Heroes Not Zombies

Surgeons are doctors of the visible par excellence. They explore their patients’ bodies to find lesions, swellings, ulcers, abnormal pieces of tissue or abnormal organs. My trainer taught me “If you send your patient to a man with a knife he’ll use it”. That was good advice. When you present your symptoms to a surgeon he or she will try to find a lesion which might explain them. They use their eyes and their hands, and, increasingly they use technology to explore the inside of the body, and discover the lesions which can’t be seen with the naked eye. Their treatments, as you might expect, are similarly very physical, very visible. They use knives, lasers, needles and thread.

Physicians are also doctors of the visible, but their concept of the lesion which might explain your symptoms can be much more diffuse than that of the surgeon. Physicians increasingly focus on the physical changes which can only be revealed by technology. Not just the imaging equipment loved by the surgeons, but also the vast array of lab tests which reveal quantities of particular molecules circulating inside their patients’ bodies. They even explore the molecules within DNA to find the “causes” of disease. Physicians, in other words, as just as concerned about the visible, the physical, the measurable, as surgeons are. Their treatments similarly match their understanding of illness. Just as surgeons use highly visible, physical tools, so physicians use those tools which are visible – drugs. This is different from the surgical toolkit of course because although a tablet, or a cream, or an injection might be very visible, the actual tools which do the job are the molecules which the visible “medicine” contains. You can only make these tools visible by using technology. The molecules can’t be seen with the naked eye.

Psychiatrists are doctors of the invisible. They explore the subjective content of human minds. You can’t see anxiety, depression, compulsive thoughts or psychoses with the naked eye and you can’t find them with technology either. These symptoms are like the wind in the trees. You can only see the effects of the symptom, not the symptom itself. It’s interesting to see how psychiatrists have used both visible and invisible tools to address these invisible diseases. The main invisible tool they use is language. All the psychoanalytic and cognitive behavioural approaches are based on listening and talking. The patient tells their story, the therapist interprets it and works to enable the patient to tell a different story, one which is healthier. But psychiatrists also use drugs the way a physician uses drugs, either to modify behaviour, or to alter levels of brain chemicals and in so doing alter behaviour. The most physical/visible part of psychiatric treatment is brain surgery, removing or inactivating parts of the brain to alter behaviour or experience.

I’m a doctor of the invisible but I’m not a psychiatrist. My everyday work consists of listening to patients’ stories in order for them not just to reveal the subjective contents of their minds, but of their bodies too. I’m interested in such invisible phenomena as pain, nausea, light-headedness, itch, numbness, well-being and exhaustion, as well as more mental ones such as depression and anxiety. Because I specialise in the invisible, in most cases I refer visible manifestations of disease to a colleague, but in acute situations I’ll initiate physical treatments myself. However, most patients who are referred to the hospital where I work have already had the visible addressed and are referred because their continuing distress or disability caused by the invisible. It’s interesting that the treatments I use, homeopathic medicines, are also invisible. Not just invisible in the way that a drug is invisible until analysed, homeopathic medicines don’t reveal their characteristics to either the naked eye or to technology. They only reveal their characteristics to the individual patient. It’s the change in subjective experience which shows the effect.

I’ve compartmentalised here to make a point. However, the reality is that most doctors deal with both the visible and the invisible. Most doctors are concerned not just with the lesions which might be found, but also with the lived, inner, subjective experiences of their patients. It’s just that most doctors are trained with a biomedical model in mind, and that gives a huge priority to the physical, the visible. With the growth of understanding around concepts such as biopsychosocial models, phenomenological and narrative approaches, and so on, we are beginning to pay more attention to the invisible, to patients’ lived experiences. It’s not only the physical that matters, and subjective experience is neither irrelevant, nor is it less important than the presence of a lesion. What we are beginning to understand is that the relationship between the visible and the invisible is a non-linear one, and that the presence or absence of a lesion may or may not be relevant to a patient’s actual experience. The logic and the science of human functioning demands that we should at least redress the imbalance between the visible and the invisible in health care, and in many cases, actually reverse the current situation.

It turns out that what is most important in health care is what the patient tells the doctor, not what the doctor tells the patient.