Reconstruction of a typical GP consultation
Dr Clare Gerada (Wessely) and Alicia Deale:
Gerada: "I'd like to review the diary that you've kept, like to talk
about treatment and I'd like also to talk again about developing a
consistent approach to activity which is something we touched on last
week, what do you remember about what we talked about.. about that
what... what what do you remember about that ?"
Alicia Deale: "Em, I remember you saying that I needed to gradually
build up my activity bit by bit."
Gerada: "Yes, I think we talked about how important it was that
activity was consistent throughout the week, rather than in bursts of
immense activity followed by nothing, is that right?"
Alicia Deale: "Yes."
Gerada: "OK. Can I have a little look at your diary? Just talk me
Alicia Deale: "OK. Well, Monday, Tuesday, Wednesday were fairly
typical I went to work and when I came home I did nothing I just
rested, Thursday I tried to do a bit more after work and I was quite
busy first part of the evening and then just felt worse and worse and
I was so exhausted on Friday I just had to take the day off and I
spent it in bed recovering, felt a bit better on Saturday and that
was a fairly normal weekend day, where I was fairly sedentary I
suppose, watching a lot of tele reading the paper, Sunday I felt I
have got to try and build up my activity and do more so I went out on
a big walk, which probably wasn't a very good idea I think, it was a
few hours, I did lots of rest along the way I was walking very
slowly, but I think I really regretted it by the evening."
Gerada: "So if I can just recap, Monday Tuesday Wednesday were fairly
normal days, Thursday you did some activity and this was followed by
you feeling exhausted, Friday Saturday, so that you had to take to
your bed on Friday, Sunday you did this enormous burst again, of
activity. I think what your diary shows is again how important it is
that we develop a consistent approach, because what we talked about
was that it's important that we break this association between
activity, and your symptoms."
Alicia Deale: "Yes, I can see what I'm doing, it's hard to know how
to change it."
Gerada: "You've got activity on Thursday followed by symptoms,
activity on Sunday followed by... how are you feeling now ?"
Alicia Deale: "Dreadful.."
Alicia Deale: "I'm feeling knackered.."
Gerada: "OK , so can you help me then over in a normal week, how can
you consistently increase the amount... or consistently do some form
Alicia Deale: "Well, I suppose I shouldn't go on these very long
walks and perhaps try and do a bit more each day."
Gerada: "OK , we've talked before about the fact that you walk at the
moment to the bustop.. is that right.. to get to work, how long extra
would it be if you walk to the next bustop?"
Alicia Deale: "Another five minutes though it takes me about five
minutes to get to the bus stop at the moment, the next one's about
another five minutes."
Gerada: "So one way then is if you walk to the second bus stop in
the morning and got off a bustop early in the evening, you'd be doing
ten minutes of activity in the morning, and ten minutes of activity
in the evening, is that right?"
Alicia Deale: "Yeh yeh."
Gerada: "And that would be an overall increase of ten minutes in one
day, well, why not then 'til we next meet, that for the week , you
did this extra ten minutes a day, so that's ten minutes in the
morning ten minutes in the evening, what could you do at the
weekends, for a similar amount of activity.. of walking?"
Alicia Deale: "Eh ... well I suppose two ten minute walks each day
at the weekend, that would be more or less the same...that would be
the same wouldn't it?"
Gerada: "OK. So you can still potter around and do the things that
you would normally do on a Saturday and Sunday, but what I would like
is for you to have that, ten minutes in the morning, ten minutes in
the evening, of activity, and it's probably better if you keep it
consistent, with ten minutes in the morning, and ten minutes in the
evening, rather than putting it together to do a twenty minute hike."
Alicia Deale: "Oh right, OK"
Gerada: "Would that be alright, do you think you'll be able to manage
Alicia Deale: "I think I probably could.. probably be a bit of an
effort at the weekends but I think I probably could but em , and of
course I could always do more can't I, if I feel really energetic on
a Sunday or something then I can always do a longer one?"
Gerada: "I don't think at the moment that you should do that I think
it's very important at the moment that we develop a consistency, and
even if you're feeling full of energy, I don't want you to do more
than a ten minute's walk in the morning, and a ten minute's in the
evening, and all the normal things that you do during the day, but I
don't want you to do these bursts of activity"
Alicia Deale: "OK, I suppose if I'm not going on hikes I'll probably
would have a bit more energy in the week would I, so probably make it
a bit easier to do those two ten minuters?"
Gerada: "I think it would and I think what we're trying to do here as
I've said to you is to break this association between activity, and
your symptoms, because equally if you feel rotten, I still want you
to do that activity."
Alicia Deale: "What.. even if I feel really, really, really
Gerada: "Even if you're absolutely exhausted, I still want you to do
your ten minute walk in the morning, and the ten minute walk in the
evening after work."
Alicia Deale : "Is that going to be safe?"
Gerada: "It will be safe.. all the evidence that we've put together
and all the the the research literature shows that it is absolutely
safe you will not do yourself any harm and as I said it's important
that we make your activity consistent across the week."
Alicia Deale: "OK"
Gerada: "So you'll be able to manage that before the next
Alicia Deale: "Yeh, I think so yeh that does sound.. it sounds just
about manageable, I think..yeah."
Professor Andre Tylee and Dr. Trudy Chalder
Tylee: "Why is the GP limiting the activity in that situation when
somebody's got chronic fatigue syndrome?"
Chalder: "Well the most important reason is because patients with
chronic fatigue syndrome get into this all or nothing approach to
activity, when they're feeling good they'll do masses of exercise or
activity, when they're feeling bad, they won't do anything, or they
certainly reduce the amount they're doing, so it's important to
develop a consistency and that means not only maybe increasing the
amount they're doing but also stopping themselves from doing too much
when they're feeling quite good."
Tylee: "So having done that, I guess the process really has to be a
slow supportive steady one so that the GP's really got to help the
person to very very gradually build up their activities and but keep
limit them initially is that correct?"
Chalder: "That's right I mean I think we're thinking in terms of
months rather than weeks so the GP needs lots of patients (laughs).."
Tylee: "Yes yes..."
Chalder: "....as opposed to people, em, to stick with it over a
number of months and seeing the patient maybe once every two or three
weeks to set new goals (AT: 'Yes') and during that time they could
discuss any difficulties that the patient's having"
Tylee: "Yes and to keep the goals realistic so really sort of
increasing them very very slowly as appropriate."
Chalder: "Absolutely, it's really important not to go too quickly
(AT: 'Right') it's much better to go slowly and surely and get there
in the end than to do things too quickly for it all to go wrong which
is what often happens."
Tylee: "Yes, now when things do go wrong I mean presumably it doesn't
always work this way, what's the point where the GP should be
thinking about referral?"
Chalder: "I think if you've given it your best shot for about a year
at that point then I would think about why it's gone wrong and if you
think a specialist referral would be helpful then at that stage then"
Tylee: "Yes, now what sort of specialist because there are
immunologists, psychiatrists, psychologists, there's all sorts of
people that specialise in this area aren't there, who would you
recommend, resources willing of course ?"
Chalder: "Yes it's extremely difficult but I think the most important
thing is that whoever you refer to whether it be the immunologist or
the psychiatrist that they're committed to a practical rehabilitative
Tylee:: "Right. Yes, so it's this pacing approach that's the sort of
key to it so if a cognitive therapist is available would you suggest
that sort of..?"
Chalder: "A cognitive behavioural therapist, absolutely. I think
initially it's important to focus on the behaviour rather than the
way in which people are thinking (AT: 'Right') because it's a bit
threatening going in directly trying to change the way in which
Chalder: "So intiially it's just a very straightfirward pragmatic
approach you need to stick with you know over a long period of time
but bearing in mind, that there are going to be times when things go
wrong, and predict with the patient that they are going to have
setbacks but and help them to plan how they're going to cope with the
setbacks as and when they occur
Tylee: "Yes yes. Now the other situation that myself and my partners
at my practise often find is that people go to the M.E. Association
and they get lots of advice off the Internet and Newspapers and
Things and they come in with a whole wealth of different agencies
that they'd like to be referred to but presumably it's more
appropriate really to contain it.."
Chalder: "Yes absolutely.."
Tylee: "...and keep it simple in the way that you've just described it
Chalder: " I think that's really important, I think if the patient's
being investigated by a number of different specialists then it's
going to be difficult to engage them in this sort of rehabilitative
approach, so I would try and negotiate with the patient actually
stopping ...erm... that process, of having more investigations, which
obviously is not always easy. "
Tylee: "No, no, no, but that's very helpful, now then to summarise
really what I think we've discussed is that people can be taught how
to relearn or to change their behaviour and their sort of
physiological processes in a way that can actually control chronic
fatigue syndrome, is that correct?"
Chalder : "That's absolutely right and in fact that's not really
different to most other illnesses you know if somebody's got diabetes
or heart disease, then essentially the health professionals are
teaching people how to cope with their symptoms and disability and we
know that the degree of pathology is not necessarily correlated with
the degree of disability, you know so I think our job generally is
about helping people cope."
Tylee: "Yes. Despite the fact that we've seen all these techniques
that can be used, it does remain that a lot of GPs feel a bit
pessimistic with these sort of patients, what do you think?"
Chalder: "Well I think it's true that GPs and doctors in general feel
pessimistic about patients with chronic fatigue syndrome, but I think
it's misguided pessimism I think there's absolutely no reason for
them to feel pessimistic at all, in that I've been seeing patients
for about thirteen years, most of them have been extremely rewarding,
and have made significant improvements both in terms of their
symptoms and disability ."
Tylee: "Right What percentage would you expect to get better?"
Chalder: "About 70% in hospital populations which is actually very
Tylee: "Over what time would that be?"
Chalder: "Well it's obviously not going to be an overnight cure.. em
it's going to take several months sometimes up to a couple of years,
but if you persist with it and don't give up and recognise that there
are going to be ups and downs.."
Chalder:"...then, patients will get better."
Tylee: "And if they're left untreated the converse must be the case
Chalder: "Left untreated patients certainly don't get better and they
Tylee: "Right, thank you."
By Professor Andre Tylee
"Chronic fatigue syndrome patients are difficult, we hope that you
will persevere with them .
It helps to arrange firm follow up and not to expect too much.
Change often occurs over the long term.
We've included with the package some guidance on using role plays to
develop your skills in working with these patients, because we've
found that it's only by rehearsing the skills that you need that
you'll be able to use them when faced with the real situation.
All that remains now is to wish you the very best of luck with it."
The Patients were role-played by
Vince Holding [Vincent Deary]
Alicia Deahl [Alicia Deale]
The GPs were
Clare Gerada (Wessely)