Quite agree. Many pts and doctors now believe that anything less than full 
health (a complaint) is by definition pathological, therefore ill  and thus 
need treatment. People forget that life is both a bed of roses and a bed of 
nails. The WHO has not helped by saying that health is a feeling of well-being 
not merely the absence of sickness. Does this mean the NHS must aim to make us 
all go around grinning like idiots all the time and take Soma if we're not?

----------
From: 	[log in to unmask] on behalf of Toby Lipman 7, Collingwood 
Terrace, Jesmond, Newcastle upon Tyne. Tel 0191-2811060 (home), 0191-2869178 
(surgery)
Sent: 	09 March 1998 00:26
To: 	[log in to unmask]
Cc: 	Toby Lipman 7, Collingwood Terrace, Jes
Subject: 	Re: RCGP. Time to be NICE?

In message <[log in to unmask]>, Bradley Cheek
<[log in to unmask]> writes
>>However I think you can overemphasise the centrality of the emotional
>>aspects of the consultation to the detriment of the biomedical. 
>
>The solution: run the psychosocial and the biomedical in parallel. Do the 
>blood tests, but diversify your thought and the consultation into the
>psychosocial AT THE SAME TIME...
>
>Often doctors will do the tests and then say "Well I can't find anythin
>physically wrong: I wonder if..." How about introducing this approach earlier
>in the scenario? That way you can't be wrong!!!
>
Absolutely spot on! You must always be aware of the psychosocial or
you'll end up medicalising the non-medical. However when you do identify
the biomedical you need to understand much more about the nature of
diagnostic tests (which of course include questions and history) than is
currently emphasised in GP training. That means getting to grips with
clinical epidemiology and EBM. Where I have doubts is in what exactly
GPs can do about psychosocial problems and whether they should get
deeply involved. There is an option of using counsellors, but evidence
for their effectiveness is limited. Harvey et al's RCT (BJGP March 97;
48:1043-48) suggests that GPs are as effective (or ineffective) as
counsellors despite spending much less time with their patients. The
danger is, of course, that GPs will be tempted to prescribe
inappropriately. 

I'd like to see an RCT of GP vs counsellor vs no intervention!

Sorry for getting a bit off topic, but this is an issue which fascinates
me. It's really a question of whether doctors are more likely to do harm
than good with this kind of problem. It seems to me that if people are
unhappy but not ill, because of circumstances quite outwith the GP's
control, then the main job of the GP is to make explicit the fact that
it is not a biomedical problem and cannot be solved by medical
intervention. If counselling doesn't help either, then should we be
spending NHS money on these problems?

Cheers

Toby 
-- 
Toby Lipman 7, Collingwood Terrace, Jesmond, Newcastle upon Tyne. Tel
0191-2811060 (home), 0191-2437000 (surgery)





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