Gurli Bagnall, Patients' Rights Campaigner, 11 August 2002

Email Gurli Bagnall: URSULA@xtra.co.nz

Response to "ABC of psychological medicine (BMJ)" - BMJ 2002;325:323-326: http://bmj.com/cgi/content/full/325/7359/323

Bass and May paint a vivid picture of the dislike and contempt many practitioners feel for their "heartsink", "difficult" and "fat folder" patients, who evoke in them "despair, anger and frustration". The difficulty they have in suppressing these emotions to avoid official complaints (as advised by Bass and May), is not hard to imagine. But really, whether or not Fat Folders evoke these feelings, is in the hands of the doctors themselves. The attitude that says, "Don't argue with me! I am the expert!" does not necessarily win friends and influence patients. All that need be said, is, "I can see you are in pain, but I don't know what is causing it." A little honesty goes a long way.

I refer, of course, to the clinical review entitled "Chronic multiple functional somatic symptoms".

It is alarming that the incidence of this newly named condition has reached epidemic proportions (over 4% of the general population), and following the very best of medical/male tradition, we were told that most of those affected, are women. Bass and May are apparently unaware that the finest example of "illness beliefs", "perceived illness", and "hysteria" are traditionally seen in men who have taken to their beds with the common cold. Women generally soldier on, for who else will look
after the children and prepare the meals?

Iatrogenic harm is a subject generally considered taboo by the profession, but it has been mentioned in articles such as "Chronic multiple functional somatic symptoms" of late. In this context, it serves to highlight two issues: (1) Quote: "It is also necessary to encourage them to concentrate on coping rather that seeking a cure." The implication of this extraordinary statement, is that in going from doctor to doctor seeking a cure, iatrogenic harm is an almost inevitable outcome, but an outcome for which no doctor can be blamed. (Blaming the patient is, of course, another "fine" tradition.) (2) This argument serves to consolidate the notion that if an investigation for possible physical disease must be made (for the sake of appearance?), then it should be no more than superficial.

 From the patients' point of view, they're damned if the do, and damned if they don't. If they do nothing to find explanations and relief, then they are castigated for not making an effort. If they make an effort, then they are castigated for being medical nuisances.

The recommendation that patients should be reminded of "the limits of medicine" when they have "unreasonable expectations", is so far removed from reality, it is laughable. It is the rare doctor who admits to such limitations for it destroys the illusion of medical omnipotence. The already mentioned attitude, "Don't argue with me! I am the expert!" is the norm, and one of which the patient needs no reminding.

Having admitted to the limits, however, they do raise an interesting point. How can Bass and May be so sure of their stance? There are no ifs, buts or maybes. The article is not based on anything even vaguely resembling science; at best it is opinion, and at worst, it is self- serving. I doubt an observer would be impressed with the interpretation the authors put forward to explain a patient's comment: "It's disgusting what doctors can do to you." Quote: It "may suggest that the patient's relationship with the doctor may reflect poor quality parental care or emotional deprivation in childhood." To an observer, this definition is more likely to suggest that the doctor is trying to absolve himself from the responsibility of some dastardly deed.

It is regrettable that no consideration was given to the despair, anger and frustration of patients who are affected by "the limits of medicine". Regrettable, yes, but not surprising, for it compounds the feeling that Bass and May place the comfort and wellbeing of practitioners first, and that of the patients last.

The authors established that CMFS exists in epidemic proportions, and one assumes that the included 15 year summary is an example of a typical case, yet in the conclusion they state: "Patients with multiple long- standing functional symptoms are relatively uncommon." Apart from anything else mentioned here, I always feel uneasy about the validity of any paper that is not consistent.