BMJ  2006;333:134-135 (15 July), doi:10.1136/bmj.333.7559.134-a

Commentary

Wide angle thinking helps patients with distressing illness

¹ Institute of Clinical Education, Warwick Medical School, University of Warwick, Coventry CV4 7AL ed.peile{at}warwick.ac.uk

Kenneth Neville presents interesting problems for specialists and generalists alike.¹ At the time of the case presentation, we were told about a young man with distressing symptoms of postprandial vomiting leading to weight loss and weakness. The local hospital had diagnosed gastro-oesophageal reflux disease, and a battery of other routine investigations had given negative results. We were presented with several possibly relevant psychological factors, and it was mentioned that his asthma had been difficult to control. Readers were invited to consider the differential diagnosis and to suggest the most helpful course of management for the family doctor to take when Kenneth re-presented shortly before Christmas.

Doctors need to look at all angles Credit: DAVID PARKER/SPL

 

How often have I heard the expression, "This patient has been fully investigated at...?" The truth is that no patient is fully investigated. Investigation, like diagnosis, is a means to an end, and the end is that a patient is able to live as comfortably as possible with disease burden, and hopefully that the burden will be relieved altogether. On bmj.com family doctors rose to the challenge and showed their ability to think widely across the range of possibilities in the differential diagnosis.² The clinical reasoning processes were both inclusive (what do we need to consider that has not been thought about so far?) and exclusive (what can we safely rule out on the basis of the evidence presented?). Most doctors resisted the temptation to think in terms of either psyche or soma, instead considering emotional and psychological factors alongside physical illnesses.

Referral decisions

I think this is the stuff of general practice, working with the patient, starting from the point that distress persists, and showing a willingness to use professional expertise to jointly review the possible causes and helpful courses of action. The evolution of this case shows eloquently how specialist expertise is needed to define why Kenneth's problem is not simple gastro-oesophageal reflux disease. In order to access that expertise the family doctor needs to have decided, on the basis of the review with Kenneth, that it is not the time to say, "Everything currently possible has been done and my job is to help you to live with your symptoms rather than refer you back to specialists."

There is a time and a place to "hold" the patient whose suffering is only prolonged by multiple referral, and part of the art of the generalist is to define when that point is reached. (This is made more difficult in countries where patients have natural suspicions that resource rationing could influence the doctor's decision.) There is no shortcut to listening to the patient, to carefully reviewing together the possible reasons for distressing symptoms, and weighing up together the courses of action that are open. Even where somatisation contributes to the problem, empowerment has been shown to be effective where rejection and collusion fail in primary care.³ Working with Kenneth holistically, his medical team helped him to find satisfactory resolution of a distressing and potentially dangerous problem.

---

Competing interests: None declared.

References

1. Fox M, Young A, Anggiansah R, Anggiansah A, Sanderson J. A 22 year old man with persistent regurgitation and vomiting: case outcome. BMJ 2006;333: 133.[Free Full Text]
2. Salmon P. Patients' perceptions of medical explanations for somatisation disorders: qualitative analysis. BMJ 1999; 318: 372-6.[Abstract/Free Full Text]
3. Electronic responses. A 22 year old man with persistent regurgitation and vomiting: case presentation, BMJ 2006 http://bmj.com/cgi/eletters/332/7555/1438 (accessed 28 Jun 2006).

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

Related Articles

A 22 year old man with persistent regurgitation and vomiting: case outcome

Mark Fox, Alasdair Young, Roy Anggiansah, Angela Anggiansah, and Jeremy Sanderson
BMJ 2006 333: 133. [Extract] [Full Text] [PDF]

Patients' perceptions of medical explanations for somatisation disorders: qualitative analysis

Peter Salmon, Sarah Peters, and Ian Stanley
BMJ 1999 318: 372-376. [Abstract] [Full Text] [PDF]