<< I actually suspect much behavioural illness eg depression,
physical symptoms no physical cause, develops strange attractors over time
but it may be a complicated way of explaining common sense.>>

Had to think about this one a while---actually I have felt a mental
resonance between GP and quantum mechanics for some time;   when I
discovered chaos theory a few years ago the resonance was even stronger.
You know the one about chaotic systems having a sensitive dependence on
initial conditions? And you know how every now and then some parent (s)
bring in the kid with headache or un-witnessed fever or general malaise or
bellyache and you know bloody well that the kid's symptoms are simply a
reflection of whatever crap is going down in the home?  And you can see, 
as if it were already happening, that you will do your best to save the kid
from the rigors of intensive medical-model paed workup, that you will try
simple medicine and minimum investigations while working some sort of
behavioural approach on the whole mess---reassurance etc.   Then you wil
try to probe what is really going on and indeed you may already know that
dad has been having it off with the waitress in the cafe on the main street
and half the village knows so very likely the wife knows and the kid's
(single) teacher always fancied the dad so now sees her chance to ---well
you know yourself, you can write pages on some of these "presenting child"
psycho-social backgrounds. 
And you can see, right off, on that first consultation, that all your
efforts will come to naught, that the kid will end with the
urgent/emergency admission to paeds, that the workup will be normal and all
symptoms will settle after discharge on no medication.  
You can see all that.  
The initial conditions have been set *before* the consultation----the
family problems, the kid's symptoms,  the NHS GP system and the hospital
specialist system,  not to mention the several ways of looking at the kid's
symptoms as representing various aspects of the family dynamics.
The system (all of them in this case) is of course chaotic.  Understanding
is limited,  control is zero,  prediction is mostly impossible---except
that Balint-like flash you get after about three minutes when you just know
that all efforts are doomed to failure.
Strange attractors?  Make up your own here!  I have a few but I would love
to hear others on this.
And I don't think chaos theory in cases like this is just another version
of common sense; common sense does not work in these cases.

What can we learn?  I think the next time I see one of these kid cases, I
shall simply restrain all urges to do the right thing.   Rather I shall
just , pick up the phone and ask for urgent paed OPD.  When I get a call
two days later from distraught mother or aggressive father complaining that
that ***** medicine isn't working and they haven't heard from the hospital
yet I shall ooze sympathy for about five seconds, tell them this is clearly
beyond my poor abilities and arrange emergency admission.  I hate dumping
crap on poor old SHOs but if I tell them there may be functional elements
at least they will have some warning.   Problem then is that if you do this
too early in the course of the condition,  the hospital admission may not
work and they will come back moaning about the hospital. 
Basically hospital specialists are not my responsibility---didn't like him
Mrs Awful?   kid no better,  Mr Shithead? Well here's what you do,  you
just phone up and make an appointment to see him right away and if your
child has bad pain tonight you just take him to hospital and take no
nonsense etc etc etc.   Might be  a good idea to let the paeds consultant
know that hassle is imminent.  Do you find that a lot of hospital
consultants have bother understanding this sort of scenario?

How about that one for starters?  Unfortunately I have *lots* more where
that came from....

Declan
(hiding in the fractals)



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