Too many medical investigations of children and adolescents can make matters worse, Dagens Medisin

Midnattsol

Midnattsol

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An opinion piece on how to diagnose functional disorders in children and young people, using a biopsychosical model of understanding symptoms. I thought it was nice for understanding how biopsychosocial is used by some healthcare workers.

Basically it advertises to look for a limited set of diseases, and if all comes back negative there is little chance of there being anything seriously wrong with the patient and the GP should "be able to convey a good explanation of the child's ailments. Such an approach contributes to the security of patients and parents..." and it is suggested that (my bold):
  • Physicians must acquire up-to-date knowledge of physical symptoms in children and adolescents. Such symptoms are no longer medically unexplained, but are the result of biopsychosocial strains in complex interaction with the body's neurophysiological regulation. Such mechanisms can both give rise to, aggravate and maintain the child's symptoms.
  • Doctors must use the consultation to give good explanations of the child's ailments - with special attention directed to the connection between the symptoms and past and present strains in everyday life. The explanations must be conveyed with commitment, credibility and security.
  • Physicians must acquire knowledge of what a positive diagnostic strategy entails, and practice working in this way in their own clinical practice.
For mye utredning av barn og unge gjør vondt verre
Too many medical investigations of children and young people can make matters worse
 
Midnattsol said:
Basically it advertises to look for a limited set of diseases, and if all comes back negative there is little chance of there being anything seriously wrong with the patient and the GP should "be able to convey a good explanation of the child's ailments. Such an approach contributes to the security of patients and parents..." ive diagnostic strategy entails, and practice working in this way in their own clinical practice.
For mye utredning av barn og unge gjør vondt verre
Too many medical investigations of children and young people can make matters worse
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I feel like these people are completely ignoring long-term outcomes - patients who are told nothing is wrong are likely to be quite angry when 20 years later, they still are ill.
 
Why is it believed that over testing results in harmful false beliefs? Is there any evidence for this?

Obviously any medical assessment has costs, both in terms of money and in terms of energy expenditure for the patient, so ideally unnecessary testing should be avoided, however, given we don’t even have any irrefutable evidence that MUS and related diagnoses exist as real psychological conditions and it is questionable that even if they exist they can be unambiguously differentiated from as yet unidentified biomedical conditions, can we even say patients believing they have a biomedical condition have false beliefs?

How common is it that people want testing for tasting’s sake, or rather do they just want to understand what is wrong with them?

Not testing also has potential costs in terms of missing treatable conditions and risking avoidable worsening or even death from an unidentified biomedical condition. Has anyone attempted to identify what we need to know in these situations to meaningfully say what is over testing and what is dangerous under testing?
 
Snow Leopard said:
I feel like these people are completely ignoring long-term outcomes - patients who are told nothing is wrong are likely to be quite angry when 20 years later, they still are ill.
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Yes these patients will feel deeply betrayed when they realize they were told some nonsense to keep them quiet because physicians back then didn't want to put in effort in diagnosing the problem or at least speak honestly about being unable to do so.
 
Overtesting is a recognised problem: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8685650/ In kids exposed to an overtesting culture there's a potential for childhood itself to get medicalised, we shouldn't get seduced into the idea that testing means only objective body chemistry assays - children are especially at risk of having their body concerns being psychologised - as much by parents as by doctors.

At some point 'unrewarding' testing has to be brought to end and for children it doesn't seem unreasonable to say that end should be 'timely', given the impact on the child's life and her/his relationship with their parents and the rest of the world. For a child being 'tested' medically may not be experienced as being any different from being tested for spelling, or sums and 'failing' to give the right answers can be felt especially keenly, a child whose parents are unable to cope with medical uncertainty* may feel either a need to supply the certainty or be bereft at their failure to supply it. On top of all that there's the unpleasantness of needles, of having to pee in a cup, of being handled by strangers etc, all of which should not become institutionalised unless it is unavoidable.

*for a psych perspective, some the failings of which will be familiar, but which does describe the problems of medical uncertainty and how that applies to children = Perceived diagnostic uncertainty in pediatric chronic pain

edited to add a rather important 'not'.
 
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Snow Leopard said:
I feel like these people are completely ignoring long-term outcomes - patients who are told nothing is wrong are likely to be quite angry when 20 years later, they still are ill.
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That's what the demonizing campaigns in the media are for. They know we're angry, they just treat it as a PR issue regarding their reputation. Or discuss it as a side-issue in academic literature, forever unable to even imagine that what they're doing is just cheap pseudoscience.

By far the most effective thing they've done. They literally accomplished nothing good, but they sure succeeded at blaming us for their own failure. That's how they dealt with long-term outcome: suppression and propaganda. Good old abuse of power never fails against a discriminated population. All it takes is zero ethics and just the right amount of cluelessness to fail to notice.
 
CRG said:
Overtesting is a recognised problem: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8685650/ In kids exposed to an overtesting culture there's a potential for childhood itself to get medicalised, we shouldn't get seduced into the idea that testing means only objective body chemistry assays - children are especially at risk of having their body concerns being psychologised - as much by parents as by doctors.

At some point 'unrewarding' testing has to be brought to end and for children it doesn't seem unreasonable to say that end should be 'timely', given the impact on the child's life and her/his relationship with their parents and the rest of the world. For a child being 'tested' medically may not be experienced as being any different from being tested for spelling, or sums and 'failing' to give the right answers can be felt especially keenly, a child whose parents are unable to cope with medical uncertainty* may feel either a need to supply the certainty or be bereft at their failure to supply it. On top of all that there's the unpleasantness of needles, of having to pee in a cup, of being handled by strangers etc, all of which should not become institutionalised unless it is unavoidable.

*for a psych perspective, some the failings of which will be familiar, but which does describe the problems of medical uncertainty and how that applies to children = Perceived diagnostic uncertainty in pediatric chronic pain

edited to add a rather important 'not'.
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This is fair enough BUT any stopping of testing must be along the lines of "We do not know what is causing your illness because of the inadequacy of our present knowledge. There may come a time when we will be able to track down what is happening and treat you but until then we will support you so you are not made worse, liaise with education authorities so you will not be forced to do anything that makes you feel worse, give symptomatic relief and help you get aids and benefits"

Instead children are told they do not have a genuine disease they just think they do so it is their own fault they are ill and if they would only do exercise and CBT they would be out enjoying life again. Frankly, peeing into a cup in front of a nurse would be a dawdle compared to that.

I can see that decent doctors are being deceived into thinking it is for the benefit of the patient but it is to save the government money and make money for the psychologists.
 
Mithriel said:
"We do not know what is causing your illness because of the inadequacy of our present knowledge. There may come a time when we will be able to track down what is happening and treat you but until then we will support you so you are not made worse, liaise with education authorities so you will not be forced to do anything that makes you feel worse, give symptomatic relief and help you get aids and benefits"
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THIS!
 
CRG said:
Overtesting is a recognised problem: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8685650/ In kids exposed to an overtesting culture there's a potential for childhood itself to get medicalised
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There is a saying in medicine to do with cost-benefit: overtest the severely-ill, undertest the mildly-ill. The problem is these doctors are often dismissing severe illness as mild illness, simply because they do not understand it - they equate known disease with severity, rather than what the patient tells them.
 
CRG said:
Overtesting is a recognised problem: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8685650/
Click to expand...

Just because some people think it is a problem does not mean that it is. From a brief glance at that paper it just shows that estimates of 'overtesting' vary so wildly as to be meaningless.

In my experience overtesting is very often a function of not medicalising enough - in the sense of getting the patient to a good quality specialist referral service. Vast amounts of unnecessary testing goes on in general practice because a decent clinical opinion would be more use. Rheumatoid factor testing is a simple example.

Medical investigation can be distressing at any age but if there is realistic possibility of making a diagnosis that matters then it is worth it.

The key point is that there is NEVER an argument for saying 'now is the time to stop'. Every time is the same. Every time requires weighing up the justification. 'Demedicalising' has no ethical basis.

And certainly in the UK for the last twenty years the problem of under investigation has been ten times greater than over investigation. Everything is driven by cost cutting. Most serious disease gets missed for far too long.
 
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