Caring for medically unexplained physical symptoms after toxic environmental exposures: effects of contested causation.

Abstract

Medically unexplained physical symptoms (MUPS) are persistent idiopathic symptoms that drive patients to seek medical care. MUPS syndromes include chronic fatigue syndrome, fibromyalgia syndrome, and multiple chemical sensitivities. When MUPS occur after an environmental exposure or injury, an adversarial social context that we call "contested causation" may ensue. Contested causation may occur publicly and involve media controversy, scientific disagreement, political debate, and legal struggles. This adversarial social context may diminish the effectiveness of the provider-patient relationship. Contested causation also may occur privately, when disagreement over the causes of MUPS takes place in the patient-provider context. These patient-provider disagreements over causation often occur because of the enigmatic nature of MUPS. We suggest that a context of contested causation may have serious negative effects on healthcare for individuals with MUPS. Context plays a larger role in MUPS care than it does for most medical care because of the uncertain nature of MUPS, the reliance of standard MUPS therapies on a potentially tenuous patient-provider partnership, and the clinical need to rely routinely on subjective MUPS assessments that often yield discordant patient and provider conclusions. Contested causation may erode patient-provider trust, test the provider's self-assurance and capacity to share power with the patient, and raise problematic issues of compensation, reparation, and blame. These issues may distract patients and providers from therapeutic goals. In occupational and military settings, the adverse impact of contested causation on the patient-provider partnership may diminish therapeutic effectiveness to a greater degree than it does in other medical settings. Contested causation therefore raises questions regarding generalizability of standard therapies for MUPS and related syndromes to these settings. Future research is needed to learn whether intuitively sensible and evidence-based MUPS therapies benefit occupational and military medical patients who are afforded care in the context of contested causation.

The relationship of modern health worries to non-specific physical symptoms and perceived environmental sensitivity: A study combining self-reported and general practice data

“…When it comes to controversial public health issues, such worries may be amplified by the interaction of multiple factors within the societal context, involving scientific uncertainty, political debate and media attention [9][10][11].…”

A miliőtan története

“…Mindkét esetben rontja a bizalmat, és nehézzé teszi a gyógyítást (ez egyfajta nocebo hatás) Ez kompromittálja az amúgy is bizonytalan kórformák megítélését, illetve terápiáját. Különösen erős ez a hatás a foglalkozási és katonai orvoslás körében Engel et al, 2002 . Egy érdekes kategória az un.…”

“…Lényegében minden definíció megegyezik abban, hogy az orvosilag megmagyarázatlan (fizikai) tünetek (MUPS) olyan tartósan fennálló idiopátiás fizikai tünetek, amelyek elszenvedőjüket orvosi segítségkeresésre vezetik, de egy alapos orvosi vizsgálat után is megmagyarázatlanok maradnak Engel et al, 2002, Looper and Kirmayer, 2002, Page and Wessely, 2003 (kiemelés tőlem). Ehhez tegyük még hozzá, hogy gyakori a magatartás, elsősorban a szociális és társas magatartás megváltozása, a beteg izolálódása személyi környezetétől, illetve az életvitel jelentős megváltozása is.…”

“…információkerülés, doctor shopping, stb. Engel et al, 2002 . A doctor-shopping tehát a szomatoform zavaroknak nem kiváltója, mint sokan gondolják, hanem sokkal inkább következménye: a szenvedő beteg nem kap megfelelő ellátást.…”

“…Engel -már jóval korábban -a magatartásorvoslásról szóló kiváló cikkében Engel, 1986, Engel et al, 2002 .…”