Medically unexplained symptoms

The review by Dr Page and Professor Wessely is a tour de force (May 2003 JRSM¹). A great problem with patients thought to have medically unexplained symptoms (as opposed to those merely inexplicable to the referring practitioner) is not only that specialist referral is not helpful (as Page and Wessely say) but that referral to a generalist is impossible. They simply no longer exist, at least in adult medicine, and the blame for this change lies with the leaders of the specialty over the past two decades. The removal of generalism from the physicianly repertoire makes 'one stop shop' referral and reassurance impossible. Both patients and GPs are reluctant to accept inexplicability of symptoms without specialist opinion, and the authors' scenario of each specialist eliminating their own area of expertise and that alone is real.

I assume that some, perhaps many, referrals from primary care lack a specific diagnosis. Speclialists are selected as a 'best guess' and, if it proves wrong, any patient can embark on the round of consultation, futile investigation and referral onwards. This is likely to lead to chronicity even in patients least prone to iatrogenic psychological injury.

Ideally, physicians should reinstate generalism. There are trainees who would like to be generalists were the vision for them not an unending round of acute takes combined with a post held in low esteem by specialized colleagues. If we cannot do this we need to take the paradigm for low back pain, a one-stop multiprofessional clinic, and transfer this to general medicine for puzzling and difficult patients—multispecialty rather than multiprofessional clinics. Finally, we need to critically look at the drift towards subspecialization in other disciplines. Subspecialization serves many patients well, but for just a few it is a serious handicap.