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Asthma inhalers, Knee arthroscopy, Pelvic girdle pain, Medically unexplained symptoms

Does using an asthma inhaler give athletes a performance advantage in their sport? Dr Mark Porter separates the rumour and gossip from the evidence.

Elite athletes are far more likely to use asthma inhalers than the general population. Do the stresses and strains of competition bring on asthma-type symptoms or does an inhaler give a performance advantage to individual sportsmen and women? Dr Mark Porter talks to sports physician Dr Babette Pluim about her review of the use of inhalers in sport.

One hundred and fifty thousand knee arthroscopies are performed every year in the NHS with most of them involving surgery to smooth, remove or repair damaged cartilage, the meniscus. But there are concerns that we do too many arthroscopies in the light of evidence that intervention isn't always required. Andrew Price, Professor of Orthopaedic Surgery at the Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences at the University of Oxford, tells Mark when surgery is useful and Inside Health's Dr Margaret McCartney reviews the mounting body of evidence that has called into question some knee surgery. Dr Annabel Bentley, former Medical Director of Insurance at the private health insurers, BUPA, describes how, back in 2011, there was an instant (and subsequently sustained) reduction of 9% in knee arthroscopy claims. The drop came weeks before a new checking process, to confirm the surgery was in line with best practice, was introduced.

Pelvic Girdle Pain is a condition that affects one in five pregnant women. It causes discomfort in the pubic region, the hips and lower back and gets worse as the pregnancy progresses. Some cases can be mild but more severe forms can leave a woman needing crutches, or even a wheelchair, to get around. But there is help out there and official advice is for women to get help early and not to suffer in silence. Mark visits the Rosie Maternity Hospital in Cambridge, and speaks to new mum Joanna Welham and Women's and Men's Health Physiotherapist, Claire Brown, about what treatment is available.

Medically unexplained symptoms, sometimes known as MUS, cause problems for both patient and doctor, and they're common, up to a fifth of a GP's workload, and around half of all specialist referrals, costing the NHS more than £3 billion a year. Rona Moss Morris is Professor of Psychology as Applied to Medicine at King's College London and she believes the NHS fails such patients. She tells Mark what she thinks needs to change, starting with the name, MUS.

Producer: Fiona Hill.

Available now

28 minutes

Programme Transcript - Inside Health

Downloaded from www.bbc.co.uk/radio4 

THE ATTACHED TRANSCRIPT WAS TYPED FROM A RECORDING AND NOT COPIED FROM AN ORIGINAL SCRIPT.  BECAUSE OF THE RISK OF MISHEARING AND THE DIFFICULTY IN SOME CASES OF IDENTIFYING INDIVIDUAL SPEAKERS, THE BBC CANNOT VOUCH FOR ITS COMPLETE ACCURACY.

 

 

INSIDE HEALTH

 

Programme 7. - Asthma inhalers, Knee arthroscopy, Pelvic girdle pain, Medically unexplained symptoms

 

TX:  21.07.15  2100-2130

 

PRESENTER:  MARK PORTER

 

PRODUCER:  FIONA HILL

 

 

Porter

Coming up in today’s programme:  Painful pelvises - and the latest thinking on how to manage a condition that affects one in five pregnant women in the UK.

 

Clip - Joanna

It was every day, I couldn’t sleep – that was the worst thing being heavily pregnant, feeling tired anyway and you couldn’t sleep.  At work I was having to have my legs up.  At home, climbing the stairs, I had to do it very gently and things like that.  It wasn’t a pain that went away and gradually got better, it was there all the time.

 

Porter

Arthroscopy – Margaret McCartney looks at the evidence underpinning an operation performed on 3,000 NHS patients a week.  But how likely is it to help them?

 

Clip - Price

One of the difficult questions is working out what the appropriate level would be in the population and in actual fact that’s a very difficult question to answer.  But I think the rapid increase, one would have to admit not in every situation were the indications necessarily mean a better outcome for the patient.

 

Porter

And medically unexplained symptoms – what happens when all the tests come back clear and your doctor can tell you what you haven’t got, but not why you are still suffering? I meet an expert who thinks it’s time for a different strategy.

 

But first drugs in sport, and continuing suspicions lingering over the Tour de France. This time it’s a cyclist whose drug tests came back as questionable but which his team attributed to being a side effect of his asthma inhaler. And lots of cyclists use inhalers.  In a recent study one in three members of a leading team showed signs of asthma – more than three times the prevalence in the general population. And it’s not just cyclists – lots of elite athletes depend on inhalers too, including one in four of Team GB taking part in the 2012 Olympics.

 

So do the stresses and strains of competition bring on asthma type symptoms or does using inhalers confer some sort of performance advantage that the athletes are keen to exploit – albeit within the law?

 

Asthma drugs have been banned in the past but, assuming you stick to the prescribed dose, the most commonly used ones are now allowed by the World Anti-Doping Agency (WADA). Despite that rumours that they boost performance persist. But is there any foundation to them?

 

Dr Babbette Pluim is a Sports Physician in the Netherlands. She has worked with WADA and recently completed a review of the effects of inhalers in athletes.

 

Pluim

Oh it has been first they were not banned, then they were a little bit banned, then the IOC wanted everyone tested.  I think if you look at the inhalers it helps you if you have asthma but it doesn’t help you if you don’t have asthma.  So if you have asthma and your airways are constricted, during or as a result of exercise, yes then it helps.  But if you don’t have that problem then there’s no evidence that it’s performance enhancing.

 

Porter

So it provides no added benefit to a normal healthy athlete?

 

Pluim

Exactly.  It doesn’t have any added benefit.  We looked at 26 studies with inhaled asthma medications and we looked at the total sum of the effect of these studies and there was no evidence of a performance enhancing effect.

 

Porter

Do you think that we can finally put to bed this rumour that asthma medicines are performance enhancing drugs, do we have enough evidence now to say that that’s definitely not the case?

 

Pluim

The problem is that no evidence of an effect is – we can’t put it to rest completely but I’m confident to say that inhaled asthma medications have no performance effect on athletes.

 

Porter

Do you think athletes themselves believe that, do you think some people are using it in the hope that it may help?

 

Pluim

Of course, an athlete will try anything.  If I tell my athlete that eating grass is helpful they will start eating grass, so they will try everything.  But I think actually taking it off the list hasn’t shown a large increase in the use of it.  The most important thing for an athlete is to have yourself tested – do you have asthma or not – because there are people who are undertreated and there are people who are over treated.  If you over treat it and you take these medications it actually increases your heart rate so it’s not that good for you.  If you undertreat it and you can’t breathe normally during intense exercise you need these medications.  So the most important thing is go to a doctor, have yourself checked out completely so you know where you stand.

 

Porter

Dr Babette Pluim.

 

And for the sake of clarity – the grass she referred to was of the lawn variety.

 

Now to something else that sportier types are more likely to have – an arthroscopy. It is one of the most common procedures carried out by the NHS and involves passing a telescope into the knee to confirm what is wrong and to fix it using various keyhole instruments.

 

Around 150,000 arthroscopies are performed every year by the NHS with most of them involving surgery to smooth, remove or repair damaged cartilage – the meniscus. But there are concerns that we do too many arthroscopies in light of evidence that intervention is not always required – or that helpful.

 

Andrew Price is Professor of Orthopaedic Surgery at the Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences at the University of Oxford. So how does the typical candidate for arthroscopy present?

 

Price

There’s a patient who will have had a moment in time, an injury, be it related to sport or be it related to normal activities where they suddenly notice something change in the knee.  So a patient will come to see you and say something went in my knee, I was dancing at the weekend, I twisted, sudden pain, it hasn’t settled down over the couple of weeks and something’s not right with my knee.  Other patients will present over a longer period of time and they can’t remember a specific injury, so that you don’t have to have had an injury to damage your meniscus, the mere fact that these tissues change in nature over time and the joint requires twisting and rotational movements, the meniscus can tear without there being a specific injury that the patient can remember.  So they can present in those two broad ways – one’s a more gradual onset, one’s a specific event they can recognise.

 

Porter

Obviously it varies from patient to patient but typically how long would you wait after someone presented with what you thought was a meniscal tear before you decide to proceed to arthroscopy?

 

Price

Well I think context is everything.  So there are certain situations where a patient who presents with a locked knee, someone who now can’t bend or extend the knee and basically can’t function, those patients may end up getting an arthroscopy quite quickly.  But that’s relatively uncommon.  The much more normal situation would be a patient who presents with intermittent symptoms which are intrusive but not really affecting many of their activities or daily living, they may be affecting their ability to play sport or to partake in activities that they want to.  And in that situation it would be sensible to wait three-six months, allow patients to have some physiotherapy, see if the symptoms settle down.  And in fact what you find is that many patients will do that themselves and won’t present initially, they’ll wait and see if this does improve and I certainly think that’s a very sensible approach.

 

Porter

Arthroscopy numbers have risen considerably over the years, what do you think’s behind that rise?

 

Price

I think there are a number of factors.  One would be that arthroscopic surgery, the techniques involved, have made this type of surgery more straightforward, that increases the access that patients have to this type of care because it becomes a more common procedure.  I also think it’s related in some ways to the medical profession thinking that this was a procedure that’s highly effective in a broad swathe of different indications.  And those two things would drive increase in meniscal surgery, as you describe.  I suppose one of the difficult questions in all of this type of discussion is working out what the appropriate level of meniscectomy would be in the population and in actual fact that’s a very difficult question to answer.  But I think the rapid increase, one would have to admit not in every situation would the indications necessarily mean a better outcome for the patient.

 

Porter

Orthopaedic surgeon Andrew Price talking to me from Oxford.

 

Well Inside Health’s Dr Margaret McCartney has been listening to that. Now this debate about the usefulness of arthroscopic knee surgery, for various conditions, is one that’s been rumbling for some time.

 

McCartney

Absolutely, so in 2002 the cat was firmly placed amongst the pigeons when a paper in the New England Journal of Medicine came out – quite a famous paper now – that had three groups in it.  The patients either had real arthroscopy, where the knee was washed out, or they had arthroscopy wash out and debridement, this trimming of the cartilage inside the knee.  But there was also a third group and this third group were treated with placebo surgery – sham surgery.  They had incisions made in the knee but no arthroscopy and no wash out.  And the point was that they all improved to about the same level and at no point did the group who had arthroscopy have any better pain relief or any better knee function than the people who had the sham placebo surgery.

 

Porter

And to be clear, the patients had no idea what was done to them, they all thought they’d had an arthroscopy.

 

McCartney

It’s an amazing trial, the surgeon swished around some fluid in the background for the people having sham surgery, so it sounded like they were having the real surgery.

 

Porter

Now since then we’ve had further trials, what have they found?

 

McCartney

Basically many trials have been done looking at arthroscopy but often finding it wanting.  So in 2008 the New England Journal published another trial, this time of over 18s who had osteoarthritis of the knee, so wear and tear changes inside, again lots of exclusions, lots of people weren’t put into the trial but they compared physiotherapy and medical treatment of the knee with that same treatment plus arthroscopy and debridement of the cartilage inside.  And at two years the groups were much the same with no advantage being seen to the surgery.  And then another trial from 2013, again looking at people with osteoarthritis and who had a meniscal tear this time, a tear to part of the cartilage, half of the group got arthroscopy plus trimming of the cartilage, the other half got physiotherapy only.  And the bottom line was that both groups improved but some people in the physiotherapy group ended up having arthroscopy later.  But the point was that many people were seen to avoid having arthroscopy if they had physiotherapy first.

 

Porter

So would it be fair to say that the sort of tide of evidence, if you like, is questioning the use of arthroscopy, that we’re overusing it essentially?

 

McCartney

Yes, I think it certainly seemed to say that there were categories of patients who probably could avoid having an arthroscopy had they had physiotherapy or other medical treatment first.

 

Porter

So what impact has this had on practice?

 

McCartney

Well there’s a salutary tale from BUPA, the private medical insurance, back in 2011.  So Dr Annabelle Bentley, who had herself trained as a surgeon, was their then medical director of insurance and she had found that patients with private medical insurance were at least three times more likely to have knee arthroscopy than patients in the NHS.

 

Bentley

I was surprised by how big the difference was.  We thought it might be a little bit more but at least triple – this is a very big magnitude.  It’s important to understand that this is a very wide variation and merits further investigation.

 

McCartney

So what Dr Bentley did was then to have an external review done for BUPA of the best evidence around knee arthroscopy.  And she then announced that BUPA would be introducing a new review process, so she told Inside Health what happened next.

 

Bentley

What we did is we let people know in good time, at least, I think, it was six to eight weeks before introducing the check-in step we communicated about it.  And what we saw is actually the rates of requests for this funding for this type of surgery dropped at the point we communicated about it.  And they dropped by about 9%.  And that drop was sustained.  And then at the point we introduced the check-in process there wasn’t really any further change.  So something had changed somewhere in the system that meant there were 9% less requests for funding for that kind of surgery.  It’s hard to be sure exactly what happened but the theory would be that once surgeons knew that BUPA was not going to pay for diagnostic arthroscopies, was not going to pay for ineffective washouts or other ineffective surgery that’s not in line with the profession’s own guidance the only requests for those types of surgery just weren’t put forward.

 

Porter

Dr Annabelle Bentley.  And Margaret that suggests that I mean the surgeons knew they were doing too many, they cut back, because frankly not all the arthroscopies were indicated.

 

McCartney

Yeah, so there’s now been very many trials done of these procedures and several systematic reviews, so reviews of all the trial evidence in this area, and the most recent was published in the BMJ a couple of months back and their conclusion, which is in keeping with most other recent data, is that arthroscopy for wear and tear osteoarthritic type changes in older people has a very small initial benefit, possibly a placebo effect from the surgery, but that’s not sustained one or two years after the surgery.  And again this is reflected in NICE guidelines which says that current evidence suggests that arthroscopic knee washout alone should not be used as a treatment for osteoarthritis because it cannot demonstrate clinically useful benefit in the short or long term but they do still recommend debridement procedures when you have arthroscopy and debridement done for people who’ve got osteoarthritis and who’ve got lots of symptoms from it.

 

Porter

So do you think we can expect to see the number of arthroscopies that are done on the NHS start to tail off now?

 

McCartney

Well I think it’s really important to know that the studies done so far all have exceptions and they all have exclusion criteria, so I don’t think there is or should be an end to arthroscopy, it still has a role and NICE do still recommend it when it occurs along with debridement for osteoarthritis.  But data published for the journal Knee – yes there is a whole medical journal devoted to just one joint – shows that the rate of arthroscopy numbers per hundred thousand of population has been falling in the UK since 2000.  However, the number of arthroscopic debridement and repair operations are going up.  Now this might be a reflection of our changing population, it might reflect more appropriate use – we don’t really know from the raw data.

 

Porter

Margaret, Prof Price suggested that a bit of watchful waiting, even in an injury, is not necessarily a bad thing and a lot of these trials are looking at physiotherapy, which of course is something you can have to see if the knee gets better with conservative management but access to physiotherapy can be an issue.

 

McCartney

Yeah, so if we’re saying that we want a good alternative arthroscopy we have to say we have the service that’s equally able to provide for that.  And most of these trials looked at physiotherapy for one or even two hours weekly for two or three months and really do we have the capacity in the NHS to do that just now, our physiotherapists are fantastic but there’s nowhere near enough of them.

 

Porter

Too true, thank you very much Margaret.  And as always, there are links to all the research Margaret mentioned on her blog. Go to the Inside Health page of the Radio 4 website for more details.

 

Now from knees to pelvises and a condition that affects more than a 100,000 pregnant women every year in the UK. Pelvic Girdle Pain is something one in five pregnant women will experience at some stage. It typically causes discomfort in the pubic region, hips and/or lower back and gets worse as the pregnancy progresses. Mild cases can be just a minor irritant, but more severe ones can leave a women needing crutches, or even a wheelchair to get around. Fortunately physiotherapy can help, but the earlier the problem is diagnosed, the better, as I discovered when I visited the Rosie Maternity Hospital in Cambridge where I met Joanna Welham and her four month old daughter Evelyn

 

Joanna

If you have back ache, it was like that but it was there all the time, it wasn’t a pain that went away and gradually got better, it was there all the time.

 

Porter

And where were you feeling it?

 

Joanna

In my hips and in my sockets of where my legs were, that’s where it was really, really painful, especially towards the end.

 

Porter

Take me back to the first signs of trouble.

 

Joanna

Probably September or October and I was due in the middle of March.

 

Porter

And what did you feel to start with?

 

Joanna

Sometimes if you’ve over-exercised or something you get that pain and it felt like that and I was like oh that’ll go away, and it didn’t, it stayed there.

 

Porter

Was it only a problem when you were doing things?

 

Joanna

It was every day, I couldn’t sleep, that was the worst thing, being heavily pregnant, feeling tired anyway and you couldn’t sleep.  At work I was having to have my legs up and then I couldn’t sit for too long, I was having to walk round like the block where I work.  At home – climbing the stairs I had to do it very gently and things like that – it was every day.

 

Porter

Your midwife recognised the story straightaway but had you ever heard of this condition?

 

Joanna

No, never heard of it before.

 

Brown

My name is Claire Brown and I’m a women’s and men’s health physiotherapist.  It can cause problems at any point in a woman’s pregnancy.  We tend to see most women in their second trimester but of course it can happen at conception and usually there’s a hormonal reason.  But usually it’s when a bump starts to develop and you find that people have bodily changes due to the pregnancy.

 

Porter

What’s actually causing it?

 

Brown

We think it’s due to the biomechanical changes and the body adaptations in pregnancy.  So a woman when they start to develop a bump at the front their pelvis will be tilted forwards, therefore they have more of a curve in the small of their spine, therefore their tummy muscles are lengthened, their back muscles are shortened and that change of biomechanical shift puts more pressure on the joints.

 

Porter

So that’s the stresses on the joints of the pelvis and the hips but are there changes in the ligaments as well that accompany all the hormone changes?

 

Brown

A very slight change but it’s not just due to the hormonal changes or the stretches to the ligament and that’s what a lot of people believe and so do the mums, they think that all the ligaments are loosening, things get a little bit loose but that – we now know that that’s not the case.

 

Porter

It’s over-exaggerated?

 

Brown

Absolutely, absolutely.

 

Porter

So what can you do for them?

 

Brown

Physiotherapy can do a lot.  We will do a pelvic assessment and a back assessment to see where the problem is coming from and do a clinical reason and assessment.  So it might be coming from an instability of the pelvis, the muscles are weak, it might be coming from stiff joints in the back.  So if it’s a still joint we’d move it, if it’s muscle problems we’d strengthen the muscles.  So we can do manual therapy on the pelvis, or the back, we would give exercises and a lot of what we do is advice as well.

 

Porter

So what you’re saying is this is a sort of umbrella term for a number of problems that can affect that part of the body.  But they’re not necessarily all the same thing.

 

Brown

No, pelvic girdle pain is an umbrella term, SPD or pubic symphysis dysfunction, used to be an old common term but it now covers any pain around the hips, pelvis and SIJ joints.

 

Porter

That’s the Sacroiliac joints between the spine and the pelvis.  Joanna found immediate relief from the physiotherapy she was offered at the Rosie.

 

Joanna

Massive, it was a massive, massive difference.  Everyday life was a bit more easier after going to the physio.

 

Porter

Joanna had a tough time giving birth to Evelyn and her baby was seriously ill for several weeks afterwards.

 

Joanna

When my daughter was in intensive care I’d like walk up to her to see her everyday while I was in hospital with her and I’d have to stop along the corridor and then sometimes they’d need to wheel me alone.  But eventually it did ease off.  It took sort of two weeks including being in hospital for things to sort of go back to normal.  There’s things now – if I walk too far I can feel like achy pains in my hips but much better, it hasn’t been as bad that I think that I need to come back and see the physio again.

 

Porter

Claire, what happens if a woman doesn’t get referred to somebody like you, if she just grits her teeth and gets on with it, what’s the natural history – does it just get worse and worse?

 

Brown

Yes it can do.  We hope and we encourage women to get an early intervention and seen quickly.  With that we know that we can manage the pain a lot more effectively, rather than it getting so bad that they can’t work, they can’t walk, it’s much easier to manage early on.

 

Porter

It makes your job more difficult if they present later on?

 

Brown

Yes it does.

 

Porter

So what happens once the baby’s born, how quickly do things get better?

 

Brown

Usually things settle down because the women will get their body back to normal again but we do know that about 7% of women will go on to have some degree of pelvic girdle pain post-natally.

 

Porter

 Physiotherapist Claire Brown and new mum Joanna Welham talking to me at the Rosie Hospital in Cambridge. And there is more information on pelvic girdle pain on our website.

 

Now imagine that your doctor – GP or specialist – has been unable to get to the bottom of whatever is troubling you. After exhaustive investigations they can tell you what you haven’t got, but not what’s causing your symptoms. Symptoms that could range from lack of energy and headaches, to aching muscles and an upset stomach.

 

Medically unexplained symptoms like this cause problems for both doctor and patient, and they are common. They make up as much as a fifth of a GP’s workload, and around half of all specialist referrals, costing the NHS more than £3 billion a year.  Yet, on the whole, they remain poorly managed.

 

Rona Moss-Morris is Professor of Psychology as Applied to Medicine at King’s College London and has a special interest in medically unexplained symptoms – although she is not keen on the name.

 

Moss-Morris

If a patient comes to you essentially what – as a doctor – what they’re wanting to know is what is wrong with them.  So they’ve got nasty unpleasant symptoms that are not going away and they want an answer, they want to understand why they’re having them.  The label medically unexplained symptoms doesn’t tell you anything, it just tells you what you don’t have, it doesn’t tell you what you do have.  And essentially the whole purpose of diagnosis is to move forward with management and understanding and the label doesn’t do any of that.  And also when we talk to patients about it they often found it really de-legitimises their condition, it makes them feel invalidated or that somehow their symptoms aren’t real.  So from that point of view it actually puts patients in a very difficult situation because they think you’re saying but there’s nothing wrong with you, where clearly there is.

 

Porter

So what would you like to see it called?

 

Moss-Morris

Well I’ve always thought I quite like the term functional symptoms because I think that says that there’s a disorder of functioning.  However, actually patients don’t like that particularly much either, which I was quite surprised about and I think partly it’s because functional has become understood as psychological.  The term that they seem to prefer is persistent physical symptoms, because it’s describing what they have and it’s acknowledging that these are persistent and they’re physical in nature.  There’s also limitations with that because obviously a lot of conditions have persistent physical symptoms, so if you have Multiple Sclerosis you have persistent physical symptoms.  So that’s why perhaps it hasn’t been adopted more broadly but that is perhaps one step forward in at least just describing what people have.  And then moving forward with a patient to start describing why they have those persistent physical symptoms.

 

Porter

What’s it like being one of these patients?

 

Moss-Morris

Well I think it’s extremely frustrating initially and often very distressing because I think what happens is you have often very nasty symptoms, so for instance you might be a patient who you had a bad episode of food poisoning and you developed nasty diarrhoea, sore stomach and quite embarrassing symptoms and you go to the doctor, they say don’t worry you’ve got food poisoning they’ll go away.  Three months later you’ve still got them and not only do you still have them they’re getting worse.  So you go back to the doctor who then runs a number of tests and they say no you don’t have celiac’s disease and you don’t have inflammatory bowel disease and you don’t have cancer – really good news, nothing wrong with you.  But clearly there is something wrong with you – you’ve had these ongoing symptoms.  So you start to worry.  So what happens then is you might go for a second opinion, you might ask to get referred to a gastroenterologist and you’re often just getting the same message, there’s nothing wrong with you.  So I think there’s often a cycle of initially feeling quite frustrated, feeling very anxious that people might be missing things and then for some people actually starting to get quite angry.

 

Porter

But this is where the label thing comes back in because in a situation like that you can well imagine that that might be a case of somebody who’s got irritable bowel syndrome that’s been triggered by the food poisoning, they’re given this label of irritable bowel syndrome…

 

Moss-Morris

Yes exactly.

 

Porter

… and it sort of makes the doctor and the patient feel better about what’s – it draws a line under it – oh I’ve got irritable bowel syndrome, thank heavens it’s nothing more serious.

 

Moss-Morris

That’s – yeah – so in some ways for the doctor it’s thank heavens it’s nothing more serious and the doctor thinks actually I’m imparting quite good news, I’m telling the person actually great news – you don’t have one of these nasty ongoing problems.  But actually for some patients IBS is a nasty ongoing problem.  And I think it’s acknowledging that’s part of it but it’s also then – and this is perhaps where we’re failing these patients – it’s then moving into good management for this and what are we going to do about it.  And we are increasingly building up an evidence base for what helps in these conditions.  The difficulty is they’re not necessarily – these approaches are not necessarily freely available to people.

 

Porter

So where are we going wrong at the moment – we’ve already talked about this sort of – lots of tests and excluding all sorts of things – we know what you haven’t got, we’re not really sure what you have got.

 

Moss-Morris

Yeah and I think that comes down to this idea that we still have a medical system that’s very much structured around a biomedical model, that if you don’t find the one biological underpinning then this is not a real condition.  But in fact you know George Engel was a very instrumental psychiatrist who proposed that we should really be understanding illness through the bio psychosocial model. And I think most medical people probably agree with that and that’s understanding how biology interacts with both our social world and our psychological world.  But actually we don’t really practise medicine that way and we don’t necessarily provide explanations from that model either.  And I think these conditions particularly are best understood in terms of an interaction between all of these factors.

 

Porter

Where the clinicians like me going wrong, what are are the sort of classic mistakes that we make when we’re looking after these sorts of patients?

 

Moss-Morris

Well I think one of the things that’s very challenging I think for GPs is the short amount of time people have because you know if you’re giving people more complex descriptions like this and you need to then often take quite a broad history to understand the problem it’s quite hard to do that in 10 minutes.

 

Porter

Does doing repeated tests and referrals does that reinforce the physical model of illness in the patient’s mind?

 

Moss-Morris

Yes, I think it can do, I think clearly in order to make a proper diagnosis there’s certain things you have to rule out. But for most of these – particularly these illnesses where the symptoms cluster and can be defined around irritable bowel syndrome, fibromyalgia, non-cardiac chest pain – so there are quite a few of these conditions – there’s a very clear diagnostic work up and that once those have been ruled out then you can say yes this is pretty much what it appears – based on the history that you’ve given me and the fact that I’ve ruled these things out this is what you have.  So I think there is a point where the system needs to join up better and actually say actually there’s no point in running further tests.

 

Porter

This is obviously an important problem for those who are affected but it’s also an important problem for the NHS too.

 

Moss-Morris

Yes, it’s a massively important problem for the NHS.  And I think partly because this group of patients is currently not particularly well treated in our system and I don’t think that’s unique to the NHS, I think this is a worldwide issue.  So it’s not an NHS knocking situation, it’s more that I just think because we still have this model where we treat patients who we perceive to have mental health problems in a mental health service and those who have physical health problems in an acute or primary care environment we very rarely actually provide integrated care to people.  So I think that’s one of the biggest challenges.  But the other thing is there’s a massive cost to the NHS.  A relatively small pilot study of three practices in London suggested that on average people who would meet the criteria of medically unexplained symptoms or syndromes were on average having eight investigations a month over a two year period, so that’s quite substantial.  Now this is only across three practices, we can’t generalise to everyone, but it gives you an indication.

 

Porter

Looking forward as to how we change this is it something that we take a more integrated approach – practice by practice, clinic by clinic – or do we need to have special units run by people like you that we refer these people to?

 

Moss-Morris

You know I think there’s a combination of these factors because I think if we restructure some of how we do things at the primary care level and we embed perhaps people more trained in behavioural methods within these services I think a lot of that can be done at primary care level.  We really should be doing far more training in this area and also spend more time understanding illness from a broader model.

 

Porter

Professor Rona Moss-Morris.

 

Just time to tell you about next week’s programme – the last in the current series – when we will be discussing the pros and cons of labelling people with pre-diabetes. A new diagnosis that could apply to as many as one in three British adults. Do join me then.

 

ENDS

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