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Rapid Responses: Rapid Responses published:
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Medical Unexplained Symptoms or Incomplete Physical Examination
- Carlos A Selmonosky,MD (31 December 2004)
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NOT THE WHOLE STORY
- BM Hegde (1 January 2005)
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"Reminders"
- John B. Griffiths, Isle of Anglesey. LL61 6HQ (1 January 2005)
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Very thought provoking
- david d derauf (2 January 2005)
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Overdiagnose of patients with "medically unexplained symptoms"
- José G. Rank (3 January 2005)
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Unexplained symptoms: drug treatment side-effects or interactions?
- Carlos E. Poli de Figueiredo, Ivan Carlos F. Antonello (3 January 2005)
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Futile management; paradigm shift needed
- Herman JD Jeggels MRCP (UK) (4 January 2005)
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Re: Overdiagnose of patients with "medically unexplained symptoms"
- susanne mccabe (4 January 2005)
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Medically unexplained symptoms are often explainable
- Peter J Lewis (4 January 2005)
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DEFENDING REASONABLE ACTIONS
- Graeme M Mackenzie (4 January 2005)
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Futile management: follow-up comments
- Herman JD Jeggels MRCP (UK) (4 January 2005)
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Unexplained symptoms need relevant diagnostic testing
- Ellen C G Grant (4 January 2005)
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A new era of psychospiritualism
- Abhijit Chaudhuri (5 January 2005)
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Unexplained to whom?
- G Lorimer Moseley (5 January 2005)
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PLEA FOR A PARADIGM SHIFT IN THE SCIENCE OF MEDICINE
- BM HEGDE (5 January 2005)
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The truth of Medical Unexplained Symptoms may be found here
- Tariq M Khan (6 January 2005)
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Disturbed homeostasis in unexplained and functional somatic symptoms
- Dr David L Beales (6 January 2005)
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Joint working in primary care
- Rhiannon England, Alice Cook Psychotherapist (7 January 2005)
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Re: Joint working in primary care
- susanne mccabe (8 January 2005)
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Dumping Descartes
- Chris L. Manning (8 January 2005)
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Medically Unexplained Symptoms: Different Diagnosises Needing Different Interventions
- Sepideh Omidvari (10 January 2005)
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Paediatric medically unexplained illness - MSBP?
- Brian Morgan (11 January 2005)
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Medically Unexplained Symptoms
- Fiona Woollard (11 January 2005)
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Medically unexplained symptoms require a new paradigm
- Giovanni Cataldi, Francesco Benincasa (16 January 2005)
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The uncommon clinical pictures
- Salvatore Corrao (17 January 2005)
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Authors’ reply to the rapid responses concerning the editorial ‘Management of medically unexplained symptoms’
- Marianne Rosendal, Frede Olesen, and Per Fink (3 February 2005)
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Re: Authors’ reply to the rapid responses concerning the editorial ‘Management of medically unexplained symptoms’
- susanne mccabe (3 February 2005)
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Carlos A Selmonosky,MD, Physician 3784B Madison Lane.Falls Church VA 22041.USA
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The symptoms of chest pain,pain and paresthesias in the upper extremity and symptoms of vertebral artery insufficiency very often are though to be unexplained by the physician.Thoracic Outlet Syndrome is commonly the etiological factor,the diagnosis requires to perform a triad of signs and to asses the presence or absence of the White Hand Sign.See www.tos-syndrome.com where the signs are visually described. Competing interests: None declared |
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BM Hegde, Retd. Vice Chancellor Mangalore-575004, India
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Dear Sir, The bio-medical model of illness that we learn and teach is incomplete to explain many a modern malady. Thanks to Descartes, we have cut off the human mind from the human body in our enthusiasm to understand the disease processes through our reductionist science. If one listens carefully to the patient’s woes and tries to understand the mind of the patient, no symptom remains unexplained. "If you listen to your patient long enough he/she will tell you what is wrong with her/him," wrote Lord Platt years ago. The divine interventionalists have forgotten that every ill starts and ends in the human mind. If someone could discover a mindoscope and show the interventionalists that it could earn dollars, we would understand diseases better in this overdo$ed medical world. Till such time our best bet is to take time to listen to our patients. “Experience is not what happens to a man. It is what a man does with what happens to him,” wrote Aldous Huxley. If one not only uses all the brains that he/she has got in addition to borrowing what he/she could, one would quickly realize this fallacy in our present thinking. Bedside medicine, if practiced diligently, would, in addition, be good for the hapless victims of various diseases. Many a patient with unexplained symptoms could be helped with “unrest cure” sans pills and potions, when one understands the patient’s anxieties, anger, hostility and frustrations. Yours ever, bmhegde Competing interests: None declared |
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John B. Griffiths, Retired G.P. Brynsiencyn,, Isle of Anglesey. LL61 6HQ
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Reading the article reminds me of two points: (i) When a student in Cardiff in the early/mid 1950s, we were taught that - on meeting a patient - the routine was: Take a History, Carry out an Examination, Make a Diagnosis, and then Decide on Treatment. (I do not know whether present day students are still taught this!). However, there was a very wise and senior consultant in the Infirmary who used to say that - having carried out the first three proceedures - and before deciding on Treatment, one should say to oneself 'Is this patient ILL? If so - what do I do about it'? That policy has stood me in very good stead during 40 years in G.P., and I think should apply in instances similar to those referred to in the article. (ii) Because it is assumed that such instances, in the first place, would be seen much more frequently by GPs, the following definition may be interesting: The G.P. Accepts the Uncertainty. Explores the Probability and Marginalises the Danger. The Specialist Reduces the Uncertainty, Explores the Possibility, Marginalises the Error. Competing interests: None declared |
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david d derauf, Executive Director Kokua Kalihi Valley Community Health Center honolulu, hawaii 96817
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Rosendal, Olesen and Fink have written a wonderfully thought provoking editorial, but I am puzzled by their conclusion that "we should offer the same professional management and quality of care to the many patients with medically unexplained symptoms as we offer to patients with explicable symptoms."1 Might this proposed solution not in fact be a good part of the problem? Certainly there is a growing body of research that doctors' usual ways of communicating with patients, not just those patients with "medically unexplained symptoms", but indeed all patients, have lots of room for measurable improvement. Frankel and Beckman2 for example, found that "in only 17 (23%) of visits was the patient provided the opportunity to complete his or her opening statement of concerns ", being interupted "a mean of 18 seconds after beginning to speak". Moreover, research has found that "perceptions about nontechnical interventions were better predictors of patient satisfaction than perceptions about technical interventions" 3 and that physician encouragement and empathy were related to higher patient satisfaction and reduction in concerns. 4 Based on this and considerable other similar research, one might be tempted to conclude that our approach to caring for patients with medically unexplained symptoms should begin with a careful appraisal and assesment of our approach to caring for all patients. Seen in this light, the challenge of caring for those with medically unexplained symptoms creates a real opportunity for us all to become better clinicians. 1 Rosendal M, Olesen F, Fink P. Management of medically unexplained symptoms. BMJ 2005;330:4-5 2 Beckman HB, Frankel RM. The effect of physician behavior on the collection of data. Ann Intern Med. 1984 Nov;101(5):692-6. 3 Brody DS, Miller SM, Lerman CE, Smith DG, Lazaro CG, Blum MJ. The relationship between patients' satisfaction with their physicians and perceptions about interventions they desired and received. Med Care. 1989 Nov;27(11):1027-35. 4 RC Wasserman, TS Inui, RD Barriatua, WB Carter and P Lippincott. Pediatric clinicians' support for parents makes a difference: an outcome- based analysis of clinician-parent interaction. Pediatrics 1984; 74: 1047- 1053 Competing interests: None declared |
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José G. Rank, MD Tucumán, Argentina. ZP 4000
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Dear Sir: I agree with you that an important number of patients comes to the GP with mild and difuse symptoms. Furthermore, many times after visiting several specialists. Many of them even carrying a bag full of Rx's and labs. I think there are many reasons why this happens every day: 1) We don't sit next to the patient with time to listen what the problem is, when it happens, how often and what they were doing when it happens. 2) It's easier to send a patient to Rx's than to expain what is wrong with him or her. 3) We tend to think that a mild symptom speaks of a banal desease. In the other hand, in restrospective surveys we can see many heath problems begins with this kind of symptoms such as leukemia, AIDS, rare infectius deseases, etcetera. I think we GP's must increase the dialogue with our patients and take a minute to think "What can I do for this man" when we can't find a clear diagnose. Yours. Gerardo Rank Competing interests: None declared |
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Carlos E. Poli de Figueiredo, Professor Adjunto Faculdade de Medicina/HSL/IPB from PUCRS C Clínico PUCRS C414, Av Ipiranga 6690. Porto Alegre,RS,Brazil, CEP 90610.000, Ivan Carlos F. Antonello
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Rosendal et al (1), correctly pointed out that medically unexplained symptoms represent a serious clinical problem. An important, and perhaps under diagnosed, issue related to medically unexplained symptoms is the possibility of drug treatment side-effects or drug interactions. Such adverse events may not be detected or lack previous report. When dealing with hypertensive patients we have observed that this may be a common occurrence. Behaviour changes, neurological or psychiatric manifestations, sleep disorders, smell and taste disturbances and ill-defined symptoms are few examples of symptoms that disappear when drugs are withdrawn. When medically unexplained symptoms are present the possibility of drug-related side-effects or interactions should strongly be considered. 1 Rosendal M, Olensen F, Fink P. Management of medically unexplained symptoms. Br Med J 2005;330:4-5. Competing interests: None declared |
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Herman JD Jeggels MRCP (UK), Medical Practitioner Cape Town, South Africa
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Dear Sir, Why are we unable to understand many complaints of patients? Allow me to add to your misery with an example. Asthma improves on passing stool: many a patient suffering from asthma have consulted me with such a symptom. Colleagues invariably are ignorant regarding such a symptom, whether this was in the setting of me functioning as Consultant Physician in one of Port Elizabeth’s hospitals, South Africa, or after resigning and working as a GP. Patients confirm that as the chest tightens, an urge to pass stool appears. Furthermore, passing a stool has the same effect as an inhaler! As such patients are often in a dilemma whether to go the toilet or take an inhaler, as both offer equal relief. Why can’t we understand the above symptom? The blame rests with modern medicine not studying man, rather bits and pieces, as Prof Wyngaarden, one of the editors of the famous textbook of Internal Medicine, Cecil Textbook of Medicine (reference below). His definition is: –“Instead of reaching for the whole truth, the scientist examines small, defined, and clearly separable phenomena.” Please read my response to Prof Djulbegovic’s article of 18/12/2004: “Lifting the fog of uncertainty from the practice of medicine -- Djulbegovic 329 (7480) 1419 – BMJ”, for an elaboration on this topic. How do I know the existence of such a symptom and how to use the symptom to find the correct treatment for not only the symptom but for the asthma as well? Is it not unbelievable that a treatment really exists for such a mind-boggling symptom? Indeed, this symptom became part of reality due to the fact that doctors administered themselves a particular plant which induced this exact symptom in the doctors. However, having elicited the symptom would have been futile without the philosophical basis for the experiment. Guided by the philosophical basis, the doctors proceeded to administer to patients suffering from exactly such a complaint, medicine made from the whole plant, curing such a form of asthma; and only such a form. This treatment would not help for a patient suffering from asthma due to mist, for instance. How are we able to understand the symptom asthma due to mist? Doctors have in fact proceeded with numerous experimentations with medicines which induced hundreds and sometimes more than a thousand symptoms; many of which are symptoms patients complain of and which are now called medically unexplained symptoms. As such many of the so-called medically unexplained symptoms are symptoms which I and my colleagues can explain in the context of every unique patient. What am I talking about? Before giving my answer, I predict that most readers would stop reading any further once they realise what I am talking about. I am talking about Homoeopathy. I regret to inform the authors that your efforts conceptualising medically unexplained symptoms is futile if you continue to adhere to your most fundamental paradigm of reductionism. Having been fortunate to study medicine at the Free University of Amsterdam in the Netherlands-which provided us with grounding in Homoeopathy-I started to employ Homoeopathy for my patients, as Homoeopathy is not only able to explain, but gratefully also able to provide medication for many of these so-called medically unexplained symptoms. What then to do? Continue on your path obstinately adhering to what Ludwig von Bertalanffy, author of the book titled General System Theory (Whole-istic biological systems theory) called Old Fashioned Science, namely reductionism. Nevertheless, continuing would still provide you with research funds and even PhD’s; alas, you would find that your patients are only stampeding away from your practices. If the authors truly wish to solve these problems they should study the undivided man as is. All that is needed is a very honest willingness for a paradigm shift; and you would not cease to be a doctor; just a much, much better one capable of not only understanding patients’ symptoms, but gratefully providing medication to stimulate a cure of the patient and alleviating those so-called medically unexplained symptoms. Competing interests: None declared |
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susanne mccabe, retired cf24 3pf
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Unfortunately some healthworkers are uneasy or impatient about living with uncertainty. There are obviously several potential unhelpful outcomes but one too common approach is to label a person as having a psychological problem if a diagnosis cannot be made after several investigations....and importantly if the practitioner him/herself has an interest in psychological medicine, belongs to a therapy organisation or has friends or colleagues who welcome referrals. For the person him/herself it can become a catch 22 diagnosis which may follow them around covertly or openly on files whilst their condition gets worse.It is actually quite difficult for many people to resist being sent down the wrong path when they are already weary from unexplained symptoms and constant referrals which shed no light,who do not have a medical knowledge base- coupled with a healthworkers own beliefs and attitudes which may undermine their own knowledge of what is going on in their own body. Cognitive behaviour therapy is something which can be used in a respectful way to help deal with the pain and unknowingness of a chronic unexplained illness. Used correctly as an equal partnership process between the person and somebody with not just an interest but appropriate skills to pass on, CBT has been found to be a valuable support which does not deny the reality of the person seeking help. The latest BMJ Learning model is instructive in passing on and reminding healthworkers of tips to use in consultations. It is useful in highlighting the need for all to be reflexive about their own thinking when presented with problems and dealing with difficult feelings. Unfortunately there is a strange flaw in the teaching module - the use of the term 'heartsink patient' is derogatory, it is a description used covertly rather than openly with persons. We all meet people we wuld prefer not to deal with but CBT is usually one of the most open, transparent and respectful of the dignity and autonomy of the person - describing others especially in the more vulnerable position, in such terms would not be therapeutic - using it covertly is an abuse of position. There have been all sorts of unacceptable terms shed since relationship issues have become more prominent - whether they are claimed to be just a shorthand or not - it is not acceptable any longer to refer to another in terms they would find hurtful - however it may be explained away. Competing interests: None declared |
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Peter J Lewis, integrative physician 15 South Steyne, Manly, NSW 2095, Australia
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Editor - Fink is correct to say that ‘currently the theoretical and practical training in medically unexplained symptoms is insufficient’ (1), but the assumption is still too frequently made that unexplained symptoms have no organic cause and are ‘all in the mind’. This, I think is a sad reflection of the narrow disease-based/symptomatic treatment paradigm of modern medicine. It is my experience, as a physician with a special interest in nutritional and environmental medicine, that if one takes a broader view of all factors affecting health, and looks hard enough, that the majority of unexplained symptoms are indeed explainable on a physical basis. Frequently such patients have nutritional deficiencies (especially B-group vitamins, vitamin D, magnesium, and/or essential fatty acids), food or chemical sensitivities, hormone imbalances (e.g. unidentified hypothyroidism, or dehydroepiandrosterone [DHEA] deficiency), and/or intestinal dysbiosis, all of which are treatable if they are identified. It is simply not good enough to say that because tests are normal, and no serious disease can be found, that there is ‘nothing wrong’ or that the patient will ‘just have to learn to live with it’ (the advice that is only too frequently given by general practitioners and specialists alike). Patients do not just want reassurance, they want to understand why it is that they feel unwell, and what is necessary to rectify the cause of their symptoms. A new comprehensive paradigm is urgently needed, with doctors adequately trained in the identification and treatment of nutritional and environmental factors in health and disease. Reference 1. Fink P. Management of medically unexplained symptoms. BMJ 2005;330:5-6. Competing interests: None declared |
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Graeme M Mackenzie, GP CA28 7RG
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The problem with medically unexplained symptoms is the destructive cycle of investigation and referral during which the patient and the doctor often collude that the next clinic or investigation will give the answer. During that long process the patient often gets a fixed idea that his symptoms will be explained and then treated in a typical diagnosis/cure fashion. Many GPs have a good idea at the first consultation where the likely outcome is "medically unexplained symptoms". However in a litigious world there is hesitation in going down this route as the most likely outcome. Of course if more GPs did this, inevitably one or two serious diagnoses would be missed, although the amount of damaging and inappropriate investigation would be reduced. It is interesting that few patients ever complain that we missed their depression or anxiety after extensive fruitless investigation in they way they do if we miss physical disease. To stop the juggernaut of investigation, which in turn deskills us a doctors, we need to defend doctors' actions as reasonable, even if they occasionally miss serious diagnoses. Competing interests: None declared |
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Herman JD Jeggels MRCP (UK), Medical Practitioner Cape Town, South Africa
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Dear Editor, I wish to deal firstly with the article by Rosendal et al (2) as well as the article by Prof Djulbegovic (3), both of which are of immense importance. Secondly I wish to discuss what the evidence of treatment would be, when such treatment is instituted on the basis of the inexactness of medicine and unexplained symptoms of patients, as discussed in the previous two articles. These articles (2 and 3) reflect honestly and painfully the fundamentally deep-seated conceptualisation problems of modern medicine. Prof Djulbegovic’s article reflected on and lamented the inexact nature of modern medicine, while Rosendal’s article merely echoes Djulbegovic’s lamenting, albeit narrowing the problem area. If modern medicine according to Prof Djulbegovic is so inexact, how would one be able to understand many of the symptoms of patients? I have stated in my response to Prof Djulbegovic (4), that “Firstly, there cannot be smoke without a fire. I fear that Prof Djulbegovic and the other authors lamenting the uncertainty of medical practice are looking at mending the smoke and not the fire causing the smoke.” In the same manner, Rosendal et al are guilty of the same futile mending process. Indeed, all the colleagues commenting on the article except for Prof Hedge are guilty of the same patch work activities. All are unfortunately guilty of indulging in very superficial analyses of the problem and are blissfully ignorant of the real depth thereof. David D Derauf (1) splendidly analysed valid reasons for medically unexplained symptoms, albeit, also superficial, which also tinkers with the smoke and not the fire. Rosendal et al mentioned that “Such assessment and proper management require good theoretical understanding of the problem, but currently the theoretical and practical training in medically unexplained symptoms is insufficient in most university curriculums and postgraduate training programmes for general practitioners.” These recommendations are laudable but futile; recall my quotation of Prof Wyngaarden (5): –“Instead of reaching for the whole truth, the scientist examines small, defined, and clearly separable phenomena.” Your theoretical basis to understand patients are flawed, as your most fundamental basis is of medicine is flawed. From Descartes onwards, medicine’s basis is flawed, and thus far no one within mainstream medicine is willing to honestly reappraise how to correct medicine’s flaws. No one is interested in investigating other paradigms. I have done and am eternally content with my decisions. Is your unwillingness due to bigotry or fear? I recall, nevertheless not exactly who was responsible for the quotation, either George Bernard Shaw or Bertrand Russell, who said that man would rather burn his own house than change his prejudices. You have to answer that for yourselves, as patients are not waiting for you to make up your minds. They simply vote with their feet. Many philosophers have analysed modern medicine’s conceptualizations amongst others Sir Isaiah Berlin. The book by Wulff et al (6) is furthermore essential reading. My second discussion point deals with what the evidence (results) of treatments based on the inexactness of medicine and the multitude of medical unexplained symptoms would be. In this regard I took the liberty of quoting the following from amongst many more: 1. DM drugs lower the glucose levels of patients, yet inevitably complications set in. Prof Leif Groop (7), MD, presented a paper entitled “Treatment and Mistreatment of Type 2 Diabetes”. He stated the following: “The history of treatment of type 2 diabetes has been a history of failures. No treatment (includes sulfonylureas, biguanides and insulin) thus far has been able to change the inevitable course of type 2 diabetes with an average increase of 1 mmol/4 years…”Amazingly Prof Groop said: “diabetes is far more heterogeneous than thought thus far, therefore treatment should be custom build for the individual patient.” This request calling for individualised treatment for patients, is calling for the impossibility to be take place. RCT are the antithesis of individual care as the individual is dismembered into bits and pieces and lost forever in the soup of RCT. How can he ever find the right treatment for the right individual, when the right individual is never considered at all? 2. Rheumatoid Arthritis drugs lower the pain, yet the mortality and morbidity remain frightening. According to Pincus (8), “RA trials paint a rosy short term picture of patients with RA, while patients’ status deteriorates over the long-term.” 3. Hypertension drugs lower the blood pressure, yet the survival and mortality of the patients is worse than non-hypertensive patients. (Anderson OK) (9) 4. The Journal of the American Medical Association acknowledged that modern medicine is the third leading cause of death in America. Most conventional medical treatments are not helping the majority of people taking those most of the time. Many Americans are seriously harmed by modern medicines while more than 200,000 a year are killed by them! (JAMA) (10) Does the above information not confirm what Aaron Wildavsky (11), 1977 said: “Most of the bad things that happen to people are at present beyond the reach of medicine.” In the same book Lewis Thomas (11) questioned concerning the major issues like cancer, heart attack, hypertension, stroke, diabetes, arthritis and peptic ulcer, the following: “For many of these illnesses, do we possess a decisively effective technology for cure or prevention, directed at a central agent or mechanism, comparable to the treatment, say, of pneumococcal lobar pneumonia with penicillin?” His answer is that “It does not look like the record of a completed job, or even of a job more than half begun, when you run through the list,” In essence a reflection of failure. Lastly, may I add for balance’s sake, that modern medicine, essentially is, an emergency medical system. It is thus no wonder that the best aspect of modern medicine is that of emergency medicine and surgery as well as the discipline of anaesthetics. What is the moral of this story? We can NEVER achieve curative results on the basis of inexactness and unexplained symptoms of patients. No one should lay the foundation of his/her building on quicksand. Who is willing to explore beyond his/her paradigm? 1. http://bmj.bmjjournals.com/cgi/eletters/330/7481/4 responses to Rosendal 2. http://bmj.bmjjournals.com/cgi/content/full/330/7481/4 Rosendal et al 3. http://bmj.bmjjournals.com/cgi/content/full/329/7480/1419 Prof Djulbegovic 4. http://bmj.bmjjournals.com/cgi/eletters/329/7480/1419 responses to Djulbegovic 5. Wyngaarden James, Cecil Textbook of Medicine, 19th Edition 1992, Medicine as a Science, page 10, WB Saunders Company. 6. H. Wulff, A. Pedersen, R. Rosenberg. Philosophy of Medicine, an Introduction, Blackwell Scientific Publications, 1986 7. (7)Groop, L. Treatment and mistreatment of Type 2 Diabetes. The J of Endocrinology, Metabolism and Diabetes of South Africa. April 2002, Vol. 7, No. 1, page22. 8. Pincus T: Rheumatoid arthritis: disappointing long-term outcomes despite successful short-term clinical trials. J Clin Epidemiol 1988; 41:1037-41. 9. Anderson OK. Survival in treated Hypertension: follow up study after two decades. BMJ 1998; 317: 17-171 (18 July). 10. JAMA. 2000; 284: 483-485 11. John H. Knowles. Doing Better and Feeling Worse: Health in the United States. 1977. W.W. Norton & Company. Competing interests: None declared |
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Ellen C G Grant, physician and medical gynaecologist Kingston-upon-Thmes, KT2 7JU,UK
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Marianne Rosendal and colleagues estimate that at least 20-30% of primary care patients have medically unexplained symptoms. That is not my experience. Over 45 years I have usually found that the more a patient complains, the more there is to find. The problem is that most doctors do not have free access to the most revealing tests. The commonest biochemical abnormalities are zinc, magnesium and copper deficiencies, which usually cause functional B vitamin deficiencies and EFA pathway blockages. Treating a positive gut fermentation test with a low yeast, low sugar diet and antifungal medication can also dramatically improve anxiety and panic symptoms. High levels of toxic metals can be lowered by removal of sources and chelation. My research work in the 1960s proved that women who react badly to taking progesterones and oestrogens for contraception or menopausal symptoms with headaches, migraine, mood changes or weight gain, have more abnormal endometrial blood vessels than symptom-free women taking the same formulations. They are also more likely to have zinc and magnesium deficiencies.2 Headches and migraines were virtually eradicated in hospital migraine patients who avoided the major precipitants and followed a low allergy diet.3 Communication with patients is simple if their abnormalities are diagnosed, precipitants are discontinued and hidden infections and nutritional deficiencies are treated. 1 Rosendal M,Olesen F, Fink P. Management of medically unexplained symptoms.BMJ 2005; 330: 4-5. 2 Grant ECG. The pill, hormone replacement therapy, vascular and mood over-reactivity , and mineral imbalance .J Nutr Environ Med 1998;8:105- 116. 3 Grant ECG. Food allergies and migraine. Lancet 1979;1:966-69. Competing interests: None declared |
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Abhijit Chaudhuri, Senior Lecturer in Clinical Neurosciences University of Glasgow
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The use of the non-specific, umbrella term Medically Unexplained Symptoms (MUS) to patients whose presentations defy the common textbook knowledge of medicine is an unfortunate product of overemphasis on Cartesian dualism and overreliance on reports rather than patients themselves. MUS is an artificial construct and its concept is entirely synthetic, created by the psychiatrists and it lies outside the natural territory of medicine. My criticisms against MUS are based on the following observations:- First, the range of symptoms that cannot be explained or are poorly explained in patients with an obvious organic disease is no different from MUS. Take for example, sensory symptoms in motor neuron disease, fatigue in multiple sclerosis and photophobia of migraine headache. Second, the level of underlying psychological distress in symptomatic patients with or without an obvious organic diagnosis is very similar. For example, prevalence of depression or anxiety associated with diabetes, cancer or multiple sclerosis is not significantly different from chronic fatigue syndrome. Third, quality of life is equally affected by a disabling symptom, such as chronic pain or fatigue, whether or not there is an obvious and explainable organic basis; Fourth, symptomatic treatments are very similar whether or not the underlying cause is “organic”. The likelihood of success from interventions such as cognitive behaviour therapy depends on the level of psychological distress in an individual rather than on the nature of symptom(s). Finally, the use of MUS as a diagnostic term shifts the responsibility of “explanation” from physicians to patients who come to seek help and are advised to get behaviour therapy by having their experience “challenged” (1). The danger of this shift was most elegantly expressed by the late Roy Porter: “ new psychospiritualism (“sickness is all in the personality”) uncannily echoes the victim-blaming doctrines of the moral majority (“sickness is God’s punishment”) [in the past]” (2) For those who care to read my response, this is the tip. Instead of using the term MUS please tell your patient the following, simple truth: I don't know but I may help." Not Yet Diagnosed (NYD) is still one of the more respectable terms in medical practice and I suggest it to those who are fond of using acronym in their clinical letters. Reference 1. Stulemeijer M, de Jong LWAM, Fiselier TJW, Hoogveld SWB, Bleijenbrg G. Cognitive behaviour therapy for adolescents with chronic fatigue syndrome: randomised controlled trial. BMJ 2005; 330: 14-18. 2. Porter R. Medicine and the People. In: The Greatest Benefit to Mankind. A Medical History of Humanity from Antiquity to the Present. London: Harper Collins 1997; p709. Competing interests: None declared |
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G Lorimer Moseley, NHMRC Clinical Research Fellow School of Physiotherapy, The University of Sydney, Lidcombe 1825 Australia
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Dear Editor - Rosendal, Olesen and Fink discuss an important issue. Of course, when the biomedical model fails it is tempting to conclude unexplainable symptoms, but modern models acknowledge that many biological mechanisms, albeit sometimes complex, can effect symptoms. So why don't clinicians explain those mechanisms to patients? Unexplainable according to a biomedical model is not necessarily unexplainable. This point is pertinent in chronic pain. Our research raises three issues relevant to this point: (a) Clinicians are reluctant to accept the current biology of pain and operate according to a structural/pathology model, which is simply no longer tenable; (b)even when clinicians understand currently accurate biology of pain, they are reluctant to change their practice and they don't give patients an alternative to the structural pathology model; (c)this reluctance seems to be because clinicians think that patients won't understand modern biology anyway, which is wrong(1). Until clinicians embrace modern biology, apply it to their practice and let patients in on it, all too many symptoms will remain unexplained. 1. Moseley, G.L., J Pain, 4 (2003) 184-189. Competing interests: None declared |
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BM HEGDE, Retd. Vice Chancellor Mangalore-575004. India
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Dear Sir, I am so much impressed by the response of Dr. Herman Jeggles from South Africa that I thought I should write more elaborately on our problems in modern medicine because we use reductionist science. There is an urgent need for a paradigm shift in medicine if society has to really bebefit from us. I was so happy that a young man is thinking like me and is asking for a pardigm shift. Many years ago, an article of mine in the Proceedings of the Royal College of Physicians of Edinburgh did have the same caption-need for a paradigm shift, but there were no takers! In emergency care we have no other choice than to follow the modern medical quick fixes, although there are warning signals that all is not well even in that area. In all chronic illnesses, I feel, our treatment does more harm than good, if one carefully audits the outcomes. Many a divine intervention in the apparently healthy population have similar outcomes. A good example is the Philadelphia-Ontario bypass audit in the immediate post Myocardial infarction period. This is not surprising at all, as time evolution in a dynamic system is not dependent on minor changes in the initial state in the human body. Correcting those changes need not (will not) result in better outcomes in the long run. "Butterfly effect" of Edward Lorenz takes over. The altered state (lowered BP or Sugar) might result in catastrophic changes elsewhere, if one understands non-linear mathematics that the human body follows. Aristotle wrote that “truth can influence only half a score of men in a century while falsehood and mystery would drag millions by the nose.” This is more than true in the case of modern medicine. Plato, in his celebrated book, The Republic, refers to his teacher Socrates’ efforts to change society when, at that time in Greece, injustice was justice and justice was the convenience of the powerful. Socrates did not succeed, though. I am only trying to indicate the inherent drawbacks in our system lest people should be taken for a costly ride! Lucien Leape of the Harvard Medical School in his excellent article, Errors in Medicine, published in 1994 in the prestigious Journal of the American Medical Association (Vol 272; page 1851-1857) gives a very graphic description of all the errors that we have been committing. This has been updated recently by Barbara Starfield in her excellent article in the same journal in the year 2000 (JAMA 2000;284:483-485) which reiterates the same, adding many more glaring dangers to the list already given by Leape. To date, I have been able to trace more than seven thousand articles showing the mistakes of modern medicine in the best western journals. Nearly 225,000 people have died in one year in the US alone due to iatrogenic diseases. Of these 140,000 has been exclusively due to adverse drug reactions. In addition, an equal number died during out patient management of Adverse Drug Reactions that cost the buyer a total of $ 79 billion in prescription bills in one year. There have been three million injuries due to medical interventions in a year with 44,000 to 98,000 deaths annually. Nosocomial infections alone caused 80,000 deaths in one year in hospitals. One hundred million people suffer from chronic debilitating illnesses partly due to medical interventions. These figures look horrible if one takes into consideration the relatively small population of US. The sad story does not include the escalating costs of modern medicine. One of the reasons why this sordid drama unfolds in that country is the heavy advertisement about screening the apparently healthy people for all kinds of abnormalities. However, all the audits of screening efforts have shown that screening healthy people could be one of the most dangerous activities in society. Time evolution in the human system does not follow linear laws of predictability. The screening industry is the biggest money spinner in medicine. A very recent editorial by Richard Smith in the prestigious British Medical Journal entitled “The Screening Industry” bares the true picture in all its ramifications. Screening probably is the main source of the above sickening numbers mentioned earlier. If doctors confined themselves to cure the sick rarely, comfort them mostly, but to console always, they would be doing a great service to the public. When doctors try and intervene in healthy segments of society problems start. Sir William Osler, a celebrated brain in medicine in the last century, was right when he said: “patient doing well do not interfere.” Modern medicine is slowly becoming unpopular in the west. In the year 1997 alone 629 million people took treatment from alternative systems of medicine in the west paying from their own pockets. This is more than the number of people that saw their family doctors in the same year, according to a survey done by Eisenberg and colleagues in 1998. India should take note of this as we have one of the best systems of health care in Ayurveda, especially for chronic illness syndromes. If this could be judiciously clubbed with the emergency care methods of modern medicine complementing each other we could bring down the costs of medical care to almost one tenth of its present level with less danger to the public as a bonus. The future lies in emphasizing promotive health. We should change the present teaching in medical schools to that of patient-centred education from the present disease-centred education. We should use statistics sparingly in medical research. One of the drawbacks of applying disease statistics to the healthy population is that the latter throws up a very high percentage of false positives, resulting in epidemiologists predicting the unpredictable resulting in epidemics. The fear of an illness could help the illness to take a firm root in a healthy person. Modern medicine has realized that the human mind plays a vital role in disease causation as well as its control. Hence there is a need for doctors to train themselves in human psychology and behavioral sciences. Health is one’s birth right. Diseases are only accidents. If one follows the correct rules of healthy life style, accidents (diseases) will be rare indeed!Unexplained symptoms also fall into place in this new scenario. Yours ever,
Competing interests: None declared |
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Tariq M Khan, Physical Medicine C1 Officers Colony zarar Shaheed Road Lahore 45000 Pakistan
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Dear Sir In the list of many Medical Unexplained Symptoms majority are pain related symptoms. It is pitiful that while many of GPs Orthopedics and even Rheumatologist and any other consultants encounter patients with unexplained pain symptoms like paresthesias, weakness, tiredness and abdominal pain related symptoms have not upgraded their understanding of new discoveries and understanding of chronic pain. Unfortunately both the undergraduate and postgraduate textbooks and examinations have not yet included these into their syllabus, there, for majority of physicians and consultants the knowledge ends there and beyond which all is termed as Medical Unexplained Symptoms. I agree with Carlos A Selmonosky,MD,and G Lorimer Moseley, that such symptoms can be explained if we learn more about chronic pain (neuropathic pain). It is sad what we cannot diagnose we blame it to the mind of the patient. I have seen many patients with even meralgia paraesthetica being treated as psychiatric patients. While many unexplained infections like with mycoplasma are yet to be diagnoses and also nutritional imbalace could be cause of so called Medical Unexplained Symptoms. Inclusion of pain particularly musculoskeltal and referred pain into the basic curriculum will bring comfort to many doctors and patients. Competing interests: None declared |
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Dr David L Beales, Clinical Tutor Bristol University Division of Primary Care The Complete Health Centre 34 Castle Street Cirencester GL7 1QH
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The excellent editorial on the Management of Medically Unexplained Symptoms highlights the key role of general practice. If the 20-30% of primary care patients who present in this way are not helped to understand and recover, this in turn leads to excessive, unnecessary presentation in secondary care. In one study of new medical outpatients 30% had no medical diagnosis, and 22% had doubtful medical diagnoses to account for their symptoms.1 Unfortunately in the new general practice contract, general practitioners are not rewarded for providing continuity of care for these patients. Worse still, the new contract lumps together in the global sum partners and staff costs, which include ongoing training that might then be available in this area.2. That practices need to review their approach to personal care with continuity for these patients is supported by the extensive evidence that patients value a positive patient centred approach.3. In this study the authors demonstrated that "without this approach patients will be less satisfied, less enabled and may have a higher symptom burden and a higher rates of referral". Time is a key element in helping patients step back and look at their symptoms once they are reassured that there is not an organic basis. "We can find nothing wrong" is taken as dismissal and rejection, and this is clearly demonstrated in a good qualitative study not referred to in the editorial.4 A key element in my own approach is in helping patients understand that the basis for their symptoms results from difficulties in maintaining homeostasis or internal balance as a result of too much pressure (sustained stress). These pressures may be from the inner world of excessive emotional arousal or from external pressures such as work or marital conflict. The presentation is often associated with increased sensitivity to somatic complaints because of psychophysiological disturbance leading to problems with information processing, and where oscillations in both physiology and behaviour, which play a major role in the balance between stability and adaptivity, are disturbed.5 In developing a model where the patient feels understood, and the negotiation of a new understanding of symptoms, as described in the editorial, the reattribution model clearly works, and is cost effective. Since this model was described it is also possible to show how disturbed breathing chemistry, resulting from breathing pattern disorder, is a direct result of excessive arousal. Involvement of the patient in understanding how internal responses can destabilise health may involve the following areas: sustained adreno-cortical drive, hypothalamic- pituitary-axis disturbance; imbalance between the TH1 and the TH2 responses in the immune system; changes in breathing behaviour shown by capnometry. This can help the individual understand how physical symptoms can result from psychophysiological disturbance, and what to do to restore equilibrium.6 This approach allows individuals to understand their symptoms in the context of their predicament. Once a mutual understanding is reached that the symptoms can be understood as the result of sustained arousal, the practitioner is able to offer a credible scientific basis for the presentation and use his training and knowledge appropriately. As general practitioners, we are generalists, and in the core definition of our role we need to recognise that this involves the front line nature of care offered, and the need to incorporate psychological and sociological perspectives alongside bio-medical ones.7 We need to see general practice as the specialty of generalism.8 This increasingly makes sense when the overlap in symptomatology is demonstrated not only in so- called medically unexplained symptoms, but also functional somatic syndromes as well.9 When disturbed homeostasis and faulty information processing is seen as the underlying basis for presentation it is possible to see both medically unexplained and functional somatic syndromes as belonging to one single mind/body disturbance - homeostatic imbalance - and the individual is likely then to work with his medical adviser to return to function and wellbeing. Patients accept the term "functional disturbance" and reject terms such as "medically unexplained symptoms" or a psychological explanation, and rightly so.10 Surely this is what makes general practice such an important and cost -effective specialty, where keen diagnostic skills are required to recognise the early signs of pathological dis-ease. The "specialty" teaches us that in addition we need to understand and help individuals to recover wellbeing in the midst of complex lives that have been overloaded. When general practitioners are trained in appropriate techniques, cost effectiveness follows.11 Surely for general practice, the next step is to encourage practice programmes, tailored around these principles with audit and research, integral to the development of effective outcomes. References: 1. Page L, Wessely S, Medically Unexplained Symnptoms: Exacerbating factors in the doctor/patient encounter J R Soc Med 2003;96:223-227 2. Sims J, The New GP Contract NHS Alliance 2002 3. Little P, Everitt H, Williamson I, Warner G, Moore M, Gould C, Ferrier K, Payne S, Observational Study of Effect of Patient Centredness and Positive Approach on Outcomes of General Practice Consultations BMJ 2001; 323:908-11. 4. Salmon P, Dowrick C, Ring A, Humphries G, Voiced but Unheard Agendas: qualititative analysis of the psychosocial cues that patients with unexplained symptoms present to general practitioners BJGP 2004, 54, 171-176 5. Saul J, Cardio-respiratory variability: Fractals, white noise, nonlinear oscillators and linear modelling. What's to be learned? 1992 Rhythmns in Physiological Systems, edited by H. Haken & H.P. Koepchen, Berlin Heidelberg: Springer-Verlag. 6. Beales D. Beyond Mind-Body Dualism: Implications for patient care Journal of Holistic Health Care 2004 1:3 15-22 7. Olesen F, Dickinson J, Hjortdahl P, General Practice - Time for a new definition. BMJ 2000; 320 354-7 8. Heath I, Evans P, Van Weel, The Specialist of the Discipline of General Practice Somantics and politics mustn't impede the progress of general practice. BMJ 2000;320:326-7 9. olde Hartman T, Lucassen, P, van de Lisdonk E, Chronic Functional Somatic Symptoms: a single syndrome? BJGP 2004, 54 922-927 10. Stone J, Wojcik W, Durrance D, Carson A, Lewis S, MacKenzie L, Warlow, C, Sharpe M What should we say to patients with symptoms unexplained by disease? The "number needed to offend". BMJ 2002; 325: 1449-50 11. Morriss, R, Gask L, Ronalds C, Downes-Grainger E, Thompson H, Leese B, Goldberg D, Cost-effectiveness of a new treatment for somatised mental disorder taught to GPs. Family Practice 1998; 15: 119-125. Competing interests: None declared |
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Rhiannon England, GP Statham Grove Surgery London N169DP, Alice Cook Psychotherapist
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We were very pleased to read the editorial by Rosendal,Olesen and Fink. Inappropriate medical treatments and referrals are not only bad medicine but are costly bad medicine.Whether patients presenting with medically unexplained symptoms are the victims of poor diagnostic skills by their doctors, or show poor self reflection by the patients themselves is largely irrelevant- as the evidence shows that treatable organic disease is rarely found on long term follow up of these patients. The doctor remains confused, irritable, blaming and hostile(or gives yet another useless prescription) and the patient leaves feeling ignored,unheard, blamed and still with the symptoms. Simple reattribution techniques are commonly used already by most GPs - explaining tension headaches or panic attacks for example. Thus it is likely that increased use of such techniques can fit in with the current acceptability of a joint biological and psychosocial model of illness and help patients with more minor or acute symptoms. However we wonder whether such an approach will help patients with longstanding and complex complaints who are likely to return to primary care repeatedly after secondary referrals fail to lead to any diagnosis. Such patients are a substantial part of many GPs workload and it may be more constructive in such cases to offer joint appointments with the GP and a psychotherapist.In this way patients can feel listened to, the GP can feel supported and the therapist can offer some insights into the consultation process.Such consultations can help free a "stuck" pattern and improve the relationship between doctor and patient.We feel that primary care mental health provision should try new ways of working which offer help to patients and doctors alike.We can then hopefully move away from considering medically unexplained symptoms as either physical or psychological in origin, towards thinking of them as starting points for the doctor, therapist and patient to explore together. Competing interests: None declared |
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susanne mccabe, retired cf24 3pf
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Can you kindly give some references to studies you mention re long term follow up of people with unexplained symptoms. Thanks Competing interests: None declared |
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Chris L. Manning, CEO Primhe (Primary care mental health and education; Member of National Mental Health Taskforce Twickenham TW11 9HG
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Dear Sir I find myself very much agreeing with Dr David Derauf when he says that "our approach to caring for patients with medically unexplained symptoms should begin with a careful appraisal and assessment of our approach to caring for ALL patients". MUS and multiple morbidities are our chance to upraise the evidence for our intraconnectdness. However,thanks to Descartes, we are still examining (and teaching people to examine), people, in an order: conventionally, the physical first, followed by the mental (if we have time). It is extraordinary that so many clinicians and services continue to re-iterate time-expired and non evidence-based paradigms and the mind-brain can be so excluded from our overall assessment of a person. Every week, the BMJ alone iterates further evidence of the way in which we are all "wired for health". Even in the absence of caseness, people are usually in predicaments before they acquire a diagnosis (it can often be better to avoid one when putting people in touch with themselves and helping them to make sense of their physical symptoms in relation to life circumstance, whether as cause, effect, or both). The new GP UK contract also perpetuates a mindless approach through considering the management of "mental health" (let alone "mental illness) as reducing to two tasks: namely, the production of a 'register' of people with "severe and enduring" mental illness (a variously interpreted non- diagnosis, but usually interpreted as schizophrenia and bipolar disorder) and a register of people taking lithium. Apparently, these are the only two areas of primary care clinical practice where there is enough evidence to support intervention. Furthermore, depression (and not even anxiety) are now kicked into the long grass of indifference through the provision of 'enhanced' services (basically, 'non-core' services that are provided if PCTs can find enough money to provide them, or feel are worth bothering about). As for medically unexplained symptoms (I like "not yet diagnosed", even if it does rather play into the potential trap of endless medical investigation), you could expect that, unless the modern GP can find evidence of diabetes, IHD or cancer, you might as well pack your bags and prepare for a long wait for more enlightened times. How is the mighty primary care profession fallen in the UK. That the mind-brain and its associated complexity and 'wiring' should be reduced down to the level of hen-pecking simplicity oft makes me want to weep. It is truly remarkable that it could only be the future GPs with a 'special interest' who will have the naus and nerve to tackle emotions and feelings. It is unthinkable that we would train doctors NOT to be able to deal with diabetes or IHD as core elements of their day-to-day practice. A so-called, and self-appointed, 'first-world country' has every right to be downgraded if its doctors do not have the skills and capabilities necessary to deal with people in a wholistic way and address the 'mental' issues. That is how we work and the caring professions should reflect that reality. Helping people to understand their connectedness (at times when they often feel the opposite)is also one of the best ways to defuse the self- stigmatising notions that attach to such statements as "so you think it's all in my mind, doctor?". Why should anyone be ashamed of that? If we all bothered to understand the latest evidence relating to mind/brain-body connectedness anyway, we would remain in awe, and not feel we are being reduced down to the sum of our parts, because there are billions of them anyway. We need to help people to understand that our mind and its mentality are part of what the brain "does" (Steven Pinker) and are delivered and governed by the same physical laws and processes, as deliver all the physical processes and attributes of every other physical organ in the body. We do not have to go to the planet Zog for special understanding or carry on thinking that brains and bodies operate in different cosmologies. One would have thought that matters of the mind-brain would, by now, be in the mainstream of clinical care. Sadly, this is not the case and the stigma and discrimination that surround the word 'mental' will continue to blight our lives and services, until we finally "Dump Descartes" and deliver a physical understanding of the term and its reality. Furthermore, whether we are seeing people with explainable, unexplained, or even inexplicable, symptoms, a highest common factor approach based on the latest evidence and interventions, would surely benefit ALL consultations with conscious human beings...and if unconscious, would still ensure dignity and respect. Yours Faithfully Dr Chris Manning www.primhe.org Competing interests: None declared |
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Sepideh Omidvari, Assistant Professor Iranian Institute for Health Sciences Research-51 Shahid Nazari St. Felestin Ave. Tehran Iran 13145-
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Medically Unexplained Symptoms: Different Diagnosises Needing Different Interventions Management of medically unexplained symptoms has been discussed by Rosendal M et al.(1). However, it seems some points remain. The term illness behavior describes patients' reactions to the experience of being sick. Illness behavior and the sick role are affected by people's previous experiences with illness and by their cultural beliefs about disease. The influence of culture on reporting and manifestation of symptoms must be evaluated. For some disorders this varies little among cultures, whereas for others the way a person deals with the disorder may strongly shape the way the condition presents itself.(2) Concerning patients consulting a physician, after doing appropriate evaluations, if there are medically unexplained symptoms, it doesn't necessarily mean the demonstration of mental disorder. Some mental disorders which may be related to presenting physical symptoms are depressive disorders (at least half of persons with major depressive disorder somatize, especially with fatigue, headache, and abnormal pain)(3), anxiety disorders such as panic disorder, somatoform disorders, some psychotic disorders (e.g., patients with somatic delusions), factitious disorder, malingering, and etc, each of each needs meeting specific criteria (and not merely ruling out general medical conditions) as well as specific interventions. Patients with medically unexplained symptoms are the best paradigm for the benefits of a team approach by mental health and primary care. It is important to differentiate "psychological factors affecting medical condition" from psychosocial factors causing them. It must be kept in mind that "all patients" not just ones with medically unexplained symptoms, need physicians' biopsychosocial point of view in evaluation and treatment of symptoms. And as the last point, the class so-called "unclassified", "idiopathic", "not otherwise specified", and the like in classification of diseases and clinical manifestations in medicine-which physicians generally don't like using it as a diagnosis- shouldn't be neglected in patients presenting with physical symptoms medically unexplained. 1. Rosendal M, Olesen F, Fink P. Management of medically unexplained symptoms. BMJ, Jan 2005; 330: 4-5. 2. Contributing editors. The Doctor_Patient Relationship and Interviewing Techniques. In: Sadock BJ, Sadock VA. Kaplan & Sadock's Synopsis of Psychiatry. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2003: 2. 3. Lipkin MJR. Primary Care and Psychiatry. In: Sadock BJ, Sadock VA. Kaplan & Sadock's Comprehensive Textbook of Psychiatry. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2000: 1931. Competing interests: None declared |
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Brian Morgan, Freelance Journalist Cardiff CF11 6LF
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I and others have reviewed families' medical records where a parent has been accused of Munchausen's Syndrome by Proxy (MSBP) and found that a clinician's inability to diagnose a genuine illness in a child turns to suspecting MSBP, without having sought an opinion from an appropriate specialist. It's a wonderful short cut, especially when the parents complain about the management of the case, as has happened. How often have symptoms caused by medications inappropriately prescribed (unlicensed for paediatric use - cisapride for example) been blamed on the mother? When the child is removed from parental care the medication is discontinued so of course the symptoms ceased. QED MSBP. How often when illnesses spontaneously go into remission after separation (as some do but just ignore the occasional repeat of milder symptoms which still occur in foster care or on the ward, as has happened) does this confirm MSBP. Where exactly should MSBP stand now in the differential diagnosis when a child's illness is (so far) medically unexplained, given concerns that have arisen about MSBP's architect and his chief supporters? Competing interests: None declared |
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Fiona Woollard, Personal Assistant YO24 1EP
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Medically unexplained symptoms includes a body of doctors who are dealing with something that perhaps they have not come across before, or are unable to think about the actual diagnosis “i.e. not thinking of the bigger picture”. Susanne Macabe rightly asks about case studies for long-term follow up of these patients that is if, of course, that they are actually followed up rather than ignored and what their eventual diagnosis is. Perhaps, then doctors would learn from this experience. There are many people with chronic fatigue, ME/MS autoimmune type disease such as lupus, lyme disease, thyroid disorders, depressive type illnesses that do take a considerably long time to diagnose often years because the symptoms are so vague. There are other such illnesses which are diagnosed initially as “a virus” turn out to be completely different and are, in fact, serious illness. An example of this, is my own son who later was diagnosed with sub-actuate bacterial endocarditis, no blood cultures were taken on initial consultation, developed complications and died despite his symptoms consistent with a potential diagnosis. He was a patient with severe multiple congenital heart disease at birth. To me, medically unexplained symptoms are those doctors who are completely out of their depth, incompetent and have no time for the patient or the mother. Perhaps proper note taking, obtaining a family history, communication not just with the patient but with other colleagues who are more experienced, undertake investigations and subsequently review them? Staying away from such non-sense diagnosis as Munchausen syndrome by Proxy, exaggeration, fabrication, somatization etc etc. Then you might be able to come to some conclusion pretty quickly. Competing interests: None declared |
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Giovanni Cataldi, general practitioner 63034 Montalto delle Marche. Italy, Francesco Benincasa
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EDITOR- The editorial by Rosendal et al. sounds surprising indeed. 'At least 20-30% of primary care patients have medically unexaplained symptoms' and all our application should be nothing more that adding psycho-social supplements to the accustomed clinical explanations? Are there alternative meanings of 'to broaden the agenda ... including psychosocial factors'(1)? Passing over the unlikely GPs' competence or substantiality about the management of problems beyond their traditional biological education, symptoms which recur so numerous and frequent and 'do not fit into the existing framework' perhaps deserve theoretical researches with regards to a different model of construction(2). We think the critical point is that of a less elusive system to make sense to those patients' specific concerns which lack a convincing clinical understanding; the crux of the matter really is the reference frame. But persisting into the actual body-mind dichotomy(3), even if half -hidden through bio-psycho-social patchwork, we'll not take any steps to get a more reliable professional equipment. References: 1. Rosendal M., Olesen F., Fink P. Management of medically unexaplained symptoms. BMJ 2005; 330:4-5. (1 January.) 2. Damasio AR. Descartes' Error: Emotion, Reason and the Human Brain. New York : Grosset/Putnam, 1994. 3. Damasio AR. The Feeling of What Happens: Body and Emotion in the Making of Consciousness. New York: Harcourt Brace, 1999. Competing interests: None declared |
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Salvatore Corrao, Director of Clinical Methodology, Epidemiology and Statistics Unit Civico e Benfratelli National Hospital Trust, Piazza Nicola Leotta 2 - 90127 Palermo
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I have read with great interest the editorial of Rosendal et al (1). However, I have just published on the official Journal of the FADOI (The Italian Society of Internal Medicine Hospitalists) a paper entitled “A new approach of scientific evidences in clinical practice: the uncommon clinical pictures” (2). The Journal is not indexed in MEDLINE even though more than 3000 internists, spread over Italy, read it. That could represent a publication bias for international readers. So, it could be useful for your readers to know a different point of view on this topic. Unexplained signs or symptoms, when they have clinical relevance, can be better defined as “uncommon clinical pictures”, and I proposed a structured method to possibly resolve them. I report the experience, lasting for approximately a decade, about the use of bibliographic databases (MEDLINE, etc.) as diagnostic/therapeutic decision-making support. A method has been developed that is based firstly on anamnestic/clinical data analysis. Then, a search method is used to construct a search string to seek out and retrieve bibliographic citations. After a systematic review of all retrieved citations and their findings, related to the specific clinical picture, a decision should be taken by a clinical audit. After all, by this paper, I propose a work hypothesis for the scientific community in order to rehabilitate and effectively make use of a type of scientific literature, until now, considered a low level of evidence(case-report, case-series etc.)In my opinion, this work hypothesis both completes Rosendal’s considerations and proposes a new management strategy of uncommon clinical pictures for quality of care improvement and related health-care expenditure control. 1)Rosendal M, Olesen F, Fink P. Management of medically unexplained symptoms BMJ 2005;330:4-5 2)Corrao. S. Un nuovo approccio all’implementazione delle evidenze scientifiche nella pratica clinica: i casi clinici non comuni. GIMI 2004; 3: 108-111. Competing interests: None declared |
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Marianne Rosendal, Senior researcher Research Unit for General Practice, Aarhus University, 8000 Aarhus C, Denmark, Frede Olesen, and Per Fink
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Thank you for the many responses to our editorial. In reply, we would like to make some general comments and clarifications. Evidence about medically unexplained symptoms is growing in these years and we find it important to rely on this evidence instead of trusting in opinions and experiences. ‘Medically unexplained symptoms’ (MUS) is a purely descriptive term and does not imply a psychological or any other genesis of the patients’ symptoms. Often patients have multiple problems when presenting physical symptoms and it is important to be able to take biological, psychological and social approaches simultaneously, especially when the patients’ symptoms are medically unexplained. Furthermore, research point to the importance of acknowledging the patients’ symptoms and not blaming the patient for them. ‘MUS’ is not a real diagnosis but it is a useful construct. We need such a construct, just like we need diagnoses, in order to conduct rigorous research and to make appropriate management decisions and predict prognosis with regard to the large number of patients presenting with MUS or functional somatic symptoms. The question about long-term follow-up is often asked. At present studies have shown, that MUS often remain medically unexplained, that is, no physical cause is found (ref 1-4) but of course further follow-up studies would be of great interest. Concerning management, we must be aware that the actions we take also have costs. If we are focussing on physical disease only we also lock the patient on this approach and they may run the risk of iatrogenic harm. Furthermore, the patient is restrained from relevant and effective treatment as for example cognitive behavioural therapy. We agree that all patients may profit from better communication and better consultations skills. However, these general skills are not sufficient in the treatment of MUS. Specific treatment strategies are also necessary. We agree that stepwise care would be a very constructive solution. We cannot expect general practitioners to become specialists in cognitive behavioural therapy and we need specialist treatment for the most severe cases of patients with MUS. On the other hand MUS is so frequent in primary health care that specialist treatment will never be available for all of them and general practitioners must be able to manage the majority of these patients. 1. Kroenke K,.Mangelsdorff AD. Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome. Am.J.Med. 1989;86:262-6. 2. Wilson A, Hickie I, Lloyd A, Hadzi-Pavlovic D, Boughton C, Dwyer J et al. Longitudinal study of outcome of chronic fatigue syndrome. BMJ 1994;308:756-9. 3. Crimlisk HL, Bhatia K, Cope H, David A, Marsden CD, Ron MA. Slater revisited: 6 year follow up study of patients with medically unexplained motor symptoms. BMJ 1998;316:582-6. 4. Gureje O,.Simon GE. The natural history of somatization in primary care. Psychol.Med 1999;29:669-76. Competing interests: None declared |
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susanne mccabe, retired cf24 3pf
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Sorry to be 'picky' but the language used to refer to people with medical conditions is important as it can convey an underlying attitude which may be inappropriate. eg., in this case....re '..General Practitioners must be able to MANAGE the majority of patients' People are not managed by healthworkers. They may help the person manage or treat a condition or they may even 'Care' for people - but the introduction of 'managementspeak'does not properly reflect the relationship between individuals and healthworkers. Competing interests: None declared |
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