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
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Editor - The BMJ should consider a theme issue on
patient. The BMJ's pages are full of references to
patients' satisfaction or dissatisfaction. It seems to be
near universal as an outcome measure for the primary
care papers that the BMJ publishes. And yet I find
myself so... dissatisfied... with what is written in these
pages on the subject. The BMJ completely misses the
core of the problem and does a disservice to its
clinician readers. The BMJ needs to re-conceptualise
patient dissatisfaction.
For example today I read in the Editor's Choice that;
"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..... Referring patients to a
cardiac clinic 'just in case' is the wrong treatment. It
may begin a disabling cycle."
Unquestionably so. However the irony is that it is easy
to satisfy (temporarily) patients with functional
symptoms, firstly do lots of tests, secondly prescribe
some treatment, and thirdly refer them to a 'specialist'
clinic (although not to a psychiatrist or psychotherapist -
even the suggestion of that can cause patient
dissatisfaction to soar). In other words give the patient
plenty of reassurance that they really do have the
physical condition that they imagine themselves have,
this will help distract them from their dissatisfaction -
i.e. maximize the primary gain of illness.
It is probable that these patients are dissatisfied with
their medical care precisely because their doctors were
unable to give continuing professional support to the
patients view of the disorder. Thus the doctors failed to
support the patients need to be legitimized in the sick
role.
My experience of patients with multiple consultations for
functional symptoms has been that they are all
dissatisfied. Function symptoms occur in everyone. We
all get aches and pains, coughs and so on. However in
the absence of dissatisfaction, the symptoms are
easily ignored, or tolerated, or dispelled by a doctor's
assessment.
There is a proportion of patients who can tolerate
addressing their dissatisfaction through psychotherapy.
But there are also those who do not wish to relinquish
the (secondary) gains of sickness. Some seek to have
the doctor to validate their sick role. Thus there is a
conflict between the doctor, who wants his patient to be
well, and the patient who wants to be diagnosed 'sick'.
In such cases dissatisfaction is not due to failings on
the doctors part, it is the very nature of the patients
problems.
Daniel McQueen, general practitioner.
London W10 4JD daniel.mcqueen@virgin.net
1. Balint, Michael. The Doctor, His Patient and the
Illness (Second Edition). Churchill-Livingstone, 1963.
Competing interests: No competing interests
Dr. Richard Smith writes:.. 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."
This is an expression of very lay opinion based on the following
assumptions both of which are incorrect:
(a) A medical textbook is complete in its definition of all organic
causes
(b) The proportion of patients seeking medical opinion due to non-
organic problem vastly outnumbers those with organic problem.
A medical text only helps a doctor in navigating clinical problems in
practice. It provides a route map, but does not chart every road or street
that exists. A doctor whose practice is solely based on what he had read in
the medical text will be missing out diagnoses that were not known or not
well characterised enough to be listed. It is also known from the medical
texts that only 5% of patients attending primary care will have somatoform
disorders, the best examples of "non-organic" problems in practice.
The ABC of psychology latterly has been missing its most important
target: providing the principles of science in the practice of
psychological medicine. From the authors of this series, the BMJ editor
and Dr. Wessely as quoted above, we are being continually offered
individual opinions and not scientific facts.
The BMJ is missing its targets too.
Competing interests: No competing interests
A triad of physical findings useful in the diagnosis of non-cardiac chest pain
What is the disease that elude diagnosis by competent physycians in
two third of patients with non-cardiac chest pain.Thoracic outlet syndrome
is not diagnosed because the lack of awarenes and not performing the
proper physical examination(See www.tos-Syndrome.com).The white hand sign
is not elicited in these patients.A triad of physical examination findings
should be performed in these patients to rule out Thoracic outlet
syndrome.1)weakness of the fifth finger.2)tenderness in the
supraclavicular area.3)Paresthesias and/or paleness of the hand on
elevation.
Competing interests: No competing interests