Commentary: A fairytale ending?

BMJ 2006; 333 doi: (Published 13 July 2006) Cite this as: BMJ 2006;333:136
  1. Domhnall Macauley, general practitioner (domhnall.macauley{at}
  1. 1 Hillhead Family Practice, Belfast BT11 9FZ

    “And they all lived happily ever after,” happens only in fairy tales. The clever hospital doctors have made a fascinating physiological diagnosis, and the patient has stopped vomiting and returned to normal life. Cured. Wouldn't it be great if life was like this all the time? Most general practitioners will suppress a wry smile, knowing that this is likely to describe a chapter in Mr Neville's life.1 His general practice file is already substantial, and his hospital notes bulging. The pattern of morbidity leading up to this admission is perhaps likely to continue long into the future.

    Our hospital colleagues can enjoy the triumph of their diagnosis aided by the latest technological advances: manometry and multichannel intraluminal impedance. We would not have made the correct diagnosis. Of course not. But most general practitioners would have spotted the warning signs that there was something not quite right. The phrase, “He was discharged despite strong objections” resonates. Most young people and their relatives are so relieved that nothing serious has been found that they cannot wait to get out of hospital. If they don't want to leave, there is a reason. And so, when he appeared unwell at Christmas time, there was no alternative but admission. But what do you write on the referral to accident and emergency? Can you imagine the response if the general practitioner had written that he or she thought there was “something not quite right.” The howls of derision would have been heard across the city.

    Ongoing support

    And yet, whatever diagnostic term was written on the hospital discharge letter, this is still the real diagnosis. The patient is still the same person, with the same background and same personality. In my opinion, he will be back. And what he needs is an understanding and supportive general practitioner who will try to nurse him through the next medicalised crisis, avert hospital admission whenever possible, and try to protect him from unnecessary investigations. Forget the much abused “insight” and other terms that negatively imply that it is all in the patient's mind. It may have a psychological basis, but his pain and suffering are real.

    He is clearly a high achiever, with good grades and peer recognition at school, and someone who is already showing leadership skills. He is likely to be successful in his chosen profession. But no one has everything. You can give it a nice medical title if you wish, but it is just the way he is. As he gets older, it is possible that he will, at different times, be anxious about various lumps and bumps, have different types of chest pain, worry about his bowels, and have many investigations. If that happens, a good general practitioner will be there to listen. What is most frightening about patients with this sort of recurrent presentation is that some day they will have something serious and, in all the medical clutter, it might be missed.


    • Competing interests None declared.


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