50 years ago, we hadn’t heard of the Irritable Bowel Syndrome. That’s not to say it didn’t exist. Unexplained illnesses affecting the bowels had been known every since the beginning of medical practice in the Eastern Mediterranean. Only then, and for most of the next 2500 years, they were put down to a combination of diet and stress, aspects of contemporary life, and treated accordingly.
Irritable Bowel Syndrome or IBS was invented with the advent of medical specialisation; not so much as a label for some well defined disease, but more as a semantic umbrella to shelter all those chronic bowel complaints that could not be characterised by such definitive diagnoses as Crohn’s disease, coeliac disease, colitis or bowel cancer.
There is, of course, a positive aspect to this. If we did not have IBS, then perhaps we would not be able to identify and treat those other diseases so well. But it has led to a logistical problem. IBS is more common than any of those diseases by at least one and often two orders of magnitude. Nevertheless, good medical practice directs that all patients with chronic bowel disturbance should be screened to rule out other treatable conditions that could give rise to the same symptoms, no matter how rare these might be. Not only can that lead to anxiety on the part of the patient as they wait for appointments and results, the tests may reveal abnormal results that may have nothing to do with IBS, but may still require further investigation and treatment.
Diagnostic methods have now become so sensitive that they can detect minor ‘lesions’ that may well heal up by themselves. In medical jargon, there are sometimes termed ‘incidentalomas’. We only have to think of the irritations, inflammations, moles or pimples that appear on our skin. The vast majority have no significance at all. Most diseases are self limited; they heal up and go away. Coeliac Disease is said to require a gluten free diet for life, but I have seen several patients, in whom antibodies and villous atrophy have disappeared, and they have been able to return to a normal diet. Colitis and Crohn’s Disease are conditions that can relapse under stressful circumstances and then disappear again. Even cancers can occasionally shrink with no treatment. And, as we all know, IBS can come and go.
In an attempt to restrict over-investigation, Professor Douglas Drossman and successive Rome Committees have worked tirelessly over the last twenty seven years to establish positive diagnostic criteria for IBS* and other so-called ‘functional’ gastrointestinal diseases. These have been revised and then re-revised but they still carry the caveat that before IBS can be diagnosed, other diseases that could cause the same symptoms need to be ruled out. I have banged on about this enough over the years, but with that caveat, it seems to me that the notion of positive diagnosis seems an exercise in hermeneutics; a circular argument.
In Britain, the importance of screening sections of the population for specific diseases came out of The Quality and Outcomes Framework, which was published in 2004 and offered financial incentives for doctors to ensure that their patients were being properly screened and in some cases treated – with statins for example. This exercise has generated no fewer 146 quality indicators, which the best practices should follow to detect and treat the most common diseases (and some quite rare ones) – anything from diabetes to glaucoma and mild cognitive impairment. This initiative, utopian in its scope, has proven very expensive for the health service, leading to more investigation and more treatment, but, for many conditions, little overall impact in terms of survival. In contrast, the quality of life for many patients may be exacerbated by worries they didn’t think they had. Too many people are being diagnosed with pre-disease and treated as if they had disease. It is probably for this reason and not because the population is any sicker that the workload of GPs and other health care professionals has expanded to breaking point.
The Quality Statements for IBS are as follows:
1. Adults with symptoms of irritable bowel syndrome are offered tests for inflammatory markers as first‑line investigation to exclude inflammatory causes.
2. Adults with symptoms of irritable bowel syndrome are given a positive* diagnosis if no red flag indicators are present and investigations identify no other cause of symptoms. (Doctors should consider investigation for cancer or bowel inflammation, but where symptoms would not suggest those conditions, a full blood count and screening tests for inflammation and coeliac disease should be conducted).
3. Adults with irritable bowel syndrome are offered advice on further dietary management if their symptoms persist after they have followed general lifestyle and dietary advice. (General lifestyle and dietary advice includes drinking at least 8 cups (approximately 2,000 ml) of fluid per day, especially water or other non‑caffeinated drinks (for example, herbal teas), restricting caffeinated tea and coffee to 3 cups (approximately 750 ml) per day, reducing intake of alcohol and soft drinks, limiting fresh fruit to 3 portions per day (a portion should be approximately 80 g), avoiding sorbitol, an artificial sweetener found in sugar‑free sweets (including chewing gum), drinks and in some diabetic and slimming products, if the person has diarrhoea, eating 30 g per day of fibre, adjusting the amount of fibre consumed by restricting or increasing certain foods.)
4. Adults with irritable bowel syndrome agree their follow‑up with their healthcare professional.
Thus, in an ideal practice, when confronted with a patient with unexplained bowel complaints, doctors should take a detailed history to check that they have the criteria for a positive diagnosis of IBS, ask about any red flag symptoms such as weight loss or bleeding from the rectum, examine the patient’s abdomen, order screening investigations and go through the patients diet to check it conforms to guidelines – all within 8 minutes, which is the average time for a GP appointment. Notwithstanding any issues we all might have regarding the dietary advice, the whole package is unrealistic, especially as similar guidelines are being issued for the 146 other conditions a GP might encounter.
It is not surprising that too many doctors are spending far too much time trying to follow the guidelines and gain incentives than practising the good sound medicine they were trained to do. What is being lost is ‘clinical judgement’. Gone is the age old established practice of ‘watchful waiting’ or ‘masterful inactivity’. There is no time to observe and listen to the patient or to monitor how the disease progresses; there are too many more patients coming through the door to be screened and investigated. It is a case of ‘effort substitution’ – wise practice is being substituted for screening for everything and it is the patients who miss out.
Over investigation and over treatment may be one side of the medical coin, the other is austerity and a drive to cut costs. Now that GPs are responsible for their own budgets, many doctors are avoiding expensive treatments or investigations even though they might work better. It is time that all financial inducements be removed from medicine, allowing doctors to use their own judgement and practice medicine to the high professional standards, in which they were trained.
One of the biggest complaints, that GPs make, is there is no time to listen to their patients and decide with them the best course of action. But there are signs the Government is having a rethink. In Scotland, the Quality and Outcomes Framework has been abandoned; in England it is currently under review. There is a growing movement throughout the world for what has been alternatively called ‘prudent medicine’, ‘slow medicine’, ‘choosing wisely’ or ‘realistic medicine’. They all mean the same thing: time to consider the clinical context with their patients and come to the decision that is right for them.
It was partly because I was so dismayed by what I could see as the increasing pressures to practice medicine by the book of guidelines, I decided to become a psychotherapist working with patients will medical illness. It gave me the time to listen and try to understand why my patients were ill. Only then could I help them get better. This often meant a change in the way they thought about their illness and in the way they conducted their lives. I often think of my job as being rather like a traditional GP. To my surprise, I have not been hindered by my inability (as a therapist and retired doctor) to order investigations or prescribe treatment. Where necessary, I can always ask colleagues to do that.
*Positive diagnostic criteria for IBS. Irritable bowel syndrome should be considered if an adult presents with abdominal pain or discomfort, bloating or a change in bowel habit for at least 6 months. A diagnosis of irritable bowel syndrome should be considered only if the person has abdominal pain or discomfort that is either relieved by defaecation or is associated with altered bowel frequency or stool form. This should be accompanied by at least 2 of the following 4 symptoms:
altered stool passage (straining, urgency, incomplete evacuation)
abdominal bloating (more common in women than men), distension, tension or hardness
symptoms made worse by eating
passage of mucus.