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is a neurologist-turned-network systems engineer specializing in Windows NT
Server based solutions development and implementation. He practiced medicine in
Texas, Oregon and Arkansas before moving to his present home in the Dallas-Ft.
Worth TX metropolitan area. Copyright® Thomas W. Shinder, M.D., 1997 All
Rights Reserved
These works are published here with permission. Please do not use or share this information without including the copyright information.
Educating Doctors: The Way We Were
In Med School
BY THOMAS W. SHINDER, M.D.
It might come as a surprise to some, but the
model of American medical education in the twentieth century is based on the
military model. The hierarchical command structure is militaristic in nature,
with the physician on top of the command chain. The development of the culture
of Medicine in the U.S. has been profoundly influenced because of this model.
Since the American military has
traditionally been male-oriented and male-dominated, it follows that medical
training built on this foundation tends to show a bias that downplays the
importance of women both as physicians and as patients.
The educational process begins at variable
points for the specific individual. There are those students who have always
known that they wanted to "be a doctor". For them, medical education began in
elementary school. Typically, the process begins in earnest during the High
School years, when thoughts of "what do I want to do with my life?" begin. There
are others, like me, who made this decision during their college years, when the
specter of finding a job versus furthering an education came to the forefront.
Regardless of the timing of the decision,
the final common pathway is medical school. In the United States, there are
about 127 medical schools. Arrival at the medical school of your choice is the
result of extraordinary long hours of study and perseverance and competition.
Like a military bootcamp, the process of
indoctrination takes place from the very first day at medical school. A lot of
time is spent talking about how outstanding we all are, and how we are the
"elite" who made it in. After all of the self-congratulatory behavior, the
realities set in. We will take 8 to 12 classes each semester for the first year,
and we must pass them all.
With what seems to be an impossible task
before us, the focus is not so much on learning and understanding, but upon the
rote memorization of "facts." I coined the term "factmaster" for myself during
the training process. Memorizing large amounts of unrelated information was
essential in order to pass the examinations later, and questioning the nature of
the information would have used up valuable mental resources which then would
not be available for memorization.
So it is in this environment that biases in
the content of medical knowledge and education go overlooked and thus become
accepted as another "fact."
In med school, "human physiology" was about
male physiology. The workings of the organ systems in the body: brain, heart,
kidneys, lungs, blood, marrow, and all the equations involved in explaining
their actions and interactions. Only after the basic male components of
physiology were completely explained and understood did we delve into what was
considered the "variant" of the "normal", i.e., female physiology.
Similar subtle biases were experienced in
other classes: psychology and psychiatry, pharmacology, neurosciences. This idea
of female physiology as a deviation from the "norm" carried over into the
clinical years, when variances from the basic male physiology were considered to
be complications and often regarded as treks into the unknown.
This situation became obvious when, during
the third year of medical school, a rotation into obstetrics and gynecology was
required. The gynecologist knew about all these "deviations" from normal
physiology. Women of childbearing years were considered automatically
problematic. They were assumed to be pregnant unless proven otherwise. Because
of this assumption, many treatment protocols are withheld from them, or not even
considered.
Pregnancy itself represented, in the context
of this philosophy, a huge departure from normal human physiology. All the rules
regarding functioning of the heart, bone marrow, immune system and nervous
system changed. Ignorance and the fear of doing the wrong things for a pregnant
woman were common. Doctors, faced with a departure from the familiar, often gave
less attention to these "deviant" physical specimens.
The reasons for this state of affairs are
complex, but there are a couple of identifiable elements which may help to
explain the situation.
Medical research has focused on male
subjects because historically it was considered "indelicate" to experiment on
women. Since many of the experiments done on living humans involved some degree
of risk, it had always been felt that women should not be involved in such risk.
This is not unlike the attitude of many towards women in the military.
Another major consideration is that women of
childbearing years are assumed to be pregnant. The risks of complicating a
pregnancy because of medical experimentation were considered unacceptable. Prior
to the 1960s this was an ethical decision, and afterward, a liability-based
decision as well.
The result is that physicians come out of
med school harboring an attitude towards female patients that is hardly
conducive to providing the best health care to women. Even female physicians are
not immune to this insidious indoctrination.
Women often complain that their doctors
treat them as "inferiors" and/or seem to brush off their concerns about their
conditions. How could it be any other way, when physicians training has
emphasized repeatedly that there is something inherently "wrong" with the female
body, that regardless of how healthy it is, its still somehow "abnormal?"
Before we can expect doctors to change their
ways of interacting with the women whose illnesses they treat, we have to change
the way theyre educated, so that they dont equate the very state of being
female with abnormality.
The Evolution of the
Physician-Patient Relationship:
The Traditional American Medical model as we
know it today became extant in the second decade of the 20th century. Prior to
what was called the "Flexner" report, the standards in the practice of medicine
were quite variable. There were hundreds of institutions and "small businesses"
purporting themselves to be medical schools, and there was little regulation
regarding the quality of the education or the quality of the graduates of these
schools.
After the findings of the Flexner report
become clear to Congress, strict regulations and guidelines were put to fore in
order to create an environment where the United States would have the best
Healthcare system in the world. The goal was to limit the number of medical
schools, have those remaining medical schools meet high standards of care and
education, and limit entrance to the schools only to what were considered to be
the "best and the brightest".
In this light began the culture of the
"American Medical Model". It was also at that time that science was able to
break through many of the mysteries of human physiology. Diseases such as
diabetes, pneumonia, syphilis and hypertension, which killed untold thousands of
people yearly worldwide, began to let loose of their secrets. And with this new
knowledge, those thousands of lives were saved each year.
The "new" American Physician was a
Scientist. To separate himself from his predecessors he eschewed anything which
was not "objective" and quantifiable. It was because of the then new scientific
approach that physicians were able to save many lives, and improve the quality
of many more. The "old style" physicians depended on qualities of intuition,
folklore, powers of suggestion and belief. The old ways were to be purged, so
that the quality of human existence could improve unimpeded.
Inherent in this belief of scientific
absolutism was the attitude that the patient knew little or nothing of the
evolving scientific discoveries in medicine, physiology, chemistry and
biophysics. Physicians then developed a "paternal" approach to their patients
in order to help them use the new tools of scientific medicine. This paternalism
certainly was not new as a medical approach, but it did become solidified as de
rigueur because it would be unrealistic to expect a general patient population
with marginal education to have any understanding of the diagnostic and
treatment modalities which were undertaken.
This paternalistic physician-patient
relationship became the standard, and was generally well received for almost
seven decades. Although many a patient would be frustrated by the usually
arrogant, almost always male physician, the sense of being "cared for"
overarched those feelings. People trusted their physicians because it was felt
the physician was beholden to only the scientific method and the fruits of that
method. We trusted our lives to these physicians and their beliefs without
question.
How did a person with a disease such as
Fibromyalgia or Chronic Fatigue Syndrome fit into this model? What was the
physicians attitude toward these patients for whom science had little to say in
terms of an answer?
Physicians bolstered by their successes with
the diseases of "known cause" were very uncomfortable with those patients who
did fit into disease categories which were elucidated by the scientific method.
Physicians are an uncomfortable lot to begin with, because of the number of
unknowns that they have to deal with everyday, even in situations where they are
dealing with "well understood" maladies.
When a patient with Fibromyalgia or Chronic
Fatigue Syndrome came to a physician in those times, there was first an attempt
to understand the pathophysiology of the sufferers malady. When attempts to
define the cause of the persons illness failed, there was often a crisis of
confidence. The American Model of Scientific Medicine had purported to be able
to diagnose and "cure" any disease. In this case, the situation created an
environment leading to "cognitive dissonance". In order to relieve this
uncomfortable state, the doctor had to either come up with an answer, make one
up, or treat the symptoms so as to make himself and/or the patient feel as
something "had been done".
This was natural in a paternalistic system.
The approach to the patients was not unlike that of parents toward children:
give them an answer regardless of its validity, and then prescribe medications
that mask or ameliorate the symptoms. This was common practice throughout the
40s, 50s, and 60s. The physician-patient relationship was strong the
patient was told she had "neurasthenia" or "hypoglycemia" or "vapors" or
"chemical imbalances" or any number of pseudonymous terms for "I dont know".
But along with these new diagnoses were popular remedies to alleviate the
symptoms of pain, lethargy, stiffness, and intermittent confusion.
In 1970, the Nixon Administration pushed
through the Drug Abuse Prevention and Control Act. And in 1973, the Drug
Enforcement Administration was founded to enforce federal laws regarding the use
and distribution of "narcotics", as defined by the Drug Abuse Prevention and
Control Act. Many factors led to the 1970 Act and subsequent organization of the
DEA, but not least among them was the common physician behavior of treating the
symptoms of people with Fibromyalgia and Chronic Fatigue Syndrome with
amphetamines, opioids, and sedatives.
Out of a sense of medical impotence,
physicians had by a significant majority "overtreated" patients with chronic
pain and fatigue. Medical "addiction" was almost commonplace, and many
less-than-scrupulous physicians used the patients addictions to keep them
coming back to the office, and to coerce them to pay their bills.
Now let us leap into the latter 1990s.
Many changes have taken place. Patients have become increasingly sophisticated
and educated. Managed Care has overshadowed and overtaken the individual
physicians judgment. When once the physician answered to the court of
scientific inquiry, that position is now considered secondary to the directives
of the managed care corporations profit margins.
What is the present day physicians approach
to the patient who walks into her office with concerns related to Fibromyalgia
or Chronic Fatigue Syndrome?
You, the patient, come into the physicians
office with need for diagnosis and relief of your symptoms of pain, lethargy,
fatigue, sleep disturbance, concentration deficits and muscle stiffness. Most of
your symptoms are considered to be controlled by the Central Nervous System
(consisting of the brain and spinal cord). Therefore, a neurological evaluation
would be considered appropriate in your case.
The physician is presented then with her
first hurdle. Let us assume that your physical examination showed "no objective
abnormalities" (i.e., there is nothing that the physician sees outside of your
verbal report of pain or discomfort). A neurological evaluation might include:
EMG/NCV, MRI, CT, EEG, various blood chemistries and antibody evaluations,
Evoked Potential studies, and perhaps others. The managed care company will
refuse to give approval for these studies because of the lack of "objective
evidence" to justify these expensive procedures.
(Also, in many cases physicians are
reimbursed, or given incentive, not to perform tests and a percentage of the
cost savings are paid to the physician.)
You, as a sufferer of Fibromyalgia or
Chronic Fatigue Syndrome, wont be effected by whether the physician is able to
get the tests approved or not; the results will be "negative" because of the
limitations of the present technologies. Now the physician faces her second
hurdle, what is she going to do with you?
In the former paternalistic system, it was
the physicians imperative to take care of their patients. The patient had
placed her trust in the physician to bring some degree of relief of suffering,
and the physician of the age had an unwavering belief that science, most of all
biopharmaceutical science, while not always providing a care, could at least
quell the extent of suffering. To this extent, the physician-patient
relationship was fulfilled; the patient felt better and the physician also felt
better because he was not rendered powerless or helpless to aid his patient.
The present system does not allow anywhere
near the same degree of latitude. CNS (central nervous system) drugs are often
expensive, and are not on the managed care plans approved formulary (which
means that you, the patient, are responsible for paying the full price for these
non-approved medications).
An even more overarching concern on the
physicians part is the DEAs oversight of their prescribing behaviors. Most CNS
drugs used for Fibromyalgia and Chronic Fatigue Syndrome are listed as
"controlled substances" by the DEA. The prescribing physician often
misunderstands the extent of DEA involvement. This lack of understanding is
communicated to the patient. "I cant prescribe that medication to you because
the DEA is watching me like a hawk and I can get into trouble". In fact, the DEA
does not record or have a central database that is updated on a daily, monthly
or yearly basis. While such centralized databases would be relatively easy to
implement and maintain, at the present time they do not consider this part of
mission.
Something that is more often the case is
that the physician does understand the extent of DEA oversight, but because she
doesnt want to prescribe the medication at all, communicates to the patient
that her hands are tied. Whether this is because of concern over addiction, or a
concern over the present state medical board position on the use of controlled
substances for chronic conditions, or just the fact that she doesnt like the
patient, is not communicated.
Therefore, the nature of the
physician-patient relationship is quite different from what it was. Feeling
hamstrung by managed care corporations, the DEA, and state/county medical
boards/societies, the nature of physician-patient relationship has evolved from
the paternalistic to the adversarial.
The adversarial nature of the
physician-patient relationship has its underpinnings with the medical liability
crises in the 70s. Malpractice is always in the back of every physicians mind.
However, there is now an amplification of what can be seen as "competitive"
behavior between the physician and patient. The patient, no longer someone who
is "cared" for, is a consumer of heath care resources, and the physician is no
longer the doctor, but a health care "provider".
You then come to the physicians office not
so much now to develop a therapeutic relationship, but rather as a customer. The
physician is part sales person and part business owner (or employee), who seeks
to make not only the customer happy, but also the regulatory agencies which
govern her business (and/or her bosses). As in, for example, a restaurant, if a
single customer is unhappy, it is considered unfortunate. However, if that
restaurant should make the Health Department, the State Tax Franchise Board, the
Alcohol Beverage Control Board, and any number of regulatory agencies unhappy,
then they are out of business. Period.
And you, the people with Fibromyalgia or
Chronic Fatigue Syndrome, are in the worst situation. You are considered to be
inappropriately heavy users of medical resources, and overusers of controlled
substances. Given the diametric change in the nature of the physician-patient
relationship, what can you do to fortify your position?
You are a customer, and the physician is the
"store". The situation is more akin to that of Used Car Lot rather than a retail
store, in that bargaining and negotiation skills are paramount. Each side needs
to understand the others position and then attempt to find a common ground,
making a "win-win" for both you the customer and the physician provider.
As a negotiator, you must have objective
facts. This means researching your condition, finding medical evidence to
support your getting the things that you need, such as diagnostic testing and
medications. Your sources must be from "legitimate" publications and authors
(i.e., reviewed medical journals or mass media publications that are not
considered "fringe").
But the scientific aspects of your negotiations are not enough. The major
challenges lay in political and business research. You need to be aware, and
enlighten the physician with whom you are negotiating the results of your
awareness, of the present stands of the State Medical Board, their county
medical society, and the DEA on those things that you want.
You must also have ready information
regarding the rules and guidelines of your managed care organization. Those
include the policies regarding the drugs which they approve for treating your
condition, the tests approved for diagnosing your condition, and the name and
qualifications of the initial reviewers as well as the medical director of your
managed care plan.
With your scientific, business, and
political knowledge you can sit at the negotiation table. With the knowledge you
have of your "competitors" situation, you should be able to come up with a
reasonable compromise. If not, you must, like in any other type of negotiative
scenario, leave the table and choose not to do business with that person.
However, you must document fully the reasons for your choosing another
physician; else you will be seen as a "doctor hopper".
The physician-patient relationship has changed radically. You now have the
information and the insights to tackle the challenges of the new "commercial"
relationship patients have with their physicians. By using this knowledge, you
should be able to maximize your abilities to seek some degree of relief from
your chronic conditions.
The Fibromyalgia Syndrome: It's Not
All In Your Head
by Thomas W. Shinder, M.D.
If you are one of the many who suffer from fibromyalgia, you know the feelings
well: pain which moves from joint to muscle to bone to back to head. If
pain were the only problem, perhaps you could handle it better, but factor in
the fatigue, lethargy, tingling and confusion, and your life
Fibromyalgia occurs predominantly in women, with the female-to-male ratio
reported to be about 20 to 1, and afflicts an estimated seven to ten million
Americans. Even more impressive are the estimates that fibromyalgia
generates between twenty to thirty million physician visits a year in the United
States alone. But it's not a condition unique to Americans.
This "unexplained pain" syndrome has been reported in almost every part of the
world.
Fibromyalgia has been defined by experts as a syndrome of episodes characterized
by diffuse body pain and the appearance of at least 11 'tender points' out of a
possible total of 18. However, to sufferers of fibromyalgia, the syndrome
consists of much more than mere tender points.
Migraine headache, Irritable Bowel Syndrome, Pelvic Pain Syndrome, sleep
disturbances, restless leg syndrome, premenstrual syndrome, Raynauds Syndrome
(spasm of blood vessels in the fingertips and toes), extreme sensitivity to cold
and generalized body stiffness all afflict the sufferer of fibromyalgia.
Women make up over 95% of those diagnosed with "fibro." This complicates the
diagnosis and treatment of the disorder more than it should, because of the
conventional medical world's historical bias toward women. That bias is
evident not only in terms of diagnosis and treatment, but also in the lesser
quality and quantity of basic research into those afflictions which are
predominantly female-oriented.
The question I have always had to deal with, and not without some degree of
medical embarrassment, is "how did I get this?" and "what caused it?" The honest
answer is that we don't know what causes fibromyalgia. We do know that it
is not new, but has gone by many different names in recent medical history.
Terms such as "neurasthenia", "fibrositis", or my favorite "non-articular (joint
related) rheumatism" have been used to describe the same constellation of
symptoms. During the 1960's and 1970's, 'hypoglycemia' was often the
diagnosis given for the same disorder which we know now as fibromyalgia.
Many hypotheses exist as to the cause of fibromyalgia, and many of them are
quite elegant. Unfortunately for the typical woman who goes to the doctor
for these symptoms, she will hear a less than elegant explanation.
"Maybe your husband isn't paying enough attention to you," quips one physician,
while another answers "Why don't you get a life? You spend too much time at home
with your children." Or you could go to the specialist which these doctors
recommend and hear, "Depression is common among women of your
age/race/racial/economic/weight/educational/marital status. By treating
your depression, we'll be able to make the pain go away".
The worst case, and a too frequent scenario: the physician pronounces that:
"You're a drug addict and you need professional help (meaning a 30 day inpatient
stay in a psychiatric hospital, at about $20,000US)."
Because of the male bias in medical research (female physiology is taught as a
deviance of "normal" male physiology), relatively little is known about the
etiology and pathophysiology of fibromyalgia. But there are some things we
do know.
Studies done at the University of Alabama using PET scan technology have
demonstrated that there are differences in the area of the Limbic System (or
emotional brain) between women with and without fibromyalgia. There seems
to be a higher level of activity in that system in those afflicted with the
disease. There are significantly fewer endorphins (naturally occurring
morphine-like chemicals) in the brains of women with fibromyalgia.
Also, EEG (electroencephalogram) studies show dysfunction in the right brain
hemispheres of women with fibromyalgia and a similar syndrome known as the
'chronic fatigue immune deficiency syndrome'. The right hemisphere is
generally responsible for the emotional and integrative functions in the brain.
Most intriguing is the estimate that up to 90% of women with fibromyalgia have
an history of either sexual, physical or emotional abuse during childhood,
adolescence or early adulthood. The changes seen in the PET, endorphin and
EEG studies could easily be associated with the long term effects of
psychological trauma. Perhaps this is what leads some doctors to discount
the condition as "psychosomatic." Yet the real significance of these studies is
the proof that fibromyalgia is marked by very real physiological differences.
Treatment for fibromyalgia is a trial and error process. Generalist
physicians will prescribe amitriptyline (a tricyclic antidepressant). Most
do this because they have heard that it's the right thing to do, although some,
with less noble motives, do it because they know the side effects are so
intolerable that the patient will stop the medication and not return for a
second visit. This is a common ploy among many pain clinic physicians who
view fibromyalgic patients as a source of annoyance and frustration, and somehow
less deserving of their time and attention than those whose pain they consider
more "real."
Among physicians who do attempt to help patients with fibromyalgia, medications
from the antidepressant, anticonvulsant, anti-inflammatory, steroid, and opiate
classes are typically tried. Trigger point injections, in which the
'tender points' are injected with a local anesthetic, are often recommended.
They occasionally lead to temporary relief, but seldom provide long lasting
benefit.
The best treatment has yet to be defined. During three years of neurology
practice specializing in pain management, I saw hundreds of women with
fibromyalgia. Many had been told by other doctors that their symptoms were
"all in their heads," but my opinion is that this is a disease of the "heart"
(limbic system, or emotional part of the brain). We do not yet know what
the exact neurochemical changes are, but knowing that they are there is very
important. Especially to all the women who have essentially been
brainwashed into believing they're "crazy." They're not -- but it's sometimes
easier for the "all knowing" medical establishment to put that label on patients
than to admit to its own ignorance.
The answer to the mystery of fibromyalgia probably lies in the field of
neurobiology, the study of the nervous system and its interactions with the rest
of the body. Until physicians can be persuaded to take the condition
seriously, to stop ignoring the medical evidence, and stop dismissing it as
"just another woman's thing," all we will be able to do is treat the symptoms.
Too many doctors decline to do even that.
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