Intended for healthcare professionals

Education And Debate

Managing patients with inexplicable health problems

BMJ 2003; 326 doi: (Published 15 March 2003) Cite this as: BMJ 2003;326:595
  1. Baruch Fischhoff, professora,
  2. Simon Wessely, professor (
  1. a Department of Social and Decision Sciences, Carnegie Mellon University, Pittsburgh, PA 15213, USA
  2. b Academic Department of Psychological Medicine, Guy's, King's, and St Thomas's School of Medicine and Institute of Psychiatry, London SE5 8AF
  1. Correspondence to: S Wessely
  • Accepted 27 January 2003

People need to rationalise their health problems, and those with medical mysteries will find some explanation. The best way to manage such patients is unclear, but the principles described in this article should help improve the satisfaction of both patients and doctors

The causes of many health problems remain a mystery despite the advances of modern medicine.1 When a medical explanation is slow in coming, patients often infer that events (and perhaps people) are responsible for their condition. They may then judge harshly anyone who does not take their condition and inferences seriously. Physicians, officials, and companies often bear the brunt of this anger.2 For example, in the controversies surrounding chronic fatigue syndrome, Gulf war sickness, and cancer clusters, authorities who denied sufferers' claims met with scorn and contempt.

Public unease, such as caused by the current threat of terrorism, is likely to make medical mysteries more common.3 We therefore need a disciplined public health response for dealing with inexplicable health effects. In this article, we discuss how illness beliefs arise and suggest principles for dealing with patients.

Summary points

Without a medical explanation, patients are likely to attribute their illness to events

Terrorist threats are likely to increase the number of unexplained health problems

Doctors need guidance to avoid alienating such patients

Communication should be focused on patients' concerns

Relief of symptoms should be the priority

Risks should be given numerically and scientific uncertainty acknowledged

Development of illness beliefs

Any widescale medical intervention will coincide with the development of medically unexplained symptoms. The intervention may then be seen as a putative cause.4 Currently, smallpox vaccinations are an obvious target for such attributions, given the publicity surrounding them and their high level of side effects.

Patients naturally want explanations and treatments for their ill health. Professionals, on the other hand, want to …

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