Choice

Medicine misses three targets

BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7364.0/h (Published 14 September 2002) Cite this as: BMJ 2002;325:h

A minority of people experiencing chest pain have a problem with their hearts (p 588). Indeed, as our ABC of psychological medicine has made clear, a minority of patients with most symptoms have an organic cause defined in a medical textbook. “The tragedy for doctors,” said Simon Wessely, a professor of psychiatry from London at a recent meeting at the Royal Institution, “is that they spend their time at medical school learning about the organic causes and then the rest of their lives dealing mostly with patients with non-organic problems.

The traditional model of care for patients with chest pain might be to exclude a cardiac cause and then reassure. But this is not enough. Two thirds of the patients with non-cardiac chest pain who attend cardiac outpatient clinics continue to be disabled by their symptoms—and many are dissatisfied with their medical care. Christopher Bass and Richard Mayou emphasise the importance of making an early and confident diagnosis of non-cardiac chest pain. The key to the diagnosis is, firstly, the quality of the pain, and, secondly, evidence of non-cardiac causes. Three specific questions on the pain will often allow differentiation of cardiac from non-cardiac pain (see p 590).

Once diagnosed with non-cardiac pain patients must be given an explanation of how their pain arises, and “explanations in terms of a single cause are rarely helpful.” Referring patients to a cardiac clinic “just in case” is the wrong treatment. It may begin a disabling cycle. Information, education, and reassurance may be enough for 30-40% of patients, but Bass and Mayou suggest a series of steps for patients who need further treatment.

Another area where medicine has missed an important target is palliative care for those dying of heart failure. The specialty of palliative care is mostly concerned with patients dying of cancer, but heart failure is an increasingly common cause of death—and many patients dying of heart failure have poor, uncoordinated care. A report on focus groups of doctors in north west England examines barriers to better care for these patients and thoughts on how it might be achieved (p 581). One problem is the difficulty of predicting the course of death from heart failure: about half of patients die suddenly, some are “pulled back from the brink,” and some switch quickly from being well to being terminally ill.

A third way in which doctors may be failing to meet patients' needs is by turning upto see them smelling of drink. Clearly it must be wrong to be impaired by drink—although I have to confess that it was somehow normal when I was a medical student doing a locum to be on call for the hospital but across the road in the pub drinking up to four pints of beer. Those days must be gone, but is social drinking while on call acceptable? A survey of doctors shows mixed views (p 579). Now we need the views of patients.

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