Thursday, October 27, 2011

Occupy Health

Humanizing Medicine
If you've ever had a great massage, you know intuitively that attention and touch can be very healing. You might also know about trigger points, hard knots in your muscles that massage therapists press, giving temporary local pain in exchange for immediate global relief. Using trigger points became the most effective strategy to cope with my chronic neck pain. But why is it I had to teach myself about trigger points? Why is research on trigger points so immature? Why isn't it covered in medical school? As I unraveled these questions, I felt like an investigative journalist on a hot beat, or an anthropologist studying the evolving culture of medicine, technology, and well-being in our society.
Dehumanizing medicine William Osler (1849-1919) has been called the father of modern medicine. He created the current residency system, requiring several years after medical school, because of his belief in the importance of doctors learning by seeing and talking to patients. He was quoted as saying "Listen to your patient, he is telling you the diagnosis." Osler's medicine was curative and pharmacological, focusing on curing conditions that had a biochemical basis. So medicine was not interested in using touch to treat anything, let alone my neck pain. And while the science of anatomy is studied in medical school, it takes a back seat in real-world practice, relegated to physical therapists and masseuses. That said, from Osler's time until the 1970s, physical examinations were a core skill that doctors mastered, grounding diagnoses in the patient's real experience. From the 1970s on, attention and bedside manner were on assault by an increasingly dehumanized medical system. Powerful new technologies discovered in the early 70s like GMO, MRI, CAT, and liposuction transformed medicine, increasing idealism about what medicine could address and demanding greater specialization. Doctors relied more on advanced testing and referral, and less on patient history and physical exam, a skill young doctors today often romanticize about older docs. Our humanity was averaged away and digitized. We became what Verghese called iPatients.
"Evidence-based" or statistical medicine is now the established standard for clinical medicine. Medical students often learn patient treatment strategy in flow-chart-like "algorithms", sorting patients into a given subpopulation bucket for treatment. Many of these buckets, like ulcers or smallpox, were solved elegantly with a biochemical basis and straightforward treatment strategy. Other buckets, as in the case of prostate cancer or inflammatory bowel disease however, gave you an uncertain diagnosis, no cure, and lots of worry.
Big pharma is pushing to "medicalize" every bucket nonetheless. Marketing directly to consumers(DTC), pharma often gives false hope in drugs where an alternative method or life change would have worked better. Good healers know that in some cases, the most effective treatment they can give is attention. But many I know who entered medicine as idealists have emerged as technicians unable to give the time, attention, or holistic care they imagined giving.
Placebo is so retro

Ironically, just after medicine's idealism soared in the 70s, we punctured our idealism in doctors during the 90s with readily available information (of varying quality) from the Interwebs. A doctor in 1981 could say "Take two of these and call me in the morning." Even if the doc gave you empty pills, they had a great chance of working, thanks to the strange powers of the placebo effect. The same doctor in 2011 would be criticized or quizzed endlessly by a patient who understood just enough to be dangerous from a WebMD article. Information has been good for us to understand the uncertainty in our own diagnoses, but it has also reduced our ability to be healed.
Technology has made our workplace more chaotic, adding new levels of stress-related symptoms and diseases, affecting us earlier in our lives. An increasing incidence of cancer during the 20th century has increased our attention towards our environment and sources of our food. Greater awareness of diet or exercise has helped to some extent, but has not cured us. Our awakening interest in new age disciplines like meditation, yoga, or acupuncture offers a lot of promise. But it's not the discipline itself, it's what's at the core -- intuition.

Bringing intuition back As a society, we invested heavily in the rational capacity through the statistics of medicine. It has greatly improved the quality and length of our lives. That said, there are a number of buckets rationalized medicine cannot effectively treat, such as autoimmune diseases or stomach pain, or does not aim to treat or research, like chronic pain. These vague buckets are getting in the way of wellness by diagnosing without providing any positive prognosis. Many younger or more curious doctors are actually admitting this and getting behind treatments like acupuncture that have shown promise in statistical trials, either because acupuncture rocks or because it's the modern-day heir of the placebo effect. Causality is irrelevant if the patient feels better. But continuing to average humans is not going to deliver well-being. While reason is plenty, intuition is scarce, and economics theory would teach you that what's scarce at any given moment is what is most valuable. We need to redevelop an intuitive capacity to address the well-being that today's rationalized medicine can't address. What physical therapists and masseuses and yogis intuitively understand about body tension has to be integrated into our own body awareness. This approach is not statistical although not necessarily illogical. For example, the same yoga posture might reveal tension in your right leg and in my left hip, so we'd have different corrective stretches. Averaging over both of us in a scientific study might be "inconclusive" even though we both healed. So body awareness is inherently esoteric -- each individual learns something totally different from another. Far from providing ironclad diagnoses, yoga teachers train us to use our intuition and listen to our bodies.
This distinction between "rational" and "intuitive" also suggests why research on trigger points has fallen through the cracks. Doctors are not interested in studying or doing touch-based therapy, and healers don't need a double-blind study to know they are making a difference on their patient. There is some overlap of the two worlds in sports medicine or physical therapy, but even there, studies often slant towards recovery of athletes at their peak, rather than muscle pain in ordinary people.

Trigger fingers There are palpable patterns in the necks and backs of those experiencing stress-related pain that are worth studying. These patterns are the indelible imprint of the anxiety of our unbalanced lives. While I never studied massage, my neck pain has given me an intuitive understanding of trigger points that make for a pretty good massage. The more bodies my fingers touch, the more universal these points seem. I will cover these in detail soon.


Jake Kring said...

Did you know there are only two countries in the world in which it is legal for big pharma to run ads on TV?

eudae said...

@jake - interesting, no i didn't know that! googled it. us and the kiwis...