BMJ article: How should we manage adults with persistent unexplained physical symptoms? - looks bad.

[Jonathan Edwards]

It seems that the recommendation is to lie. The symptoms are unexplained but the management is to provide a 'tangible explanation'.

 

[Sean]

and explain that no underlying medical condition has been identified and is unlikely to exist.

Somebody has been guzzling from the Edward Shorter Memorial Kool-Aid Barrel.

 

[PennyIA]

Ugh... if this was their treatment of me, I'd be dead now. I had symptoms of gall bladder attacks for a solid year before someone bothered to look at my gall bladder, so they would have tried to convince me it was all in my head. As it was it was the 11th trip to the ER (with NOTHING from the first 10 trips) before someone asked me what my last gall bladder scan looked like. I had a dumb stare back and went, what do you mean my gallbladder? ugh.

This all comes down to the hubris of ... if we can't diagnose it... it must be somatic.... instead of...maybe we missed something or maybe we have something to learn still.

 

[Snow Leopard]

How can anyone be awarded a PhD on the basis of such abysmally narrow 'research'?

PhDs these days are awarded on the basis of several primary investigations (of modest scope as PhDs don't have access to much money), a meta-analysis or systematic review and if they're lucky, assist with some other research led by others with greater impact.

PhDs have to do what their supervisors tell them to do. This is just par for the course. It's the leaders in the field who should be criticised for their acceptance of uncontrolled studies as evidence. (or poorly controlled studies - eg unblinded, convenience samples etc)

 

[trishrhymes]

PhDs these days are awarded on the basis of several primary investigations (of modest scope as PhDs don't have access to much money), a meta-analysis or systematic review and if they're lucky, assist with some other research led by others with greater impact.

PhDs have to do what their supervisors tell them to do. This is just par for the course. It's the leaders in the field who should be criticised for their acceptance of uncontrolled studies as evidence.

I agree that the blame lies almost entirely with the supervisor who sets such a narrow reading list, researchers who do uncontrolled studies, and publishers who publish them and publish articles like this one.

The thing that saddens and worries me, for the PhD student, is the apparent lack of curiosity.

I am trying to imagine myself in such a position, and hoping I would have explored more widely. Even just googling the conditions specifically mentioned - CFS, FM and IBS would have raised loads of issues that a good researcher should explore - biomedical research, patient support groups and what they say, etc.

What has happened to scientific curiosity? And integrity?

But then of course, the student may have done this, and been told firmly to stick to the supervisor's orthodoxy if they want to get their PhD and get papers published, such is the narrow world some academics live in.

 

[Snow Leopard]

What has happened to scientific curiosity? And integrity?

Same as in any field, whether it be carpentry, architecture, science or medicine - most people settle on mediocrity, a small minority take risks to push the field forward and some achieve high levels of excellence.

 

[Barry53]

• Persistent unexplained physical symptoms—Physical symptoms existing for ≥3 months not sufficiently explained by an underlying medical condition after adequate examination and investigation2

• Somatoform disorders—Psychiatric disorders (DSM-IV, ICD-10) with persistent unexplained physical symptoms as key factor6

• Undifferentiated somatoform disorder—One or more physical symptoms without medical explanation with clinically significant suffering or functional impairment, existing for ≥6 months6

• Functional somatic syndrome—A combination of unexplained physical symptoms occurring together (such as irritable bowel syndrome or chronic fatigue syndrome)

As usual this embeds the most basic logical error/assumption into everything else that hangs off of it.

It arrogantly (as per much of medicine unfortunately) presumes that lack of explanation can only be due to the patient going ga ga. Never acknowledging even the possibility that as-yet-undiscovered knowledge might be the underlying reason for lack of explanation. Scientists above all should know that very little is completely certain, yet one of the highest probabilities, is that there is still much more to be learned. Yet they still persist in this "if no-one has concrete proof it is physical, we shall do a medical-territory land grab and defy statistical rationale - it must be psychological". It is Victorian quackery.

 

[user9876]

I agree that the blame lies almost entirely with the supervisor who sets such a narrow reading list, researchers who do uncontrolled studies, and publishers who publish them and publish articles like this one.

The thing that saddens and worries me, for the PhD student, is the apparent lack of curiosity.

I am trying to imagine myself in such a position, and hoping I would have explored more widely. Even just googling the conditions specifically mentioned - CFS, FM and IBS would have raised loads of issues that a good researcher should explore - biomedical research, patient support groups and what they say, etc.

What has happened to scientific curiosity? And integrity?

But then of course, the student may have done this, and been told firmly to stick to the supervisor's orthodoxy if they want to get their PhD and get papers published, such is the narrow world some academics live in.

For a PhD you would expect a literature review in the first couple of chapters that demonstrates a full understanding of the competing literature. Then you should show how you have improved knowledge in the area. You cannot show you have progressed research unless you are aware of what has previously been done.

More recently there seems to be a trend for a PhD to be given for someone who can wrap up a few papers into a thesis. I think this doesn't provide a good grounding in understanding what it takes to do research in a given field. Part of the value of a PhD is in writing up you have to think about methodology etc and hence reflect on how research can be done.

Stuff like this just seems to be regurgitating the same old opinions without adding anything new.

 

[Mohawk1995]

More recently there seems to be a trend for a PhD to be given for someone who can wrap up a few papers into a thesis. I think this doesn't provide a good grounding in understanding what it takes to do research in a given field. Part of the value of a PhD is in writing up you have to think about methodology etc and hence reflect on how research can be done.

I remember listening to people explain their process to get a Master's degree and even passing a fellowship/Diploma program as being much more difficult than what they appear to be granting PhD for in some circle's today.

They would explain the intense scrutiny of supporting every claim made and reading volumes of research while giving support and criticism for each point of every article.

I would also agree with the curiosity comments @trisharhymes . The role of a scientist is to always question the data, the results and to consider new and different explanations for what we are observing.

 

[Woolie]

"...perform a focused but thorough physical examination"

The way this is phrased makes it look like an afterthought - something the reviewers asked for. The "focused" part makes it clear these authors believe that you shouldn't got too far here. We shouldn't indulge patients' beliefs that they have a physical illness!

@Mohawk1995, the word "somatic" is used in medicine to mean sensations that "feel" like they're physical, but its almost never used for sensations that have a clear biological cause. So its use here is consistent with a psychological view of the illness.

No, it's the middle aged, married women whose children didn't turn out as she had hoped, and doesn't feel fulfilled by her marriage. I heard a British psychiatrist say this once in an interview.

I saw the same interview, @TigerLilea. Astonishing to hear such Victorian ideas coming out of the mouth of a 21st century doctor!

The only good thing I can see coming out of this is that, at least they conclude that the research evidence for treatments, both antidepressant and CBT and other psychological therapies is so poor as to be almost non-existent.

Yea, ironically, this actually puts the article a quality level above the PACE articles. where issues of bias and lack of blinding are not recognised as problems.

 

[RogerBlack]

I noted in my response online at the BMJ that the article rested on two fragile pillars - that people with unexplained systems overused health resources amongst them.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4848781/ - I find this paper by the same lead author.

MUPS were positively associated with HCU over 2 years (medical services: RR 1.020, 95 % CI 1.017-1.022; contacts: RR 1.037, 95 % CI 1.030-1.044). Neuroticism and depression had the strongest influence on the associations. After adjustment for these factors, the associations between MUPS and HCU weakened, but remained significant (services: RR 1.011, 95 % CI 1.008-1.014; contacts: RR 1.023, 95 % CI 1.015-1.032).

Once you remove the controlled for factors, this is a purported finding that people with 'medically unexplained symptoms' visit the doctor around one percent more.

This sort of paper needs a medically unexplained punch in the face.
It for example assumes that undiagnosed underlying real issues causing actual symptoms is CONSIDERABLY UNDER ONE PERCENT.

The stats look dodgy on a quick look.

 

[Sean]

This sort of paper needs a medically unexplained punch in the face.

 

[Valentijn]

The "focused" part makes it clear these authors believe that you shouldn't got too far here. We shouldn't indulge patients' beliefs that they have a physical illness!

Well they do have to rule out anything that might kill us within 6 months of the psychosomatic diagnosis. If patients died that fast, it would be awfully embarrassing for the quacks

 

[Snow Leopard]

Enhanced care by general practitioners comprises reattribution—where symptoms are reframed, making the link to presumed underlying psychological problems—and cognitive behavioural therapy. A Cochrane review on enhanced care (6 RCTs, 1787 participants) found no significant effect on quality of life in terms of physical and mental health and severity of physical symptoms

Hmm...

 

[A.B.]

Who said the enhanced quality of life was that of the patient?

 

[Snow Leopard]

Who said the enhanced quality of life was that of the patient?

Ah, good old passing the buck.

They talk about excessive healthcare utilisation. Such utilisations stems from the lack of patients needs being met - the fact is if quality of life or physical symptoms do not improve, the underlying needs are not being met and hence the healthcare utilisation will continue until any resolution is found - just with the help of more sympathetic medical practitioners.

 

[Woolie]

They talk about excessive healthcare utilisation. Such utilisations stems from the lack of patients needs being met - the fact is if quality of life or physical symptoms do not improve, the underlying needs are not being met and hence the healthcare utilisation will continue until any resolution is found - just with the help of more sympathetic medical practitioners.

I know, I know! Even the claim that these patients are a "drain on healthcare" rests on the assumption that they don't need any actual healthcare. In other words, their probablem is psychological, not medical.

If you thought a person had a serious chronic illness that was not being treated, you'd never accuse them of "overutilisation" when they persist in their attempts to get treatment!

 

[user9876]

I know, I know! Even the claim that these patients are a "drain on healthcare" rests on the assumption that they don't need any actual healthcare. In other words, their probablem is psychological, not medical.

If you thought a person had a serious chronic illness that was not being treated, you'd never accuse them of "overutilisation" when they persist in their attempts to get treatment!

It also suggests that they don't think people who they say are a "drain on healthcare" are worthy of treatment (probably because they believe the problem is psychological and reflecting weak people).

 

[user9876]

Well they do have to rule out anything that might kill us within 6 months of the psychosomatic diagnosis. If patients died that fast, it would be awfully embarrassing for the quacks

I'm not sure they notice or care. My experience is it takes several visits potentially over several years till a GP in the UK will take anything seriously. That includes lumps (dismissed as fat lumps) as well as "harder" to diagnose things like fatigue caused by having no blood.

Perhaps there should be a research project looking at what % of cancer patients had early diagnosis of psychosomatic illness or were labelled as the worried well. I suspect it would be significant.

 

[TiredSam]

Well they do have to rule out anything that might kill us within 6 months of the psychosomatic diagnosis. If patients died that fast, it would be awfully embarrassing for the quacks

I thought if you didn't return after 6 months a quack considers you cured.

Enhanced care by general practitioners comprises reattribution

For some reason I read that as "Enhanced care by general practitioners comprises retribution" - as in "I'll teach you to come in here wasting my time pretending to be ill - take some of my ´"enhanced care", damn you!"