I just found this article by Dr. Muhammad Yunus entitled "Suffering, Science and Sabotage". I think he has some GREAT things to say. He basically criticizes so much of the medical profession that depends only on Evidence Based Medicine. I ended up putting in more than I planned to, but I like so much of what he said. I think he "gets it". What do you think? *************** SUFFERING Cassell (2) states that modern medicine has, at best, an ambivalent attitude towards suffering and that suffering is an embarrassment to currently practiced medicine. In Cassell’s view, “suffering can be defined as the state of severe distress associated with events that THREATEN THE INTACTNESS OF PERSON” [emphasis is mine]. Distress or pain per se, according to this definition, does not necessarily cause suffering. Many ailments cause much distress or pain, such as tooth extraction, a viral infection, or the fracture of a bone, but patients are able to rationalize that they are most likely to recover from these conditions, and their overall sense of intactness remain unchanged. The patients comfort themselves by thinking that these conditions are not serious in the long term, and they do not experience a sense of irretrievability. Thus, pain and suffering are not synonymous. It also appears that acute conditions are not necessarily immune from suffering, such as an acute attack of panic or anaphylaxis, when a sufferer feels quite helpless and fears that he or she may die. On the other hand, most chronic diseases cause continued anguish and misery in such a way that an individual feels hopeless and helpless. He or she feels out of control, and uncertain about the course of the disease. This individual is suffering, since the intactness as a person is threatened or lost. He or she cannot escape from an invisible shadow that haunts her or him every day and every night, and sometimes every existential moment. Here is a quotation from Abraham Lincoln during some of his darkest days, that has all the components of suffering: “I am now the most miserable man living. If what I feel is equally distributed to the whole human family, there would not be one cheerful face on earth. Whether I shall ever be better I can not tell; I awfully forebode I shall not. To remain as I am is impossible; I must die or be better, it appears to me” (3). Gunderman (5) states that it is not distress that destroys people, but the misery without meaning. For a woman in labor, the horrendous pain has a meaning and a noble purpose. Most women take the labor pain as a positive experience. Chronic pain has no meaning and no purpose. It promises no luminance at the end of the tunnel. In fact, the patient feels that she or he is constantly confined in a subterranean existence where the sun never penetrates. It is the feeling of an eternal and inescapable dark sphere that causes so much suffering among so many chronic disease sufferers for so long. SCIENCE AND PHENOMENOLOGY: DUALISM IN MEDICINE Only a few medical schools offer a targeted course on immeasurable [or incompletely measurable], but vital areas of human feelings, sensibility, and existentialism. Examples include: suffering, fear, want, frustration, unresolved psychological conflicts, old psychological trauma, hopelessness, despair, love, optimism, happiness, kindness, and empathy. We measure some of these things by having the sufferers fill out a questionnaire or rate them in a visual analog or similar scales. Such measurements have been useful in clinical practice and research, but all the dimensions of suffering are truly not measurable. Aristotle said that a physician should know when it is wiser not to measure (10).... Many practicing physicians rate symptoms of their patients [they should]. But, they question the patient’s rating if no structural pathology is present, saying that their symptoms are purely subjective and, therefore not dependable as a basis for any action. The red flag of intentional misrepresentation and desire to achieve secondary gain springs up in a physician’s mind. Such thinking is still pervasive from the examination room to the courtroom. This kind of judgmental attitude is an iatrogenic cause of accelerated suffering. Despite a clear admonition, in recent decades, for treating patients as a whole, including an assessment of their psychosocial difficulties (13-16), little attention is being paid by most physicians to these vital elements of patient care (11). There is a lot of lip service to the psychosocial issues, but this seems to be more of a current fashion statement, rather than any true attempt to understand, empathize, provide the necessary time, and help the suffering. A large number of patients complain that their physicians spent just ten minutes with multiple interruptions and the real concerns of their patients were never addressed. The physicians hurriedly pull out a prescription pad before hearing the full history, scribbled Prozac [fluoxetine], or Elavil [amitriptyline], and asked the patient not to return. Scientists in other fields, such as physics, chemistry, and molecular biology, do not have to deal with the question of suffering. The reason for the existence of the medical profession is to uniformly serve the sick and the suffering without derogatory or prejudicial views. Such service is the mission of the profession. A dogged reliance on science of structural pathology will not help us to keep our promises of caring when we first espoused the Physician’s Oath [commonly used oath is that of the World Medical Association, based on the Hippocratic principles]. Henceforth. the World Medical Association Oath will be referred only as “Oath.” Because of the overwhelming influence of the science of structural pathology that is emphasized in medical education, it is not surprising that most physicians focus on the classical or “organic” pathology of disease, since they have been taught to believe that such pathology provides the only rational approach to treatment. There is only cursory attention to the mind, as if mind and structural pathology are two different and independent domains. All the attention goes to the latter. The first is regarded as not real and not worthy of time and effort. This is surprising in view of the fact that the nexus between mind and body, was fully appreciated in Ayurvedic medicine that taught that a person as a whole needs to be treated by a physician. Ayurvedic medicine was the first system of medicine—developed some 3,000 years ago in India (17), but even now a holistic approach to disease management, as advocated by Ayurvedic medicine, is not commonly practiced by the medical community. APATHY, ANTAGONISM AND SABOTAGE There are varying attitudes among physicians who ignore human suffering due to currently defined illness, because they perceive no objective pathology in these conditions. Among these, I shall talk about a group of interrelated conditions, such as headaches, fibromyalgia, irritable bowel syndrome, and chronic fatigue syndrome. They have been called “functional” syndromes [an intriguing term considering that their pathophysiology is based on a dysfunction of the neuroendocrine system]. Now it seems quite likely that these conditions share a common pathophysiology of central sensitization, hence the recently suggested term “central sensitivity syndromes,” [CSS] (18,19). In this article, I shall refer to these “functional” syndromes as CSS. Some physicians simply ignore the suffering of the CSS patients, telling them, directly or indirectly, that their symptoms are imaginary [“there is nothing wrong with you”] and making sure that no further appointment is given. They are often derisive and rude to their patients. Other physicians tell their patients that they are suffering from depression or another psychiatric disease [with no intention of finding out if this is the case] and ask them to see a psychiatrist. Often, psychiatrists fail to find any mental illness in such cases. Thus, patients are left in the lurch and they have nowhere to go for help. They suffer silently. The patients learn to distrust and hate the medical profession for what they view as its ignorant pomposity. Other physicians recognize the problem and genuinely want to help, but they have been the victims of the current medical education system (10) and are ill equipped to manage such patients. Empathy is an awkward emotion for them. There are still others [the passive aggressors] who are passively antagonistic though not actually abusive to the patients suffering from functional problems. They, too, quietly get rid of these patients. The worst type of physicians spew out their engrained and virulent bias against suffering patients who do not fit their definition of “organic” pathology. They altercate in any forum [corridor, meetings, journals] to discredit and decimate the concept and science of CSS through their paralogism—an invented “logic.” Many caring and well-informed physicians would regard such views as fatuous. The fact that the term CSS is based on a pathological mechanism, would nettle many of these biased physicians. Worse, some of them actively sabotage (20-25) the service of others who devote their time to research and care of these unfortunate patients. The CSS opponents complain that if there is no “organic” pathology, the problems of the CSS sufferers do not exist. Some of them state that the symptoms are all psychosocial and that the misery is “all in the head” (24). One of the cardinal mistakes they make is that they put all the patients in the same basket (20-25), despite the well-accepted concept of subgroups in any disease or syndromes in modern medicine. My colleague Dr. Alfonse Masi and I have always maintained that in FMS, there are subgroups based on physical and psychological variables (25-29). Recent analysis of our data by cluster analysis showed that only 34% have high psychological distress (28), a figure similar to 32% reported by Giesecke using the same technique (30). To these physicians, when it comes to taking care of these patients, ‘mind’ is a separate domain for the psychiatrists only, and is far removed from bodily pathology. Some of them are self-declared FMS experts without much patient contact. They seem to be under a perpetual spell of Cartesian curse. They make no attempt to understand the agony of the sufferers [“it is all psychological”]. They have no intention to understand the pathophysiological basis of the CSS patients’ symptoms. They ignore many properly conducted studies published in well-known journals that show abnormal neuronal functions, neurochemicals, and neuroendocrine status (18,19,31-37). They can rarely read any scientific paper on the CSS conditions with an open mind, since in their biased minds they have already decided that these studies are no good. This reminds me of an old advertisement for Guinness [a dark looking beer that is perceived by many Britons to have bad taste] that I once saw in London, UK. It says, “I do not like Guinness, since I never tasted it.” One of the insensate complaints of the saboteurs regarding FMS is that there is no adequate treatment for it (22). Was there any meaningful treatment for RA before the methotrexate era in the 1970s, despite the fact that it has been characterized for at least 200 years? FMS characterization and research barely began in the late 1970s and early 1980s (38,39). Why is there a quixotic expectation regarding FMS, particularly given the fact that it is a recently characterized condition and it received very meager extramural support compared with RA? Is there an adequate treatment for all cancers, connective tissue diseases or cardiovascular disorders? If there is to be a cure or satisfactory treatment for FMS [or other CSS members], it will not be achieved by a pure psychosocial approach. Treating depression alone does not cure FMS and it is hardly surprising that cognitive behavioral therapy is ineffective in FMS when a proper study including attention controls is conducted (40-42). Research in both biological and psychosocial areas will be needed to adequately treat the CSS sufferers. It is good to recall the Oath of The World Medical Association, and read it aloud: “I solemnly pledge to consecrate my life to the service of humanity. . Twill maintain the utmost respect for human life.” Charaka, a great physician of ancient India [200-300 BC], who wrote six volumes of text books of medicine [called Charaka Samhita] on different disciplines of medicine [including obstetrics/gynecology and psychiatry], had urged a similar oath for the graduating disciples: “Day and night, however thou mayest be engaged, thou shalt endeavor for the relief of patients with thy heart and soul . . . Thou shouldst speak words that are gentle, pure and righteous, pleasing, worthy, true, wholesome and moderate” (43). The Charaka oath exhorts physicians not only to relieve patient distress [irrespective of cause], but also to be devoted and compassionate in patient care. They should also be gentle and respectful in their interactions with the patients. An erudite patient of mine with both FMS and RA, who also teaches ethics in a college, complained that many physicians are reneging the Oath and are iatrogenically exacerbating the patient suffering. The callous actions of some physicians threaten the very reason for the existence of the medical profession—namely service of humanity and relief of distress. Part of the reason for the utter failure of our profession is an overemphasis on science, the meaning of which has been taken to imply only the Virchow’s dictum of structural pathology. Does anybody care that some of the physicians are destroying our trusted profession by their conscious or unconscious abandonment of the Oath? CAN WE TREAT SUFFERING? As always, the patients are the innocent bystander victims of the firefights between the physicians. The real practical problem of the disease-illness chasm is that those with currently defined illnesses are relegated to the status of a second class citizen and are not taken seriously. In medical training programs, the residents and their attendings trivialize illnesses and consider them benign, “all in the head,” less important, and less real than disease. However, CSS conditions, even excluding depression, are associated with increased morb idity and even mortality (117). Listening and empathizing: So, what is empathy and can it be taught? A well-written pithy essay by Howard Spiro (10) on this topic is worth reading. Spiro states that empathy is evident when I and you becomes I am you, or at least I may be you. Simply and proverbially speaking, empathy is putting oneself in a patient’s shoes. Can it be taught? In a phenomenological study, Raingruber and Kent (125) subjected students and faculty ofanursing school to real life traumatic experiences: a bloody crush injury; the helpless moaning of a teenage girl who lost her child; the terror in the eyes of a little boy with multiple fractures from the daily abuse and violence by his father; and a dying patient’s last hour or minutes. All the participants later described overwhelming bodily sensations, such as sick stomach, and distress of sudden onset. They described troubling perceptions of suffering in their own mind through patients’ descriptions and non- vocalized expressions, and developed a great desire to help them. The authors state that the embodied responses of the participants after such encounters help them to understand human suffering at a personal level and to develop a feeling of empathy. Empathy can he trained by taking patient history with sensitivity, focusing on all problems, including implied ones, and having a kind attitude and patience with all patients irrespective of pathology, social standing, religion or ethnicity. It can be developed, says Spiro (10), through narratives of human life and its difficulties that are well expressed through paintings, stories, novels, and literature in general. I agree. The problem of physician arrogance and apathy cannot be solved unless we attack the root cause that has its inception in the early years of medical school or perhaps even before that. This trait should be considered, along with academic achievement, in the process of choosing future medical students. Many candidates may be brilliant in their science knowledge but would not make good physicians because they lack genuine caring and compassion. However, this does not imply that we should accept a student who lacks a strong science aptitude. Both science and beneficence are important. Every medical school in the country must teach science [with structural as well as NCE pathology] and humanities with equal emphasis [although equal emphasis does not translate into equal time], so that a future physician is scientifically adroit and also learns to be kind, humble, sensitive, attentive, and respectful to a patient’s complaints and concerns. Medical students should be emphatically taught that a patients suffering lies not only in what is currently known as classical or organic pathology, but also in NCE pathology, both of which are interactive, and both may contain psychosocial elements. Such a goal can be met by implementing relevant courses, and more importantly, through inculcation by the physician teachers who themselves practice medicine with gentleness, humility, and humanity in their daily practice, as advised by Charaka and Hippocrates. In summary, this discourse emphasizes the need for a physician to be both a scientist [with its broader definition] and a humanist. These humane qualities need to be taught and inculcated from the very beginning in medical school and throughout the residency program. Charakan and Hippocratic oaths should be the burning flame to guide the professional mission of young physicians. Suffering cannot be allayed unless we deal with the whole person. Our obsession with the old paradigm of science that deals only with structural pathology, and a distinction between disease and illness has been among the most destructive forces of our time in shaping the pejorative and reckless physician attitude towards patients. Disease- illness dualism has reinforced this attitude and such an outmoded paradigm should be abandoned. In recent years, it has become clear that CSS conditions are based on demonstrable pathophysiology that promises to be deciphered better with continued and committed research. Referring to the epigraph of this article, many physicians are undermining, knowingly or unknowingly, the very reason for the existence of our profession. Some are the renegades of the sacred Oath, and have embraced a destructive faith of CSS bashing. I implore upon them to become “born again” physicians and retake their badge of honor as a true devotee of the Oath. Followers of the oaths will truly enjoy the profession of medicine, as Hippocrates said, “where there is love of man, there is also the love of the art.” (140). We need a national debate on the quintessence of the medical profession and to embark on major reforms before it is too late.