Charles Todd qualified as a GP in 1981 and then spent twenty years working in Zimbabwe. He recently retired as a GP partner in Buckinghamshire.
Termination of the coronavirus pandemic by vaccination will be heralded as a triumph for science. Indeed, vaccines are an incredible intervention, freeing us from the harms caused by a swathe of diseases.
A vaccine is a classical biomedical intervention, in this case targeted against a specific virus. The development of Koch’s postulates for determining whether a specific microorganism is the cause of a given disease, and the work of Louis Pasteur, were key elements in the development of the model not which just laid the basis for the development of vaccines, but also forms the bedrock of modern medicine.
The biomedical approach relies on categorising patients through agreed, standardised criteria for diagnosis.
The biomedical approach relies on categorising patients through agreed, standardised criteria for diagnosis, thence providing a basis for the development of effective treatments. Infectious diseases and a wide range of other conditions have been classified into distinct entities. This approach has been immensely successful and has created the conditions for the huge progress we have seen over the past century. A widespread assumption is that all human illness can be classified into specific biomedical entities, and all we need to do is look hard enough. However, we should never forget that these entities are not laid down by some higher power, rather they are defined by human beings.
Many of the diagnostic categories we use every day have no known biological basis. This applies to virtually all psychiatric diagnoses.
Many of the diagnostic categories we use every day have no known biological basis. This applies to virtually all psychiatric diagnoses. The fluidity of defining entities in mental health is illustrated in the changes over time in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This categorised homosexuality as an illness until 1973.1 Meanwhile the number of psychiatric diagnoses increased from 128 in DSM-1 published in 1952, to 541 in DSM-5 published 61 years later.2 Thus many human traits have been medicalised, and the myth engendered that these disorders somehow represent a chemical imbalance in the brain, ever extending the reach of Big Pharma into everyday life.3,4
Perhaps the greatest absurdity of this approach to defining entities is the “non-diagnosis”, such as “non-organic pelvic pain” and “non-cardiac chest pain”. These are popular with vertical specialists and often mark the point where they discharge the patient. Alternatively, the patient may be given a dustbin diagnosis like irritable bowel syndrome or fibromyalgia. For patients acquiring such a diagnosis comes with the perception that many doctors have little interest in such conditions and show negative attitudes towards patients affected by them.
The term “Medically Unexplained Symptoms” …. represents a hubristic extension of the biomedical model.
The term “Medically Unexplained Symptoms” is widely used as an overarching dustbin category; its adoption represents a hubristic extension of the biomedical model. Its use implies that there should be a single approach to the management of a wide range of patients seen in everyday practice. It serves to legitimate the idea that their symptoms are not as “real” as those of say a person with cancer, while it promotes the notion that further investigation may be needed. It reinforces the concept that mind and body are separate. It undermines the patient’s own narrative, and other possible explanatory or treatment models.5 Finally, as a label it can ultimately stand in the way of a specific diagnosis being made.
…these patients cannot be neatly pigeonholed …. They… deserve to be listened to without judgement and responded to honestly.
Modern general practice comprises less and less of interactions with patients with a single classical disease which forms the archetype of the biomedical paradigm. Once the dust settles after the pandemic, our focus will return to patients with complex multimorbidity, those with chronic pain and distress, the “worried well”, and elderly patients with varying degrees of frailty and cognitive decline. Many of these patients cannot be neatly pigeonholed as suffering from a specific biomedical entity and we should not attempt to do so. They and their carers deserve to be listened to without judgement and responded to honestly. We should be judicious in our investigations, avoid unnecessary diagnostic labels, and accept uncertainty. We must not slip into lazy thinking habits.
Above all we should never lose sight of the uniqueness of every individual we encounter.
References
- Rose H, Rose S. Genes, Cells and Brains. Verso, London. 2014. 256-7.
- Blashfield RK, Keeley JW, Flanagan EF, Miles SR. The Cycle of Classification: DSM-I Through DSM-5. Annu. Rev. Clin. Psychol. 2014. 10:25–51. doi: 10.1146/annurev-clinpsy-032813-153639
- Middleton H, Moncrieff J. Critical psychiatry: a brief overview. B J Psych Advances (2019), vol. 25, 47–54. doi: 10.1192/bja.2018.38
- Iylas S, Moncrieff J. Trends in prescriptions and costs of drugs for mental disorders in England, 1998–2010. B J Psych (2012) 200, 393–398. doi: 10.1192/bjp.bp.111.104257
- Danczak A. MUS: actually we can and should explain such symptoms. BJGP (2017) 67, 204. doi: https://doi.org/10.3399/bjgp17X690773
Featured photo by Jessica Ruscello on Unsplash
This article by Charles Todd is interesting and relevant … but perhaps something important is being missed – especially in the final paragraphs?
Our blog for BJGP Life just a few weeks ago may offer some insight:
https://bjgplife.com/2020/12/03/the-patient-voice-antidepressant-withdrawal-mus-and-fnd/
Dear Dr Todd,
If you have time on your hands then I suggest you read Goodelf’s ‘Untangling the MUS Web’ blogs and then decide if doctors should risk abandoning the biomedical model in favour of the biopsychosocial one when managing patients with symptoms that aren’t easy to explain. Patients are suffering untold misery and harm on an appalling scale because of the BPS/MUS model.
Thanks for drawing attention to the Goodelf blogs on MUS. S/he discusses the high rate of MUS mis-diagnosis in secondary care, and critiques services commissioned for patients with MUS. As GPs we practice a speciality which offers “person focused (not disease-oriented) care that is appropriate, safe, effective and compassionate…” (quote from WONCA). Embracing the idea of categorising a huge and very heterogeneous group of our patients as having MUS goes completely counter to this.
Nobody doubts that the vast majority of GPs want to do their best for their patients in terms of their physical and mental health and social wellbeing, but GPs are also NHS commissioners and Goodelf’s blog entitled ” DESPICABLE MUS: Document Leads UK Healthcare Commissioners up a Perilous Garden Path” tells us how the JCPMH’s “Guidance for commissioners of services for people with medically unexplained symptoms” is gravely flawed. This 2017 document, that was jointly produced by both the RCGP and RCPsych in collaboration with other organizations, appears to be of a very poor standard indeed and should be denounced and redacted. It DOES embrace the idea of categorizing a huge and heterogeneous group of patients (especially women) as having MUS, and following this guidance is likely to leave millions of patients in the UK without the physical healthcare that they need. The diagnostic safety net in medicine is effectively being destroyed for the sake of reducing secondary care outpatient expenditure, but there is no record kept of levels of medical misdiagnosis so there is no way of monitoring the damage that is being done.
It is very interesting to see the response above about the 2017 RCGP/RCPsych Joint Commissioning Panel for Mental Health document about ‘Medically Unexplained Symptoms’ (MUS) . This same document is quoted and referenced the the ‘Patient Journey’ Infographic that we (I together with many patients having experience of what is happening to real people ‘in the system’) put together to illustrate. I have written for, and done a podcast, for HGI.org.uk and this is used to illustrate what we are seeing – over and over again:
https://www.hgi.org.uk/sites/default/files/hgi/Marions%20infographic_for%20print%20A4%20x%202%20pages.pdf
Something is surely going wrong when people are becoming ‘made ill’ by medicines which are so freely and commonly prescribed?
I agree that patients with adverse drug reactions and withdrawal effects are likely to be frequently misdiagnosed and ignored under the MUS banner, but other physical problems are being misdiagnosed a lot too. It’s been widely reported that women with endometriosis are suffering for far too long before being correctly diagnosed. Quite often they’re told that their pelvic pain is psychological/in their heads. As long as doctors are taught that women are at a greater risk of ‘MUS’ then this sex discrimination will continue, reinforcing the self-fulfilling prophecy that already exists. Because women are more likely to be given a MUS label they are also more likely to end up being prescribed antidepressants that have the potential to do so much harm, compounding their medical problems and/or unexplained symptoms.