I am rather puzzled by “High Expectations”, in the September 2014 issue. From the description of the case, it sounds very likely that this was indeed a case of post viral fatigue syndrome (also known as Myalgic encephalomyelitis or chronic fatigue syndrome).
No explanation is given of the basis of the probable possible diagnosis of chronic fatigue or what management was given for the condition. Post viral fatigue syndrome is a common condition probably affecting about 1% of the population. It is not difficult to diagnose as there are clear diagnostic criteria available today and it would be interesting to know whether this patient fitted the diagnostic criteria or not.
They do indeed seem so bizarre to doctors that I feel a misdiagnosis would be unlikely if the criteria were properly used. In addition, in the following paragraph it is stated that the patient “… was convinced that there was a physical cause for his symptoms…” as if this rebutted the specialist opinion.
However it is well-known today that chronic fatigue is indeed definitely an organically-based physical condition. This was clearly shown at the last conference of 2014 in the United States and it is no longer considered acceptable to consider a non-organic basis for the disease.
It is probably a chronic encephalitis but this has not been definitely proven. There is management available for chronic fatigue syndrome. In my opinion, it is indeed negligent to miss this diagnosis in a patient who fits the criteria for it (eg, Carruthers et al 2003 and 2011 – these are the criteria I use). In addition the patient’s prognosis can be adversely affected if proper management including management of activity scheduling is not instituted as soon as possible.
Unfortunately, at least in South Africa, this disease now occupies the same space as mental illnesses did in the dark ages and as multiple sclerosis did at the turn of the last century (“Faker’s Disease”).
Patients generally do not have the energy or financial means to pursue their cases against doctors regarding this diagnosis but in my opinion it certainly should be a source of litigation because of the poor diagnostic skills of most practitioners in this regard, the ignorance about management and the stigma which doctors attach to this disease, greatly increasing the significant suffering of patients.
Dr Elizabeth Murray
Rondebosche Medical centre, Mediclinic Constantiaberg
UCT Private Academic Hospital,South Africa
Thank you for your letter of 21 September, regarding the case report “High Expectations”.
By necessity, our case reports are a summarisation of the actual case, where the documents often run into many hundreds of pages. This does mean that we are only able to focus on the most salient features of the case from a medicolegal perspective.
In this particular case, even after the involvement of a number of specialists, the diagnosis was not completely certain. The claimant alleged a failure to make the diagnosis (probably a variant of chronic fatigue syndrome), as well as a failure to arrange vestibular rehabilitation. This will have been based on the advice of his solicitors and, in all probability, an expert opinion.
However, the expert opinion obtained by MPS on behalf of our member was supportive, as explained at the end of the article. It is important to bear in mind that the standard to be applied here is that of a responsible body of general practitioners, and not any higher, or different, standard.
It is also the case that where there might be more than one school of thought on a particular issue, a doctor will not be negligent for choosing one over the other, as long as the option he chooses is supported by a responsible body of practitioners, skilled in that particular specialty, even if that is a minority opinion.
In this case, the claimant withdrew their claim before the matter came to court, which generally indicates that their solicitor (with the help of their expert) has advised them that their case is unlikely to succeed. Of course, medicine is constantly changing and advancing, and what would have been acceptable practice five years ago may no longer be supportable.
In the context of medical negligence litigation, the standard which applies is, of course, that which applied at the time in question.