? One of my colleagues likens them to dementors - they suck the life out of you. Re-read the comment above - they are demanding a response and blocking our attempts at the same time. We are the ones constrained by time - that pressurises us, but not the patient. You don't know what you are talking about - perhaps a career at the Mail beckons? Competing interests: I have an interest in managing MUPS and TATT. |
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Trefor J Roscoe, GP for 20 years Sothall Medical Centre, Sheffield S20 5JX
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This article seems to be blaming the doctors for not managing the patients properly. As others have pointed out this is not easy. I agree that many of these patients may have psychiatric illness and somatisation disorders, but some do not. At what point are medically unexplained symptoms allowed to be ignored and not investigated again? I can think of several "difficult" patients who had extensive investigations over prolonged periods before their slowly developing rare pathology was diagnosed. One patient in particular was told by two eminent orthopaedic surgeons that her peculiar back pain did not have an organic cause until her chronic staphylococcal discitis was diagnosed. Another patient had a retro pancreatic abscess diagnosed after 5 years of complaints of abdominal pain with normal laboratory results and scans. Retroperitoneal fibrosis, Lyme Disease, autoimmune disorders, thyroid disease, diabetes and many others can present in such an insidious fashion that the diagnosis can be missed for months or even years. General Practice is an art not a science with many patients, you have to keep an open mind or you may miss something treatable. I also suspect that Dr Smith is probably winding us up to get his journal more widely read. Well done Richard! Trefor Roscoe Competing interests: None declared |
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Lisa C Blakemore-Brown, Psychologist Uk based
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For years a mother was told she was making up her children's problems - despite brains scans proving brain damage - and that she was making up her own - she ended up in a wheelchair through the delays in recognising an ovarian tumour. When her 19 year old daughter, living away from home, became seriously ill with headaches, her family had been put through so much pain through not being believed, extending to the education systems who would not provide support and the whole family treated like liars, that she would not go to the GP about the headaches. She knew she would be dismissed just like her mother had been for many years, She died on Good Friday of a massive brain haemorrhage. The Nursing Sister at Leeds wanted to know if there was a religious reason for this child not going to the GP to report her symptoms. Please don't pretend to be psychologists and psychiatrists -be the Doctors you trained to be. Competing interests: None declared |
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Ellen Goudsmit, Health Psychologist London TW11 9QX
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I concur with the views expressed by my colleague Lisa Blakemore- Brown. What do you do when a patient has amassed a thick file after a series of misdiagnoses? When a neurosis turns out to be acute rheumatic fever, when a fibroadenoma turns out to be malignant, and when anorexia nervosa is in fact, a post viral vestibular disorder (Pedersen's syndrome). Be glad when that patient recognises the complexities of medicine and does not threaten to sue for negligence. One can only diagnose a symptom as 'medically unexplained' when all the appropriate tests have been done and the relevant experts have been consulted. In the above case, the patient did not fulfil the criteria for anorexia nervosa, but had simply lost weight after several weeks of extreme giddiness and vertigo. She expressed her concern at the loss of weight and thought herself too thin. Yet, no psychiatrist was consulted, no information was obtained from the people she lived with, nor was the patient offered vestibular tests. How did this diagnosis remain unchallenged for three years? The patient respected the GP and the GP respected the consultant and did not question his judgement. For his part, the consultant (neurologist) took a short cut when diagnosing a psychiatric disorder, and had not ordered all the appropriate tests to rule out the obvious. Having seen too many misdiagnosed 'neurotic\somatising' patients in my thirty years as a psychologist, my advice is to be cautious and review cases regularly. Sometimes even that is not enough. When I trained, one of the patients we learned about was a middle-aged fireman with chronic stomach pain. An X-ray was clear and his GP suggested his problem might be related to his stressful job. When a long holiday failed to improve matters, the GP ordered an endoscopy. This revealed his cancer, from which he died a few months afterwards. The GP did the right thing, even though it turned out to be too late. The bottom line is that we have an NHS with limited resources, so there is often a reluctance to order the more expensive tests. And a few are still a tadd prejudiced, particularly when it comes to the fairer sex. Perhaps we should delay further discussion of medically unexplained symptoms until we have more resources and can order all the tests required. When we have the time to do thorough work-ups, and to refer to consultants when that isn't enough. Routine tests are not always sufficient. And it certainly does not warrant generalisations about time- wasting scroungers who enjoy being ill. Competing interests: I have a special interest in the psychologisation of illness |
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Graham Wheatley, GP Principal Spalding, Linconshire
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Fascinating to have a qualitative study on these interesting but challenging patients – shame that the author’s discussion merely reflected what appeared to be their preconceived views and prejudices. The authors appear intent on showing that their data “reveal” that the GPs in the study were only capable of offering symptomatic treatment to these complex and often difficult patients – yet the paper records the discussions GPs had with their patients to attempt to find meaning (not necessarily physical diagnosis) in these symptoms, and the investigations that were arranged to exclude potential physical illness. General practice involves complex risk management behaviour on the part of the GP to attempt to identify or exclude a spectrum of physical disorders while attempting to effectively and humanely address what may well turn out to be complex psychological problems. And all this in the intensely time-pressure environment of the NHS 10 minute GP appointment. Stating that “none of the patients requested investigations” does not self -evidently mean that none should have been considered or arranged, as the personal view above illustrates clearly. The GPs in this study have been badly used by the authors and editor and deserve an apology from both. Richard Smith’s ill-infomed comment speaks volumes about his lack of grasp of general practice. Rather than Daily Mail, as has been suggested above, I wonder if he is chasing the Lancet to be the News of the World of medical publishing! Competing interests: None declared |
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Joan T McClusky, medical writer New York, NY 10003
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There are a number of medical treatments that are well accepted as effective, but the physiologic basis for their efficacy is not clear. In addition, a number of treatments are effective in a certain proportion of patients, but not in others (eg, antidepressants). Physicians have no problem prescribing medications with unexplained effectiveness, or treatments that they know might well not be effective in a particular patient. In both cases, it is often "the best they've got." It should hardly be surprising that patients who feel pain, despite a lack of a physiologic explanation, or who do not respond to the treatment initially prescribed, would continue to seek help from their GP for "real pain." It's often the best they've got. Competing interests: None declared |
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Phillip J. Colquitt, Technical Advisor Self employed
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When contemplating this article[1], readers of this online, free, full-text journal, who have lost close relatives prematurely to killing cancers, symptoms of which killing cancers the lost relative complained about for years to their much loved GP, and which cancers could have been excised/cured, had said GP seen fit to order a low dose screening CT scan, will perhaps be less likely to be impressed by the defensive attitude of some of the Rapid Responses[2]thus far. Thus the value of the second, third……opinion. [1] Ring A, Dowrick C, Humphris G, Salmon P. Do patients with unexplained physical symptoms pressurise general practitioners for somatic treatment? A qualitative study. BMJ 2004; 328: 1057-0 [2] Responses to Ring A et. al. http://bmj.bmjjournals.com/cgi/content/full/328/7447/1057#responses Competing interests: None declared |
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Lisa C Blakemore-Brown, Psychologist UK based
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Mr Colquitt may be surprised to learn that second opinions are severely frowned upon when this type of thinking is brought into cases - that the `difficult` patient may fit the criteria for FII (fabricating or inducing their symptoms or the symptoms of others in their care). Indeed, the wider professional group who may be brought in if children are involved - mainly social workers - will frequently threaten individuals if they dare to seek out second opinions as they have been taught that this is another criteria for such `illness`. Many parents are threatened with having their children taken should they have the temerity to seek alternative advice about their children's problems which are being denied. If their children have already been taken they will be told they may never see them again or their access be dramatically reduced. So, if this thinking gains even more of a hold than it already does, we can expect more people with rare or unusual illnesses to suffer and maybe die, as the more they try to find out what is wrong with them or their children by going to other medics, the less the medics will take them seriously and the more the system will punish them. Mad world isn't it? Wouldn't you think that for those who have trained for years to become Doctors, they would be all the more intrigued to understand rare disorders. The differential diagnosis may include the possibility of FII but this label becomes farcical if the fundamental premise -that there is no real disorder or illness - is jumped on before consideration, testing and thorough investigation for the possibility of rare (and some not so rare) disorders - for instance Lyme Disease, Kawasaki Syndrome, autoimmine disorders, various genetic disorders, iatrogenic abuse. Some 6 years ago (1) I wrote that to help avoid falsely accusing people of falsely creating their symptoms, by missing real disorders, contact with other professionals via the internet in unusual cases for presenting features could help to fast track investigations. The BMJ has certainly made inroads into this with its case presentations. However, the most prominent `diagnosis` which I have seen spread like wildfire through such methods - and the phone - is FII. What a shame that all the medical training, the skills, the years in the business - and the increasingly available technology - is used to promote something which is not even medical, but which on the contrary actually denies everything medical. Is that not the medical equivalent of an own goal? 1. Blakemore-Brown LC 1998 False Illness in Children or simply False Allegations? Volume 5 Number 2 Pages 24 - 29 Competing interests: None declared |
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Mark Struthers, GP HMP Bedford
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General practice is full of surprises and it's the people involved that make it so - and so interesting as well. Some of these people are difficult: researching the infinite variety of interaction is difficult too. This paper is not perfect but does not deserve the disdain that Dr Wheatley pours on it. Neither does the editor. It was fascinating to reflect on Graham Wheatley's preconceived views and prejudice in his haughty critique of the research. There are 'heart sink' doctors too and I fear that Dr Wheatley is one of them. There are some very difficult people out there whose behaviours defy investigation, symptomatic treatment and explanation. You don't have to be a GP to know that - even if it helps. There are some patients - not many - who I know for certain have shortened my life. It is just possible that there are some patients - not many - whose lives have been iatrogenically shortened by myself. There are some patients - even fewer - with no insight into their mutually life threatening behaviour, in whom the relationship is no longer useful and has to be terminated. Another interaction - and it doesn't have to be with a doctor - may be the heartlift that some patients need to save their lives and mine. Life is a bitch of course - and then you die. Keeping a sense of balance and proportion are the challenges along the way. Some honesty,humility and a sense of humour help too - and may lessen the need for that embarrassing apology when we get it wrong. Competing interests: None declared |
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Graham Wheatley, GP Principal Spalding, Lincolnshire
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I was under the impression that "rapid responses" were to allow discussion of papers - not for random musings on life, mixed with mystifying personal abuse that Mark Struthers appears to enjoy. If he bothers to look, he could see in my response a line of argument supported by example and quotation from the paper in question - none of which he sees as necessary in his own comment. For someone who claims to value "balance, proportion ... honesty, humility and a sense of humour", I would be interested in reading what he thinks of the paper itself, his one comment on which was that was "not perfect". So come on Mark, tell us what you think of the paper, as that's why we here. Competing interests: None declared |
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Charles Pragnell, Expert Defence Witness - Child Protection and Child/Family Advocate U.K./Australasia
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Surely every disease and disorder now known to the medical profession was at one time “medically unexplained”?. So the question which these `researchers’ should have been investigating was, `What are the limitations of the knowledge of medical science or of this particular medical practitioner which have led to the failure to make an appropriate diagnosis'?. But of course it is far easier to `Blame the patient’ for inventing or causing their own condition, and as Lisa Blakemore-Brown has pointed out, this is happening far too often in cases of alleged child abuse such as Fabricated and Induced Illness in Children (MSBP) and also in Sudden (Unexplained) Infant Deaths and Shaken Baby Syndrome. This was never better illustrated than in the Clark/Cannings Trials where a well-known virus and a genetically inherited condition were found to the most likely causes, rather than the suppositions of a paediatrician and a pathologist who ultimately exposed their own lack of knowledge and expertise. Great and wonderful advances are being made in medical science but a huge shadow is being cast on such advances by those who prefer to blame the patient rather than honestly and simply admit, “I don’t know” and either refer the patient to another physician who may have the required knowledge or as another respondent has said, to just wait and observe and gather information. This is particularly needed where children are concerned as the rush into child protection procedures is causing immense harm to many thousands of children and their families every year and as has been seen in recent time, has resulted in the wrongful imprisonment of many parents. Competing interests: Concern to reform the child protection system |
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Jenny L Robertson, Freelance Journalist London SW15, Peter Robertson
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When our daughter suffered from crippling complications following a (improperly treated) septic arthris at the age of 8 years old, we were repeatedly told by orthopaedic registrars, and GPs (not our own GP, we hasten to add) that she was making up the pain in order to gain attention. She had no history of attention-seeking behaviour - and nor do we. Quite frankly, we can think of better things to do with our time than take umpteen hours off work (unpaid) and wait for an eternity in a doctor's surgery only to be told that our daughter - in chronic pain - has a propensity for telling lies and, on one unforgettable occasion, be asked: "what do you want me to do, wave a magic wand?" Well - how about considering appropriate treatment for a start? But then it's so much easier to blame the patient for the problem - and it's a nifty little diagnosis that can easily be fitted into a five minute consultation without any bother. No wonder a growing number of people now resort to making their own diagnoses via the internet before approaching members of the medical profession. The truth is, sometimes it is not the patient who is making things up and wasting people's time, but the doctor. Competing interests: None declared |
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Gurli Bagnall, Independent Patients' Rights Campaigner Marlborough 7372, New Zealand
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Lisa C. Blakemore-Brown tells us how it is (all too often) from the patient’s point of view and I would like to add to it. This is the case of Mary who was diagnosed with CFS in 1991. She is a typical example of a person doctors describe as a heart-sink patient. During the first year or so of her illness, she desperately sought help - if not a cure, at least relief for the many symptoms that plagued her. She received neither and was instead ridiculed and demeaned. Even her blood pressure was not accurately assessed. Taken once during any consultation, it was inevitably high, but when the prescribed drugs caused adverse reactions, she knew something was wrong and also knew that there was little point in relying on doctor “management”. Instead, she weaned herself off the medication and bought her own blood pressure monitor. To her amazement she found that not only did her pulse rate vary from minute to minute, but so did the b/p. At times it was so erratic that the digital monitor would not register a reading at all. When it did, it was more often normal to low than high. No one had ever thought to monitor this pattern and adverse reactions aside, continued treatment to lower the blood pressure presented obvious dangers. Hard experience over those first couple of years, taught her that she was more likely to survive the very real crises that arose from time to time alone and at home, than in a hospital where she had no doubt she would be misdiagnosed and inappropriately treated. Despite the fact that she suffered a very serious neurological disease which she now knew to be myalgic encephalomyelitis (classified thus by the WHO), she had to endure the stress and strain of fighting tooth and nail for essential assistance. In 1999, the irregular heart beat was there constantly and her doctor’s response was that she was anxious and needed to exercise. Every attempt she made to say something was shouted down. He did not bother to listen to the chest nor take an ECG reading. His attitude was so intimidating that she felt if she had to call upon him (the only doctor in a small town) for an emergency home visit, she would have to have a witness - a friend listening in on the telephone at the very least. When she made a written request to this person for a referral to a cardiologist, she was ignored as was her written reminder of the request a month later. Eventually she got to see a cardiologist some 8 months after the initial request and atrial fibrillation was diagnosed. The stress and strain which the local doctor continued to impose - such as removing her 4 hours of home help per week at a time when she could hardly get out of bed - worsened her condition. Two and a half years ago, she moved away from the small town and went to live in the country. Dr. X was the closest doctor. When asked if the practice would take on an ME patient, the answer was, “No. That is a psychiatric disorder.” By March of this year it was becoming clear that medical advice was urgently needed. Mary’s usual breathing problems were very much worse and even oxygen offered little relief. She had gained a great deal of weight and her legs from feet up were swollen. She could not lie on her side or her back; she could recline for short periods but the only way she could breathe with relative ease was sitting bolt upright. For several weeks, the only sleep she got, was a few snatched moments here and there. On the 25th March, she contacted Dr. X’s office to ask for an emergency home visit and was refused. On the 2nd April, she asked again, and given the telephone conversation with the receptionist that ensued, Dr. X agreed to come, but with poor grace. It was clear that the visit concerned the protection of her legal position rather than concern for a fellow human being. On arrival, her attitude left a great deal to be desired. She agreed there was swelling in the legs but not as far as the knees. The chest was clear, the lungs were doing exactly as they should be doing, and yes, there was some atrial fibrillation going on there, but since Mary had said that it had been there for a number of years, it was nothing to write home about. The finding that excited her most, was ear wax and it was announced as if she had discovered the root cause of all Mary’s discomforts. She instructed Mary to take a mild diuretic, lectured her about the visit being a one-off and that she had no room in her practice for any more patients. A week later, on Good Friday, Mary was rushed to the nearest hospital where she was immediately admitted with congestive heart failure and pulmonary oedema. Within the first three and a half days, IV diuretic treatment reduced Mary’s weight by over 10 kgs. (22 lbs) and the doctors told her there was probably 20 litres still to go. That is equivalent to 20 kgs. (44 lbs). An echocardiogramme carried out about 5 days after admittance to hospital, showed a heart function reading of 11. The normal is between 60 and 70. It is a myth that ME does not kill. In some cases it does, and death is usually the result of cardiac complications. That Dr. X was negligent, abusive and malicious cannot be denied, and all because Mary suffers ME and is regarded as a “heart-sink” patient. The reality is that medical science has not even scratched the surface in a number of areas, and the indicators are that many have a vested interest in keeping it that way. Even the BMJ does not deny it. (1) What good would the psychiatric recommendation of cognitive behavioural therapy, graded exercise and psychotropic drugs for ME sufferers, have done Mary? More to the point, what harm would it have done? Reference: 1. Editorial: “Why do doctors use treatments that do not work?” BMJ 2004; 328: 474-475 (28 February) Competing interests: None declared |
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Sharon Davies, letters editor BMJ
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Subsequent to legal advice, we have taken certain responses to this article from view because we have received notice that some have been contributed by an impersonator. Competing interests: None declared |
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Michael D Innis, Director Medisets International Home 4575w
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Editor, Both Mr Charles Pragnell and Ms Lisa Blakemore-Brown have expressed concern at the accusations which may be laid against parents when doctors are unable to explain certain features of alleged child abuse. From an analysis of some 20 cases brought to my attention I conclude those making claims of child abuse have not thoroughly investigated: 1.Adverse reactions to vaccines given within a period of 21 days prior to the onset of symptoms. It is within this period that most hypersensitivity reactions occur. Among these are vasculitis [1]and Barlow’s disease[2] both of which can resemble “battered baby”. One should always enquire the date of the last vaccination. 2.Liver disease or immaturity causing defective clotting factor activity and thus spontaneous bleeding [3] 3.Congenital or acquired defects of haemostasis causing bleeding. A history of spontaneous bruising is importamt. 4.Malnutrition or Malabsorption causing Rickets, Infantile Scurvy and Temporary Brittle Bone Disease [4,5,6] Having obtained a history of a possible hypersensitivity reaction some attempt should be made to look for Antinuclear and Anti-endothelial Cell antibodies as well as Immune Complexes. [1] Liver disease and/or immaturity can be investigated by the standard Liver Function Tests, the Prothrombin Time, the Partial Thromboplastin Time, and the Protein Induced by Vitamin K Absence of Abnormality test (PIVKA). Congenital or Acquired defects of Haemostasis should exclude defects of Platelets, defects of the Vasculature including von Willebrand’s disease and Factor XIII deficiency, Malnutrition and Malabsorption can be screened by estimating the level of Serum Albumin, Blood Urea Nitrogen and Essential Aminoacids in the blood. In my records these investigations were either not carried out, or were wrongly interpreted Judges and Juries should be wary of accepting “expert” evidence without confirmatory Laboratory evidence. Michael D Innis MBBS; DTM&H; FRCPA; FRCPath Reference 1.Reik L Disseminated vasculopathy : an immune complex disease. Neurol. 7. 291-295; 1980 2.Clemetson CAB Barlow’s diseaee Medical Hypotheses (2002) 59(1)52- 56 3.Williams WJ; Beutler E, Erslev AJ, Lichtman MA. Hematology 4th Edition p1587-88 McGraw Hill Publishing Company New York 4.Backstrom MC; Kuusela AL; Maki R. Metabolic bone diseases of prematurity. Ann Med 1996 28(4):275-82 5.Msomekela M; Manji K; Mbise RL; Kazema R; Makwaya C. Ann Trop Paediatr 1999; 19(4)337-44 6.Paterson CR, Burns J, McAllion SJ. Osteogenesis Imperfecta: The Distinction From Child Abuse and the Recognition of a Variant Form. Amer J Med Gen 45:187-192. (1993) Competing interests: I have advised accused and been paid for my advice. |
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susanne McCabe, retired cardiff cf24 3pf
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The strength of clinicians beliefs in somatic and psychological conditions may depend on a variety of factors, eg their own temperament;influence of trainers; their own personal development through other avenues, eg there are many clinicians, especially those interested in mental health/relationship issues, involved in spiritual groups such as the 'Janki Foundation'(see web site) or eg Buddism with it's particular take on suffering. Whatever the interest it is important to be open to critical points of view as well as those which support a perspective. A useful book which gives salutory messages about the need to be cautious about how little we understand about minds/bodies, and gives a perspective on the devlopment of 'Somatic Medicine' is 'The Freudian Fallacy' by E.M. Thornton, Grafton Books, 1986. Competing interests: None declared |
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