Matt Morgan: Those three little wordsBMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l5918 (Published 15 October 2019) Cite this as: BMJ 2019;367:l5918
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This article is entirely sensible - of course doctors can't possibly know everything, any more than any of us can, and there is honesty and humility in saying so.
I have been seriously concerned, however, to discover that even these important three little words 'I don't know' have been exploited in a way that has effectively dismissed very real issues that patients have been experiencing, especially with 'safe and effective' (sic) antidepressants, including dependence and withdrawal issues - assigning these to 'medically unexplained symptoms'. I have been writing about this for some time, initially for GP View (1) and most recently for BJGP (2).
I wish to draw attention to the still widely recommended RCPsych/RCGP 'Guidance for Health Professionals' (2011, updated RCGP 2014) (3). Doctors have been actively encouraged to 'not know' (and indeed to 'not learn') about the effects of these very widely prescribed medications and to:
"Use 'word scripts' to encourage a shared plan; Be open about your uncertainty yet reassuring that a serious cause is unlikely, but stress that you will keep an open mind" (3).
Patients' experience, at the receiving end of such interactions, has been of distress and desperation at not being believed by their doctors, who in turn consider them as 'heartsink'/'difficult' patients. This has had a very detrimental effect on doctor/patient relationships.
The recent announcement by NICE (4), following the publication of the PHE review October 2019, is the first glimmer of (long overdue) recognition and acknowledgement of patients' experiences with antidepressants that have been hitherto mostly assigned to 'medically unexplained symptoms' of 'unknown aetiology'.
(1) Brown M. Update: Managing patients with medically unexplained symptoms. GP View 25 Sept 2017 https://gpview.co.uk/update-managing-patients-with-medically-unexplained...
(2) Brown M. Unexplained physical symptoms: What is being missed? e-letter BJGP 25 April 2019 https://bjgp.org/content/69/681/e246/tab-e-letters#unexplained-physical-...
(3) Chitnis A, Dowrick C, Byng R, Turner P, Shiers D. Guidance for Health Professionals on Medically Unexplained Symptoms – 2011; Royal College of General Practitioners & Royal College of Psychiatrists; 2014. https://www.rcgp.org.uk/clinical-and-research/resources/toolkits/~/media...
(4) Iacobucci G, NICE updates antidepressant guidelines to reflect severity and length of withdrawal symptoms BMJ 2019;367:l6103
Competing interests: No competing interests