Friday, August 05, 2005

On mind-body medicine, history, and sugar pills

Do the most fashionable people get the most cutting-edge symptoms? If a medical procedure - any procedure - suddenly becomes possible, is it probable that doctors will start doing it? If we suspect that a placebo will help a patient feel better, should we prescribe it? Medical historian Edward Shorter discusses psychosomatic medicine, past and present:
If we're talking about today, new illnesses appear first among educated people simply because they are more plugged into medical media. These middle- and upper-class people are the first to begin monitoring themselves or their children for evidence of peanut-butter allergies or excessive tiredness. It is from these relatively small social groups that the symptoms radiate out...

STAY FREE!: You've written that patients today are more sensitive to body signals; they're more likely to go to the doctor for something than they would have a few decades ago. What's the evidence for this?

SHORTER: There are surveys by the National Center for Health Statistics with comparable surveys from the 1930s showing that patients are much more sensitive.

STAY FREE!: That's ironic. On one hand people are less trusting of their doctors, but on the other, they are more trusting of medical science because they believe that they can be relieved of every imaginable symptom.

SHORTER: Our confidence in science and medicine is very well placed. It's just a shame there has been a breakdown in the doctor-patient relationship, because doctors are able to help patients with psychosomatic problems if the patients are willing to trust them.

STAY FREE!: You've said that most of the things people visit their doctors for are psychogenic.

SHORTER: At the typical family practice, about half of patients' complaints are not the result of an organic disease; they are the result of some sort of mind-body interaction. That's what drives family doctors crazy--they see all this hysteria.

STAY FREE!: There needs to be another word than hysteria. It's so stigmatizing.

SHORTER: Of course, doctors don't use that word with patients. They'll say "functional," which means "not organic..."
A fascinating interview from 2003, via Mindhacks. Well worth reading for his thoughts.

We part ways with our views about placebos, though:
STAY FREE!: Didn't doctors used to prescribe sugar pills?

SHORTER: Yes, it was once very common for doctors to prescribe a placebo, and that went on for decades and decades to the benefit of patients, I might add, because placebo remedies really do work. You destroy their effectiveness when you tell a patient, "I'm prescribing baking soda." I have a lot of problems with a particular version of bioethics we have today that says it's unethical to lie to patients. If we can help patients by lying to them, then by all means, lie to them.
Do we really help patients by lying to them? When he says "placebos really do work," we need to look at what sorts of benefits they provide. They validate the non-psychic origin of a complaint, and provide relief from the outside. ("I'm not just anxious...I have a bona-fide illness, and this pill will take care of it!") Placebos also help doctors, obviously. Sugar pills can halt a string of frustrating calls and office visits, and make a doctor look like a genius to a satisfied patient.

But placebos can't help patients learn the reality of their situation and find ways to cope with it. That's the sort of "help" that we psychiatrists try to provide.


Blogger blondzila said...

And what about the mind/body interaction where palpable pathologies are created? E.G.: patient gains excessive weight (in the obese range) as a result of overeating that was a subconscious attempt to cope with an ongoing stressful situation in life (let's say a husband that abuses her children). From the weight gain, a number of bona fide pathologies develop. In addition, when she is in hospital getting her (foot, bunions, gall bladder, slipped disc, ulcer) operated on, it is the only time she is able to focus on herself, getting special treatment. The pathology is rewarded. Placebos in this case simply assist in the maintenance and furtherance of her neurosis.

What do you think, doc? Not a bad analysis??? :-)

6:22 AM  

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