The Right Stuff

Roger Jones

doi:10.3399/bjgp19X701825

On this month’s cover of the BJGP, Hercules confronts the Hydra. The beast had poisonous breath, many heads and a bad attitude — remind you of anyone? Hercules completed this, his second labour by the application of surgical skills — transection of the neck(s) and diathermy of the bleeding points to prevent re-growth — despite a flanking attack by a giant crab. Hydra and Cancer now gaze down on us from the Empyrean on high.

Hercules wasn’t simply a mighty warrior and a good surgeon, but he was also courageous, imaginative, resourceful and resilient, a sort of Matthew Bourne of The Peloponnese. These are some of the qualities needed to confront the challenges of providing high-quality health care in the 21st century, many of which are highlighted in this issue of the Journal. Challenges is an overworked word these days, but challenges they certainly are.

The editorials this month set some of the scene. Malterud and Aamland assess the state of progress in our understanding and management of what are still widely labelled ‘medically unexplained symptoms’ (MUS), a complex and heterogeneous spectrum of disorders running from chronic fatigue to irritable bowel syndrome. Their conclusion is that we aren’t there yet, and that new research questions need to be elaborated and answered in order to understand the complex inter-relationships between the biological, psychological, and social in the origins and natural history of these conditions. In research articles later in the Journal, the potential longevity of unexplained physical symptoms is highlighted, along with factors associated with continuing problems. I wonder what we’ll call MUS in 20 years’ time? Another study sounds a note of caution about treatment. Although cognitive behavioural therapy has been widely advocated in this context, the systematic review published this month suggests that its beneficial effects are fairly limited, and advocates a more nuanced approach to diagnosis, linked to a more targeted approach to therapy.

The very timely editorial by Faraz Mughal and colleagues on self-harm in young people drills down into what we can do in the consultation, not simply to be vigilant to the occurrence of self-harm, but also to provide an open, informed, non-judgemental, and confidential atmosphere in the practice and the consulting room to encourage disclosure and discussion, and to facilitate care. Although self-harm has almost become a rite of passage in the early teens, it is important not to forget its strong association with death by suicide.

Social media — the link to the previous paragraph is obvious — is having unpredictable effects on personal and professional life, and it’s a good time to publish the Debate & Analysis article by Andrew Papanikitas and colleagues on the safe and ethical use of social media forums by GPs. Patient confidentiality is paramount, and identifiability is easier than you might think. All social media forums should be regarded as public — not bad advice for any form of electronic/digital communication nowadays — and because they are generally unmoderated, unreliable information about clinical interventions or examples of unprofessional conduct can easily find their way onto your smartphone. Caveat textor!

There is another, bigger challenge, too, which we don’t really get to grips with as frequently as we should, and that concerns the role of medicine in campaigning against health inequity and health injustice in society, The theme is taken up in Richard Horton’s report, in the Lancet,¹ of the fantastic celebration of Julian Tudor Hart’s life and work organised in Glasgow by Graham Watt recently, and reviewed in Life &Times by our American colleague and guru John Frey. GPs at the Deep End are leading the way here, and we should be following: let’s hope we can develop this theme, along with some good news for the NHS, in future issues of the BJGP.

Finally, it’s a delight to see our brilliant Deputy Editor Euan Lawson launching his own column, Debrief, in Life & Times this month. Fresh, imaginative and often provocative writing from an accomplished clinician and medical educator. This will keep me on my toes.