Skip to main content
NCBI home page
The BMJ logoLink to The BMJ
. 2001 Aug 18;323(7309):397.

Medically unexplained symptoms in secondary care

Doctors in secondary care should respect general practitioners

John McCormack 1
PMCID: PMC1120989  PMID: 11548691

Editor—The patronising tone adopted by Turner towards primary care referrals in her editorial is quite disconcerting.1 As the original article by Reid et al refers to medically unexplained symptoms in secondary care it is unfair to infer that this has a bearing on the primary care physician's competence or referral pattern.2 The “bread and butter” of primary care is dealing with symptoms that do not fit the disease model. Uncertainty is a real commodity. If you can deal with it you will thrive; if you cannot you should opt to work in secondary care, where you are more likely to reinforce what you already know by performing often unnecessary, expensive, and invasive tests. With the move to increased subspecialisation there is a greater tendency to propagate the medical bandwagon—for example, “All your tests are negative, Mrs Jones, therefore you have no oro/neuro/endocrino/otorhinolaryngo/gastro/respiritro/rheumato/ophthalalmolo /cardio/reno/physio/psycho-logical problem.” Medicine is much more than positive or negative investigations, and it seems that the only specialty that consistently recognises this is general practice.

When a specialist in secondary care has exhausted his or her efforts to explain a patient's symptoms the patient should be re-referred to the general practitioner with the documentation, “I do not know what is wrong with your patient.” Now that doctors in secondary care are realising that many medical consultations bear no relation to the disease model, perhaps those who practise there will condescend to refer their dilemmas to those with expertise on the human condition rather than to another ivory tower.

I would like to say the following to my colleagues working in secondary care.

Please send my patients back to me when you have exhausted your efforts in explaining their symptoms.

Do not refer them to a colleague unless you think they need an inpatient review.

Please do not propagate the disease model.

Please tell my patients that you have ruled out harmful causes for their symptoms.

Let general practitioners be general practitioners, and let specialists be specialists.

References

  • 1.Turner J. Medically unexplained symptoms in secondary care. BMJ. 2001;322:745–746. doi: 10.1136/bmj.322.7289.745. . (31 March.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Reid S, Wessely S, Crayford T, Hotopf M. Medically unexplained symptoms in frequent attenders of secondary health care: retrospective cohort study. BMJ. 2001;322:767–769. doi: 10.1136/bmj.322.7289.767. . (31 March.) [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2001 Aug 18;323(7309):397.

Unexplained symptoms may reflect overstretched service

Editor—I wonder just how many of the medically unexplained symptoms recorded by Reid et al reflect our stressed health service?1-1 They claim that all cases had completed a thorough investigation but how did they define thorough? Were patients with headaches checked for sensitivities to foods; did all middle-aged patients with dizziness have an x ray examination of their neck? Reid et al also included symptoms if psychosocial reasons were suggested, but were these the opinions of a mental health professional or did a speculative comment by a senior house officer suffice?

Five years ago, I developed disabling vertigo after a minor cold. I had several rounds of blood tests, a neurological consultation, and a magnetic resonance imaging scan of the brain. When everything came back negative, my general practitioner and neurologist said that perhaps my vertigo was due to somatisation or anorexia.

For 18 months my attention was diverted by a ductal carcinoma in situ and several operations. When I recovered, I complained to the neurologist, noting that, without vestibular tests and a psychiatric opinion, he should not have lumbered me with such a stigmatising diagnosis. He agreed to see me, but he refused to apologise or admit to the error. The experience left me so depressed and demoralised, I paid the £70 he charged me for making the complaint. Eventually, I saw a professor with an interest in my condition. He took my history, repeated the neurological examination and pronounced I had vestibular damage.

I don't know why the other doctors had missed the nystagmus, etc. I don't know why no one did a scan of my neck (which would have identified further abnormalities). I don't know why I was denied vestibular tests for four years. I have no idea why anyone would interpret the weight loss after vertigo as a likely cause. Perhaps my sex played a part or my former occupation (I trained as a psychotherapist). Perhaps there is a general lack of knowledge about chronic postviral vertigo?

In my view, “medically unexplained” does not necessarily mean that all organic disease has been ruled out. A few doctors take shortcuts. Others may be unduly influenced by variables such as sexism, racism, ageism, or a lack of resources. As for psychological reasons, how many doctors recognise the stress of fighting an inaccurate diagnosis? Speculate, by all means. But if a patient disagrees with a psychosocial explanation, please consider the possibility that he or she might be right.

References

  • 1-1.Reid S, Wessely S, Crayford T, Hotopf M. Medically unexplained symptoms in frequent attenders of secondary health care: retrospective cohort study. BMJ. 2001;322:767–769. doi: 10.1136/bmj.322.7289.767. . (31 March.) [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2001 Aug 18;323(7309):397.

People with somatic symptoms may be medically misunderstood

John Heptonstall 1

Editor—A Western medical diagnosis is expected by patients and doctors to be meaningful, accurate, and a means to receive valuable treatment. Conversely, we practitioners of alternative medicine are often said to provide a meaningless, inaccurate, form of placebo. Both varieties of medical intervention depend, however, on doctrinal models that provide a diagnosis leading to a treatment; the degree to which a model is effective must depend on outcome. If the patient gets better, qualified by subjective and objective measurement, and an “insignificant” number are harmed, the model is successful.

Turner describes an inability to diagnose appropriately such that patients are accused of somatising for disorders that cannot exist in the framework of Western medicine2-1; is it that this model does not cater for complexities that we who follow traditional Chinese medicine recognise and treat successfully?

Traditional Chinese medicine has no simple diagnosis for anxiety or depression: they never exist in isolation but are always part of a complex emotional, mental, physical, and spiritual flux that is the human animal. It is no surprise when someone with anxiety has concurrent symptoms such as back pain, flushes, irritable bowel syndrome, tension headaches, depression, diarrhoea, hypoglycaemia, irritability, frequent micturition, premenstrual syndrome, cardiac problems. These are expected symptoms that define a diagnosis of “hyperactive kidney yang,” which in simple terms is a state of imbalance of the hypothalamopituitary-adrenal axis that traditional Chinese medicine can recognise and treat with modalities such as acupuncture and moxibustion.

A “depressive” person has symptoms of depression coincident with others such as circulatory problems, fatigue, irritability, anxiety, cardiac irregularities, weakness, lethargy, scanty menses, premenstrual syndrome; he or she is not a somatising person but a patient who experiences concurrent complex symptoms that will disappear with appropriate treatment.

Turner reminds us that “there are large numbers of patients whose frequent attendance suggests distress that is neither appropriately identified or addressed; that medically unexplained symptoms are common in primary care, primary care physicians seem to have considerable discomfort in managing these patients; studies describe that half of patients with depression report multiple unexplained somatic symptoms, 11% denying psychological symptoms on direct questioning; and patients with somatisation disorders often feel that medical explanations reject the reality of their symptoms.” I rest my case.

The experience I have gained from successfully treating alleged somatisers, who invariably see themselves as either castoffs or escapees from the medical system, suggests that it is the system that failed them, not vice versa.

References

Articles from BMJ : British Medical Journal are provided here courtesy of BMJ Publishing Group

RESOURCES