Beware of mentioning psychosocial factors
BMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39370.657130.59 (Published 18 October 2007) Cite this as: BMJ 2007;335:801
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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
Competing interests: No competing interests
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
Consultant Psychiatrist
Competing interests:
None declared
Competing interests: No competing interests
diagnosis please
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
Competing interests: No competing interests