BMJ Opinion “Functional disorders”: one of medicine’s biggest failures, 2023, Smith

https://www.bmj.com/content/380/bmj.p221
Richard Smith

 

We have a thread on the book he's just read and opining on: The Sleeping Beauties: And Other Stories of Mystery Illness (link to Amazon).

 

Narcissistic delusion. "X is a failure, long live X". They literally can't imagine not knowing things and having to work to know those things. It just never comes into their small closed dogmatic minds. The same ideas going around in circles, destroying millions of lives to raucous applause.

 

Yeah, he should probably have just stopped at the title.

To which my response might be: "And patients were cursed when medicine tried to reunite them as some form of Frankenstein's monster."

 

About a third of patients attending neurological and gastrointestinal, or almost every outpatient clinic—have functional disorders, meaning that they do not have a physical cause that can be detected with a microscope, scanners, or blood or genetic tests.​

Starting from a false premise is never going to end well.

Add one crucial word and the whole story changes: do not have any known physical causes.

By Mr Smith's standard they also don't have any known psychological ones either.

Why is it so hard for medicine to say 'we don't know'? Why must they insist on filling the gaps with such destructive sophistry?

These are patients whom medicine has failed more than almost any other group.​

Says a man among those most responsible for allowing this appalling situation to come about.

Irony is dead.

 

As far as I can see Richard Smith is not a doctor but a health economist.
The chanting of the BPS mantras seems to be second hand.
Embodied cognition isn't even a theory. It is a sort of pseudoscientific incantation.
When one sees this garbage trotted out in this blasé way by some one doesn't even know what it means it comes hoe how much this is all moronic tribalism rather than anything rational.

 

Amazing, and yet not, how some "experts" can casually discard millions of those suffering with conditions yet to be understood.

Do none of these people acknowledge advances in medical science?

Over time, we have learned about diseases, and developed treatments.

We're not done yet!

To say certain diseases or conditions do not have a cause is to ignore history, and the potential for medical progress.

Another important point regarding the statement, " about a third of patients" symptoms do not have a physical cause, is that gender bias, racism, misguided government policies, and a failing medical structure are some of the barriers to diagnosis of physiological dysfunction for this community.

 

If a patient tells her that their main symptom is exertion intolerance leading to LTSE, is she really going to treat that symptom as if it is real or is she going to prescribe exercise?

 

If the patient isn’t tested for every single possible biological cause known to exist, and they aren’t, not unless they are a multi millionaire at the very least, then how can one possibly know that their bodies pathologies don’t show up on scans blood tests or genetic testing?

At current technological capacity you could spend the rest of your life however long that is, hunting down researchers to study your own genetic makeup and not get through every possible genetic abnormality that could cause or contribute to sickness.

A “third of patients” presenting at clinics don’t have access to unlimited medical testing.?They probably can’t even get basic scans what with medical ableism, racism, sexism and distaste for lower income people.


When pontificaters like to lump “a third of patients” into the ‘no biological findings’ basket, and they refer to negative findings in objective tests to justify this, they are referring only to the few that have actually been done.

Such tests will vary in quantity, quality, and appropriateness.

They who propose a turn away from the biology of the body then make a claim that (since these few will always outstrip the preferred number for people whose tests return nonspecific or negative results), these were excessive extensive or at least adequate.

Because be it one two or three tests, any test with a negative finding is to be mourned as a waste of ‘resources’. After all these could in every case be saved if we just retire testing and call it good. Or FND or MUS or FSS or BDD or conversion disorder or hypochondria or SSD. But not psychosomatic or hysterical because……. you know.

 

Yet another repetition of the fiction that 'about a third have functional disorders'. Journalists and other opportunistic writers are latching onto that fiction.


Richard Smith, BMJ, 2023
'About a third of patients attending neurological and gastrointestinal, or almost every outpatient clinic—have functional disorders, meaning that they do not have a physical cause that can be detected with a microscope, scanners, or blood or genetic tests.'




Natalie Shure December 2022

'Dr. Mark Hallett was gobsmacked by just how badly medicine was handling these cases. As a chief investigator at the National Institute of Neurological Disorders and Stroke at the NIH, he’s invited referrals from clinicians across the country for decades of tough-to-diagnose patients presumed to have rare neurological diseases. “I began to get the sense that we were seeing large numbers of what we were calling ‘psychogenic disorders’ at the time,” Hallett told me. “Around 30 percent of our cases had a functional diagnosis. And I said, ‘Gee, this is a major problem.’” In 2006, Hallett went so far as to describe as a crisis medicine’s inability to grasp such common manifestations of illness.
https://newrepublic.com/article/168965/might-long-covid-wrong


(I think what Mark Hallett really means is that him and his colleagues handed out functional diagnoses to about 30% of their patients)




David Tuller
'Why does it matter if FND experts argue in one paper that the prevalence of FND among outpatients at neurology clinics is “approximately 6%” but elsewhere report that it is 16%, or even state that it is up to one-third? A key reason is that doing so undermines the credibility of the argument that FND is now a rule-in diagnosis and not a diagnosis of exclusion. Lumping together patients with and without rule-in signs in a single category risks turning FND into a wastebasket diagnosis applied to anyone with unexplained symptoms. That happened routinely with the hoary construct of “conversion disorder,” the term FND is meant to replace. Suggesting that patients without rule-in signs have FND is, in effect, misdiagnosing them. And misdiagnoses can lead to an array of unfortunate consequences.

Given that the term “functional” is now frequently used to describe any symptom or condition for which no organic cause has yet been identified, it is understandable that patients with unexplained neurological symptoms might automatically get slapped with an FND diagnosis. But the term now has a more specific and clearly defined meaning. When it comes to prevalence rates, the frequency with which investigators appear to be casually conflating “functional” and FND, as if the two were interchangeable, is likely to generate serious confusion for patients and clinicians alike. In medicine, words matter.'

'Trial By Error: A Letter About the Inflated Prevalence Rate of Functional Neurological Disorder'
https://www.virology.ws/2022/07/07/...nce-rate-of-functional-neurological-disorder/

 

Who is commissioning these pieces at BMJ Opinion??

 

The author is the former editor-in-chief of the BMJ (1991-2004), so possibly just volunteered it.

On this paper, he is credited as the Chair of the UK Health Alliance on Climate Change (no further comment made on the placeholder texts on that page).

 

I'm glad that you've pointed this out.

This whole thing struck me as a relabelling of the 'lump and dump' of a whole demographic/area of people a few individuals decided were no longer allowed access to investigation or medicine for a few decades ago to pretend the underlying commonality of them all was something different to political bigotry.

It is just sleight of hand to rename a bigotry and injustice done by certain individuals and pretend it is some health condition to hide that awful brutal action by muddying the waters it could be something else.


It is like the old ActionFraud hotline strategy (where they ran a line to take people's reports with no intention of doing anything with it, to give the impression there was that service https://www.dailymail.co.uk/news/ar...raud-reporting-service-Action-Fraud-axed.html) but with the added twist of hiring a massive staff, poached from those who could have actually investigated the fraud, to run kingdoms where they tell callers and the rest of the population they are untrustworthy witnesses but who 'it is very real for them, the belief they have been a victim of fraud bla bla' attitude is thrown at.

It might have added up early on (with people doing it thinking they'd have moved on by the time the cost of leaving things hit the metaphorical fan) but what I don't get is how these accountant types aren't seeing the huge swathes of people's jobs being spent on all this snowballing (as such conditions just get worse). At least ActionFraud didn't have its leaders writing books, being paid for conference speeches and doing iterative pretend research.

By now it should be to such beancounters that the stats on 'value for money' aren't present from these people, who aren't cheap/free, and who use a model more akin to 'off-rolling' of students who would fail exams to another centre and calling it cured.


I horribly suspect the only things those dumped under these labels have in common (if anyone were allowed to count them) would be demographic-specific combined with absence of a small list of red-flag conditions such as cancer and heart disease that society wouldn't accept being de-listed and which potentially have strategic, political importance (don't fund healthcare for chronic conditions anymore, and the best way to hide this is to never diagnose people with them). And poor care with lack of investigations.

That is the real 'disease' and symptoms we are talking about - it is just disability bigotry masked by selling a mass delusion to 'the rest' that it's OK now as long as you use new synonyms. It is just the shocking thing is the sheer amount of money they are spending funding this illness-worsening industry vs proper scientists and proper clinicians who really want to do actual medicine.

But I guess those selling this nonsense aren't very 'up front' about 'lifetime costs' of their interventions - something the NHS might want to get on top of when looking at funding places who want money for short course type things with no responsibility for actual outcome. A nice story barely hides the barefacedness of and holes in this well-worn tactic but is it really worth the sheer amounts being spent on keeping doing it?

But it helps very much if such labels infer both a tendency 'to imagine things' and 'get upset over nothing' (so noone even listens anyway to what they are reporting, as well as their witness testimony being undermined). Genius if you can make that circular and get some to believe the very symptoms and situation are caused by these slanderous disses being 'medical terms applying to the person dissed' rather than a function of the disser. Unless you are the person responsible for medium-long term costs of someone's illness getting worse (a figure that rarely seems to be demanded).

 

Oh Groan - a sit on the fence Rapid Response. The writer gives the standard 'mind-body are inseparable' guff platitude, then warns against making the blunder of misdiagnosing organic diseases as functional - but concludes we need psychiatrists on the case .....

'... Whether COVID-19 pandemic has added to and aggravated the psychosomatic scenario is a moot question, but the answer is more likely to be in the affirmative; frenetic lifestyles, day-night blurring, 24/7 living linked sleep deprivation and drugs - psychedelics have been known factors before the pandemic. Psychiatrists have helped resolve many problematic situations, and their role deserves to be rightfully acknowledged.'

https://www.bmj.com/content/380/bmj.p221/rapid-responses

 

Modern medicine at work, folks.

Does their role in the exacerbation and even creation of many problems get equal acknowledgement?

 

Well that explains a lot about the quality of ME research in the BMJ during his editorial reign.

 

As far as I can see there are two Richar Smiths, both involve in political pressure groups on health. I had thought it was the other one but it looks as if it is the one who was a doctor and once editor of BMJ. He has a reputation for callous commentary - in relation to cancer in particular.

 

Ah. In which case Richard Smith the doctor has even less excuse.

 

Richard Smith is a busy fellow:

(1) https://en.wikipedia.org/wiki/Richard_Smith_(editor)

"In December 2014, Smith wrote on the BMJ blog that trying to find a cure for cancer was a waste of money, claiming that, "with love, morphine, and whisky", the disease is the best way to die.[8] His remarks provoked outrage.[9][10] The British Medical Journal said:

Smith’s New Year’s Eve blog on thebmj.com about cancer offering the best death garnered global media coverage and triggered a social media storm from thousands of bereaved relatives and the parents of children with cancer. He was accused of “glibly glossing over the pain” of cancer, to quote Michael Broderick, one of the 173 respondents on thebmj.com.[11]

Smith responded and tried to clarify some of his points in a follow-up blog post on 5 January."

(2) https://ukhealthalliance.org/about/our-team/

"Richard Smith is chair of the Point of Care Foundation, which promotes compassionate, dignified care, and Patients Know Best (a company that brings all medical and social care records together in one place under the control of patients), and a cochair of the Lancet Commission on the Value of Death. From 1979 to 2004 he worked at the BMJ and was the editor of the journal and chief executive of the BMJ Publishing Group from 1991 until he left. From 2012 to 2018 he was the chair of icddr,b, which was formerly known as the International Centre for Diarrhoeal Disease Research, Bangladesh."

(3) https://www.pointofcarefoundation.org.uk/about-us/people/richard-smith/

"Having practiced as a doctor in Scotland and New Zealand, Richard Smith joined the BMJ in 1979 and was editor-in-chief from 1991-2004. He has served as chief executive of the BMJ publishing group and UnitedHealth Europe, and was the director of the UnitedHealth Chronic Disease Initiative to combat chronic disease in low and middle income countries. For six years until November 2018 he was the chair of the board of trustees of icddr,b (formerly the International Centre for Diarrhoeal Disease, Bangladesh), one of the largest health research institutions in a low income country.

He is also the chair of Patients Know Best, a company that gathers together all the medical and social care records of patients and puts them under the control of the patient, the UK Health Alliance on Climate Change, and Open Pharma.

An adjunct professor at Imperial College Institute of Global Health Innovation and a Founder Fellow of the Academy of Medical Sciences, he is well known for his work on death and dying, and chairs the Lancet Commission on the Value of Death. He also worked on the 2018 report from the Royal College of Physicians on medical professionalism. As a regular contributor of blogs for the BMJ, he is an outspoken voice on issues including end of life care, public health, scientific publishing, and health in the developing world.

Richard joined the Point of Care Foundation board in 2019, succeeding Sir Adrian Montague as chair."

(4) https://patientsknowbest.com/team/

"Richard is Director of the Ovations initiative run by world-leading health care organisation, UnitedHealthcare. Its mission is to combat chronic disease in the developing world, funding centres in China, Bangladesh, India, Pakistan, Tunisia, Tanzania, South Africa, Central America and the US Mexico border.

As a member of the board of the Public Library of Science, he is also an honorary professor at the University of Warwick, a member of the governing council of St George’s, University of London and editor of Cases Journal. Previously he was Chief Executive of UnitedHealth Europe, a subsidiary of UnitedHealth Group that works with public health systems in Europe.

Before that, Richard was the editor of the British Medical Journal (BMJ) and Chief Executive of the BMJ Publishing Group. Having qualified in medicine in Edinburgh, he worked in hospitals in Scotland and New Zealand before joining the BMJ. He also worked for six years as a television doctor with the BBC and TV-AM and has a degree in management science from the Stanford Business School."

(5) https://www.marketscreener.com/quot...nounces-Global-Partnership-to-Stem-th-343896/

"Ovations, a subsidiary of UnitedHealth Group, is the largest company in the U.S. dedicated to meeting the health and well-being needs of people age 50 and older. It provides chronic disease management services, health insurance, Medicare-managed care and related services, access to prescription and non-prescription medications, and other healthy living products. It has a long track record of innovative partnerships with governments and not-for-profit organizations. "

 

This reminds me of a quote i read ages ago.

'The time to diagnose an autoimmune disease can take upto 7 years'

Tests are negative poof a conversion disorder diagnosis.
Especially if younare serum negative