E-Book, Englisch, 200 Seiten
Roth The Me in Medicine
1. Auflage 2018
ISBN: 978-1-7322584-1-9
Verlag: Changing Lives Press
Format: EPUB
Kopierschutz: Adobe DRM (»Systemvoraussetzungen)
Reviving the Lost Art of Healing
E-Book, Englisch, 200 Seiten
ISBN: 978-1-7322584-1-9
Verlag: Changing Lives Press
Format: EPUB
Kopierschutz: Adobe DRM (»Systemvoraussetzungen)
Autoren/Hrsg.
Weitere Infos & Material
CHAPTER 1 The Downside of Diagnosis and the Need for Disease John’s back pain began to take over his life. It was his first thought every morning when he struggled out of bed. It was what he discussed with his friends. It was the source of fighting with his wife. John had a sense that people began avoiding him. He knew they didn’t want to hear about how crummy he felt. He didn’t want to talk about it either, but he was no longer able to work because of the pain and so he felt the need to justify himself. His wife had lost patience with John. She was an empathetic soul, but couldn’t understand why he couldn’t simply deal with the pain and get back to work. She knew other people who worked with chronic pain. He had become a different person than the one she had married. Once the rock in her life, John now appeared feeble and needy. John had seen several different specialists. Each had promised him that they could make him better and yet nothing had worked. Ultimately, he had been sent to a pain management doctor. While the decision to treat the pain may seem prudent, pain management often functions as a dumping ground for patients who are deemed not helpable. This doctor told John that the other doctors, by not sufficiently treating his pain early in its course, had enabled the growth of a pain pattern. He prescribed narcotic pain medications. At first, the drugs helped, but now John was not so sure. His wife thought that the medications had further “changed” John and this added to their deteriorating relationship. Finally, still searching for both a diagnosis and a solution, John sought out a rheumatologist who told him he had fibromyalgia, an autoimmune disease. While there is no blood test or scan to make this diagnosis, John’s sensitivity to palpation of his muscles was the hallmark of the disease. The rheumatologist confidently told John that he was certain of the diagnosis. He suggested an antidepressant. Although John didn’t want to add another medication, he obliged, secretly thrilled with the diagnosis because, finally, he had an explanation for his pain. His wife and friends had doubted him—he had doubted himself—and now he was vindicated. This is why he couldn’t work. This is why he wasn’t himself. Sure, this was his plight in life, but at least there was a reason he felt the way he did. But, is the diagnosis of fibromyalgia a good thing in this setting? Fibromyalgia is a controversial disease for several reasons. First, no conclusive reason has ever been worked out to explain it. Second, the disease is associated with many bad situations: inability to work, difficult family life, chronic pain, medication addiction, etc. Third, diagnosis is often subjective and, even the objective criteria of diffuse hypersensitivity—the muscle palpitation John described—used to make the diagnosis is fairly subjective. Are there advantages to a diagnosis of fibromyalgia? The disease provides the organizational structure to fund research or to do data analysis. The diagnosis provides Internet portals for patients with similar symptoms to exchange successes with medications, therapies, or other interventions. The diagnosis provides the patient with a sense of vindication. “There is a reason for me to have been complaining all of these years,” John says. Finally, a diagnosis gives the doctor a way of finishing the office visit. Once the patient has been told that the diagnosis is fibromyalgia and that there is no proof and no ideal treatment, there can be closure to the patient’s search for answers and the actual office visit. At the same time, there are disadvantages. Once there is a diagnosis, costly treatments with little efficacy will follow. Some of these treatments will carry with them dangerous side effects, introducing more side effects and more cost. The patient may succumb to the chameleon effect—when patients begin to manifest symptoms of a disease simply because they now think they have the disease. This definitely happened to John, who began to walk slower, bend more carefully, and interpret every ache he felt as part of his diagnosis. He literally became a fibromyalgia sufferer simply because of the diagnosis he was given. Finally, a diagnosis can undermine the normal coping mechanisms that patients form for many of life’s common symptoms, like muscle sensitivity and back pain. If fibromyalgia is not a disease, these disadvantages represent what is known as the medicalization of some symptoms. Medicalization is a process by which conditions and problems that are characteristically a typical part of life come to be defined and treated as medical conditions, allowing them to become subjects of research study, diagnosis, prevention, or treatment. By definition, it is not a good thing. The explaining away of symptoms that are in some cases inevitable (e.g., degeneration) has been associated with the pejorative “disease mongering” that threatens the Me in Medicine and stands to sabotage the facilitation of doctor-patient narratives that are honest and transparent. In this case, the possible medicalization of John’s diagnosis has the risk of undermining his coping mechanisms and redirecting the focus from coping to treating. The world of back pain is a great example of a high demand for, and a need to offer, a diagnosis. While people who experience back pain are subjected to a variety of treatments such as chiropractic, anti-inflammatory medicines, different hands-on therapies, etc., none of the treatments have been shown to be effective when subjected to the scrutiny of evidence-based medicine, which emphasizes well-designed and well-conducted research. Does this mean that we don’t have any good treatments for back pain, or rather, that the diagnosis “back pain” is many different things and thus counterproductive when used as an umbrella term? The jury is still out on this question, but the diagnosis of back pain, its presumed cause in each instance, and the justification to treat reigns supreme, despite the lack of demonstrated efficacy. Now That I Know I Have Dis-ease, I Feel So Much Better I would like to consider the conceptual use of diagnosis as a double-edged sword. Diagnosis provides patients a target to Google. It allows doctors and insurance companies to communicate what is being treated. Adding another statistic to a diagnosis can be used to raise money for research. At the same time, disease can pigeonhole us into inappropriate treatments and burden us with counter-productive beliefs about our health and our limitations—the chameleon effect. Patients’ descriptions are often quite broad and may intermingle and thus confuse one diagnosis with another that has shared symptoms. For example, low back pain is a symptom of both a kidney infection and a herniated disc. Diagnosis is often made in the radiology suite or laboratory rather than at a bedside or in the office. Patients come into an office or hospital and a host of tests are ordered. These studies are admittedly spectacular. But here is what happens: they further distance the doctor from the diagnosis, which takes the personal relationship, the use of narratives, the practicing of cooperative medicine, and the chance to empower the patient away. As diagnosis becomes easier and more automated and more removed from the doctor, we cannot let the concept of diagnosis itself become empowered because that eliminates the Me in Medicine. Our Need to Find a Reason We are wired to have a why. When someone commits a heinous crime, we want to uncover a motive. When a spouse ends a marriage, the other needs to know the reason. When someone catches a cold, they wonder where they got it from or from whom they caught it. Everything is cause and effect, right? Black and white? In medicine, there is a long history of assuming causation after finding a correlation. We, as doctors, have been taught to try and find a diagnosis or explanation in every setting. This is the reason why people are frustrated by new studies that say certain things are bad for health, only to hear a study a year later that reverses that information. This shows that we know that correlations are not the same as causations, but we continue to confuse the two. For instance, initially a correlation between colds and cold weather may be noticed because having a cold seems to occur more commonly in the winter. However, with the knowledge that a cold is caused by a virus, we can understand that in cold weather we tend to be crammed together indoors allowing for the transmission of the virus. Therefore, causation and correlation are not one in the same thing. As patients, our desperation to have a “reason,” is similar to the desperation of doctors to give one, and so we continue to spin our web to distract us from the truth: more times than we think, there is no cause, or, at least, none known. There isn’t always black and white. We must learn to be comfortable with shades of gray. This gray area is important because, while it is true that establishing a cause can be a powerful conduit to better treatments which is part of the fabric of progress in medicine, confusing correlation with causation does just the opposite: creates confusion and overtreatment. Nortin Hadler, M.D., Professor at University of North Carolina School of Medicine, refers to the pain that John was feeling as a predicament, which is neither cause or effect nor black or white. A predicament implies that there is a choice to be...
