Steven Reid and colleagues (Reference Reid, Wessely and Crayford2002) have introduced a welcome addition to the UK literature on somatisation with their clear demonstration that unexplained symptoms may be associated with significant use of secondary care health care resources. They emphasise a key point, repeatedly demonstrated, that somatisation is expensive for health care systems. However, their report may tell us more about the behaviour of doctors and health care systems than the behaviour of patients.

By selecting only frequently attending patients, they have controlled for the most important variable in cost of out-patient care, the cost of out-patient attendances. Their own figures show that the costs of attendances represented 74.5% and 85.9% of total out-patient care costs for somatising and non-somatising frequent attenders, respectively. They refer to a major US study (Reference Escobar, Golding and HoughEscobar et al, 1987) which demonstrated very high rates of use of secondary care medical resources among patients with separately diagnosed somatisation. By controlling for attendance in their study design, they have almost certainly diluted the apparent impact of somatisation on secondary care use in this sample — an impact they rightly emphasise.

For a significant number of these frequently attending patients, negative investigations were followed by a repeat of the cycle. Those with repeatedly unexplained symptoms were designated ‘somatisers’ by the authors, implying a disorder in the patient. The medical response to these symptoms may in fact be as important in explaining continued resource use. The reasons why doctors behave in these characteristic ways are less than clear — our inability to live with uncertainty, our unwillingness to go with our judgement. Recent attempts to emphasise the importance of the issue are welcome (Reference Bass, Peveler and HouseBass et al, 2001), but until we more clearly understand doctors' behaviour when faced with these patients, we may remain simply counting the considerable costs.