This week in the BMJ
Volume 324, Number 7342, Issue of 13 Apr 2002When is a disease a "non-disease"?
When is a disease a "non-disease"?
A recent vote on bmj.com to identify "non-diseases" found almost
200, some of which already appear in official classifications of
disease. Smith (p 883) argues that to have your condition labelled as a
disease may bring considerable benefit, but the diagnosis may also
create problems
you may be denied insurance, a mortgage, and
employment. He says that everything is to be gained and nothing lost by
raising consciousness about the "slipperiness of the concept of
disease."
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Women opt for expectant management of miscarriage
In an observational study of 1096 consecutive patients with a suspected
first trimester miscarriage, Luise and colleagues (p 873) found that
70% of women chose expectant management when it was offered, rather
than electing for immediate surgical removal of retained products
identified by transvaginal ultrasonography. Eighty one per cent went on
to complete their miscarriage without the need of intervention. The
authors conclude that patients should be encouraged to persevere with
expectant management, and they call for more research to validate the
use of ultrasonography in defining an outcome measure for complete
miscarriage.
Many junior doctors experience bullying
Many junior doctors in the United Kingdom experience bullying during
training. Of 594 doctors surveyed, 37% reported being bullied in the
past year. Black and Asian doctors were more likely to be bullied than
white doctors, and women were more likely to report bullying than men.
Quine (p 878) says that although these findings should be interpreted
cautiously, the disturbingly high levels of bullying and mistreatment
during training are part of many junior doctors' perceptions and experiences.
Longer consultations are better for patients
Doctors who give longer consultations prescribe less, offer
more lifestyle advice, handle psychosocial problems better, and empower
patients. A systematic review of 14 research papers by Freeman and
colleagues (p 880) also found that the most effective consultations
were those in which doctors directly acknowledged and responded to
patients' problems and concerns. The authors say that 15 minutes is
barely adequate to see and examine an elderly patient with several
active problems. Longer consultations should be a professional
priority, and ways to introduce them should be found.
Action is needed to stop "disease mongering"
Some forms of medicalising of ordinary life may be better described as
"disease mongering." They include turning ordinary ailments into
medical problems, seeing mild symptoms as serious, treating personal
problems as medical ones, and seeing risks as diseases. Moynihan and
colleagues (p 886) believe that more could be done to expose and reduce
misleading "wonder drug" stories which help to promote so much
disease mongering. They maintain that corporate funded information
about disease should be replaced by independent information.
(Credit: CHRIS GROENHOUT)
Obstetricians have medicalised childbirth
Johanson and colleagues (p 892) argue that there is a growing
trend of obstetric intervention in childbirth; this is associated with
increasing medicolegal pressures, and women are not involved in
decision making. Obstetricians have now taken over responsibility for
normal births, in addition to their role in complicated births. Caesarean rates in Britain have now reached 20% and obstetricians, the
authors say, must be held accountable. If this trend is to be reversed
then the "blame and claim" culture should be addressed, and
childbirth without fear should become a reality for women, midwives,
and obstetricians alike.
Medicalising sex damages relationships
Medicine has long been exercising its authority over sexual behaviour
and in an increasingly secular society definitions of what is morally
acceptable now fall to medical science. Hart and Wellings (p 896)
examine the increasingly medical approach to sex, which they say
ignores the social and interpersonal dynamics of relationships. They
argue that the medicalisation of sex has resulted in the use of surgery
and drugs to enhance sexual pleasure and that our obsession with sexual
gratification increases expectations and feelings of inadequacy.
(Credit: NLM)
The time has come for "post-psychiatry"
Modern psychiatry encourages a biomedical model that encourages drug
treatment to be seen as a panacea for multiple problems. Antidepressant
prescription rates have increased alongside the number of consultants
in psychiatry, which have been rising steadily. Double (p 900) is sceptical of this approach and questions the legitimacy of psychiatric interventions for common personal and social
problems. He says that psychiatry should return to a biopsychological view and recognise the uncertainties of clinical practice. Such an
approach has been called "post-psychiatry," which emphasises social
and cultural contexts, places ethics before technology, and works to
minimise medical control.
Is a good death now a medical death?
The development of palliative care began in the 1950s, when concerns
were voiced over the apparent neglect of dying people. Research, a
greater openness about terminal conditions, and a more active approach
to the care of the dying person have all developed since then. The term
"palliative care," first proposed in 1974, came to symbolise this
broadening orientation. Yet the charge of creeping medicalisation has,
considers David Clark (p 905), now been levelled at palliative care.
All doctors now face the problem of balancing technical intervention
with a humanistic orientation to their dying patients.
(Credit: SPL)
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