Download the new app today ausdoc ausdoc . com com . au au
HOW TO TREAT 39 platforms . Murtagh ’ s safe diagnostic strategy is another approach . This involves identifying the probability diagnosis , serious disorders not to be missed and pitfalls and masquerades , as well as systematically ensuring these diseases are not missed . 69 Identifying and formally excluding these potential diagnoses can narrow the possibilities and reduce uncertainty . As doctors , we are unable to exclude disease despite requests for blood tests to “ check for everything ”. Patients often find this uncertainty unsettling , and it is understandable given medically unexplained illnesses rarely feature in public discourse . It is therefore important to manage expectations around investigations . A normal investigation does not indicate that there is nothing wrong .
CF
Download the new app today ausdoc ausdoc . com com . au au
13 DECEM- NOVEM- BER X MONTH 2022 library at www . ausdoc . com . au / therapy-update
LEARN MORE ONLINE Visit our Therapy Update
HOW TO TREAT 39 platforms . Murtagh ’ s safe diagnostic strategy is another approach . This involves identifying the probability diagnosis , serious disorders not to be missed and pitfalls and masquerades , as well as systematically ensuring these diseases are not missed . 69 Identifying and formally excluding these potential diagnoses can narrow the possibilities and reduce uncertainty . As doctors , we are unable to exclude disease despite requests for blood tests to “ check for everything ”. Patients often find this uncertainty unsettling , and it is understandable given medically unexplained illnesses rarely feature in public discourse . It is therefore important to manage expectations around investigations . A normal investigation does not indicate that there is nothing wrong .
Box 2 lists strategies when managing patients with elusive illness .
The contested illness
Patients with medically unexplained symptoms lack social legitimacy as sick people , so it is understandable that they look for a diagnosis to validate their suffering . 70-73 Some of these patients become invested in “ illnesses you have to fight to get ”, using online communities and their own internet searches . 24 These contested illnesses , like multiple chemical sensitivity or chronic Lyme disease , provide a framework for suffering , a shared community and a strategy to seek care but can also lead to significant
24 , 70 , 74 , 75 harm .
Consider Francis , a 65-year-old woman who presents with a thick folder of evidence to share with her GP . She has seen multiple doctors and multiple non-GP specialists . Although she has never travelled , and her investigations are normal , she insists she has Lyme disease . She describes fatigue , headaches , joint pain and fleeting rashes . She is seeking a referral to an American pathology company for “ more accurate testing ” and a German clinic for treatment . Patients like Francis do not want the doctor to make their own diagnosis . Instead , they seek validation for their own point of view . The difficulty arises because they may need the doctor to provide them with access to services , including expensive investigations or treatments . These patients invest significant work , time and energy to earn their status as credible
24 , 25 , 32 , 76 , 77 patients .
A common topic in online support groups ( see figure 6 ) is how to approach the doctor : what to wear , what to say , what not to say and what articles to bring . 24 , 27 There is a delicate balance for these patients ; they need to provide compelling evidence of their incapacity so they can legitimately seek support while not being seen as passive and incompetent so they can retain their dignity and
42 , 78 self-worth . Understandably , there is the potential for significant conflict in the consultation . Many patients have already encountered doctors who believe they are impossible to help and have been harmed by the invalidation they have experienced in the medical system . The result is a consultation that can be “ a duet of escalating antagonism ” that various writers have described as a law court , a medieval siege or a tug of war . 82-84
Box 3 lists strategies when managing patients with contested illness .
Figure 6 . Online support groups provide a framework for suffering , a shared community and a strategy to seek care but can also lead to significant harm .
Box 2 . Strategies when managing patients with elusive illness
• Acknowledge that rare and early diseases can be difficult to diagnose and may take time .
• Acknowledge that many tests will exclude diseases but will not diagnose them .
• Explain that it may be possible to isolate the cause to an area of concern ( for example , Anna ’ s likely autoimmune arthritis ) without identifying a specific disease : “ We may be able to get in the right ballpark , but we may not be able to identify the game .”
• Revisit diagnosis regularly .
• Monitor mental health as medically unexplained illness is often associated with significant depression and anxiety .
• Acknowledge your own frustration , and reiterate your commitment to care for the patient and their family regardless of whether a specific diagnosis is made .
• Co-ordinate care to relieve the patient of as much of the burden of managing their disability as possible .
• Utilise multidisciplinary colleagues who may be experienced in different diagnostic frameworks and may recognise conditions that GPs may miss .
Box 3 . Strategies when managing patients with contested illness
• Validate their subjective experience , but do not collude with the explanation :
— This may involve articulating what you can and cannot agree on — for example , “ Francis , the fatigue and the pain must be difficult to manage . I do not have any way of verifying if this is Lyme disease , but I can help you manage your symptoms until we are clearer about what is going on .”
• Where necessary , reiterate your role as a doctor of Western medicine , especially if patients propose treatments or investigations that are outside your scope or responsibility : — This may involve refusing to order tests or treatments that are not clinically justified . — Use the patient ’ s words and frameworks if you can — for example , “ I think there is an inflammatory component to the joint pain too . Let us see what we can do to manage that .” — Use their language to broaden the agenda to include physical , psychological and social strategies for management — for example , “ Patients with these sorts of illnesses seem to respond best to a combination of treatments . I would like to look at strategies to address the pain but also see if we can help you manage stress because stress seems to make inflammatory pain worse .”
• Involve a multidisciplinary team where possible : — Keep a focus on active intervention — for example , “ I know you are often quite tired , but patients with joint pain do better if they undertake some regular light exercise . What exercise are you able to do at the moment ?”
• Explain that different strategies work for different people , so you will have to try several strategies to see what works in their case .
• Practice harm minimisation : — Maintaining a non-judgemental open relationship will allow your patient to discuss alternative treatments that have the potential for harm .
• Organise a regular physical health assessment to help screen for unexpected comorbidity .
• Keep an open mind and reassess regularly : — These patients are unwell , and the cause can become apparent over time .
The chaotic illness
Consider Dana , a 35-year-old Aboriginal woman who is a survivor of intergenerational trauma . Her grandmother is a survivor of the stolen generation , and Dana experienced severe domestic violence as a child . She has four children and lives with poverty and unstable housing . She presents with crippling headaches , with a normal MRI . The headaches are not migrainous in character .
Patients like Dana have problems that are too complex — medically and socially — for fixing . 85 There are few places in the health system for people like Dana to get the help they need . Many of these patients are survivors of childhood trauma , and most have complex social needs . 86 The cause of Dana ’ s symptoms are over-determined : there are multiple reasons why she is unwell , and every time one is managed , another emerges . Patients with chaotic illnesses have deep psychosocial needs that cannot be met — often because there are insufficient social supports available in the community . Even if resources are available , these patients may struggle to access them because there are significant barriers , including distance , cost and literacy requirements .
Trauma complicates the therapeutic relationship . These patients often find it difficult to trust and have difficulty establishing and maintaining positive interpersonal relationships . 36 It is therefore not surprising that the consultation dynamics can be challenging . Consultations can feel like a whirlpool , where it is easy to get caught in the multiple needs of the patient , with no solutions available .
Strategies for managing chaotic consultations include ensuring there are regular opportunities to undertake care planning , reviewing and documenting all the agencies and health professionals involved in treatment , as well as ensuring that important preventive activities are performed . A yearly health assessment can help avoid focusing on the cascade of presenting symptoms alone . For each consultation , it is important to plan and record what needs to be achieved and to utilise medical software to make sure follow-up is not missed . It is easy to be reactive and drown in symptom management without managing the whole person effectively .
Box 4 lists strategies when managing patients with chaotic illness .
The mental illness
Patients with mental illness commonly present with physical symptoms . Consider Ed , a 40-year-old farmer with anhedonia , weight loss , slowed speech and poor memory . His wife says he has become irritable and forgetful . He insists his mental health is “ fine ”.
Patients like Ed may have a mental illness , like depression , but find it difficult to articulate their psychological symptoms . Others will not be aware of any psychological component of their symptoms at all . Many will experience internalised stigma and shame and so will not feel comfortable expressing their mental health needs . 87
In Western culture , psychiatric illnesses are often seen as less real or legitimate than physical illness . Nevertheless , comorbidity of medically unexplained symptoms and psychiatric illness is high . 88
Frank somatisation is more common in children as they frequently express their emotional needs in physical ways . Consider Charlotte , a 10-year-old girl who is refusing to go to school . She has vomiting and abdominal pain and , on questioning , has experienced significant bullying . She says it is because she has always seen herself as a boy , and her parents agree . Abdominal examination and blood tests are normal , and a trial of PPIs has been unhelpful . Children like Charlotte commonly present in general practice and can benefit greatly from holistic care .
Box 5 offers an approach to