August 10th, 2002
To the Editor,
Bass and May, cite a frighteningly high percentage of persons whom they feel qualify for a diagnosis of “chronic multiple functional somatic symptoms”. There is no doubt that such a diagnosis will fit certain individuals. However, the criteria used for making this determination was as follows:
Potential CMFS patients may be identified simply by the thickness of their paper notes, from records of attendance and hospital referral, and by observation of medical, nursing, or clerical staff.
I suggest that in a significant number of cases, this paragraph should be rewritten to read as follows:
Potential doctors of patients who will ultimately receive diagnoses of CMFS, may be identified by short attention spans for reading thick charts, heavy patient loads with brief appointment slots, a strong reluctance to write justifications for referrals to annoyed HMO organizations sending them checks and a near complete absence of scientific curiosity for the unfamiliar. The physician may have an unreasonable fear of litigation, despite the fact that some ailments have their roots in negligence on the part of employers or third parties involved in the work setting. In the U.S., where it is illegal to charge a patient for having an illness of occupational origins, charts may be surprisingly bare of certain diagnostic and historical facts. Few doctors will wait for the worker’s compensation board to review a case in five years to obtain a minimal fee. This is understandable but places the patient in the position of forgoing appropriate medical care as well as justice in injury cases.
Perhaps this may seem harsh to the many dedicated, overworked physicians who are, after all, taking the time to read this journal for their continuing education in a terribly stressful occupation. However, no practitioner can be educated in the nearly unlimited array of illnesses and injuries that can befall the human being. Our age is littered with advanced technologies such as chlordane and phthalates that do the tasks for which they were created – at a cost only counted later when the science behind the technology catches up to our marketing style. Sell first, examine later.
Life is often stressful, so pointing a finger at stress can be a “saving grace” for a doctor reluctant to further investigate vague or multi-system complaints. CMFS may be an unfair assumption often leaped at prematurely to ease the burden of guilt carried by doctors who find themselves unable to help a sick individual. Some doctors, unsure of themselves, may be reluctant to contradict other doctors previously consulted.
I watched one man struggle for nine years with debilitating illness only to learn he had hypoglycemia when a doctor finally prescribed a glucose tolerance test. His thick chart became bare of new entries as he enjoyed the best of health for the next twenty years with only a special diet as a prescription. Another patient developed a variety of gastro- intestinal complaints, neurological problems and respiratory symptoms which all appeared to wax and wane depending upon environmental circumstances. Five physicians later, a neurological evaluation revealed brain damage and toxicological testing indicated chronic cholinesterase inhibition – classic signs of organophosphate pesticide toxicity which should be familiar to British physicians in rural areas. She was considered a resistant patient due to her refusals to take offered medications which only exacerbated her symptoms.
The statistic of 6 percent brings to mind the percentage of British and American Gulf War veterans suffering from similar, “mysterious” complaints so long denied as having a basis in organicity. No matter the findings of researchers indicating that many have CNS and immune system damage or that some belong to a class of individuals prone to toxicological insult (low paroxonase levels). No matter that peers in the French armed forces, not subjected to multiple experimental immunizations, showed a more normal rate of disability post-service.
Perhaps it is immaterial that six percent of the population of California has been diagnosed with chemical sensitivities, a disorder with multiple correlates in the diagnostic codes of the ICD-9 (for example, 989.9, Toxic Effects of Chemicals). Most persons with such a diagnosis are told for years they have some form of CMFS that worsens with administration of multiple medications. Anecdotal evidence is an essential part of such diagnoses, a “test” which doctors are afraid to interpret freely.
What is most important to remember is that the diagnostic criteria used by psychologists and psychiatrists are frequently anecdotal in nature. Yet when patients show patterns typical of certain complex ailments and attempt to partner their doctors in identifying an illness based upon the anecdotal experiences of other patients. they are deemed “absorbed by their illnesses”.
Reminder: When a patient sees a doctor, they are there for the sole purpose of discussing their health. At $200 per hour, few will show their well-rounded natures by discussing sports or politics.
Doctors and patients must all be accepting of the limitations of knowledge; that no doctor is appropriate for all patients who will enter their doors and that some ailments can only be discovered over time with extensive investigation. A diagnosis must never be based upon frustration, wishful thinking or a fear of legal systems which may become involved when appropriate.
This is submitted with respect for the unique partnerships required in the doctor-patient relationship. In particular, this is submitted with respect for those physicians who discuss such conclusions honestly with patients instead of making vague pacifying promises of aid that will never materialize. Sometimes the sentence, “I do not know how to help you.” may be the most appropriate.
Categories: British Med. Journal