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- Page navigation anchor for Why is MUS conflated with heartsink?Why is MUS conflated with heartsink?In response to this month's BJGP edition’s two letters regarding MUS, I would like to question why MUS is being conflated with ‘heartsink’ patients? (Letters from Reinhold E and Watters J.) Whilst MUS provide the often fascinating detective work challenges that we should be using to attract potential new recruits into general practice, heartsink patients, in my view, are the ones that challenge me on an emotive – rather than clinical level. My heartsink patients are the ones that make me feel inadequate, cross or miserable for a variety of reasons that are rarely simply my lack of diagnostic acumen. Some of the ‘consultation models’ help us understand these reasons: personality clash, communication problems, manipulative behaviour and issues of consultation dominance, and sometimes the challenges of fixedly held cultural beliefs or illness behaviours. To move beyond heartsink labels, we should learn to understand the psychology of ourselves first; - more than furthering my clinical knowledge, learning to be aware of my own set of prejudices has helped me to avoid letting them govern my consultations. I’m an imperfect human and doctor - but I shouldn’t have to feel omnipotent towards my patients in order to act professionally.Competing Interests: None declared.
- Page navigation anchor for Medically unexplained symptoms - challenges and dilemmasMedically unexplained symptoms - challenges and dilemmasHaving read the article about medically unexplained symptoms and the collection of e-letter responses to date, these seem to reflect quite clearly the observations that were published in my article for GP View December 2016:These are serious issues - for all of us. Doctors and patients. People are being harmed.Competing Interests: None declared.
- Page navigation anchor for Medically evaded symptomsMedically evaded symptomsI'm a patient who is not in the least bit impressed with this diagnosis. It smacks of dismissal to me. The BMA have just flagged up that anxiety and depression sufferers who took antidepressants have incurred serious harm. This has come after years of denial. Then along comes the Royal College of Psychiatrists with this diagnosis, which is being marketed as if it is the latest trend in healthcare despite being a little known and seemingly unimportant label. This begs the question why when funds are tight, GP time is at a premium, resources are scarce and litigation against prescribers is on the horizon! This diagnosis targets the "unexplained" symptoms of antidepressant withdrawal....which incidentally can now be explained and recognised....and all those who waste GP time and resources. It very much seems to me that this diagnosis is being actively promoted for economic and defensive reasons rather than to provide the reassurance to patients it pretends to achieve. This is deeply unethical considering that the diagnosis could be seen as protective to prescribers. The anger of patients described by Dame Sheila Hollins during the BMA negotiations will be inflamed further by this diagnosis. Somatisation isn't a label for patients whose symptoms can be explained and attributed to a cause...namely antidepressant withdrawal!Competing Interests: None declared.
- Page navigation anchor for Medically unexplained symptoms: continuing challenges for primary careMedically unexplained symptoms: continuing challenges for primary care
I wish doctors would finally started to take patients seriously. Please doctors, listen to what the patient is telling you!
I've been on an odyssey, trying to get recognition for my symptoms. I have gotten all kinds of diagnosis: migraines, chronic fatigue syndrome, fibromyalgia, a functional movement disorder, conversion disorder etc. The only tests done were an MRI and a standard blood test.
No doctor I spoke to was interested in my explanation for the symptoms: All of the issues started with an adverse reaction to a commonly prescribed medicine. All of the symptoms are clearly stated in the patient information leaflet. There are thousands of other people with the same problem in Internet Forums and on Facebook. But the medical community prefers to label us as "crazy" or "hypochondriac" instead of addressing the actual problem: Unsafe medicines on the market.
Competing Interests: None declared. - Page navigation anchor for Medically unexplained symptomsMedically unexplained symptomsI am concerned about the use of the term "MUS". As a patient suffering from iatrogenic harm resulting from withdrawal from a benzodiazepine after 40 years' consumption, I am unable to find a doctor willing to acknowledge the true cause of my current state of neurological disability. I therefore am collecting a myriad of spurious diagnoses such as depression and ME/CFS. This only serves to compound my distress. "MUS" seems to be another potential dumping ground for the many patients harmed due to prescribed drug dependence and withdrawal, thereby diverting attention away from the real problem.Competing Interests: None declared.
- Page navigation anchor for Medically unexplained symptoms: What's in a name?Medically unexplained symptoms: What's in a name?
The recent editorial on medically unexplained symptoms (MUS) is welcome.1 However we suggest that it is time to ditch the term MUS. While patients with MUS look for explanations, they find that doctors are unwilling to provide them. Instead, their doctors attempt to bridge the explanation gaps by building relationships.2 Using the term 'medically unexplained symptoms' keeps this gap open and discourages GPs from providing the kind of rational explanations which give patients agency to manage their symptoms better.3 The term is also going to be wrong occasionally. Although the proportion of cases which turn out to be due to 'explained' disease is not large, neither is it trivial. As GPs we need to operate in a way which keeps open the possibility of 'explained' disease, while at the same time providing explanations for symptoms and helping patients to manage them well. We have to find a language that can manage both reassurance with self-management and safety-nets.
A recent proposal for a prognosis-based classification, which can be summarised as 'multiple symptoms, multiple systems, and multiple times' may provide one way to support clinical decision making.4 Many patients dislike terms such as MUS.5 Perhaps it is time to discard this name in favour of alternatives: 'persistent physical symptoms' is more acceptable to patients and may be more helpful for GPs.
...Show MoreCompeting Interests: None declared. - Page navigation anchor for MUS: actually we can and should explain such symptomsMUS: actually we can and should explain such symptoms
The authors of this article make frequent reference to "unexplained" and even "unexplainable" symptoms. However, the work of Professor Christopher Burton, amongst others, has clearly identified helpful explanations for such functional symptoms. Using more positive language about normal aging,(wear and repair), the effects of chronic muscle tension and weakness (back pain, deconditioning), the effects of vicious cycles of focussing on symptoms and ignoring pain free periods (by both doctors and patients) and the effects of the adrenocorticoid system are some of the helpful ways to talk about functional symptoms.1,2 Dobbin has highlighted the need for doctors to understand the mind/body relationship and the healing potential for positive social and other feedback via parasympathetic networks.3
We can recognise the predisposing factors arising from the effects of trauma and attachment processes in infancy and early childhood which influence how distress of all kinds is communicated to doctors.4 Van de Kolk5 has elucidated the neurological correlates of abnormal responses to distress; beginning in childhood, stress chronically affects the cortisol axis and affects the brain’s responses. When we manage distress and insecure attachment skilfully, avoiding unhelpful labels and treating symptoms, we enable better emotional regulation. Mindfulness, “HeartMath” and bodywork therapies such...
Competing Interests: None declared. - Page navigation anchor for Medically unexplained symptomsMedically unexplained symptomsHard evidence regarding diagnosis, care and management of this area of practise is, unsurprisingly, hard to come by. It is disappointing that this article does not specifically mention the importance of personal continuity of care in these cases, and the desirable development of trust of a patient with a clinician. Fragmented care at best makes management of patients with these conditions difficult. Without trust, satisfactory explanation and understanding, a positive impact is much less likely. At its worst, fragmented care can act as a reinforcement, rather than a relief of symptoms.Only with this recognition, and appropriate dedicated review opportunities within the GP appointment system (perhaps into which ONLY the GP is authorised to book) can desirable continuity be achieved (continuity was given prominence with several articles in BMJ 2017;356).Competing Interests: None declared.
- Page navigation anchor for 'MUS' or 'DEN'?'MUS' or 'DEN'?I have long despaired at the focus on the 'consultation' and the psychological approach to patients whose symptoms have not yet acquired a diagnostic label. Since learning the latest about the linked conditions of mast cell activation syndrome, postural orthostatic tachycardia syndrome, dysautonomia and the hypermobility syndromes (including Ehlers-Danlos), I have yet to find anyone with 'MUS'. I just find patients who have been failed by a lack of medical knowledge amongst their caring clinicians. Stop feeling that heartsink and stop giving patients the message that it's all in their head. Instead, educate yourself about the manifold presentations of these newly recognised conditions and give your patients the validation they deserve.Competing Interests: None declared.
- Page navigation anchor for MUS - continuing challenges for primary careMUS - continuing challenges for primary care
Once upon a time in general practice patients with MUS were known as 'heart sink' patients courtesy of a must read to diss paper from the 1970s1 - the patients we can't cure because their symptoms are not related to a specific pathology, but relate to altered physiology caused by psychological distress which they cannot voice as emotion or conscious thought, but experience as physical symptoms. While the term medically unexplained symptoms is more politically correct I'm not sure it's any less patronising. It is just as good in allowing us to blame the patient for being difficult. In 33 years of medical practice I have not encountered genuine medically unexplained symptoms in the patients I had long term contact with, although it may have taken several consultations to find out what the source of psychological pain was. The lady with chronic neck and chest pain turned out to have have had a congenitally disabled child who died aged 5 (long before I met her mother). The lady with severe back pain turned out to have seriously injured someone else in a car accident. Another lady with chronic pelvic pain had a very unhappy marriage but could not contemplate divorce.
MUS is a label that doctors can use to regard patients as untreatable. It is second to borderline personality disorder in my personal pet hates regarding labels, which allow us to blame patients for being difficult.
We need to acknowledge that we cannot cure ever...
Competing Interests: None declared.