Symptoms of unknown origin: A medical odyssey

Having just a little more time to myself over the holidays has meant I’ve been able to read more.  Not that I EVER stop reading, but I did have some time to really read some great books, one of which is a slim book by the title of my heading above.  It’s written by Dr Clifton Meador, published by Vanderbilt University Press, 2005, and the ISBN is ISBN 0-8265-1473-1 (cloth : alk. paper), ISBN 0-8265-1474-X (pbk. : alk. paper).

It’s the story (or a series of stories) about the journey Dr Meador took to move from his original training as a physician who sought to ‘fix people’ to a doctor who learned the art of listening and gently helping the very challenging patients he was seeing to move from being patients to being people again.  He described the scene in his medical school training where he was exposed to the miraculous effects of physostigmine on a woman with myasthenia gravis and immediately became enraptured with the idea of ‘[being] able to have that effect on a patient, to be able to find the chemical defect, find the missing hormone, and discover what bacteria or virus had invaded the body. I wanted to make a diagnosis and give the drug or chemical that would precisely correct the biochemical lesion or kill the invading organism. I wanted to do all of that and treat patients and give a normal life back to those who were afflicted.’

I am certain many of us, like Dr Meadon, thought when we first graduated ‘…that the sole job of the physician [clinician] was to find out what was wrong in the body and fix it. However misguided I might have been, I saw the physician [clinician] as purely a combination detective and biochemical mechanic of the body.’ At least until we started to see that people don’t often fit into the patterns that we learn about during our training – and that we haven’t got the technology to ‘search and destroy’ all the bits that aren’t working and correct them.  We also begin to learn, as Dr Meadon did, that ‘…separating the mind from the body impose[s] clinical restrictions.’

This book takes clinical anecdotes from Dr Meadon’s life, and uses them to illustrate some of the problems with his original view that he acknowledges left him seeing ‘… the mind and body as two separate systems. Disease was either medical-physical and therefore “real,” or it was mental-emotional and therefore “not real.” Amy was the first patient to show me vividly that the human mind and body are not separable. Further, the internal physiological world and the external social world for each of us are quite connected. More important, the social connections and their power can be unique for each patient.’

Dr Meadon describes developing an appreciation for the biopsychosocial model of humans – but not simply this, also that as a physician, he didn’t have as part of his clinical skill repertoire, those skills that are essential to carry out good clinical work using this model.  He had to develop them.  The skills and attitudes he identified are these:

• Having the primary intention of being maximally helpful with each patient.
• Honoring the personal integrity of each patient.
• Approaching the patient in a mild state of awe, to watch and wonder and listen.
• Making no distinction in level of interest between physical, social, psychological, or spiritual information.
• Avoiding cuing when asking questions about symptoms.
• Accepting the patient as having symptoms of unknown origin even at the initial visit.
• Learning to listen and reflect back what I hear until there is nodding agreement from the patient.                                          • Learning to gain and hold the full attention of the patient and, by watching the facial expressions, knowing when it is achieved.
• Paying attention to the breathing of the patient and sometimes matching my breathing to the rate and depth of the patient’s breathing.
• Paying attention to the posture and body positions of the patient.
• Watching the face of the patient, paying attention to representations of emotion in the face and using those facial expressions as guides to the patient’s attention, understanding, and internal emotional states.

Dr Meadon describes these in summary form as ‘establishing rapport’.  Easy to say – not so easy to do with very challenging patients!

He then describes what he calls ‘physician-directed recollection’

• Avoiding specific diagnoses and disease labels until certain.
• Saying “I do not know what you have . . . yet.”
• Using unspecified language when asking questions.
• Embedding confronting-type questions in “I wonder if . ..” statements.
• Assisting the patient to find the pattern or variation of the symptoms.                                                                                                • Having the patient use a diary when appropriate.
• Suggesting that the patient may be doing something he or she should not be doing or not doing something he or she should be doing.
• Continuing to delve into variables even when a medical disease is present.

This book describes in loving detail and simplicity the path that this physician took to move from a mechanistic, reductionist point of view, to a much more encompassing one that honours the human in the person presenting with, as Dr Meadon puts it, ‘symptoms of unknown origin’.  These patients are often passed over, or denigrated by clinicians because they are difficult, there is no simple answer – and often get multiple ‘fuzzy’ diagnoses that lead to iatrogenic problems, that is, problems arising from what we as clinicians do.

I think this book should be compulsory reading for all health professionals – while I don’t completely agree with his conclusions, I do think the way he describes his own journey and the sense he makes of the people he sees – and the skills he turns to in order to help them in the best way possible – these are the skills we need to work effectively with people in chronic pain.  Especially to avoid giving any diagnosis until the evidence is unequivocal, and to allow the patient to decide ‘what s/he should be doing more of, what s/he should be doing less of’.

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