In order to capture the essence of this \u201cpractice\u201d we would apply the term \u201cinstitutionalised malpractice,\u201d as in our experience most physicians do it. Like institutional racism, institutional malpractice is a long term, behavioural bias, which is borne more out of inertia than intent. However, if this is our modus operandi, we do our patients and ourselves a disservice.<\/span><\/p>\n Physicians need to be cautious when making a diagnosis of absence, i.e. non-cardiac chest pain, and broaden their diagnostic sieve to include the psychosocial context. <\/span>Many physicians perhaps don\u2019t see it as their role, but the acute care clinician from the above example could, at least, offer an understanding response, \u201cI think you may have stress\/anxiety. It would be best to discuss that with your GP.\u201d In the perfect clinical world this would be a natural and expected comment. Avoidance of any psychosocial issues will likely only result in repeated visits to some component of healthcare. <\/span><\/p>\n There are many reasons why doctors may not make a mental health diagnosis, even if they are aware that the patient is experiencing psychological distress, and qualitative research has elicited from doctors some of the most common ones. Firstly, doctors are generally trained to explore the physical aspects of illness first, based on the premise that it is bad practice to miss a physical diagnosis but less problematic to miss a mental health diagnosis.<\/span>[1]<\/a>\u00a0Some doctors prefer not to deal with mental health issues.[1]<\/a> Some are reluctant to explore psychosocial issues in case they open Pandora\u2019s Box.[1]<\/a> (Ironically, hope lies at the bottom of this Pandora\u2019s Box.) Some avoid doing so due to a lack of confidence or perceived incompetence in raising mental health issues.[2]<\/a> Some doctors have concerns about stigma for the patient, while others are concerned about the impact a diagnosis of depression will have on a patient\u2019s future insurance claims if it is recorded in their medical records.[1]<\/a><\/span><\/p>\n Underlying all this, we\u2019d suggest that we clinicians shy away from psychosocial issues as often our personal and clinical resources do not allow for us to venture into that domain. As the primary care poet Glen Colquhoun said, \u201cI saw a young woman for a repeat prescription. Her story was so large I knew not to ask about it in the morning when the day is fragile with need.\u201d[3]<\/a> He rightly makes the point that on some days we do not have enough resources or resilience to venture forth. <\/span><\/p>\n In an article about the need for healthcare to respond to suffering, not just specific conditions, authors Epstein and Back <\/span>comment that \u201csuffering can make physicians feel helpless.”[4]<\/a> Too often, they argue, when feeling helpless we withdraw\u2014by referring to another specialist, scheduling the next follow-up appointment in the distant future, or blaming the patient. We would add to that list:<\/span> \u201cmaking a biomedical diagnosis when a psychosocial diagnosis is more appropriate<\/span><\/i>.\u201d[5]<\/a>\u00a0At times, we seek to address an emotional need with a cognitive response. That, in itself, might add to the patient\u2019s suffering.<\/span><\/p>\n This phenomenon touches upon medically unexplained symptoms, which has been a focus of research.[5]<\/a> Data from tertiary care has previously revealed very high rates of medically unexplained symptoms, with one study giving an average of 52%.[6]<\/a><\/span> While an older study to determine the incidence, diagnostic findings, and outcome of 14 common symptoms (e.g. headache, back pain, insomnia, constipation etc.)[7]<\/a><\/span>\u00a0estimated the probable etiology was that 16% of symptoms were organic, 10% psychological, and 74% unknown. The authors said that \u201calthough only 10% of the symptoms were classified as psychological it is probable that many of the symptoms of unknown etiology were related to psychosocial factors. Patients with depression, anxiety, or stress present with physical rather than affective complaints.\u201d They also said that \u201cdiagnostic and therapeutic strategies focusing solely on organic causes may be inappropriate for the majority of patients.\u201d[7]<\/a> Our view would be that not much has changed in the intervening years.<\/span><\/p>\n The solution to this for both the patient and the physician is to turn towards the suffering. To be in a healing relationship means that we must stay present in the suffering of others. <\/span>Indeed, given the complexity of modern medicine, we\u2019d argue that the doctor who can hold the biomedical and the psychosocial diagnoses simultaneously will be the one with the better job satisfaction. <\/span><\/p>\n When we chose the term \u201cinstitutionalised malpractice,\u201d it was carefully done. Physicians need to resist institutional pressure to meet volume and administrative targets when this compromises considering their patients\u2019 psychosocial state and wellbeing. Persisting with institutionalised malpractice serves neither the patient, clinician, healthcare organisation, nor society as a whole. Perhaps there is value in remembering the apposite quote of our co-author David Kuhl, \u201cWhat we know, cures and who we are, heals.\u201d[8]<\/a><\/span><\/p>\n Competing interests:<\/strong> None of the authors have any financial and personal relationships with other people or organisations that could inappropriately influence (bias) this work.\u00a0There has been no external funding for this paper.<\/span><\/p>\n Competing interests:<\/strong> None of the authors have any financial and personal relationships with other people or organisations that could inappropriately influence (bias) this work.\u00a0There has been no external funding for this paper.<\/span><\/p>\n Competing interests:<\/strong> None of the authors have any financial and personal relationships with other people or organisations that could inappropriately influence (bias) this work.\u00a0There has been no external funding for this paper.<\/span><\/p>\n Contribution:<\/strong> BA came up with the idea and all authors contributed to the paper.<\/span><\/p>\n References<\/strong><\/p>\n [1]\u00a0<\/a>Dew K, Dowell A, McLeod D, et al. “This glorious twilight zone of uncertainty”: mental health consultations in general practice in New Zealand. Soc Sci Med<\/em> 2005;<\/span>61(6):1189-200.<\/span>![\"\"](\"https:\/\/blogs.bmj.com\/bmj\/files\/2018\/05\/bruce_arroll.jpg\")
Bruce Arroll<\/strong> is a professor in the Department of General Practice and Primary Health Care at the University of Auckland, New Zealand.<\/span><\/em>
\n<\/span><\/p>\n![\"\"](\"https:\/\/blogs.bmj.com\/bmj\/files\/2018\/05\/robert_phillips.jpg\")
Robert L Phillips Jr<\/strong> is the vice president of research and policy on the\u00a0<\/span>American Board of Family Medicine.<\/span><\/em><\/p>\n![\"\"](\"https:\/\/blogs.bmj.com\/bmj\/files\/2018\/05\/david_Kuhl.jpg\")
David R Kuhl\u00a0<\/strong><\/span>is a professor in the Departments of Family Medicine and Urologic Sciences at the University of British Columbia, Canada.<\/span>
\n<\/strong><\/span><\/em><\/p>\n
\n<\/a>[2]\u00a0<\/a>Maxwell M, Harris F, Hibberd C, et al. A qualitative study of primary care professionals’ views of case finding for depression in patients with diabetes or coronary heart disease in the UK. BMC Fam Pract<\/em> 2013;<\/span>14:46.
\n<\/a>[3]\u00a0<\/a>Wilson H, Cunningham W. <\/span>Being a Doctor Understanding Medical Practice<\/span><\/i>: Published by Otago University Press. 2013.<\/span>
\n<\/a>[4]\u00a0<\/a>Epstein RM, Back AL. A piece of my mind. Responding to Suffering. JAMA<\/em> 2015;<\/span>314(24):2623-4.<\/span>
\n<\/a>[5]\u00a0<\/a>Williams N, Wilkinson C, Stott N, et al. Functional illness in primary care: dysfunction versus disease. BMC Fam Pract<\/em> 2008;<\/span>9:30.<\/span>
\n<\/a>[6]\u00a0<\/a>Nimnuan C, Rabe-Hesketh S, Wessely S, et al. How many functional somatic syndromes? J Psychosom Res<\/em> 2001;<\/span>51(4):549-57.<\/span>
\n<\/a>[7]\u00a0<\/a>Kroenke K, Mangelsdorff AD. Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome. Am J Med<\/em> 1989;<\/span>86(3):262-6.<\/span>
\n[8] <\/a>Kuhl DR. Keynote talk ” What we know cures and who we are heals.” In: <\/span>https:\/\/www.goodfellowunit.org\/symposium\/programme#day1<\/span><\/a>, ed. Goodfellow Symposium, 2017.<\/span><\/p>\n