Ill-fitting models and labels – #sapcasm day 2

Domhnall_MacDomhnall MacAuley is a CMAJ Associate Editor and a professor of primary care in Northern Ireland, UK, currently at the Society for Academic Primary Care annual conference

 

All the problems started with Descartes, who conceptualised the mind-body separation, described as the Cartesian model, began Rona Moss-Morris in her plenary talk.

She continued by explaining that, while we ought to focus more squarely on the bio-psycho-social, Medicine has not yet fully embraced this model. In general practice, however, we cannot explain everything using the biological model alone. There is often a mismatch between clinical signs, objective tests and the health of the patient.

Clinicians have always recognised the concept of medically unexplained symptoms (MUS), particularly in primary care, and various descriptive terms have been used including “Heart sink”, “Thick files” and “the undeserving ill” ....the perception of patients as not being ill; that it’s all in the mind. Similarly, patients have been told “there is nothing I can do for you”. And, as medicine still holds with the Cartesian model, we tend to turn to Psychiatry for those patients whose condition cannot be explained by biological model.

These conditions are, however, just as legitimate as other illnesses but cannot be identified by a test or confirmed on histology. Medically unexplained symptoms includes many conditions characterised by symptoms, suffering and disability rather than by disease specific physiological findings. They correspond to 18% of UK GP attenders and 52% of new referrals in specialist care with enormous direct and indirect costs.

But, is medically unexplained symptoms a useful label? It’s the one that everyone uses but it doesn’t really work. Most patients want a positive description of their symptoms but this condition is defined by what it is not- it implies no organic cause. Or “We can find nothing wrong with you and there is not much I can offer you in any way of treatment”. As Rona said, these are not really unexplained symptoms; it’s just that they cannot be explained but the biomedical model

I was also fascinated by Rona’s thoughts on treatment and the need for us to think more about, and understand, psychological therapies. Medicine tends to lump all psychological therapies together but each has a different theoretical model and mechanism. Cognitive behavioural therapy should be uniquely specified for the particular condition. Saying that psychological therapies don’t work is akin to a general statement saying that drugs don’t work without specifying which drug in which condition.

Tom Cowling from imperial College started his talk by pointing out that while the (UK) Prime Minister and Health Secretary believe that increasing access to general practice will reduce emergency room attendances, this hypothesis is relatively untested. Looking at hospital data he identified patients admitted either through direct access by general practitioners or through Accident & Emergency (A&E). And, from the latest GP Patient survey data he looked at information on those who reported they had been able to get appointment on their most recent attempt. The numbers were impressive with 2.3million emergency admissions and 81.9% of these through A&E. There was a linear relationship indicating that those patients whose GPs were more accessible were more likely to be admitted through general practice. He proposed future research into what features of a condition influenced access and work that would ultimately define primary care sensitive conditions.

Fiona MacKichan from Bristol also looked at GP access in her ethnographic study and described patients’ frustration with the system. To be fair, she also described an example of good care. But, I was struck by her reflections on the difficulties of seeking help in general practice while A&E, by contrast, was a straightforward place to seek care. The consequence, she said, was a rational assessment of risk and actions by patients who could see that “It’s the only place that, even if have to wait all day, something will happen that day.”

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