Upside Down Medicine

What Happened to  Medical CARE?: Upside Down Medicine
                                                 
I was recommended to visit a well-regarded foot surgeon for repair of a dislocated toe, likely incurred while running. At the initial (and only) appointment with him, I was kept waiting 3 hours. When he arrived, he was followed by his surgical residents, and for much of the 15-minute appointment, the surgeon directed his comments to them rather than to me. I did not see him at the surgery center either before or after the surgery. Indeed, I never saw him again. Immediately upon arousing from anesthesia, I was instructed to get up and was placed on crutches after just  5 minutes of training. I was so dizzy I could barely hold myself upright, and struggled extensively with the crutches. I was  nonetheless ushered out the door within minutes. When I arrived home, my foot, still numb, brushed a stair up to the mudroom. The stitches opened, and my wife whisked me to the an ER for a re-do of the stitches. We were not back home until 1am the following day.



Several years later I was scheduled for a colonoscopy. Staff had no interest in my new hypertension or my hypertensive headache. The liquid preparation I was told to take seemed to trigger a significant rise in my blood pressure . I was left to shiver with a throbbing headache for the next 40 minutes, unattended by anyone. I was actively awakened following the procedure by the disinterested physician, whose only message was to instruct me to make another appointment for an endoscopy on my way out .



This is shabby medicine. I’ve seen medicine, to paraphrase Judy Collins, “from both sides now,” both as a patient and a physician, and I firmly believe this kind of treatment is not just deficient, but in fact downright  counter-therapeutic and even harmful. It totally misses the point of what medicine is supposed to accomplish: healing.



When I was in medical school. we were taught the following astonishing lesson by one sagacious professor: “90% of what walks into your general practice will heal itself!” Our teacher was not dissing our profession’s efforts. On the contrary, he was referencing the incredible healing powers of seemingly non-medical interventions: Looking at the patient, acknowledging her, expressing interest in her situation, understanding and empathizing with her pain and being genuinely curious about her stressors as well as her successes.



Patients, myself included, come to their doctor expecting to be healed. This expectation, if properly nurtured and managed by a caring physician, accounts for a good 40% of the patient’s healing.  How else can we explain the healing powers of shamans, folk-healers, and curanderos? These old-time physicians were able to heal certain conditions without the use of lab tests, MRIs, or indeed any background in science.



We can find many examples of the healing power of paying attention to the patient, of attaching, of caring. Consider this. A large and famous study of antidepressants known as the STAR*D Program demonstrated that 50% of patients treated with the initial antidepressant (citalopram) had a positive response and 30% remitted (no longer met criteria for the diagnosis of depression). However, other antidepressant studies, of which there are many, have shown a response rate to placebo pills just a few percentage points less than the 50% response to antidepressants. On the surface, it might appear that antidepressants hardly have any effect at all. After all, placebo pills work almost as well. Not so. Why not? Because in the drug trials the placebo cohort of patients were sitting down and conversing with the researchers, who were showing the same level of interest as they did to those receiving the actual medication. Moreover, like the experimental group, they were given something to take in their mouth which they might well have expected to be the active antidepressant.  This is no gauzy, touchy-feely notion. Proper interpersonal interactions can heal in and of themselves.



Another line of evidence comes from the world of substance abuse. PET scanning, which allows for identification of those parts of the brain which are metabolically active at any given moment, demonstrate that the reward center of the brain lights up when cocaine addicts are given a dose of the drug, Dramatically, the same reward center turns on when the subject is told he is going to be given cocaine. The expectation of the reward is already rewarding!



A wonderful book titled  “A General Theory of Love” (Thomas Lewis, et. al) addresses precisely this topic.  The authors <sup>discuss the biology of human emotions and human attachments. The limbic brain, unique to mammals, is the seat of human emotions, impulses, and attachments. Indeed, the limbic system craves attachment, first and foremost to the mothering (or nurturing) figure of one’s early years. The “limbic resonance” established between the mother and child has enormous and lifelong ramifications for the child, in terms of  the infant learning to regulate emotions, read others’ emotions, and control maladaptive or destructive impulses.  To the point, healthy mother-child  emotional resonance and regulation are also vital to maintaining physiologic (“medical”) health.  Primates, including humans, become not only anxious and depressed when deprived of proper emotional attachment; they also die earlier and more frequently.



Physicians are the ones we look to for healing as well as caring. Tragically, the institution of medicine has drifted further and further away from understanding the healing power of attachment. Medicine now comprises lab tests, CT and MRI scans, and patients passing unseen before the physician’s oversized computer screen.  Rather than attaching to the patient, the physician’s focus is now on whether he or she has checked the proper boxes, or on copying and pasting from an earlier progress note.



Here is a template for medicine as it should be:  Dr. R was my internist several decades back. I made an emergency appointment with him, frightened that the  enlarged lymph nodes I felt in my neck signified a lymphoma, or blood cancer. Dr. R asked a few questions to rule out symptoms of fatigue, weight loss, and others.He palpated my neck and armpits briefly, then looked me squarely in the eye and asked: “Marnin, what is happening in your life?” “Well, I just had my second child, moved my office, and I’m dealing with a lot of stress.” “Marnin”, he said, “it it anxiety you have. Those are nothing but old, matted nodes from prior infections.”He did not order blood tests; he avoided visualization studies; he did not send me to a specialist in his group.



My anxiety immediately subsided. He cured my acute condition. I’m here 40 years later kicking still, and able to thank Dr. R for his help as well as for his magnificent example of the power of human attachment to heal patients.



Human connection does not cure all medical maladies, but it has been the critical substrate of healing for years. Its effects are rooted in science. Medicine’s next leap to the future should renew focus on this essential pathway to healing.</sup>