(Not a recommendation) BMJ Opinion: Missing the psychosocial diagnosis—a form of institutionalised malpractice

Indigophoton

Indigophoton

Senior Member (Voting Rights)
We see it almost every week. A discharge note from an acute care clinician with a diagnosis of “non-cardiac chest pain” or musculoskeletal chest pain. The patient, a 22 year old female, for whom there is essentially zero chance of cardiac chest pain, has had an ECG, chest x-ray, and blood work for cardiac enzymes—all are normal. It is surprising that there is no mention of any psychosocial component. We wonder why the words “panic attack” or “anxiety” are not mentioned. These kinds of cases are surprising, but sadly commonplace, as all too often clinicians overlook the potential psychological diagnosis that is in front of them. We consider this a misdiagnosis, and in that context an act of malpractice.

In order to capture the essence of this “practice” we would apply the term “institutionalised malpractice,” as in our experience most physicians do it. Like institutional racism, institutional malpractice is a long term, behavioural bias, which is borne more out of inertia than intent. However, if this is our modus operandi, we do our patients and ourselves a disservice.
Click to expand...

https://blogs.bmj.com/bmj/2018/05/2...osis-a-form-of-institutionalised-malpractice/

This seems like an attempt to claim more patients for MUS/IAPT programs. Ironically, I was just reading something where the patient was dismissed as having non-cardiac chest pain, and further investigations with a private specialist revealed costochondritis - inflammation of the cartilage - not serious, but certainly not psychosocial.

So far as misdiagnosis and "institutional malpractice" goes, this seems a bit breathtakingly pot/kettle.
 
Last edited:
My comment:

Given that medical error is the 3rd leading cause of death in the US (and probably very similar rates in other 'developed' countries), and misdiagnosis of biological / organic illness as psychological the greatest contributor to these deaths, this editorial essentially promotes greater iatrogenic harm and death.

The last thing the medical system - and patients - need is more psychologizing of physical symptoms.

History is rife with examples of the medical establishment attributing psych-social explanations to physical diseases: multiple sclerosis, epilepsy, ulcers and on and on.

Yet these authors want more of this harmful practice in the medical system.

Institutionalized malpractice indeed.
 
Non cardiac chest pain is often costochondritis or gastroesophageal reflux disease. Maybe panic or anxiety aren't mentioned because these two common problems haven't been ruled out (not to mention various other problems that can cause chest pain), and having anxiety in a situation with chest pain severe enough for the person to seek ER care sounds normal to me.
 
Last edited:
Some thoughts:

-Firstly, I tried to agree with the authors as much as possible because I think they are sincere. Unfortunately, I couldn't really find anything helpful here.

-Regarding the 'patient': there are dozens of other differential diagnoses than panic attack/disorder (as alluded to by @Indigophoton ). Some are quite prosaic. Reflux. Drinking too much coffee. A careful history, listening to the patient, is in order. Jumping directly to psychogenic is logically invalid and toxic in practice for all of the million reasons we talk about here.

-Broach the possibility of psychological diagnosis forthrightly: "Tests didn't show anything that would explain your symptoms. [Explore other avenues, get careful history...] Also, one possibility is that you are having (anxiety/panic/depression/high stress...); Do you think that this could be causing or contributing to your symptoms?"
-If they get mad at you for even suggesting this in a totally reasonable way, guess what? you're a big boy or girl now and you can take it.
-If they say no, take that seriously. Don't shove anything down their throat. If it ultimately is 'psychogenic'/'psychosocial', they'll come around, or they won't.
-If they say 'maybe, I'll think about it', okay, let them, and take the answer they come to seriously.
-If they say 'yes, I really think so', try an appropriate treatment and see if it helps things at all.
-If treatments don't really help, go back to the drawing board. Keep an open mind to non-psychosocial causation. If they do help, Wonderful!​

The reason I can't come to any sort of agreement with the article is that what it's really encouraging doctors to do is:
-Do some tests
-Negative? Jump to psychosocial conclusion.
-High-five self for your cleverness, enlightenment, and moral superiority.
Well, what if you're wrong? First, you committed 'institutionalized malpractice' on the individual patient. Second, you've closed your mind to all scientific knowledge outside of what we already know now and are complicit in stifling all scientific progress! High-Five?

Seriously, how arrogant do you have to be to look at 52% of symptoms being 'medically unexplained' (a number they quote) and say "Well, I'm pretty sure that's mostly psychological"? And how little regard you have for your own self-efficacy as a scientist when in the face of this challenge you say "There's no way I'll ever contribute to a more insightful explanation than 'uh, well, it's, you know, psychosocial.'"
 
ScottTriGuy said:
My comment:

Given that medical error is the 3rd leading cause of death in the US (and probably very similar rates in other 'developed' countries), and misdiagnosis of biological / organic illness as psychological the greatest contributor to these deaths, this editorial essentially promotes greater iatrogenic harm and death.

The last thing the medical system - and patients - need is more psychologizing of physical symptoms.

History is rife with examples of the medical establishment attributing psych-social explanations to physical diseases: multiple sclerosis, epilepsy, ulcers and on and on.

Yet these authors want more of this harmful practice in the medical system.

Institutionalized malpractice indeed.
Click to expand...
Great comment, glad you posted it as a direct response.
I wonder if any doctor or even patient could write an official response to be published
 
I look forward to the Author's revealing how many patients have received a diagnosis of victim of mass unemployment/poverty leading to a lack of funds to meet basic needs for a healthy life, or variations thereof from themselves.

If there is no evidence of such diagnoses, why not? After all they have appended the word social to psycho(logical).

If all the diagnoses are one hundred per cent psychological and zero per cent social, why add the word social? It would be malpractice to assign blame of the effects of mass unemployment and poverty on an individual surely? Why wouldn't they want these diagnoses to inform the health policy of the people with the power to fix the social side of the illness?
 
Hmm, it was precisely because I was a young female with those symptoms that I was continuously dismissed by cardiologists as an attention-seeking anxiety case.

It literally took decades before I was finally diagnosed with POTS, by which time I was too sick to drive, hold down a job and was even fainting into my dinner if I ate more than a few mouthfuls, or the food was too warm.

Only then was I taken seriously. Not by the cardiologist, though, who still believed that I was faking my symptoms and didn't hold back on telling me so, even after I collapsed following an exercise stress test.

After much research, I was able to diagnose myself and then persuade my GP to refer me to a local syncope consultant who had an interest in OI issues.

Thank goodness for "Dr Google", I say. Sadly, my experiences with "real" doctors has left me somewhat gun-shy of the medical profession in general.
 
I really think that the notion of "panic" in panic attack is oversimplified. In such instances isn't it also likely that something is not regulating correctly in the body at that moment which causes the symptoms.

It's just so easy to psychoanalyse the person and ask "is there something in your life that you find stressful"? Well once that question has been posed the patient is bound to come up with something.

Does that make it the cause?

Strap someone onto a treadmill and turn it on full so they cant get off, eventually they will get the symptoms of a "panic attack". Does that mean they where panicking?
 
Last edited:
You must log in or register to reply here.
Back
Top Bottom