The commonest error in these patients is procedural rather than intellectual. The clinician suspects a disorder of gut-brain interaction, orders tests to be safe, tells the patient the tests are normal, and by doing so teaches them that nothing has been found. The next visit starts from scratch, usually with more tests.
Invert the sequence. Name the diagnosis at the first visit using the symptom criteria, which are positive criteria and not a diagnosis of exclusion. Say which alarm features you are looking for and why their absence matters: unintended weight loss, gastrointestinal bleeding, iron deficiency anaemia, a family history of colorectal cancer or inflammatory bowel disease, onset after 50, nocturnal symptoms that wake the patient. Then order the small number of tests that are actually indicated, and say in advance what a normal result will mean.
The sentence that does the work is the one given before the tests, not after: these tests are to exclude a short list of specific conditions, and normal results will confirm the diagnosis I have already made rather than leave us with nothing. Patients told this are markedly easier to treat, because the consultation that follows can be about management instead of about what else might be wrong.
- State the diagnosis by name at the first visit, using positive symptom criteria
- List the alarm features explicitly and record that you have checked for them
- Tell the patient what a normal test result will mean before the test is done
- Resist repeating a normal investigation for reassurance; it reliably reduces reassurance rather than increasing it
- Ask about the symptom that bothers the patient most and treat that, rather than the full symptom list
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