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

Three Sharp Strokes

So, doctors have a dilemma, we are told (1). Some of them are
“uncomfortable” when patients present with their own diagnostic labels.
One strategy is to engage in “constructive labelling” which in the case of
chronic fatigue syndrome (CFS), involves "….treating [it] as a legitimate
illness…while gradually expanding understanding of the condition to
incorporate the psychological and social dimensions" (1). Yet, as implied
by this opinion piece, this strategy is likely to involve some
dissembling, for doctors (fed on a regular diet of articles similar to (1)
deposited in the medical literature from psychosocial stables) probably
believe in their hearts that CFS is not a "legitimate" illness and that
psychosocial dimensions are paramount. So, how can doctors be helped to
move forward?

Allow me to cut this Gordian Knot with three sharp strokes from the
non-psychosocial literature of the past few months alone.

First, the CMO report of 2002 - albeit without the endorsement of the
group of psychosocial professionals who refused to sign up to its
conclusions (2) - does, in fact, state that, "CFS/ME is a genuine
condition that imposes a substantial burden on patients, carers, and
families….clinicians need to apply current knowledge despite the remaining
uncertainty; inaction due to ignorance or denial of the condition is not
excusable" (3). Second, a recently-published review notes that, "… a
growing body of literature suggests that abnormal biological processes are
present in many patients, including subtle abnormalities of the CNS and of
neuroendocrine regulation and chronic activation of the immune system.
These abnormalities across many domains suggest that chronic fatigue
syndrome is a heterogeneous condition of complex and multifactorial
aetiology" (4). Last, an excellent rigorous consensus panel report (based
on extensive collective clinical experience of the diagnosis and/or
treatment of more than twenty thousand "ME/CFS" patients), published in
the past few weeks, has stated that, "Research has now established the
legitimacy of myalgic encephalomyelitis/chronic fatigue syndrome as a
biological illness" (5).

There - the problem is solved. Clinicians need not dissemble or, if
you prefer, indulge in medically-explained dissimulation in response to
“medically-unexplained symptoms”. Instead, they can truthfully say that
ME/CFS is a genuine condition for which there is mounting evidence of a
physical basis, and can proceed without delay to give the appropriate care
and treatment demanded by the CMO (3) for the constellation of symptoms
among which pain is prominent. Simple, really - and more conducive to a
genuinely healing encounter between doctor and patient.

1. Fischhoff B, Wessely S. Managing patients with inexplicable health
problems BMJ 2003;326:595-597.

2. Abbot NC, Spence VA. Unhelpful Counsel? Response to the Chief Medical
Officer's Working Group report on CFS/ME.(Analysis 02-M001): Available at

3. A report of the Chief Medical Officer's CFS/ME working group.
Department of Health. January 2002. Available at

4. Afari N, Buchwald D. Chronic Fatigue Syndrome: A Review. Am J
Psychiatry 2003; 160:221–236.

5. Carruthers BM, Jain AK, De Meirleir KL, Peterson DL, Klimas NG, Lerner
AM, et al. Myalgic Encephalomyelitis/ Chronic Fatigue Syndrome: Clinical
Working Case Definition, Diagnostic and Treatment Protocols. Journal of
Chronic Fatigue Syndrome 2003; 11(1): 7-115.

Dr Neil C Abbot

Director of Operations,

ME Research Group for Education and Support (MERGE),
The Gateway, N Methven St,
Perth PH1 5PP, UK

Competing interests:  
None declared

Competing interests: No competing interests

18 March 2003
Neil C Abbot
Director of Operations
ME Research Group for Education and Support (MERGE), The Gateway, N Methven St, Perth PH1 5PP, UK