Heroes Not Zombies

A study of medical students in Brazil found that 38% of them had at least 10 of a list of 63 depressive symptoms during their internship years –

Affective symptoms represent the core symptoms of a depressive mood, based on students’ reported levels of sadness, dissatisfaction, episodes of crying, irritability and social withdrawal. The cognitive cluster assessed pessimism, sense of failure or guilt, expectation of punishment, dislike of self, suicidal ideation, indecisiveness and change in body image. Finally, the somatic cluster assessed the presence of slowness, insomnia, fatigue, loss of weight and loss of sexual interest

Such study results are both shocking and no surprise. A junior doctor’s job is highly stressful for a host of reasons. Pretty much every doctor I know would identify with the symptoms highlighted by the Brazilian researchers. When I read this I wondered these two things –

Does such a training make for better doctors? I doubt it. Such an experience is something to be survived and whilst I’m well aware that difficulties and even illnesses can teach us a lot about ourselves and even contribute to our growth, I wouldn’t recommend dysfunction and disease as the best teaching methods!

These experiences are more likely because we pay insufficient attention to the humanity of the real people who are health carers (the parallel to paying insufficient attention to the humanity of the real people who are patients). We practice a system of medicine which is focused on tools and techniques, not least on drugs, because our clinical focus is disease (lesions, pathology), not health. The rise of something called “Evidence Based Medicine” has made this worse. “EBM” is based on the statistical analyses of experimental “controlled” trials. The design of these trials is intended to “control for” the human factors in order to reveal the specific treatment factors ie the effects of the prescription, not the prescriber. It is virtually impossible to read in any significant clinical trial who the actual carers were. It’s as if they don’t count. They are irrelevant. But they aren’t. And until we change our values in health care and give a higher priority to the fact that health care is delivered by real people to real people then we aren’t going to change the outcomes.

Is it impossible to imagine a medical training which doesn’t cause depression in a third of the people who embark upon it?

The focus of medical practice is the lesion. It’s the lesion, the abnormal cells, tissue, organ or body system which IS the disease. This is the pathological approach to health. It gives pre-eminence to physical, “organic” abnormalities, names them (diagnosis) and then seeks to directly address those abnormalities with treatments. The treatments are primarily surgery to physically remove the lesions, and chemicals (drugs) to act against the lesions (or, in the case of infections, to act against the infecting organisms).

This approach works well for most acute disease and for clearly identifiable lesional problems. In fact, the more localised the problem, the greater the success of this way of working. However, there are at least two major difficulties. Firstly, the more complex a disorder, the harder it is to identify a “lesion” which is the sole cause of the patient’s illness. Secondly, there’s the difference between objective findings and subjective experience. Studies of symptoms have shown clearly that there is no direct linear relationship between lesions and symptoms. Not everyone with the “same” lesion (same diagnosis at same stage of disease) has the same symptoms or the same symptom severity. And, a person can have debilitating or incapacitating symptoms without lesions.

Here’s a study which highlights the other side of this coin – people can have lesions without symptoms. In this study, people with abnormalities in their MRI scans typical of Multiple Sclerosis but without any symptoms of MS – in other words where the findings were by chance while investigating some other problem – were followed up. 30% of them had developed symptoms of MS within about 5 years, but another 30% showed more lesions on the scan within 5 years but still no symptoms of MS. The researchers ask the question – does someone have MS if they have MRI-revealed lesions but no symptoms whatsoever? They argue a definite NO.

“Diagnosing a patient with MS has serious psychosocial and treatment implications, and physicians have an obligation to follow appropriate criteria in making the diagnosis,” Bourdette said. “Patients must have symptoms to receive a diagnosis. This study sets the stage for establishing a process for evaluating these patients and following them to help determine the risk of developing MS. Until then, we should not tell them that they have MS or treat them with disease-modifying therapies. For now, it’s best to remember the wise advice that we ‘treat the patient, not the MRI scan.'”

Read that conclusion carefully. They are arguing that we should address people not lesions. If we fully take that on board, there are significant consequences for the way we provide health care.

The placebo effect is much misunderstood, seriously under-researched and full of peculiarities. I must admit I’ve assumed that the placebo effect is the body’s self-healing effect. I’ve always thought that’s an important point to make because otherwise people tend to think of the placebo effect as some kind of trick. Whatever it is, it’s real. Symptoms can be modified or even removed, and the “nocebo” effect (that’s the one where harm is caused) can cause real illness. It’s not a pretend effect, even if the intervention is deliberately a pretend one!

However, I’ve just read a short article on the Edge, where a psychologist muses about the placebo effect and raises an issue I hadn’t considered. If the placebo effect is the self-healing effect, why doesn’t the body just get on and do it without the placebo? That’s a good point. Where’s the advantage in waiting for a push? In the article, Nick Humphrey considers the phenomenon from an evolutionary biology perspective and there’s something in what he says, but I’m left with the nagging doubt that whatever the placebo effect is, it IS NOT the self-healing effect. It might be related to the self-healing effect. It might even have its impact by provoking the same, or similar pathways to the self-healing effect. But maybe it’s distinct and different from the placebo effect, not least in it kicking in and getting to work without the need for an external push.

We tend to use such concepts in un-thinking ways. One of the tricks we use to stop our thought processes is to name something and in so doing convince ourselves that we now KNOW it. It’s not true though. Sadly, often when we name something, that naming stops us from thinking – especially if the naming is judgemental. (I think it was Wendell Johnston, the General Semanticist, who said “Judgement stops thought”) After all, what exactlly IS the placebo effect? Spontaneous healing? The natural capacity to recover? A statistical trick? And what IS the self-healing response? How DO people get well? We know some of the components and pathways eg inflammatory responses, the immune system, various hormones and so on, but can all these components be considered together to constitute something called the “self-healing response”?

The answer is…….we don’t know. But don’t you think it would be a good thing if we did? (fields of research such as psychoneuroimmunology and psychoneuroendocrinology are exploring these questions – google them and see what comes up!) If we understood the self-healing system then we could develop the healthcare interventions which were not only designed to promote healing but which actually did stimulate and support it. Why do we concentrate on “disease management” and “symptom control” instead?