Medically unexplained symptoms: assessment and management (2021) Mujtaba Husain and Trudie Chalder

https://www.rcpjournals.org/content/clinmedicine/21/1/13

This is barely worth posting, but I read it. It's so basic it felt like it was written for children - is that because it's in a journal for doctors rather than researchers? So many strong assertions ("The first and most important step is a positive diagnosis and explanation of what the diagnosis means") that were then so vague on implementation.

Table 3 is based on the PRINCE trial's approach to MUS and managing activity: https://www.rcpjournals.org/highwire/markup/11946/expansion?width=1000&height=500&iframe=true&postprocessors=highwire_tables,highwire_reclass,highwire_figures,highwire_math,highwire_inline_linked_media,highwire_embed

I remember @dave30th writing about some exaggerated claims on this, but I think that this figure is lower than the ones previously used: "PPS are also estimated to account for approximately 10% of total NHS expenditure for the working-age population in England.7"

 

This paper is part of a whole special issue on functional disorders, I think. That figure is a slight misstatement of what the paper said. In the working age population, 11 % of total NHS expenditures is spent on those in that age group with PPS or MUS. That's not to say that all the expenditures were for MUS, although most probably were. The mistake was that Chalder & her colleagues kept writing that these costs accounted for 11% of the cost for the total NHS population, which was about three times as large as for the total costs just for the working-age population.

 

It is produced by the Royal College of Physicians and is clearly intended as curricular material for trainee physicians. Which makes it a catastrophe. Medicine based on the blind leading the blind.

 

("The first and most important step is a positive diagnosis and explanation of what the diagnosis means")

So, diagnosing a non-diagnosis (by definition) of MUS is the best and sparkliest thing for our trainee physicians. Pretty patronising to patients and the trainee physicians

 

Indeed: 'The first thing to learn in medicine is how to make things up without letting on - how to bullshit professionally.'

 

Ha ha start them young

 

I'm sure this is all supported by good science and not a confusion of consequences of illness with cause of illness.

 

Looking at the blurb for the magazine is pretty dispiriting. It is indeed for children. The mission statement includes:

peer-reviewed journal of the Royal College of Physicians, Clinical Medicine (ClinMed) publishes advances in general and specialist medicine and authoritative reviews ... it particularly encourages submissions from trainees and early-career researchers who wish to build their publication portfolio.

I.e. it publishes authoritative reviews by trainees who know nothing much about their subject. Maybe that is who the first author is here. I have always been appalled by the tradition in medicine to get trainees to write review articles so that they can polish their CV (openly admitted as the aim here). Usually there is also a senior author who is happy to tag their name on to her enlarge their publication list to 900.

I see that the editor in chief is at UCH.I have met him. He seemed pleasant but I had a suspicion he was tied up with 'functional' diagnoses in a muddled sort of way.

 

I assume I'm missing something here but wouldn't it be better to try to understand what the underlying problem is and treat it? E.g. if there's a shed load of money, to investigate an apparent case of MUS - say in the US or a wealthy country where money is no object - and it turns out that MUS was actually a biomedical problem "X", then find a biomarker for "X" and see how many MUS are actually explained by "X". OK it may not be that simple e.g. MUS may be many things (rare diseases) and understanding a particular case may be extremely difficult. A genome-wide association study (GWAS) might turn up something but if MUS is many things then I guess that is really difficult (finding suitable controls).

 

I don't know. Children usually have mastered object permanence. This is more at the toddler level, "if you don't test for it, you have zero cases".

 

He's also one of the persons who gave their expert testimony to the NICE committee.

https://www.nice.org.uk/guidance/GID-NG10091/documents/supporting-documentation-3

 

I'm struck by the comment of 'broad eligibility criteria'

We have broad eligibility criteria to
ensure we do not exclude people from getting help.

It occurs to me that we hit a wall with this because it's backwards. It is explicit in stating that as many as possible be considered and implicitly it suggests that only we with ME would be included otherwise. Yet the evidence is the other way round. There is more evidence to exclude PwME than general fatigue. So one might more correctly say that the many with fatigue are the primary focus and that PwME are looking to be excluded form that -- not as is suggested in the way they put it -- that people with general fatigue should also be included.

If that makes sense.

 

This is an interesting find. Because this is why they are arguing against PEM/PESE being the core symptom in the new NICE guidelines. They want them to cover as many people as possible, including those who have general fatigue.

 

One thing that has never occurred to me until just now is :

Who makes the MUS diagnosis? Is it a GP? A doctor in secondary care? Can someone be seen by a GP, get given an FBC (Full Blood Count), and end up being sent straight to an MUS clinic without being seen by secondary care, do not pass Go and do not collect £200?

 

I reckon most of the time the GP will have formed an opinion based on presentation and who you are referred on to will reflect that i.e. whether it's rheumatology or neurology or straight to IAPT.

The snag is once referred to IAPT you may never climb back out of that particular waste basket whereas other specialist clinics will refer back to the GP if they feel they can't help & the patient needs a different speciality.

So if you get sent to IAPT I reckon it may be a GP diagnosis by default because I doubt they'll turn many away.