January, 24, 2017 | 31 Comments


  1. If anyone needs a pick-me-up on one of these dark nights – well this is the place to be; humorous – yes, but also so true in many ways. It took me a while to work out where this was heading – I found the so called ‘attached piece’ so depressing – but then, as I moved on to the ‘husband’ I realised where we were going – well worth the wait though! I reckon the ‘surrendered doctor’ section could do with an addition :-
    7. Accept that I have two ears but only one mouth for a reason – and that reason is not just to hold my glasses!
    I’m sure the ideas will be flowing and that you will have more appropriate pictures than you ever imagined!

  2. Great post – will share widely.

    The patient did know best when she told her doctor the newly prescribed and very first antidepressant was making her suicidal. The doctor didn’t believe her and upped the dose. The patient is dead. I carry a supply of RxISK cards with me wherever I go. The doctor was insulted when presented with information from RxISK’s interaction checker. I prefer Dr. Google to any other doctor.

    Exchange with two of my husband’s cardiologists: “He needs this procedure immediately. (A potentially life-threatening procedure.) He could drop dead any second”. Me: “But he’s feeling better.” Cardiologist: “People often feel better just before they drop dead.” Enter Dr. Google. A few months later – cardiologist #3: “For whatever reason he is no longer a candidate for any procedure.”

    A patient was in critical condition after surgery which was considered ‘a success’ – there was a slight problem – the bleeding wouldn’t stop. The novel anticoagulant hadn’t been withdrawn in time. This patient lived.

    Cardiologists are right up there with psychiatrists.

  3. This is my first reading of the ‘Hippocratic Oath’…and it’s a lot to live up to…particularly, in the Age of Rxisk..

    Written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University, and used in many medical schools today.

    I swear to fulfill, to the best of my ability and judgment, this covenant:…

    I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.

    I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism.

    I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.

    I will not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.

    I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. Above all, I must not play at God.

    I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.

    I will prevent disease whenever I can, for prevention is preferable to cure.

    I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.

    If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.

  4. Obviously, in the UK the doctors are largely surrendered but surrendered to the Department of Health (DH) and the General Medical Council. There is whole hirearchy of surrenders involved in health policy – politicians surrender to the DH, journalists surrender to Science Media Centre, Sense About Science and Ben Goldacre (but that is not news here). The DH surrenders to the pharmaceutical industry, and so does Public Health England (and curiously if you write about Public Health England to the DH they say it has nothing to do with them). Finally, citizens are of course supposed to surrender to the doctors.

    Some years ago an Oxford philosopher, Prof Julian Savulescu, wrote an article in BMJ against private conscience citing Shakespeare’s Richard III having failed apparently to realise that Richard III was supposed to be a villain – there were quite a lot of protests from readers but the reality was that the profession had long ago surrendered and nobody noticed. It was only about three years later that BMJ Rapid Responses finally accepted a letter from me:

    “A bit more context

    “I returned to this extraordinary article today. These are the words
    of Richard III in Shakespeare’s play as he goes out to fight his last

    “”Let not our babbling dreams affright our souls,
    For conscience is a word that cowards use,
    Devised at first to keep the strong in awe.”

    “Richard has just been visited in his sleep by the ghosts of those he
    has murdered on the route to power and in remaining there: Henry VI, the
    Duke of Clarence (his brother), Lord Rivers, Lord Grey, Lord Hastings, the
    Princes in the tower, his wife Anne, and the Duke of Buckingham.
    Juxtaposed with conscience is naked power.

    “I have a few questions.

    “How could an Oxford philosopher claim authority from a line ripped
    out of context in this way, as no undergraduate literature student would

    “How can we justify any authority except through continuing open moral

    “Do we really live in an age in which we can confidently defer to the
    state and its servants?

    “And how is the Uehiro Foundation funded – a subject upon which I can
    find no information?”

    I see that Prof Savulescu is a fellow of St Cross College like Prof Pollard.

  5. I am the ‘surrendered doctor’..

    Patients are dying from lack of good medical research

    Ben Goldacre

    3 hours ago

    @Ralph Naderbolsinmattu Why do you criticize pharmaceutical companies for the behavior of prescribers of their products. Have you ever been in a job where your decision can cure or kill the man in front of you. Doctors do their best but err on the side of caution, thank Hippocrates!

    Ralph Naderbolsinmattu
    31 minutes ago

    It is s matter of balence. Yes some unpublished studies, some non transparency but if the good done to bad ratio is 100:1 it’s a small issue.

    Goldacre lacks balence and perspective, but many career critics are like this. He would be better respected if he acknowledged where the balence lies. Also if he had done any credible research which had led to an advance, that is making a difference, sniping at the good is not productive.

  6. When I first went to work as a teenager, older workers taught me a basic rule: Shit rolls downhill. It’s sort of a First Law of Thermodynamics for the workplace, at least in the USA. It definitely applies to healthcare these days, both openly for-profit and allegedly non-profit. Thus doctors “surrender” to their bosses, which leads them to push patients to “surrender” to them.

    A recent book memorably titled Drug Dealer MD, by psychiatrist Anna Lembke, explains that a big driver of the opioid epidemic has been the movement of doctors into large hospital-owned practices and the relentless pressures for “productivity” this brings. For fifty minutes of psychotherapy or patient counseling, she can bill a maximum of $300. For brief “medication management” visits she can bill $230, and can cram up to five of them into a single hour. Dr. Lembke gets monthly reports from her managers, complete with pie charts and graphs, tracking her “productivity” – and it’s obvious which way they want her practice to go.

    Her colleague Susie works in the emergency department, where lots of opioid pain pills are handed out. Susie knows she’s seeing plenty of patients who have become addicted to opioids. She wants to talk to them about it, maybe even help them get treatment. But Susie is paid as an independent contractor – 22% of whatever she bills. $220 if the patient runs up a $1,000 bill; $2,200 if the bill is $10,000. Even if she’s willing to see her income cut, her bosses are not. She’s been advised to “give these patients what they want and send them on their way” if she wants to keep her numbers up.

    Then there’s the Electronic Medical Records deployed in most of these places, which are geared towards billing and insurance more than patient care. Many of us have seen our doctors not just “surrendered” but utterly kidnapped by the screens. Nowadays you can often sit there making funny faces at the doctor with total impunity, because they can’t see you – they are riveted to that screen.

    So, every gesture of “downward surrender” to the patient means defying the “upward surrender” the bosses expect. You have to make shit roll uphill. It’s hazardous work.

  7. John Stone couldn’t have put it better when he says:

    Obviously, in the UK the doctors are largely surrendered but surrendered to the Department of Health (DH) and the General Medical Council. There is whole hirearchy of surrenders involved in health policy – politicians surrender to the DH, journalists surrender to Science Media Centre, Sense About Science and Ben Goldacre (but that is not news here). The DH surrenders to the pharmaceutical industry, and so does Public Health England (and curiously if you write about Public Health England to the DH they say it has nothing to do with them). Finally, citizens are of course supposed to surrender to the doctors.

    In my case they all surrendered to the police officer who’s non medical trained opinion was followed through to all the law makers of the land and they were all surrendering to the above authority’s as well.

    As Cameron quoted “We are all in this together”. I always wondered what he actually meant by that but thanks John you have cleared that query up for me.

  8. When people heard I was trying to appeal my convictions because of the SSRIS the first and most repeated comment made from most people was “You cant beat the system”. Now why would anyone make that comment in the first place? Shows that most people do not have faith or trust in the system at all and that they also believe we are all being controlled by the above powers. Hence why Brexit probably happened but sadly I don’t think that was the greatest thing to do either.

    • I agree with a lot of what you say Anne -Marie, but I would like to add a little to your “you can’t beat the system” remark. If we just keep saying that, then, surely, things won’t change – why would they? It implies that things are as they are and we must stick with it and never complain. The fact that Brexit happened shows that many decided to beat the system last June. This week, we’ve heard from the Supreme Court that Parliament, not simply the Government, must be united to trigger Article 50 – this happened because a small group decided, against all odds, to test their might against ‘the system’. Many talk about ‘winning’ and ‘losing’ as regards this issue – I disagree. It was simply a case of ‘searching for the truth’ which, thankfully, was found. Like you, I’m not convinced yet that Brexit will be a fantastic step forward but I certainly believe that it stands a far better chance now, of making life better for every layer of British life, than it would have had if the ‘hard Brexit’ of Theresa May had been allowed to bulldoze its way onwards.
      ‘Beating the system’ is something that we only dare to do when our backs are against the wall. That’s true in any walk of life. When jobs are plentiful, you can dare to do so knowing that if things go badly wrong there should be another opening awaiting you almost immediately. In the present situation here in the UK, where everyone is treading on eggshells for fear of upsetting the ‘powers from above’, no-one will want to rock the boat for fear of losing out.
      The result of all of this is increased fear …which leads to anxiety …which leads
      to a visit to the doctor ….which adds to their anxiety……which leads to their absence from the workplace…..which leads to poor hospital/ GP reports in the papers ….which leads to more panic among the community…..which adds to queues at A&E……this list is endless! Who gains from it all? Very few as far as I can see! The more we test the ‘system’, the more we upset the ‘top of the tree’. We must remember that the higher they are the greater their fall – therefore is it any wonder they do all they can to keep us in check? That doesn’t mean though that we can’t try to get them to change their ways.
      Where does this leave us and our struggle to get the truth noticed? Do we dare to ‘beat the system’? I hope that we do. I feel that every time we share a comment here shows a certain degree of defiance. Not enough to change the world I grant you but maybe enough to change the mind of someone that we introduce our ideas to – or point in the direction of like-minded others who also fight on tirelessly, whose truths may well, eventually, change the minds of past doubters.

  9. Your right Mary you should keep on going, being knocked back is tough but it shouldn’t be the end either. I agree the more people that speak out the better. My vision of Brexit is not a good one either lol No businesses (There all moving abroad) which means no jobs and worse poverty and hardship. The government will be cutting back on even more. The loss of the human rights act isn’t good either, I fear laws will get even tougher when that’s gone but lets hope I’m wrong on all of that as well.

  10. Tentative suggestions for illustration for this post: on the lines of the Spot the Difference games in children’s activity books – two line drawn identical doctor images, white coat, stethoscope etc, sitting behind identical outline of desk, one with calm receptive fairly serious but non threatening expression, head slightly inclined, with inference of listening ears, toward patient. Patient (back of head seen only) sitting between the two identical images. Face of second doctor with menacing protruding eyes, teeth bared, eyebrows enraged. Thought bubble near patient, asking himself ‘whatever did I say to cause this?’ Spot the Differences.

    Another idea – somewhere on RxISK I read a DH comment along the lines of describing patient nervously talking to doctor, like mouse facing benevolent smiling cat but at same time aware of swishing furious tail behind it, so speaking with heart in mouth, afraid of going too far and causing annoyance to cat. Mouse on hot bricks, in other words. Could make good image but swishing tail hard to illustrate…

    I think, for me, this new Post demonstrates the fear we all have of annoying the god-like doctor, however nice and open-minded he at first appears to be. The phrase ‘walking on eggshells’, springs to mind. And yet, this is about our health, our most precious possession, indeed, our very life. We are also well aware that if we cock this little interview up, our Notes will be peppered with some dismissive or derogatory opinions, which can never be erased, except by appealing to that same doctor to take them off, and good luck with that, folks! So WE are in a position of abject SURRENDER from the start, because ‘we know our place’ – always the mouse, never the cat….

  11. ‘I am an obstacle to work around rather than a source of support’ – from Surrendered Doctor suggested list of aims.

    We can’t expect doctors to be our only source of support any more. There are too many of us, there are too few of them, the ratio of doctor to patient is now so different to how it was even in the 1950’s when some of us were very young and enjoying the euphoria of 1948’s new National Health Service. In those days, we knew our doctor, usually, we had respect for him or her, they had time to hear our medical problem, and although there was probably a lot of patronising attitude from medics, there were also plenty of common sense tried and tested treatments before the great rise of Big Pharma power and influence.

    We learn today (BBC News) of the massive rise of suicides, self harm and violence in our prisons. Also 1 in 5 children in UK are living in poverty with ill health. We know that the NHS is in crisis, and can see it for ourselves in the weekly BBC series ‘Hospital’. Too few beds mean that doctors are kicking their heels unable to do scheduled operations all day because there is no bed to put their patient into afterwards. Surely this is total madness, and we have ALL surrendered to it.

    Is this happening because of lack of money and resources? The NHS is paying massively for Pharma drugs. There are wards full of beds being kept out of use because we can’t provide personnel to staff them; the same applies to equipment like expensive scanners.

    We are hearing about new Well Being Local initiatives being rolled out now. We are being encouraged to take more responsibility for our individual health. This is good. But until we realise that trailing into our doctor’s surgery with an ailment and not feeling satisfied unless we are clutching a prescription when we leave after our allocated 7-10 minutes, we are surrendering ourselves to unnecessary risk and possibly onto a treadmill of endless drug taking.

    I’ll bet most of us reading this Blog will be extremely careful about accepting any prescribed drugs, and will only see a doctor as a last resort, if we are suffering a medical emergency. But how long is it going to take before the majority of the population begin to think like this? And what will get the message across to them? Some say we should start charging for visits, which would make people weigh up more carefully whether their visit is essential. Better surely to bring in Social Prescribing, encouraging communities to get to know each other and care for their own. Set up Respite Centres where those in distress can go for support, and so that carers can have a break and recharge their batteries. People should not be alone and unsupported when suffering, but we can ‘t expect doctors to provide this support. We need human beings to take the place of reliance on drugs. To talk to each other and care about each other. Perhaps we should be surrendering into accepting that this is the only viable way forward. And perhaps doctors should be hiding their prescription pads and talking straight to us, in a friendly and reasoned way, instead. Surrendering to working in a partnership with us.

  12. All this talk of ‘surrender’ has got me thinking about our own stand – ‘our’ meaning all of us who are trying to get the true picture of modern medication across to the rest of our communities. Could it be that we need to surrender in any way as regards our relationship with the ‘disbelieving majority’? Could it be that our critical stance against doctors/psychiatrists/pharma companies etc. is overwhelming the inexperienced in our midst? Might we do better by showing a little more compassion towards the difficulties experienced by some of those whom we criticise? Being compassionate need not mean forgetting how we have been wronged but rather accepting that maybe the situation was not as black/white on the other side of the fence as we, due to our hurt, have made it out to be. If we could find it in our hearts to forgive a few of the many faults that we know exist, might the general public relax a little and surrender to our pleas? If we genuinely feel that our dearest wish is to inform the next generation of the pitfalls of modern medicine, would it not be worth our while to reach out a hand in friendship without harsh words – firm, but not threatening? To hold our heads high – so that our example can shine a light for the 99%, mentioned by Sally in an earlier post, to follow – in memory of the hurt sustained by the 1% ( a figure that the majority of us feel is far higher in reality). To believe in the need for far more transparency need not lead to. a battle cry – sometimes a surrendered kind word hits the spot just as effectively

  13. Another suggestion for illustration:
    I was reminded of the John Cleese, and the Two Ronnie’s sketch first seen on the Frost Report many years ago and now available if Googled. ‘The Meaning of Class’. One could adapt this. Three guys standing in row, tallest to smallest. Instead of JC as upper class, one could use Big Pharma, guy in middle becomes doctor, and small guy (but wisest in the end) patient, who says he looks up to other two for their class superiority, ( for this it would have to be because of their power over his health) but in the end, he says looking up to them just gives him a pain in the neck….he keeps saying, ‘I know my place’ but he says it tongue in cheek. He knows they are really in cloud cuckoo land, obsessed with their own importance, only each surrendering to the might of the other above him, but he has no choice, he has to stay in the position he is, but it doesn’t prevent him, uneducated as he may appear, from seeing straight through them.

    Having thought about it a bit more, a better caption for the Spot the Difference cartoon, in patient’s thought bubble, might be, ‘Was it Something I Said?’.

  14. Nice title Rose-Coloured Lenses and adds to the first comment on the Post by Mary.

    I thought this was a good read particularly as he draws attention to Study 329 and David Healy and not many authors do that.

    It set me thinking about the document SSRI learning module for doctors which has been around a long time now.

    I don’t know whether we all read different papers, study different studies, read different protocols, but, there seems to be a huge disconnect between the multiple, multiple, multiple prescribing habits of doctors which despite all the efforts of a few is one of the most singular missed opportunities to not only stop this stampede of the pernicious prop but might be a useful philosophical argument for creating a more resilient public without very questionable props.

    I don’t necessarily think avoidance of doctors is the right way to go.

    We have to be mature about our needs and sometimes we needs..

    I have learnt to be perfectly charming, the charm offensive, to all doctors along this long road.

    I can do this and hold my own quite adequately and point out quite often the sometimes error of their ways. Not in a critical fashion, rather a smiley, jokey, complimentary, getting on to their level, type approach.

    I have watched probably all of David Healy’s videos, presentations, speaking engagements on the site and what it mostly showed me was you don’t have to make your point by being critical or even nasty.

    The covert way to make your point.

    Someone commented on the IAI madness incorporated video that he didn’t at all agree with DH but he liked the way he put words in to other peoples mouths.

    So, in essence, we don’t need to surrender to doctors, we can be there, see them, play the game, and, feel much better for it.

    I am very lucky here in rural Scotland, to have a new rural outreach with around 8 gps travelling up from their practice to help us out.

    A nice day oot for them as it is so quiet around here you can here a pin drop and may be a learning curve for them when they sit around twiddling their thumbs to get through the day with few patients in the waiting room..

    I have accepted that my previous surgery was very bad luck indeed, and, moved forward to the new outreach and it’s possibilities..

    SSRI learning module

    Learning objective
    Used in conjunction with authoritative guidelines on disease management, this module will help you maximise the benefits of SSRI treatment.

    The full SSRI learning module for doctors is available online.

    I like this one, for its simplicity..

    and lest ye forget, I have to put up with St. Urge on…N.

  15. I would strongly urge a campaign for ‘NO PSYCHIATRIC OR ‘MENTAL HEALTH’ DIAGNOSIS WITHOUT FULL SPECIALIST (consultant psychiatrist) PSYCHIATRIC ASSESSMENT’. If the government is serious about parity for mental health then surely patients deserve to have their mental health problems properly diagnosed by well-qualified specialist psychiatrists, not by GPs who may have had very little learning experience in psychiatry or in a mental health setting.

    This should be what psychiatrist themselves are pressing for – afterall are serious biomedical diseases left up to GPs to diagnose/investigate and assess?

    So, if ‘medically unexplained symptoms’ / ‘MUS’ is a ‘mental health’ disorder, as is currently being peddled across the UK, then these patients deserve a full psychiatric assessment by a consultant psychiatrist, don’t they? After all MUS symptoms can be very debilitating indeed, Suzanne O’Sullivan tells us so in her book “It’s All In Your Head”.

    Let’s see the President of the Royal College of Psychiatrists and the mental health charities campaigning for this, together with ‘mental health’ advocates like Norman Lamb. (Of course, I daresay GPs will still need to be able to help some patients on the spot but this should be classified and labelled on their systems as a ‘working mental health hypothesis/diagnosis’ WHILE secondary referral is underway and NOT as a definitive diagnosis.)

    Incidentally, it may interest people to know that the Royal College of Psychiatrists felt the need to chastise its own members for asking for ‘mindfulness’ therapy to be included in the ‘Choosing Wisely’ list of interventions that didn’t help or actually did harm to patients. Presumably these well qualified members (apparently a significant number) thought that ‘Mindfulness’ was a waste of money and/or harmful to patients but they were overruled, THEIR considered opinions didn’t count …..well there’s democracy for you. But it really is no surprise when psychobabble is preached from the top and is a politically expedient tool to deny NHS patients (especially women) appropriate care.

    • Liz

      First of all I have to declare an interest. I know Liz from other settings and some of the work she does there on MUS is wonderful. But psychiatrists are not the answer. GPs are in general better doctors than psychiatrists. When it comes to adverse events you want a Generalist – not a Partialist. There is more cholesterol in the brain than in the blood and more serotonin in the blood and gut than in the brain – so you do not want a doc who knows nothing about little but thinks he knows something about the brain.

      The origin of a great deal of our problem is that drug companies put shrinks up on platforms to browbeat GPs into switching to SSRIs for instance often with threats of legal action – if the patient suicides on a tricyclic you might be legally liable – and with absolute assurance you could not get hooked to SSRIs.

      Most people, especially adolescents would be far safer in the hands of a generalist than a shrink. Unless of course the shrinks showed any ability not to shrink when it came to recognising problems.


      • David – I stand corrected. Perhaps my campaign for ‘no psychiatric diagnosis without full psychiatric assessment (from consultant psychiatrists) was not such a good idea after all. I had not realized that the situation was quite so dire with respect to psychiatrists and prescription of these dangerous drugs – SSRIs in particular.

        I shall explain though my reasoning behind my comment/campaign which may have come across as an extreme/ ill thought out/ somewhat reckless statement……in case the issue behind it wasn’t clear to readers. There is another, arguably equally dire (or even more dire) and dangerous situation developing at an alarming pace within the NHS in England. It is driven by government’s desire to find £20 billion plus in so-called ‘efficiency savings’ to the NHS budget. It goes like this (all information obtained from NHS documents):

        1. Persuade doctors – secondary care specialists in particular- to label any awkward or difficult to diagnose patients as having ‘MUS’ or ‘PPS’ (‘medically unexplained symptoms’ or ‘persistent physical symptoms’). The failure to diagnose is not the doctor’s fault or a failure of medicine or of the health services in any way …..rather, the patient has a mental health problem. TICK (already achieved)

        2. Maintain and produce statistics to show that up to 50% of patients referred to outpatient clinics have ‘MUS’. TICK

        3. Put pressure on GPs not to waste NHS money by referring ambiguous or ‘MUS’ cases. ….and instruct GPs that these patients need psychiatric help in the form of psychotherapy instead. (They are failing in their job if they don’t pick up on their patients’ mental health distress). TICK

        4. Introduce referral management centres (some private companies) to block ‘unsuitable’ referrals to secondary assessment and care. TICK

        5. Provide low-paid psychotherapists to primary care to show how serious the government is about mental health parity.  (thousands of extra psychotherapists being recruited across England). TICK

        6. Entice GPs to MUS training workshops, conferences and seminars across the UK with easy-to-get CPD credits. TICK

        7. Teach GPs that up to a quarter of their patients (that’s up to ONE IN FOUR – where have we heard that before?) will be consulting them about MUS – ie will have a mental health problem that needs diagnosing. TICK

        8. Provide research evidence that this approach to MUS patients works, is cost effective and is an effective ‘treatment’. TICK (Underway – PRINCE trials at Institute of Psychiatry.)

        9. Encourage GPs to identify potential MUS patients in primary care by using a computer app to scout the GP record system for ‘identifying factors’ * see below. TICK (computer app called the ‘Nottingham Tool’ )

        10. Label identified MUS patients with a clinical code such as 16H so that other health professionals know not to refer them for further investigations. TICK (some GP practices)

        11. Introduce the notion that individuals are responsible for taking care of themselves and their own health and are therefore entirely to blame for their own sickness and downfall if they do not follow government advice on diet, exercise, drugs, lifestyle choices etc. TICK

        12. Introduce the public to the idea that there are some services you should have to pay for, it is unreasonable for the NHS and state to be required to provide these services. TICK

        13. Sit back and watch hospital departments, units and even whole hospitals close, rejoicing in the fact that we now have much better ‘care in the community’. Watch desperate patients flooding to private providers with acute undiagnosed or misdiagnosed illnesses (missed cancers etc) and with chronic debilitating diseases.

        Voila! Privatization by the back door, helped along substantially by the MUS ‘euphemism’. Healthcare only for the rich, the rest can rot……especially women because women are up to 4 times more likely than men to be diagnosed with ‘MUS’ (again from NHS literature). And even Age UK is now on board urging that MUS diagnosis MUST be considered with respect to elderly patients, – patients who are likely to have multiple health problems and be on multiple drugs with multiple ADRs -, how sick can you get? So how to counter all of this – perhaps by making it more expensive for the NHS to label patients with MUS and other mental health disorders by mandatory specialist psychiatric assessment before any (permanent) psychiatric diagnosis . That was my reasoning.

        * Identifying factors for MUS (parameters searched for by the Nottingham Tool) –
        • age
        • prescription of opiate analgesics
        • presence of multiple pain sites
        • chronic fatigue
        • life stress
        • a normal ESR

        Past prescription of –
        Antidepressants, analgesia, inhalers, anxiolytics, laxatives, antiemetic, antihistamines, antisecretory & mucosal protectants, antiepileptic (neuropathic pain)

        NB This could lead to extremely dangerous diagnostic overshadowing.

        • Crikey – thanks for all this info Liz. I thought I knew a bit about how the NHS is being slowly but surely dismantled but had no idea that MUS were playing a role. Trouble is, no ordinary punter has the faintest idea about any of the details – not least that the extra money (which was simply pinched from elsewhere) promised for MH services in response to various terrible crises goes direct to local Clinical Commissioning Groups who have complete control over how the money is spent and absolutely no obligation to spend any of it on MH…all too depressing.

          • Except the CCGs don’t actually have complete control – that’s another myth. They (at least sometimes) have to bid for funds presumably from NHS England/central government as is the case for money for the Transformational Fund for the Five Year Forward View for mental health that includes the roll out of IAPT (Improving access to psychological therapies) including for MUS across England. see Scroll down to •Mental Health Call to Bid and •Mental Health application form part A under Integrated IAPT. If you open these up you will see that in order to get this funding the CCGs (or ‘STP’s) applying need to show exactly how will they will fulfil the government’s/ Department of Health’s wishes and demonstrate how their implementation of the MUS directives will lead to savings – eg the question at end of MH application form
            – please show your your savings assumptions.
            For example:
            • % reduction in length of stay for people with co-morbid mental health problems and physical health conditions.
            • Reduction in outpatient appointments and investigations.

            So much for local decision making……it’s frightening stuff.

    • I was given this book for Christmas – and have to say that its most serious shortcoming was the message that all the poor patients whose debilitating neurological symptoms were deemed to be ‘all in the mind’ would benefit from being passed over to a shrink. To anyone who has experienced the tender care of our psychiatric system (medication first, and 6 weeks of CBT in a year’s time if they’re lucky) knows that is ill-informed and naive. The book would have benefited enormously from some acknowledgment that such patients are likely to fall down a great big hole. Neurologists don’t want them because they cost too much and clog up the system- but neither do psychiatrists. And the really key point is that secondary care has become all but unavailable – desperate and suicidal people can’t get help so how likely is someone who a neurologist has decided is suffering from hysteria to get help? A busy GP will simply dole out a prescription for antidepressants.

  16. The Bad Doctor by Ian Williams is a graphic novel: written/illustrated by a medic and artist and comic book fan – it’s a great and rare example of a story about an ordinary GP who is as vulnerable as the rest of us, suffers from OCD, does his best in trying circumstances and does at points ‘surrender’. I wish there was a single image to use for the next post but there isn’t so all I can do is highly recommend the whole book. (He’s not a bad doctor – but feels he is..)

    Becoming a doctor requires young people to decide very early in their education (14, here in the UK) to follow the science route: chemistry, physics and biology which means abandoning the humanities (and humanity?); literature, history, art, etc which can throw light on the complexities of the human condition far more powerfully and subtly than knowing the chemical formula for hydrogen.

    Getting into med school requires top grades, so youngsters, however bright, must slog hard. When they get there they occupy a strange role: not only do they have to work hard but (in my memory as a student sharing a house with a number of medics) they have to be tough drinkers too. And rowdy. Being sporty is also encouraged. Not much room for sensitive introverts.

    Then as junior docs they are expected to work their guts out. And they enter an incredibly hierarchical world where the consultant still reigns supreme. Medical students are expected to know their place and I guess questioning authority is very rarely possible. Yet all the while students and young docs will be aware that they are training to get to the perceived top of the professions. Being a doctor is probably still one of the most respected/revered positions (lawyers come close but being widely regarded as utterly venal they are subject to more abuse). So doctors have an awful lot to surrender. My criteria for the ‘surrendered doc’:

    1. Accept that my job should not grant me special status and I am not a particularly important member of society. No special reverence is due to me, and bin men and cleaners contribute far more to the health of the public than I do.

    2. Accept that I am very well paid for what I do, especially as I don’t have to bother with the messy bits (nurses mop up sick and worse).

    3. Accept that status does not grant the right to bully – either fellow medics or nurses or patients.

    4. Accept that I am often wrong and that the fact that I don’t know what is causing my patient’s severe pain does not mean there is no pain. It just means I don’t know what is causing it, no more no less. That is my shortcoming not the patient’s.

    5. Accept that MUS (medically unexplained symptoms) has become synonymous with hysteria/conversion/psychosomatic/functional/malingering disorder and has therefore been rendered useless as an accurate descriptor. This is wholly the fault of a serious misuse of the term by doctors, attempting to shed responsibility for caring for someone whose symptoms remain a mystery – and an excuse to kick them over to the shrinks who will probably do them more harm than good.

    This below – a letter from a kind and thoughtful neurologist, Peter J Goadsby, is a useful take on the misuse of MUS too…maybe Prof G is already a ‘surrendered’ doc?

    “MUS surely depends upon who is providing the explanation? If I were to go with my somewhat foggy gastroenterological knowledge, based on my Membership examination, and do a busy GI clinic I imagine that I would reach fewer diagnoses than a general physician with an interest in gastroenterology. In turn the generalist might do less well than a specialist gastroenterologist, who might do less well than an upper GI superspecialist, and so on, if one looked at the subset of patients proven to have upper GI problems as the outcome.
    As a neurologist interested in headache I see patients labelled with various terms, usually as functional, who have a clearly definable headache syndrome. It is rare in my experience to encounter undiagnosable headache, yet this is often a symptom quoted in such research.2 The unexplained portion seems to have been inadequately explored in the sense that those providing the data were not sufficiently expert to explain it. This brings a question of what is sufficient. We do not accept blood pressure information from faulty devices, so how can such research accept potentially flawed diagnoses?
    To assure doctors that 30% of patients are medically unexplained is not very helpful as it implies that there is no diagnosis. To say that a patient has an unexplained problem would require that it has been adequately investigated, or at least a complete history taken by someone sufficiently trained to do so. Research in this area surely requires some standard of measurement of the accuracy of the explanation, or lack of it. Perhaps funds directed to MUS might be directed to better training of doctors in some common clinical problems that are misdiagnosed rather than unexplained.”

  17. Liz and Sally, thanks indeed for all this info.
    The thing which really gets to me is the way so much money is being guzzled into payment of interest, at ridiculous rates, by the PFI hospitals. If these crazy contracts, set up in the main under Tony Blair and his brown nosing backside licking senior CEO managers doing his bidding, if these could be taken apart and re-jigged, I bet you we would not be anything like so deep in deficit.

    What we need is Annie’s brilliant sleuthing, maybe on FOI requests, how much money is being wasted this way in various Trusts. Start with Worcestershire, it will blow your mind. Also, how many of those very affluent Senior Managers all over UK, mostly now retired on enormous pensions, have shares in the PFIs. And even worse, how many of those in Government have them. No wonder the information is so hard to get hold of and publicise.

    We have raised the issue of PFIs in our own Trust on Patient Forums and have been blocked from getting answers. We noticed even on the Victoria Derbyshire investigation (BBC2) into the state of the NHS on Monday, that when the PFI issue was briefly raised, it was kicked into the long grass. Even if we had to pay some kind of forfeit to break these contracts, it must be worth it. Blair and his cronies in the NHS bureaucracy have a hell of a lot to answer for, as we look at the crisis in healthcare today. Our friends and we just pray daily that we don’t get ill and land up in this danger zone. It was tough in the 1970s when I worked in it, but it was NEVER scary, and we trusted it without any real worries.

    So, PFIs and Big Pharma rip-off drugs bills. Stop these and we could slowly get back in business using a few £billion to recruit and pay hordes of frontline staff (not managers and back room staff please). And why not ask Victoria Derbyshire whether the BBC really don’t want PFIs investigated, whilst we’re at it?

  18. Indeed Heather, I couldn’t agree more.

    To add insult to injury with respect to MUS the following document has just been published – “Guidance for commissioners of services for people with medically unexplained symptoms” by the Joint Commissioning Panel for Mental Health, available to download here – . It’s not difficult to read between the lines. (And it reckons that 66% of gynaecology outpatients have MUS, so disgraceful sexism to boot). GPs won’t be allowed to refer on suspicion of illness/disease any more, they’ll need solid proof that a patient is seriously ill/dying and will have to ascertain this all within the very limited consultation time. It begs the question – will secondary specialists then cease to be diagnosticians at all (except for discovering the MUS patients that have slipped through the net to pass on to the psychs perhaps)?

    And where, oh where is the evidence-based research into misdiagnosis rates and the causes of misdiagnosis?

    I’m afraid we’re all going to hell in a hand cart.

    NB Excellent article on MUS by Annemarie Goldstein Jutel here –

    and 3 good and interesting responses to a disappointingly poor article that was published in this week’s BMJ

  19. Quoted on BBC discussion programme today – £200 billion being spent on PFIs. Would this be the annually, as interest? Does anyone know? If so, no wonder the NHS is in a desperate state.

  20. I am very lucky to have a Psych that is pretty open to my feedback, suggestions, and generally allowing me to be actively involved in my ‘recovery’.
    In the past 4 years since we have been ‘working together’, I have become significantly more ‘predictably stable’ – A massive change from the complex, unpredictable and unstable mess I had been for the 5 years prior to that. Diagnosed with BPD (amongst ADHD inattentive, M depression, Anxiety, PTSD,OCD…. etc) 4 years after escaping a 13 year ‘relationship’ with a sociopath, and finally diagnosed at 40 with ADHD and had become quite good at researching – thanks to this ‘thirst for knowledge’ I even saved my own life thanks to reading about a combination of meds that were noted as causing ‘suicidal tendancies’ – I fell into the 1% unfortunately and after 2 years of a living nightmare, it took only 3 days after stopping one of the meds to be free of all suicidal compulsion and so because of this, my Dr started to pay attention and gave me lots of resource suggestions, and listened more. I even bring Mum or my daughter to my 1/2 hour sessions / month for a debrief with my Dr, through their eyes (my daughter, 23 even sends emails to her)
    In brief, I have gone from ‘circling the drain’ with Drs out of ideas to save me to OWNING myself again. I even stopped hoarding and am pretty much on top of my BPD and reclusiveness and have some self esteem again

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