The sort of patient we are discussing here is the one who attends repeatedly with physical illness that is unclassifiable in modern medical understanding. The unexplained breathlessness or fatigue, the flitting chest pains, the weird pins and needles that fit no dermatomes, all possible precursors of nasty diseases but without the clinical evidence to confirm a diagnosis.
Common things are common, most illnesses are not serious and most symptoms are not disease. We are talking of problems of living turned by anxious people into symptoms, and turned by biologically trained doctors into disease.
Patients who are prone to turning inner anxieties into symptoms are called somatisers. Doctors who turn such symptoms into disease have been called medicalisers. It is a sad truth of modern medicine that a medicalising doctor and a somatising patient is a bad combination.
I am afraid GPs have to be on guard for manipulative behaviour because this is a common feature of the somatising patient. It is not easy, but referral to outpatients should be viewed as a last resort - only when all reasonable avenues and likely diagnoses have been considered and rejected should a referral be made.
I still believe that one of the GP's primary duties is to protect their patients from hospital medicine. Hospital medicine is almost exclusively disease-based; patients must be diagnosed thoroughly and possible causes ruled out. Once an anxious, introspective patient reaches outpatients, the die is cast; investigation is coming and all that might entail. Fixation with the symptom will be intensified and the vicious, self-reinforcing circle encouraged.
Write explicit and detailed referral letters. These should contain biographical details, clinical and physical symptoms and signs, the course of the condition, your own hypotheses, previous history, important psychosocial background and what the patient believes and wishes.
There should also be a clear statement of what you are asking of your colleague, and what you wish to happen after your colleague has seen the patient.
So we must use our traditional disease-based medical model with care. We all need to be good diagnosticians, but good, efficient clinical practice demands balances - most headaches do not warrant MRI scans - investigation on demand is bad medicine and treatment on demand may be worse.
We must not create disease where only poor individual coping mechanisms are the problem. The trouble with this pattern of behaviour is that once it has become established it is very hard for GPs to break the vicious circle, and the main villain of this piece is the doctor-patient relationship itself.
It may be that sometimes we overestimate the importance of sustaining such a relationship while at the same time colluding with an unhelpful illness behaviour that only maintains incapacity.
Sometimes tough love may be best rather than feeling increasingly powerless to resolve such problems just for the sake of not rocking the boat. We need to change our patient's purely biomechanical view of illness and use strategies to help them 'reattribute' their explanations for ill health.
How can we as GPs break out of a therapeutically hopeless relationship and give our somatising patients a fighting chance of functional recovery? By taking a deep breath, setting aside some time and starting again.
The aim is to make our patient feel listened to and understood, and then to broaden the agenda to negotiate a new shared understanding of the symptoms, including possible psychosocial factors. The real secret is to discover, in depth, the patient's specific concerns, because without this knowledge, ill-informed reassurance will exacerbate their presentation of somatic symptoms and increase the severity and chronicity of the presentation.
It is often the case that our ill-founded explanations are at odds with the patient's own thinking, which results in conflict, a feeling of rejection and undermined confidence.
The crucial point is to base explanations on the patient's own ideas, concerns and expectations, which means discovering them in the first place.
Not rocket science but we must do it. The strongest predictor of a poor outcome in patients presenting with fatigue is their expectation of chronicity.
At the end of such a consultation we must check our patient's true understanding by asking questions such as: 'What will you take away from this visit?', 'Is there something you can use?' or 'Would it be reasonable to do (such and such)?'
- Dr Tate is a retired GP in Dorset and author of The Doctor's Communication Handbook and the Effective Consulting DVDs. To order his latest educational DVD, Developing an efficient consulting style, for £27.99, visit gponline.com/consulting
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1. Salmon P, Peters S, Stanley I. Patients' perceptions of medical explanations for somatisation disorders: qualitative analysis. BMJ 1999; 318: 372-6.
2. Dowrick CF, Ring A, Humphris GM et al. Normalisation of unexplained symptoms by general practitioners: a functional typology. Br J Gen Pract 2004; 54: 165-70.
3. Rosendal M, Olesen F, Fink P. Management of medically unexplained symptoms. BMJ 2005; 330: 4-5.