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LETTERS TO THE EDITOR |
Bethlehem Royal and Maudsley NHS Hospitals Trust; London, U.K.
Editor’s Note: Salmon and colleagues chose not to submit a reply to this letter.
Salmon and colleagues’ (1) study of doctor–patient interactions reports findings that they claim are incompatible with the widespread assumption that physicians offer medical care to patients with unexplained symptoms because the patients demand treatment for a physical disease. Instead, Salmon and colleagues suggest the reason why many of these patients experience high levels of medical care should be sought by investigating the motivations behind physicians’ responses to patients’ symptom presentation (1).
The article pointed to previous literature that suggests that physicians feel pressed by patients to provide physical approaches and treatments, and this is because patients arrive at the consultation convinced physical disease is present (1). In contrast to this view, Salmon’s group has pioneered an alternative perspective that suggests in contrast that patients’ overt pressure for treatment is rare and their suggestions of physical disease tentative (1–3).
Instead, they contend it was physicians’ reactions to graphic, elaborate, and extended accounts of symptoms and their effects that resulted in physicians reflexively providing a physical approach (1). This new model is founded on a misperception and misunderstanding by doctors of patients’ desires and their accounts.
Is it possible that these results could be explained by an alternative explanation to the "pressurizing patients" or the "misunderstanding medics" theories? Instead, it might be that both doctors and patients endure a more problematic dialogue over what nonphysical causation could mean when it comes to bodily symptoms.
Once doctor and patient depart from the reassuring moorings of physical disease into the more uncharted waters of psychological or nonphysical mechanisms that the consultation becomes more troublesome; doctors come to view the nonphysically caused symptoms as "psychiatric," whereas patients hate the "all in your mind" implication given the stigma surrounding mental illness (4).
Beyond merely resisting psychological accounts, it could be patients interpret the absence of positive tests as heading toward a "there’s nothing wrong" medical conclusion, and given there palpably does feel to be something very wrong to the patient, this does not reassure them. So they may come to fear abandonment and loss of care by the reassuring authority figure of the doctor (4).
Also, the absence of a physical account for symptoms appears more dangerous to many patients who are keen to adopt a sick role for various reasons. If it is "all in the head," then maybe there is more uncertainty over whether the sick role is permitted or for how long it might be allowed (5).
It is not so simple as doctors feeling pressured by patients into providing physical investigations and treatments for medically unexplained symptoms, but perhaps more that the alternative or psychological account is fraught, complex, and represents too difficult an option in contrast. The more readily available and understandable physicality account dominates the consultation because the alternative appears so murky and ominous in comparison.
Among other problems for nonpsychiatric doctors thinking about patients with psychological etiologies to their symptoms is demanding because so many possible and often rival perspectives exist in which to frame their distress (6).
Salmon et al. are right to suggest the answer to the unsatisfactory outcome for many doctors and patients over medically unexplained symptoms is likely to lie in a deeper understanding of the consultation.
However, this understanding needs to reflect a more nuanced grasp of the choreography by which both sides dance around the "mental" as opposed to knowing the steps when it comes to the "physical." The findings in this area are yet another example of the strength of the stigma surrounding psychological dysfunction, in particular the pessimism surrounding the notion that once something is "all in the mind," then nothing can be done for it.
DOI:10.1097/01.psy.0000248897.97492.06
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