Medicine and man's fall
Authors: Richard Smith
Journal: BMJ (2004)

but not for irritable bowel syndrome.This antipathy was due to the lack of bodily location, patients failing to conform to the work ethic and traditional "sick role," and disagreement with patients over causes and management.Referral for mental health interventions was unlikely because doctors were unfamiliar with them or thought them unavailable or unnecessary. Editor's choice Medicine and man's fallIf medicine were simply a matter of prescribing drugs and wielding scalpels then monkeys-or at least robots-might make adequate doctors.It's the human bit, as in most enterprises, that makes medicine tricky, fascinating, and difficult.Medical journals might be accused of ignoring much of that complexity with their diet of drug trials and systematic reviews.Increasingly, however, we are publishing qualitative research that probes the interactions between doctors and patients.Three authors from Australia and Canada have asked patients receiving palliative care and their families what they want to be told and found that many were unhappy with the communication process-particularly the disclosure of the initial diagnosis (p 1343).The authors identify six things that are important in communication in such circumstances: playing it straight, making it clear, showing that you (the doctors) care, giving time, pacing the information, and staying the course.Each individual, of course, wants something different and may be far from clear, even to themselves, about what they do want-putting a high premium on the doctor's sensitivity.The two content areas that are most important are prognosis and hope.The difficulty with prognosis is that many patients want to be told but do not want to know.Not everything needs to be said at once, and patients commonly want lots of information at the beginning but ever less as they come closer to death.Hope, including for some hope of a long life when close to death, is vital, and one of the worst experiences for participants was "to have hope dashed by a rushed or insensitive health carer."To be honest but be able to keep hope alive are two fundamental attributes of a "good doctor."As I read this paper I couldn't help thinking that it deals with the easier stage of terminal care-when the patients have registered with a palliative care programme.The worst communication failures come, I suspect, in that time between the doctors thinking the patient will die and the patients and families registering for palliative care.Four authors from London delve into some of the darker aspects of medicine by comparing and contrasting doctors' perceptions of patients with chronic fatigue syndrome and irritable bowel syndrome-both complex, poorly understood conditions where symptoms, outlook, and responses to treatment are similar (p 1354).Yet one doctor says: "I would rather treat a whole surgery full of people with irritable bowel syndrome than people with chronic fatigue."The authors identify five reasons for the difference, but one is nothing more complicated than one illness having a precise bodily location.The most important finding from the study is that with both conditions doctors are reluctant to use "mental health approaches," which may often be effective.