A prospective study of dyspepsia was carried out in a primary referral hospital between 1974-1987 including 1540 patients of whom 1433 were seen as outpatients. The study protocol was agreed in advance and a structured questionary was used to elicit relevant clinical information: up to three diagnoses were permitted for each patient. The commonest principal diagnoses were duodenal ulcer (26%), functional dyspepsia (22%), and irritable bowel sydrome (IBS) (15%); alcohol related dyspepsia (4%) was as common as gastric carcinoma or symptomatic gail stones. Multiple diagnoses were common (31% given two diagnoses, and 6% given three) so that in ali 2111 diagnoses were given to 1540 patients; the functional disorders (IBS and functional dyspepsia) considered together accounted for 39% of ali diagnoses made. Whereas organic conditions were diagnosed by clinicians with confidence (63-98% considered 'certain'), even when given as the principal or first diagnosis IBS was considered 'certain' in only 61% and functional dyspepsia 48%. The demographic symptom data, together with information on tobacco and alcohol use, and work lost are described in detail.
In this paper, the consequences were there greater autonomy in nursing practice, are considered. Autonomous practice implies accountability which entails both personal and professional responsibility: a personal responsibility to endorse ethical conduct consistent with professional practice; and a professional responsibility to exercise discretionary powers to the ultimate benefit of the patient. In this context, discretionary responsibility implies: recognizing a patient's wants may not be consistent with a patient's needs; abstaining from collusion with noncompliant patients; supporting the patient's right to refuse treatment only after full psychological exploration; understanding the psychological ramifications of informed consent from a practitioner and recipient point of view; maintaining appropriate personal and professional boundaries; and fostering collegiate relationships with the medical fraternity grounded on egalitarian principles. The author provides a philosophical and psychological analysis of responsibility in an effort to achieve a deeper understanding of the relationship this has with the concepts of 'freedom' and 'accountability'.
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