Views & Reviews Starting Out

The bottom line

BMJ 2008; 337 doi: (Published 05 November 2008) Cite this as: BMJ 2008;337:a2395
  1. Kinesh Patel, junior doctor, London
  1. kinesh_patel{at}

    “I’ve just passed a 12 inch stool,” said the voice over the telephone with a degree of solemnity commensurate with such a statement. “Is that normal?”

    “Well, I’m not sure,” replied the secretary, a little baffled as to what the appropriate response was to such a question, while no doubt at the same time wondering why anyone would bother to measure a stool, let alone share that information with anyone else.

    There’s nowt as queer as folk, as the saying goes. And although such an anecdote makes us snigger quietly to ourselves, it does illustrate how trusted we are as professionals that people feel prepared to tell us anything and everything.

    It is easy to dismiss what we perceive as the crazed ramblings of patients with functional syndromes but harder to remember that to these patients those symptoms are very real. Each specialty has its own condition that makes clinicians throw their hands up in exasperation: from fibromyalgia to irritable bowel syndrome and non-ulcer dyspepsia (gastroenterology seems to have more than its fair share).

    The bottom line is that we’re not very good at assessing patients’ mental state, let alone offering them appropriate treatment for their conditions. It is much easier to comment matter of factly on the large ulcerating carcinoma you’ve discovered than to explore putative environmental influences on diseases affecting the human condition.

    Patients with cancer need surgery, chemotherapy, and emotional support, whereas those with commoner functional ailments mainly need just emotional support and reassurance. This takes time and effort, often without a satisfying tangible result such as ceremoniously dropping a neoplastic lesion into a pot with the command “Send that to histology.”

    Modern financing structures, such as the NHS’s Payment by Results, do not help encourage a psychologically supportive approach. Time spent regularly with a patient is largely regarded as “waste” time that could have been used to see a new referral, thereby keeping the hallowed “follow-up to new ratio” (abbreviated, rather ironically, to FUN) within target.

    And while I have no doubt that such reforms have led to shorter waiting times for patients with organic disease, those with debilitating conditions that do not fit neatly into any pathologically proved diagnosis have undoubtedly suffered as they are bounced from hospital back to GP and then back to hospital again.

    What can we do to solve this quandary? Taking an interest is an important first step—for although these conditions are not glamorous or popular with clinicians, they affect far more people than do the rarer diseases we often seek. And just in case you were wondering, a 12 inch stool is entirely normal.


    Cite this as: BMJ 2008;337:a2395

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