In her essay On being Ill,1 Virginia Woolf wrote that:
‘Illness is a part of every human being’s experience. It enhances our perceptions and reduces self-consciousness. It is the great confessional; things are said, truths are blurted out which health conceals,’
And later in the same essay:
‘Let a sufferer try to describe a pain in his head to a doctor and language at once runs dry. There is nothing ready made for him. He is forced to coin words himself, and, taking his pain in one hand, and a lump of pure sound in the other (as perhaps the people of Babel did in the beginning), so to crush them together that a brand new word in the end drops out. Probably it will be something laughable.’
Much of what we have published in this issue of the BJGP reflects the difficulties of communication and understanding in many aspects of pain — the control of cancer pain, the less-obvious physical pain that frequently accompanies chronic physical illness, the difficulties often encountered in diagnosing painful conditions, and the problems of measuring and rating the experience of pain — yet these are some of the core tasks, the daily bread, of general practice.
Headache is a good example: not just of a painful condition but of a common symptom which may have sinister significance, but almost certainly does not. A busy GP could see two or three people with headache every week but, with an incidence rate of about 15 per 100 000 in the UK, a new brain tumour will be diagnosed about every 3 or 4 years. The difficulties of ‘triaging’ headache, and variations in diagnostic approaches, are well described in the study by Stefan Bösner and colleagues from Marburg, Germany, while Jan Frich and co-workers, reporting from Oslo, Norway, underscore the importance of the potential therapeutic alliance between doctor and patient in the application of a brief intervention to deal with medication-overuse headache,
The place of imaging and of open access to MRI scanning for headache is the topic of a Debate & Analysis article, in which a successful diagnostic pathway including direct referral for MRI is described by Timothy Taylor and colleagues. This is counterpointed by a thoughtful discussion of patient selection for investigation by David Kernick and Willie Hamilton. They propose a model in which costs, cost effectiveness, and cost utilities would be used to add to the current guidance. They conclude that:
‘All of these calculations can be benchmarked against NICE estimates of cost per quality-adjusted life year (QALY). In an emotive clinical area and against a background of political rhetoric driving the agenda, knowing how much different management options cost, and how much they yield, can facilitate the difficult decisions GPs face when patients present with headache.’
We are prisoners of the technology: weighing the impulse to ‘have an answer’ against the inconvenient trip to hospital and 30 minutes inside a very loud and expensive magnet. In 10 or 20 years time, when every GP will be able to wave a magic diagnostic wand over the distempered part, what sort of ‘head to head’ discussions on the pros and cons of open access scanning will we be publishing?
Electronic cigarettes have been in the headlines lately and we are fortunate to have been able to commission an editorial from a world expert in the field, Professor Robert West, and his colleague Dr Jamie Brown. Another editorial addresses the equally current problem of safeguarding the wellbeing of children. In a particularly strong Clinical Intelligence section we have material on shoulder pain, spinal cord compression, and autoantibodies in rheumatology. Finally, and hot off the press at Thomson Reuters, the BJGP ’s Impact Factor has gone up by almost 20% to 2.356.
- © British Journal of General Practice 2014
REFERENCE
- 1.↵