What are the two hardest things to do in medicine? To say nothing (or “I don't know”) and to do nothing. We have all felt parents' disappointment at the end of a consultation. So, rather than discharge their child, we offer a follow-up appointment, hoping that by then the parents will be more accepting of the situation or that they will be seen by a different doctor. However well meaning our action may be, it medicalises the child's condition: the parents may well feel that their child must have a serious problem because he or she is “under” a specialist.
We might also request another test, and risk inducing “Ulysses syndrome.” Ulysses fought in the Trojan war but afterwards took 10 years, with many dangerous and often pointless adventures, before he got back to where he had started. Patients with Ulysses syndrome find themselves caught in a web of further investigations, referrals, and sometimes treatment before finally being recognised as healthy, which they were in the first place. Ulysses syndrome is a side effect of unnecessary and inappropriate investigations or wrong interpretation of results. It was first described 30 years ago,1 and the number of tests available is now much greater. With greater choice comes greater responsibility and the need for greater discernment. Otherwise we may condemn our patients to a similar odyssey.
When a colleague (A W Coe) and I reviewed the records of children on the waiting list for magnetic resonance imaging of the brain we found that half had not had their head circumference measured, a basic indicator of brain growth. Yet £400 brain scans had been requested, few of which would alter the clinical management and some of which would lead to further referrals and investigations because of results that would turn out to be normal variations.
The upper and lower 2.5% of the normal distribution of results are usually deemed to be abnormal, so 5% of the population are labelled “abnormal” even though they are probably healthy. If you request an unnecessary test in order to please the child's parents and to satisfy your wish to do something, what do you do if the results are slightly outside the normal range? Do you reassure the parents that it is probably a normal variation, or do you suggest repeating the test “to be on the safe side”? Do you admit the child for further investigation? At the very least you have set in train a very anxious time for the parents, further tests on the child, and at least one further outpatient appointment. The worried parents may even arrange for a second opinion, leading to more appointments and investigations on the child. Such needless procedures are a side effect of an unnecessary investigation and uncritical practice.
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References
- 1.Rang M. The Ulysses syndrome. Can Med Assoc J 1972;106: 122-3. [PMC free article] [PubMed] [Google Scholar]