Exploring pain: Chemicals, health practitioners and inner wisdom

Every body has a story nestled in its muscles and bones, fascia and skin.  Every body makes its own compromises on its journey through this world.  Marie’s is soft and compact, its stride short and confident.  A round face with sparkly, inviting eyes sits atop a short neck, framed by flowing gray hair.

Every body makes its own compromises on its journey through this world.

I imagine she had the same sparkly energy emanating from her eyes thirty years ago as she raced down a glitteringly snow-covered hillside.  Perhaps the sparkle in her eyes gleamed a hotter shade of red as the toboggan and her tail bone flew into the air and came crashing down onto the glistening ice of a northern Ohio pond.  And I imagine, too, after an initial yelp of pain, she transformed her vocalization to laughter, the sound of strength.  The idea of going to the doctor flitted briefly through her mind over the next couple days, as pain seared her hips and, some mornings, she was unable to get out of bed; but she found she could take care of it all by herself with the help of the then-new pain killer, ibuprofen.

The pain in her hips flirted with her over the next few decades, as did strain in her neck.  It flared up when she was, in her words, “fighting herself” as a middle school science teacher.  But in general, this farm girl from northern Ohio was tough enough to stave off its advances with the help of ibuprofen.

This farm girl from northern Ohio was tough enough to stave off the pain’s advances with the help of ibuprofen.

Marie’s first plunge into seeking human, rather than chemical, help for her pain was during her 30’s.  She was married by then, and although she and her husband had good health insurance, they had not sought out a family doctor.  Her husband was seeing a chiropractor for low back pain, though, so she went in as well to see what she could do to help balance out the stress of teaching that rendered her neck close to immobile.

She went to the chiropractor to see what she could do to help balance out the stress of teaching that rendered her neck close to immobile.

She had mixed feelings about her relationship with the chiropractor and the treatment.  On the one hand, it sure did seem to help – her neck regained mobility and the sciatic pain in her leg from her hip problems vanished.  On the other, she had some doubts regarding the validity of chiropractors, though she strove to be open to these alternative health practices.  Additionally, she did not like the sense of dependency and lack of control it instilled her.  “The human body should be designed so it doesn’t need help,” she thought.  And “anything that helps me shouldn’t hook me in.” Yet here she was feeling dependent on visits to this chiropractor every couple of weeks just to remain pain free.  She continued to see him for three years.  When she stopped teaching so she would have time to tend to her growing family, her body regained balance and she no longer needed external forces – chemical or human – to maintain it.

“The human body should be designed so it doesn’t need help,” she thought.  And “anything that helps me shouldn’t hook me in.”

Ten years later, she got back on the toboggan, and again her hip was a disaster.  Her chiropractor suggested a PT, so she started jumping through the hoops to see one.  She found a doctor, who gave her a prescription for a PT, a pain killer (flexoral), and a back specialist.  She tried the pain killer and PT for a couple weeks and started feeling better.  “The initial influence of the drug turned things the other way,” she told me.  “But it looped me out, made me depressed.  I would tell my husband, ‘I feel like a big pile of person.’”  By the time she got to see the specialist, her pain had subsided and the doctor had little to tell her.  She left feeling like “a stupid head, costing money, when there’s nothing wrong with you.”

Zoom ahead another ten years.  The kids are leaving the house, heading off to college instilled with the same work ethic Marie grew up with, cared for in a loving home tended by a mother and wife who chose to be just those things.  And Marie?  Well, she is on a new adventure of her own, still learning what fits — massage school!

A few years ago, she was training for a mini triathlon when her shoulder gave out during a swim.  Just reaching up caused pain and caused her to quit swimming.  Unlike tobogganing, which she was just as happy to go through life without, she was wistful about no longer being able to swim, and her entrance into massage school seemed just the time to check out what might be underlying the swimming-induced pain.  She bravely set off to investigate. “If I ask for help, where will it take me?  Now I understand,” she said with a chuckle, “why people don’t go to the doctor. … They don’t want to know.”

“If I ask for help, where will it take me?  Now I understand,” she said with a chuckle, “why people don’t go to the doctor. … They don’t want to know.”

She decided to start with her primary care physician (PCP) this time.  “I don’t trust a chiropractor to be able to assess [my condition] with only a bad x-ray machine and just one technique.”  And by this time, she had established a relationship with a PCP, Denise, who was also a family friend — someone she knew cared about her as a person.  Denise sent her to a PT, another family friend.  At least this time, Marie felt cared for by the health professionals with whom she was working.

She established a relationship with a PCP, Denise, who was also a family friend.

After a small but incredibly frustrating SNAFU which made Marie’s blood run hot as she told me about it months later (mixed communications between the PT and doctor’s office when Denise wasn’t in), she had X-rays taken of the same area of her neck that the chiropractor had looked at decades before using his antiquated technology and low quality images.  Technology aside, the assessment was the same — kyphotic curve in the neck — only this time, it was coated with a layer of mild to moderate arthritis.  When the PT showed her X-ray to an orthopedist, they marvelled at it. Marie believes she’s in good hands, but feels out of control, like someone else knows more about her body than she does.  “I don’t know how dire the situation is.  It challenges my idea of ‘I’ll be fine.’”

“I don’t know how dire the situation is.  It challenges my idea of ‘I’ll be fine.’”

Her goal now: See the PT intensively for the next few months.  Start doing exercises.  And in the long run, keep caring for herself (which will require some lifestyle changes) check in with Denise and see a massage therapist for relaxation.  She expressed some regret that she had been told about the underlying problem twenty years ago and not done anything.  But her strength and perseverance shone as she finished by saying “Thankfully, every day I wake up and get to live another day and see what happens.  It’s not over yet!”

Marie’s story touches on many of the important questions that arise over and over again as people make decisions about how to tend to their own bodies and minds in pain.  Is dependency okay — chemical, human? Do we want someone else to understand our bodies, our being, better than we ourselves do?  How do we form a connection that allows deep understanding to be mutual and not invasive?  How do we find a lifestyle that fits us?  What compromises must we make in order to lead the life we choose?  Is ignorance, in the end, bliss?

How do we form a connection that allows deep understanding to be mutual and not invasive?  How do we find a lifestyle that fits us?  What compromises must we make in order to lead the life we choose?

In the next few posts, I will explore the technology vs. humanity question that Marie touched on. Ibuprofen or a chiropractor?  Big data or an acupuncturist?  I will also be exploring the role of a healer — what makes a therapist’s work successful? Is it specific learned techniques or an ineffable presence?

Tune in again soon!

Contradiction and vision

Ted Kaptchuk, in The Web That Has No Weaver, puts forward the notion that Western medicine has more promise for incorporating Eastern ideas than vice versa.  He suggests this difference derives from basic tenets of Western ideology, which put forward fundamental seeming contradictions and ask us to find a greater truth which envelops them.

Western thought, at its most noble and honest, is nourished by the constant tensions between unkown and known, imperfect and perfect.  Western humanity is quickened by a metaphysical dilemma — on the one hand, it was created in the image of the Almighty, and on the other, it was created from dust.

And now I hold these two opposing viewpoints and try to unify them (does that make me the quintessential Westerner?):

1. Unlike the West, Chinese philosophy sees apparent contradictions as part of life.

To be bent is to become straight.
To be empty is to be full.
To be worn out is to be renewed.
To have little is to possess.
– Tao-te Ching, as quoted in Kaptchuk

2. Holding apparent contradictions is fundamental to Western thought (see above).

Perhaps the two trains of thought are not so different after all.  Or perhaps the difference lies in what we choose to do with our perception of contradiction.  Perhaps the Eastern way is to simply notice what is — ‘Ah look, the fabric is all red and all blue’ — and the Western way to search for an underlying greater truth.  For example, fabric is woven from cross-fibers that appear blue when at one angle to the light, and red at another.

In the West, we want a vision of what will be — a vision that is better than what we see in the external world, an unachievable pinnacle to aspire to.  Not Buddha (a human), but Adonai (super-human).  Not just peace on Earth, but the Messiah.  Is this delusional?  Is this the definition of hope?  Is this at the very core of Westerners’ thought patterns?  The 2008 Obama campaign would suggest it is — hope quickens our blood, brings fire and water to our eyes, enlivens our gaze.

Okay, Ted Kaptchuk, I’m on board with this: the Western paradigm is open to change and improvement.  We just need the East to enter with West flare, with vision.

What does this vision look like?

It includes Western primary care physicians embracing other modalities.  Perhaps learning to practice them on their own, otherwise knowing when to refer.  It suggests the importance of the Doctor-patient encounter.  If any specific Western doctor does not want/need/have the capacity do this, they must be required at least to have the analytic capacity to know when it would be beneficial to the patient and respect that.  The notion that healing can take place in a human encounter must be demonstrated and ingrained into Western medical training so that when a patient has such an ailment (and, as I have argued before, these are in fact the most common ailments primary care physicians see), their healing is put first and foremost and they are guided toward the most useful resources.

As I have said, it means changing the system, broadening our view, using our Western ability to sit with opposites and opening medical education to new ideas.  This includes continuing education for practicing doctors.  It also means changing the insurance system to promote people’s health.  And it means educating ourselves, after all, we are the patients, on how we can hope (how quintessentially American!) to achieve health and vitality.

From knowledge to intuition

Eastern and Western medical paradigms have different uses for knowledge.  In both systems, it is important for novices to use  observable or quantifiable measurements and facts to create treatment plans for patients.  None of us want a 20-something fresh out of med school, be it Eastern or Western, to assume they can take one look at us and understand our deepest  existential quandaries, nor do we probably believe they can heal us with their presence.

The key to good decision making is not knowledge. It is understanding. We are swimming in the former. We are desperately lacking in the latter. … Being able to act intelligently and instinctively in the moment is possible only after a long and rigorous course of education and experience.

-Malcolm Gladwell, Blink

Yet many of us can probably call up the wizened face of some elder in our lives — a grandparent, a rabbi, a psychologist, maybe even a doctor — whose very presence and implicit understanding created space for us to deal with whatever was thrown our way: cancer, depression, war, loss of a limb, or the death of a family member.

Intense communication and intimate recognition automatically resonate and affirm the integrity of a patient’s Qi and Spirit. … Just from being and talking with Dr. Hong [an old, highly respected Chinese doctor], most patients encountered within themselves a depth of humanity deeper than the difficulty or tragedy of any illness.

– Ted Kaptchuk, The Web That Has No Weaver

Achieving this wisdom, this intuition for the vitality of others, is the highest aim for a traditional Chinese medical practitioner (Kaptchuk, 2000).  In contrast, while there are wise Western doctors who practice it, knowingly or not, it is not something that Western medicine, as a system, aims for.  Biomedical research is increasingly recognizing the importance of the doctor-patient encounter and the gaping hole that exists in Western medical training in this regard.

Currently, neither doctors and patients, nor plans have adequate skills in the doctor–patient relationship. (Goold & Lipkin, 1997)

Western doctor training programs that emphasize creating connection and being present with patients are sprouting up (see, for example, the growth of mindfulness-based courses for doctors).  I also put forth that Western doctors and the Western medical system, from med schools to insurance companies, can tap into the available resource of alternative medical practitioners, who were trained in these skills from the beginning.

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Kaptchuk, T. The Web That Has No Weaver. McGraw Hill Professional. 2000.

Gladwell, M. Blink. Little, Brown & Co. 2005.

Goold & Lipkin. “The Doctor-Patient Relationship.” SGIM Symposium on Managed Care. 1997.

Scientific rigor off the pharm

Good news!  Here’s a study that is using scientific rigor to test the utility of a non-pharmaceutical therapy.  The existence and prominence of this study is as important as the results.  It was published in The Lancet and highlighted in the BBC’s health section.

Both the original and the BBC report on it are refreshingly honest.  The BBC’s article is entitled “Schizophrenia: Talking therapies moderately effective”.  They do not claim to have cured the world, but simply by publishing the article they underscore its importance.

The authors of the study also reach conclusions with caution, point out the weaknesses of their study and discuss what needs to be done from here on the scientific side.  At the same time, they quietly but forcefully make a profound point: when we test other therapies with the same rigor with which we test pharmaceuticals we can get results that are at least as good, and the side effects are minimal to non-existent.

In their words, “Evidence suggests that the effectiveness of [antipsychotic] drugs has been overestimated, whereas the severity of their adverse effects [has] been underestimated … Although differences in efficacy between antipsychotics and placebo were noted, they were smaller than those for most of the analysed adverse effects.”  In my words, antipsychotics are somewhat effective.  So is cognitive behavioral therapy (CBT).  Antipsychotics have devastating side effects.  CBT has none.

State of the Science

Let’s take a look at the state of the science.  What does western medicine have to offer for the treatment of chronic conditions?  I am going to lay out a framework for how Western biomedicine addresses common, chronic, systemic maladies of everyday life, such as high blood pressure, diabetes, autoimmune diseases, and anxiety (see my last post for more details).  And I am going to suggest, because Western medicine takes a reductionist view rather than a systemic one, it is rare for it to hit upon a solution to these types of maladies.

Okay, here are the three ways in which Western medicine currently addresses systemic problems.

  1. There are the rare cases where a microscopic, singular trigger causes a plethora of systemic, chronic symptoms.  Western medicine searches for these causes and occasionally finds them.An example of this?  One that I have personal experience with: celiac disease. It’s an autoimmune disease. Like all autoimmune diseases, it has a vast array of seemingly unrelated symptoms: stomach aches, fatigue, joint pain, neuropathy, the list goes on.  But it’s unique — it is the only autoimmune disease for which we know the cause, the trigger: gluten.  We found the needle in the haystack, the control parameter that sets the whole system running out of whack.  There may be other diseases, autoimmune or otherwise, with such solutions, and hopefully western biomedical research will find them with time.  Until we do, I say, let’s help people who are dealing with multiple sclerosis, fibromyalgia, depression, anxiety, myasthenia gravis, Type II diabetes (the list goes on!) with the best treatment available to us at the moment, right now.  That is usually going to be something that addresses the whole and rebalances it as best we can.
  2. There are (or may be) diseases that have lots of nonlinearities and feedbacks, don’t have a single cause, but which we understand in enough detail to reliably manipulate.  These are truly rare.  In fact, I can’t think of a fully satisfactory example.  If anyone out there can, please do share!  But to get the ball rolling, here’s somewhere we get kind of close.Many women experience irregular menses and/or painful menstruation.  We have a qualitative picture of the hormonal feedbacks that drive ovulatory and menstrual cycles.  Given that knowledge, we can use exogenous hormones (i.e., birth control pills) to manipulate the cycle and remove the hormonal experiences that generate severe cramping.  However, this example is not satisfactory to me because western biomedicine does not understand the system well enough to rebalance it.  Instead, we can hammer away at it and change it to something different: in fact, it is not an ovulatory cycle at all anymore, as ovulation has ceased to occur.  But it does remove certain undesirable symptoms.
  3. For the smorgasbord of systemic diseases that we really don’t understand — haven’t found the silver bullet, don’t have a good enough grasp to hit over the head with a particular chemical, what tools does Western biomedicine provide?  Shots in the dark.  We adjust parameters that we know affect the system, but they are not key control parameters, ones that restore balance.  So we try. We cross our fingers and hope that luck or trial and error will lead us to a key control parameter for this particular person.Maybe a little more serotonin would do the trick.  Try these pills.  Or maybe you need the slow release version.  Try these ones.  Oh, these make you feel anxious all the time?  Lower your blood pressure to the point where you faint?  Try adding this medication on top!  Sometimes these things help, whether from their inherent chemical properties or people’s faith in biomedicine allowing the placebo effect to be quite strong (citation).  Much of the time, they are frustrating for patient and physician alike.

I believe Western biomedicine can be a powerful force for helping people restore their health.  I have experienced this first-hand watching my father heal from cancer following chemotherapy and a stem cell transplant and survive a heart attack.  And, after ten years of struggling with disparate symptoms, I was I was diagnosed with celiac disease thanks to my mother’s sleuthing into the world of biomedical research combined with medical testing.

But it has limitations too: lifestyle diseases, women’s health issues, mental health, chronic pain.  Many of these limitations line-up with success stories from other medical paradigms.  So let’s be honest about where we are today.  What is western biomedicine ready to treat? And what diseases is it still happily mucking about in the world of primary research?  For those problems that western biomedicine isn’t ready to tackle in a living body (yet!), let’s look to different viewpoints that are ready to treat, paradigms in which the healer’s role is to create space for the patient’s body to heal.

Paradigms of vitality

    The Western medical paradigm is great for curing complex problems so long as the complexity leads, ultimately, to simplicity.  In general, it seeks to identify the microscopic cause of a macroscopic problem and then excise that cause or change it in some way.  The tools developed through biomedical research have led to advances that would look like miracles to folks living 100 years ago: antibiotics for bacterial infections, vaccines that transformed last century’s blights into blips on the epidemiological radar screens of today, and surgical techniques that bring heart attack patients back from the brink of death.  Funny enough, these sorts of problems, which Western medicine is so good at addressing, are not what bring most people to their doctors .

Here is a startling observation: the top six ailments for which people see their primary care physician (PCP) are high blood pressure, high cholesterol, diabetes, back pain, anxiety, and obesity (http://www.practicefusion.com/ehrbloggers/2011/02/25-most-common-diagnoses.html), all chronic, systemic problems for which, thus far, biomedical research has not been able to identify a solitary microscopic cause.  They are nonlinear, involving feedback loops of behavior, hormones, neurotransmitters, responsibilities at work, relationships with family members, and cultural pressures, just to name a few of the ingredients that are  cause and symptom, illness and cure.

Western biomedicine has not created tools that satisfactorily support people through these problems.  In contrast, some other medical paradigms look at problems systemically; they do not reduce them to a microscopic cause, but instead find a way to create space in the human system to allow healing to take place.  The numbers are in: thousands of years of Chinese medical practices have been vindicated by western scientific methods as well.  Many alternative and complementary therapies have been shown to work as well as, if not better than, the narrowly-focused drugs that Western biomedicine provides for these problems.  Chiropractic, massage therapy, yoga, social work, and mindfulness-based stress reduction, to name a few, provide services that allow people to heal.

You’re better off going to your MD for an infection, heart attack, broken bone, or paralyzing pain.  But if you’re one of the millions of Americans feeling like you can’t handle the little ups and downs of life, or your doctor has told you repeatedly that you have a constellation of risk factors for heart disease and now you need to change your lifestyle, I suggest there are tools outside the Western biomedical box that our system and culture of health must consider to support a population full of vitality.  Most MDs are ill-equipped to help you with the seriously challenging process of finding space and attention to do the work of changing habits that have taken a life-time to build.

In this blog, I want to explore with you what does work well for these systemic problems, and I’m hoping you’ll explore with me how we can change the system and promote the use of paradigms that work.  Let practitioners within each modality work within their paradigm, while being aware of its strengths and weaknesses.  Our lives and health choices are wrapped up not just in the many factors that contribute to disease, but also in the economics of making choices to be healthier.  So in this blog I want to look to health insurance and practices in other countries that utilize varying degrees of non-western medicine, for example China and the UK.  I want to know where we are today.  How much do today’s PCPs know about complementary and alternative health practices and their uses?  How do insurance plans shape people’s treatment choices?  I will share with you quantitative research, investigative journalism, and stories of people’s lives.  Hop on the boat and share this journey with me!