Why are there so few PAIS doctors? [Blog post]

[Sean]

Patients need to be very careful about demanding 'treatments' when there are none. That just opens the door wide to every charlatan with a pill/ointment/powder/incantation/spiritual journey/whatever happy to prey on desperate suffering people.

Patients should be demanding good diagnostics (as best can be offered at this time), robust non-ideological research programs, and adequate non-judgemental generic medical care and social-material support until the research starts actually delivering clinically useful results, which may be some time.

Don't demand what cannot yet be genuinely delivered. That cannot end well.

I wonder if there are any truly psychosomatic conditions?

On the basis of the methodologies used to claim there are, I have very serious doubts.

Everything I have seen is either poor experimental design and/or interpretation, hypothesis heavy but evidence light, or just modest, short-term modifications of patients' questionnaire response behaviour, none of which adds up to a practically meaningful explanatory nor therapeutic result.

 

[Jonathan Edwards]

To me the recent fad for blaming psychological factors is something new and different from 100 years ago. It got going around 1990 - around the time when the pace of scientific advance in medicine was stalling and the touchy-feely brigade started taking over. It went along with an anti-elitism that spread training everywhere instead of in centres of excellence and dumbing down.

 

[Utsikt]

I identify the following reasons:
No attention to PAIS in medical school curricula (each UMC sets its own)

It is covered, just not in the way we want it to.

No dedicated training capacity - no fixed place with skilled supervisors plus enough patients

I think this is a key reason.

No official place within existing medical specialties, and no specialty of its own

It has a place: psychology or rehab. It’s the wrong place, but still.

No dedicated billing codes (DBCs), so doctors can only bill under generic "other conditions"

That depends on the country. G93.3 is used in ICD-10 for ME/CFS, PVFS, etc., and LC has U09.9.

No RCT-proven treatments, so nothing to build reimbursement or protocols around

I don’t get what this means. In which national context is this?

Many patients go undiagnosed, so there's no clear care pathway creating pressure for change

I don’t understand what you mean by this.

 

[Siebe]

That depends on the country. G93.3 is used in ICD-10 for ME/CFS, PVFS, etc., and LC has U09.9.

A diagnostic code is different from a billing code used for insurance. I'm referring to the latter. All examples are about the Dutch healthcare system, as I write in the blog post.

 

[Silip]

To me the recent fad for blaming psychological factors is something new and different from 100 years ago. It got going around 1990 - around the time when the pace of scientific advance in medicine was stalling and the touchy-feely brigade started taking over. It went along with an anti-elitism that spread training everywhere instead of in centres of excellence and dumbing down.

If I recall correctly from my lectures on the history of psychology, the 1980s were roughly the time when certain schools of thought in psychology began comparing the cognitive processes in our brains to cybernetic systems or computers in general.
Around the same time, cognitive behavioral therapy, as developed by Aaron T. Beck (you may be familiar with the Beck Depression Inventory, or BDI), became increasingly popular and had definitively become the dominant form of therapy by the late 1980s at the latest. Beck’s theory on depression (circa 1976) posited that depression is directly caused by distorted cognitions. By changing (or, to use the computer analogy, “deprogramming”) these cognitions, it was believed that depression could be treated directly, and that feelings, experiences, and behavior would consequently change as well. Previously, depression had been treated primarily with psychiatric drugs and a focus on behavior, rather than on thought processes.

The renewed belief that mental illnesses can be influenced simply through the “power of thought” thus dates back precisely to this period. Interestingly, there are studies showing that in depressed individuals whose depression subsides due to changes in circumstances, the season, medication, etc., their cognitive distortions also disappear—suggesting that these distortions may be a consequence rather than a cause of depression.

I always have to laugh or depending on the mood get angry when there is another Brain Retraining or "neuroplasticity" bullshit that's advertised as a new kind of therapy, as basically all ideas and methods that they contain do stem in fact from the 1980s.

 

[Holinger]

GP telling me that studies don't matter and I should just want to get better to get better and try acupuncture and 100 antidepressants?

Wow that is quite a low bar. You have to wonder if they were always like that and if so how did they get their licence. I have had a specialist who didn’t believe in medical science the last 5 years they had a license and then it was pulled.

 

[wingate]

7. Many patients go undiagnosed, so there's no clear care pathway creating pressure for change

These are all great points and I also agree with @Hutan’s points about stigma.

One small addition I would make to point 7 is that even those that get a diagnosis may give up seeking treatment due to inadequate care received. And others are too sick to even go to the doctor. So there is an underestimate of the population impacted.

 

[Sean]

Wow that is quite a low bar. You have to wonder if they were always like that and if so how did they get their licence.

As the old joke goes:

You know what they call the person who graduated bottom of their year in medicine?

Doctor.