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The opening paragraph of the paper by Thompsonet al (see page 78) goes to the heart of a major problem in clinical research which is that most thinking, research, teaching, and clinical guidance on medical conditions, in this case irritable bowel syndrome (IBS), are based on patients referred by general practitioners to specialists. For a number of reasons our knowledge of the natural history and optimum management of many conditions frequently encountered in general practice and primary care remain relatively scanty. Indeed, the stimulus to undertake this study came from a previous survey1 in which the same authors found that general practitioners, despite their unfamiliarity with diagnostic criteria for IBS, diagnosed the condition with reasonable confidence, found it less troublesome than many other painful conditions such as pelvic pain, headache and backache and only referred a minority of patients to specialists. In that questionnaire survey general practitioners estimated that they referred about one in seven patients with IBS to specialists and in the present, prospective study, 29% of patients identified were referred to specialists. It is, however, important to remember that in this series, there was a mixture of incident and prevalent cases, and that only 11 (15%) patients had not previously seen a doctor about their symptoms.
If this selection bias causes problems, matters are made more complicated by the fact that general practitioners themselves see only a minority of people with symptoms compatible with a clinical diagnosis of IBS. Community based surveys have indicated that between 10% and 20% of the general population will report a symptom complex compatible with IBS, but only one quarter to one third of these will seek medical attention.2-4 In doing so, the decision to consult a general practitioner has as much to do with patients' concerns about the interpretation and possible seriousness of their symptoms as it has with their severity or impact on quality of life.5Psychological factors are also important; although anxiety, neuroticism and depression were originally thought to be part and parcel of IBS, it has become clear that psychological morbidity is associated with health care-seeking rather than with IBS per se.6 7Interestingly, a recent study from Sydney, Australia, has reported conflicting data in patients consulting with dyspepsia.8
The long term course of IBS symptoms in the community has been less well described, although Agreus et al have studied a stable Swedish population and found that there is a good deal of movement between functional abdominal pain subgroups, with some patients with lower bowel symptoms going on to report predominantly upper abdominal symptoms one year later.9 Interestingly, in an earlier study from Denmark, only 5% of a randomly selected population sample of patients with IBS were completely symptom-free at five year follow up.3 A surprising finding in a recent one year follow up study of patients identified in a large general practice database was that health care resource utilisation was no greater in the year after the diagnosis of IBS was made than in the year before.
The emotional and psychological baggage which accompanies patients seeking medical advice for IBS is described well in this paper. Fear of cancer was present in 46% of the patients with IBS (compared with 30% of those with organic bowel disease), but unfortunately only about a quarter of these patients seem to have been reassured in this respect after seeing the doctor, and a mere 26% felt entirely better about their symptoms after the visit. Although it has to be remembered that these are prevalent as well as incident cases of IBS, many of whom will have established at least the beginnings of an illness career, it does suggest that although general practitioners may be aware of the psychosocial dimensions of their patients' problems, it is often very difficult to deal with deeply rooted concerns about serious disease. Thompson and colleagues point out that this may be in part due to the fact that about 20% of patients with IBS were not correctly diagnosed by general practitioners. These patients, who were left without a clear diagnosis, might well have been more difficult to reassure. Conversely, only one of the patients diagnosed as having IBS by the general practitioners turned out to have organic disease (proctitis), a reassuring finding in view of the fact that most general practitioners are unfamiliar with the Manning criteria and are probably unaware of the Rome criteria.1
The penultimate paragraph of this paper contains some sound advice to primary and secondary care physicians. Referred patients—those whom general practitioners find difficult to manage—often refuse to recognise that there are psychological facets to their illness; the likelihood of referral also increases with the number of tests performed. The authors point out that repeated testing suggests an unconfident doctor and that investigations can be both beneficial and detrimental, as likely to prolong anxiety as to allay it, deflecting attention from “the crucial business of teaching the patient the nature of their problem and how to handle it”. Wise words indeed.
See article on page 78
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