Preventive Medicine Column
Dr. David L. Katz
The practice of medicine- and it is, indeed, “practice,” as in the perennial pursuit of perfection that will never be achieved- is most humbling. We are repair people for a human body we did not design, and don’t fully understand. Imagine calling in the Maytag repair guy to service an extra-terrestrial washing machine. That’s us! You are the washing machine.
But on the other hand, the prowess of modern medicine is both captivating, and compelling. We practice in the age of wonder, if not miracle- of MRI and drug-eluting stent; robotic surgery and monoclonal antibody; thermography and Lasik.
Modern progress has been astounding. In the early days of my father’s cardiology career, mainstays in the treatment of myocardial infarction (heart attack) were aspirin, hand-holding, and waiting patiently for the inevitable. Now, failure to abort a heart attack as it’s happening -with drugs or angioplasty- is all but a lapse in medical standards.
Such progress and prowess can be intoxicating, leading us to believe we are mightier than we are. There is peril for patients when modern medicine gets too sure of itself. This past week was a sobering reality check that should, for those paying attention, help forestall any such hubris.
First came a report in the Journal of Neuropathology and Experimental Neurology suggesting that even Lou Gehrig may not have had Lou Gehrig’s Disease! Rather, it’s possible that Gehrig had progressive, neurological deterioration mimicking amyotrophic lateral sclerosis (ALS) due to head trauma. Among other traumas, he was hit in the head by a fastball.
The obvious implication of this report is that the head trauma to which many athletes (and soldiers, and to a lesser extent, others) are subject may have serious long-term health consequences not previously recognized. If some ALS is, in fact, due to trauma- perhaps quite a bit is. Perhaps many other conditions of the brain can be caused by, or at least propagated by, injury.
This is only novel thinking up to a point. Muhammed Ali’s Parkinson’s Disease is widely recognized to be a consequence of his many years of suffering blows to the head. Boxers have also long been known to be subject to a form of dementia named for their trade: dementia pugilistica.
But for me- a doctor who these days specializes in the care of the hard-to-treat- the implications run much deeper. If physical trauma can cause the nervous system to fail, what else can it do? Can it cause chronic inflammation we don’t know how to measure? Can it lead to chronic pain we can’t detect on any scanner? I believe it can.
And if physical blows can take a toll we have overlooked until now, what of psychological blows? Can emotional and psychological trauma induce failures in the immune system, the endocrine system, and/or the nervous system- resulting in chronic pain, chronic fatigue, fibromyalgia?
Second came a report in the New England Journal of Medicine that palliative care for terminal lung cancer patients not only meaningfully improved the quality of their remaining life- but actually extended it! Those of us who advocate for ‘holistic’ care seek out every opportunity we can find to make the case that medical care should treat a patient, not just a disease. The dark side of modern medicine’s technology-driven advances is that the patient may indeed be subordinated to the pathology.
That patients who receive care focused on how they feel wind up feeling better is just more of the same-old, touchy-feely, holistic care refrain. That they actually live longer than patients receiving comparable, state-of-the-art treatment for their cancer is anything but! Effective treatment for a disease, quite simply, does not obviate the need for effective treatment for the person with the disease!
Third, and completing the humbling trifecta, was another report in the New England Journal of Medicine demonstrating that Tai Chi is an effective treatment for fibromyalgia syndrome. Tai Chi, although much used in alternative medicine circles, gets little regard in conventional medicine from either practitioners, or payers.
Fibromyalgia, although now more readily diagnosed than in years past, languishes in the realm of ‘syndromes’ where medicine tends to be begrudging with its respect. By definition, a syndrome is merely a pattern of symptoms and signs that doesn’t quite manage to be a disease. Syndromes can’t be clinched with blood test or scan, and tend to be diagnoses of exclusion.
Each time medical knowledge and understanding advance by even a single step, it tells us something we neglect at our peril, and certainly the peril of our patients: our knowledge and understanding are incomplete. They are subject to such advances. We will know something tomorrow we simply don’t know today.
Such ignorance is a potent goad for medical modesty. How much easier it is when the source of a patient’s pain or fatigue can’t be traced to its origins with a blood test or MRI…to blame the patient, rather than our ignorance. How much easier it is to imply that it must be “all in the patient’s head,” rather than concede it is knowledge that isn’t yet in ours.
Good medical practice is comparably undone by close-minded conviction as by vapid gullibility. Our patients, and the complexities they present, warrant our most thoughtful reflection, our deepest thinking- and our cautious open-mindedness. More than anything, they warrant our humility.
I conclude my response to a couple of humbling reports with a couplet for myself, and my clinical colleagues:
We must resist all inclination to be dismissive, roll our eyes-
for gestating in today’s implausibilities,
may be tomorrow’s Nobel Prize!
Dr. David L. Katz; www.davidkatzmd.com