Doctors don’t listen to us. That’s one of the reasons for the growth in
complementary medicines. No matter what their medical benefits, they treat
patients as individuals and not just the sum of their parts. What concerns
me is that by not listening to patients, doctors and other health
professionals are not only making patients feel excluded, they are missing
out on information about their history that could reveal the true root of
their medical problem.
One bestselling textbook for medical students pays lip service to the
doctor-patient relationship, telling doctors to indicate to the patient that
they recognise their experiences. Then it explains why: “Otherwise the
patient may tend to believe that the clinician has not got things right,
which increases the risk of the patient not adhering to the recommendations
that follow.” In other words, it makes it more likely that the doctor will
be obeyed.
It wasn’t always like this. Just before the Second World War doctors were
lamenting how the study of disease had begun to overshadow the study of the
patient. They recognised that illness was not an isolated physical problem
but something that concerned the whole person and his or her relationships
with others. Then, but not now.
Now patients are shunted from consultant to consultant, each one unable to
follow a patient for long, removing any possibility of learning about their
ways of coping, reacting and dealing with their lives. The patient is
alienated in a chain of medical procedures, and any chance of studying the
relationship between illness and the person as a whole has been lost.
Until the mid1950s, it was not uncommon for a psychotherapist or psychiatrist
to receive referrals from a dentist. Yet today this would be a newsworthy
event. What happened? In a series of papers in learned dentistry books and
journals in the 1940s, psychological factors were recognised as bringing
about changes in the saliva and gums that encourage bacterial activity.
Medical students, for example, have higher rates of dental decay after exam
time than at other less tense moments. Nighttime gnashing of teeth has been
linked to a psychological state in hundreds of studies.
Yet, today, teeth problems simply mean a trip to the dentist. Case closed.
Does the patient lose out here? I heard about a dentist who diagnosed
constant clamping of the jaw at night in a patient who was an artist, a
painter. The dentist advised on dental procedures but didn’t ask any
questions of the patient. So he was unaware that the symptoms had started
when the painter knew that a canvas she was particularly attached to was
going to be sold. Once she realised that it was her wish not to part with
the painting that produced her jaw clamping, the nocturnal symptoms
disappeared.
It’s a similar tale with eyes. Psychiatrists once received many referrals from
ophthalmologists, yet today this would be seen as bizarre. In 1960, a paper
in Psychosomatic Medicine estimated that between 40 and 100 per cent
of recorded eye disorders were influenced by psychological factors.
Intraocular pressure, for example, can be associated with states of anxiety,
and may influence conditions such as glaucoma. But today, drug treatments
are applied almost automatically.
The move away from listening to patients to looking at bare physical facts is
reflected in the way that we now regard the only authoritative research as
being about numbers, not people.
In America and Britain research is almost exclusively to do with statistics,
and patient stories are dismissed as being “anecdotal”. There are remarkable
differences between the styles of the Anglo-American and European
publications. In the course of researching my book, Why Do People Get Ill,
I waded through pages of mathematical equations and statistical calculations
in Anglo-American journals, and found not one single piece of reported
speech from a patient. In contrast, I came across some Swiss conference
proceedings where there wasn’t a single graph, chart or number, just
detailed case reports of individual patients.
Such major differences in scientific style almost guarantee that the Swiss
research will not be taken seriously, if read at all, by an Anglo-American
audience. A recent survey of psychosomatic literature on pain research in Psychosomatic
Medicine found that since the 1960s, not a single clinical case had been
published.
So we seem to have two fundamentally different ways of looking at patients.
One is to study them by the laws of statistics and averages. The other is to
study them as individuals, with stories to tell.
What do the statistical methodologies tell us about illness? As the
philosopher Henri Berg-son said, it is unlikely that anyone analysing
thousands of buckets of water from the ocean will learn much about the
tides. What you learn depends on what you ask in the first place. And if we
ask exclusively in the area of what is “measurable” we may be missing
something very important. It is just like G.K. Chesterton’s story of the
drunk found searching the ground beneath a street lamp. When asked what he
was doing, he replies that he is looking for a lost coin; a coin, it
transpires, that he lost in the next street, but a street too darkly lit to
search in.
Even mental states that would seem to defy quantification have been deemed
fair game. What do you learn from a questionnaire that asks questions such
as: “Would you rate your childhood as (a) unhappy, (b) fair, or (c) happy?”
Aside from the fact that a framework of vocabulary is being imposed on the
patient, can we assume that people know what they are saying? It can involve
truth, lies and, most importantly, self-deception. Questionnaires which
supposedly come up with measurable answers show only a specific style of
responding and do not assess how human beings repress, deny and rewrite
aspects of their lives.
If one study found that 54 per cent of city dwellers would donate a kidney to
an unrelated stranger, is this really an objective piece of information
about donation probabilities or about the way people wished to be perceived
by the person interviewing them? A recent cardiology study said that “one
patient (0.7 per cent) developed somatic contraindications for a heart
transplantation”, but apart from knowing that they represented 0.7 per cent
of the total, we learn nothing more. Not who the patient was, not what they
said, or even what the “somatic contraindications” (physical reasons for not
having the operation) were. It reminds me of the ironic comment made by a
doctor in the 1950s: “The patient recovered and lived to be a statistic in a
published report.”
So we have two fundamentally different ways of viewing the world — one
exemplified by the doctor, and one exemplified by the psychoanalyst. One
favours statistics and does its best to remove all human subjectivity that
cannot be measured. The other gives priority to the nonquantifiable aspects
of human life. The latter approach raises complicated questions. How can the
smoker with heart disease measure a craving for cigarettes? How can the
migraine sufferer overly involved with her parents quantify her attachment
to them? They can’t, but the issues need to be addressed all the same. It
would be easier just to measure the amount of soya in their diet. But much
less revealing.
Why Do People Get Ill (Hamish Hamilton, £16.99) by Darian Leader and
David Corfield is available at £15.29; 0870 1608080, timesonline.co.uk/booksfirstbuy
How one woman’s experiences made her ill
Mandy was advised by her doctor to follow a stress-management course after
work pressures seemed to badly aggravate her symptoms of lupus, an arthritic
disease that affects the joints and skin. She had felt the pressure of
having a new manager at work and a house move. It seemed she had too much to
cope with and this was wearing her down and making her symptoms worsen.
The course was helpful, but although her symptoms became less acute, they soon
returned just as strong as before when she returned to work. Then, a year
later, psychotherapy began to clarify what lay behind her stress. Her
illness had first been diagnosed when she was in her early thirties.
Her parents had separated when she was 11and she had been brought up by her
mother She married a boy she had been friends with at school and moved out
of the maternal home to a small flat with her husband.
At this point, the father, who had shown no interest in her apart from sending
the occasional birthday card, announced that he intended to visit.
Mandy had a great deal of difficulty in describing the subsequent encounter to
the psychotherapist. Her father had shown up much earlier than expected,
before her husband came home, and she had been alone with him in the flat.
She felt awkward, unsure of how to behave. It was from this time onwards
that she complained of odd sensations in her body, sensations that were
later to be confirmed through immunological tests as lupus.
The psychotherapist noticed that when she spoke of her physical symptoms,
would often use the same words to describe the scene with the father. It was
as if her body had been stuck at the point she was most aware of his
proximity when alone with him in the flat. And it was this sense of
proximity that also characterised her new work situation. The manager had
reorganised the office, insisting that she stay on to help him after normal
office hours.
For Mandy, the problem was the feeling of unbearable proximity. Being alone in
the office with her boss evoked the scene with the father and the sense of
enigmatic, inexplicable menace. Unable to make sense of this or know what to
do in the face of this impossible proximity, her body responded with an
intensification of symptoms.
Extracted from Why Do People Get Ill (Hamish Hamilton, £16.99) by
Darian Leader and David Corfield, available at £15.29; 0870 1608080, timesonline.co.uk/booksfirstbuy
Quote "It wasn’t always like this. Just before the Second World War doctors were lamenting how the study of disease had begun to overshadow the study of the patient."
Just before the second world war we didn't have an NHS. Maybe the problem is that nowadays doctors figure we don't pay them, so we don't count.
Lynne, Nottingham,
How true it is that statistics rule and define how we are treated by Drs etc now. I have been trying for over a month to find a cardiologist who will at least have some knowledge of a complementary approach to care and treatment but despte trying many angles I have not managed to come up with one. Where does this leave those who wish for a different approach than intervention according to government targets and statistics? We are failing those who want to help themselves rather than/or as well as, ask the doctor.
J Harvey, Wakefield,