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Rapid Responses: Rapid Responses published:
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where even wise men fear to tread
- mark s salter (22 October 2007)
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Tell the whole story!
- Charles T Vivian (22 October 2007)
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diagnosis please
- judith m neaves (28 October 2007)
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mark s salter, consultant psychiatrist city and hackney centre for mental health, London E9 6SR
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Goldacre (BMJ 20th October) describes how a radio interview left him sounding like “an ass” after he tried to describe the complex pathogenesis of lower back pain. If he committed any error at all, it was only to underestimate the need, or rather the craving, for certainty that we all display in the face of complexity. If our species has learnt anything over the last million years, it is that the world is awfully complicated. The evolution of the human nervous system, and with it the mind, has provided a way to reduce this complexity to manageable proportions; psychologists nowadays view subjective reality at any one moment as the ‘best fit’ between perception and belief. These explanations do not need to be true to be comforting, but it doesn’t take much extra data to upset the mental applecart. Such reactions to complexity seem forgivable for a species of ape that only came out of the caves 800 generations ago, but for all of our pretensions to favour rational over inexplicable descriptions of our world, it only takes a radio phone-in to show that vitalism is alive and well, exerting a fierce grip over our ways of seeing the world. This is something that is not lost on the media professions, who are no more committed to rationality than the rest of us. Whatever broadcasters may say about the enrichment of debate, they know that making their listeners feel uneasy is bad for ratings, thus most stories merely retell us what we already like to believe. Our cosy dipole of mental versus physical seems set to define our view of illness for some time to come. Goldacre is one of a handful of doctors who have the courage to remind us that the truth is much less simple. Ass? Pioneer would be a better term. Dr Mark Salter
Competing interests: None declared |
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Charles T Vivian, Consultant Occupational Physician Gloucestershire Partnership NHS Trust
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Dr Goldacre is unduly harsh on himself. His message is not wrong, and he is not an ass. However, there was perhaps an opportunity for better gift-wrapping. (See Neighbour: The Inner Consultation). Western Medicine is based on the biomedical model. This model is reductionist; ie all symptoms can be explained by underlying pathology. It is also dualist: if there is no pathology, it's all in your head. This model was drilled into us at medical school, and is the principal model for the NHS. Society largely accepts the model too. But it's wrong. For up to 90% of individuals presenting to their GPs with genuine physical symptoms, the symptoms will not be explained by pathology. Labelling them as anxious or depressed is also inappropriate for the vast majority of them. I've started explaining this to patients, and telling them that the problem lies with the model, not with them. It is normal to have entirely genuine physical symptoms, and not be able to explain these through X-Rays or blood tests. Thereafter, you can move on to helping the patient understand that extensive research has proved what will help. The psychological yellow flags act as obstacles to recovery and return to work. These include catastrophising (fearing the worst), low mood, avoidance behaviour, and having an external locus of control (ie you need to make me better, doctor). These all inhibit recovery. The tools of CBT are excellent in addressing these. (eg see www.livinglifetothefull.com). When coupled with graded exercise programmes, the outcomes are excellent. So, Dr Goldacre, don't be too hard on yourself. You told the right story, but if you'd provided a more comprehensive explanation, the angry patient may have been reassured, rather than alienated. Reassured and recovering patients has been my experience since I switched approaches. Competing interests: None declared |
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judith m neaves, medical osteopath holt medical practice, holt, NR10 4RF
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A paper on the treatment of abdominal pain, or shortness of breath would clearly leave one wondering where is the diagnosis? Well back pain is no different. Back pain is simply a symptom. It is possible to make a diagnosis, other than diagnosing radicular pain, but requires alot more training than most doctors, even those such in rheumatology or orthopaedics who have specialised in spinal problems, have acquired. No news, however, to those of the medical profession who have developed such skills, the medical osteopaths. Only when we start diagnosing better, will the research into treatment then start to demonstrate clearly what is effective treatment. Competing interests: None declared |
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