Two themes have been running in tandem in the BJGP since April, both of which highlight a more fundamental issue within general practice.
The first theme comes from the GPs at the Deep End series.1,2 This is the appreciation of the need for an intimate knowledge of family backgrounds and for more time during consultations to ascertain and manage the psychosocial components of ill health.
The second theme is the ongoing debate started by Mike Fitzpatrick regarding the involvement of general practice with child protection.3 More broadly, this is the debate about the extent to which GPs should be concerned with seeking out an understanding of patients' family/social circumstances compared to just concerning ourselves with the traditionally more narrowly-defined, ‘medical symptoms’.4,5
Both themes flag up a fundamental problem with the current biomedical model, in otherwords, its basis in a Cartesian mind-body split.
The Deep End articles have very clearly shown how the psychosocial aspects of patients' lives are deeply bound up with their illness presentations. I would like to add another theme that brings the problem of a belief in a mind-body split into clear relief, the problem of medically unexplained symptoms (MUS).
These constitute 20-30% of primary care consultations, and 40-50% of secondary care consultations6 and yet how often do we see MUS featured on medical education programmes?
Although we have very little understanding so far of the underlying mechanisms, we know that there is an association with a history of past trauma and that incidence increases down the social scale.7
It is likely that underlying social factors have an impact in aetiology and one could hypothesise that these social factors are being manifested as physical symptoms through the mediation of ‘the mind’.
We are still waiting for neuroscience to provide a scientific understanding of mind-body connections, but meanwhile it seems that approaching physical symptoms only in narrowly defined medical terms is missing the very large elephant in the room.
Whether we like it or not, illness is intimately bound up with patients' social lives; once we have the scientific understanding these issues will no longer be subject to debate.
- © British Journal of General Practice 2011
