Wednesday, July 20, 2011

more on medicine

A few months ago I came across this outstandingly and amazing and fabulously terrific article from a few years ago in the New Yorker. (I don't know how I missed it the first time around in 2008, but my god I made a huge mistake in doing so). In the article Gawande talks about the failure of conventional medical wisdom to explain things like chronic itching or sensations in phantom limbs, in heart-wrenching—and also somewhat terrifying—fashion. He starts to hint at how a not-really-so-recent-anymore revolution in cognitive psychology—suggesting that our perception of bodily sensations is much more brain-directed, or "top-down," than we intuitively believe—is juuuuust barely starting to influence medicine, where that influence is long overdue. The article will fascinate almost anyone but it resonated especially with me due to my history of chronic pain that was for years grossly mismanaged and misdiagnosed—at great cost—by dozens of doctors. If you haven't read the article, do yourself a favor and read the article; it's worth half an hour of your time.

Today I read this article by Thomas Freedman in this month's Atlantic. It's pretty decent, but can summarized much more easily: Alternative medicine, despite its consistent failure to establish its worth in placebo-controlled, double blind studies, is gaining acceptance in medicine because of the failure of the traditional treatment model for many of today's prosperity-driven chronic illnesses. In other words, many people seem to (or at least think they do) benefit more from a genuine interaction with a caring practitioner who discusses the person's overall well-being, than from a drug that tests marginally better than a placebo, even when the ultimate treatment is completely useless. There are, of course, a number of reasons this might be true, but the article focusses on the importance of the doctor-patient relationship, and how the difference in that relationship between alternative practitioners and traditional doctors is dramatic.

Well, then, my reactions! The two articles have some common threads. First, when it comes to lots of common medical problems (as well as other, less common ones), traditional medicine is a bit of a disaster. People get anxious, have aches and pains, digestive problems, skin diseases, and we really don't understand the mechanisms behind either their waxing or waning. We treat them with drugs or other interventions—at great cost—but on the whole, after all the money we spend, we see only modest improvements in many of these conditions, if any, and again, we have little understanding of how or why these improvements happen. M., the woman with the insatiable itch in Gawande's article, is an outlier, but her story is instructive all the same.

Yeah, I know, I've said all that before. Along those lines, though, the Atlantic article really misses the sense of bewilderment that its New Yorker counterpart captures brilliantly. It's easy for us to blame poor diet and lack of exercise for our medical problems, as Freedman does on multiple occasions. But what happens when we eat right, exercise often, and still feel terrible? In this respect, alternative medicine sometimes shares traditional medicine's liability in its incessant search for an intervention or cure that isn't always there.

Of course, that reaction is based largely in personal experience as well, so take it or leave it. A better diet, exercise, and a supportive doctor of any kind probably would help a lot of people with their medical woes, but it sure didn't help me. Those who know me well know I'm a big proponent of mindfulness meditation—which Freedman brushes over and Gawande doesn't mention—not as a cure for illness but as a different approach altogether, and one that has a solid empirical backing. A brief web of science search reveals hundreds of studies, reviews and meta-analyses (oo fancy) showing support for mindfulness-based interventions in controlled studies.

Now interestingly I couldn't find any studies on mindfulness that were double-blind, even though in principle, they could be, since the practice of mindfulness doesn't really depend on interacting with a doctor, or interacting with anyone. Traditionally it's taught and practiced with a doctor, or meditation guide, and often with a group of people, but in my case it has been effective—dramatically so—without any outside help at all, but merely from reading. So how bout it medical community


  1. Several comments that probably precisely echo whatever I said last time you wrote about this article:
    1. I think a lot of the angry skepticism toward alternative treatments comes from the logical fallacy that many people have that basically says that since traditional (ie evidence-based) medicine can't perfectly manage all problems, it is worthless for any problem. There is nothing more frustrating than patients who decide that since neurology hasn't cured their chronic pain, they might as well stop taking their hypertension drugs too. I'm not implying that you fall into this category, being generally a much more reasonable person than that, but it is very easy to slide from "traditional medicine doesn't fix everything" to "traditional medicine is bad" to, weirdly, "'natural' medicine is automatically good."
    2. This is all terribly compounded by the (I think) unfair rap that medicine has picked up, whereby regular doctors only care about drugs and surgeries and fancy treatments and don't believe in noninvasive, conservative treatments like diet, exercise, physical therapy, meditation, what have you. This is just plain wrong. It would be anathema in medicine to give someone a bunch of drugs without exploring the possibility of managing them with other, clearly less problematic measures first. The issue is that many, many, many people are TERRIBLE at complying with conservative regimens like diet and exercise. In the situation where someone who has diabetes that could easily be managed by not having a terrible diet, but the person simply isn't changing their diet, the only responsible thing to do in that scenario is give them some medicine. They are probably going to do poorly because they are failing to take ownership of their health and drugs can only do so much. But it's not the drugs's fault, it's the global picture.
    3. Along those same lines, often the problem with promising treatments like PT and mindfulness meditation are simply that they require immense motivation and commitment. This is just not realistic for many people. (I had this thought when reading that Atlantic article -- of COURSE people love acupuncture, where they just chill out and then get a massage. Practicing meditation is much harder, and will subsequently always be less popular and less effective as a population-level solution, in my opinion).
    4. All of that said, I appreciate the point about making people feel weirdly responsible for their own diseases. I think this is definitely as much a problem among enthusiasts of so-called natural practices as among regular western medicine (since so much of it is about achieving ever-increasing levels of personal purity and well-being, suddenly having a legitimate diagnosis can be terribly destabilizing to that worldview). I think it would be great if more practitioners bothered to directly address this in sick people.

  2. Sarah: So what about double-blind trials of effectiveness of mindful meditation? If for no other reason, evidence it works (for "committed" people) might convince traditional practitioners to try it on apparently uncommitted. Remember that 10 years ago many Western medical folks doubted that poor Africans could follow an HIV/AIDS treatment regime.

  3. @sarah, yes I agree on all counts, as only a fool wouldn't. I have no doubt that when you are doctor you will practice according to the noble principles you have set out, but I have no doubt that many many doctors don't live up to such principles, as in fact i have experienced many times. hopefully times are changing, and it seems they are, but i suspect it's happening too slowly!