White Coat Underground

You say you want a revolution

Medical science rarely undergoes revolutionary changes. Progress tends to be slow and steady, with new ideas undergoing extensive investigation before being implemented. This pace can be frustrating and every once in a while, someone comes along who thinks they have discovered The Secret to It All. Despite the apparent insanity of such grandiosity (or perhaps because if it), you can always rely on the Huffington Post to give it a platform. (Interestingly, most of these Ideas can’t be simultaneously correct, but that doesn’t seem to bother HuffPo).

The latest Revolutionary Thinker is Dr Frank Lipman who writes about what he calls “the myth of diagnosis”. Let me remind you what “diagnosis” is (paraphrasing liberally from an earlier post).

We have a couple of ways of going about defining diseases. One is pathophysiological where we can clearly see a disruption of normal function or anatomy. Another is genetic; if we can trace pathophysiologic changes to a specific genetic change, Bingo! Of course, genes are rather complicated, and the relationship between genotype and phenotype can sometimes be frustratingly variable. But no one said science would be easy.

The least satisfying way of defining a disease is syndromic. Humans are pattern monkeys, which is both a good and a bad thing. The earliest medical texts were descriptive, and defined illnesses by their outward manifestations, the inner workings being inaccessible to the ancients. We still are forced to resort to description from time to time in medicine. For example, in the 80′s a new disease emerged which didn’t appear to be any single disease but a grouping of different diseases and symptoms with some commonalities. We called this grouping “Acquired Immune Deficiency Syndrome” to acknowledge the fact that all the patients had immune dysfunction and all appeared to have “acquired” it rather than having been born with it. It was called a “syndrome” rather than a disease because it was more of a grouping of illnesses and the unifying pathology wasn’t yet understood. (Now, of course, HIV disease is one of the best understood illnesses in human history.)

Ultimately, the goal of defining a syndrome is to look for the disease or diseases that may underlie the symptoms. We realize that when we define a syndrome we may improperly include and exclude patients from our net, but we try to come up with rational definitions so that we may find the cause. “Syndrome” is more of a tool than an explanation but it can be a very useful tool.

The reasons that we diagnose diseases rather than taking some other approach to human disease is because it works. Generalization is important. Knowing patterns and causes of diseases allows us to intervene. Studying groups of individuals to find knowledge to apply to individuals is how medical science works. For example, a heart attack is (proximately) caused by the occlusion of a coronary artery. This knowledge has allowed us to study and implement ways of opening these arteries and saving lives. If we did not use this system and treated each presentation as a unique disease, we would have no way of generalizing treatments.

Of course, heart disease has more distant/ultimate causes as well, such as genetics, diet, cholesterol, and smoking, so we also have ways of preventing heart attacks. Understanding the proximate and ultimate causes of diseases, and being able to define them is what makes modern medicine work.

Diagnosing people with specific diseases does not preclude treating people as individuals; this is the heart of medicine.

But Dr. Lipman does not agree:

After 30 years of practicing Medicine, I have learned that for any chronic illness or ailment, treating underlying imbalances and dysfunctions is more important than making a diagnosis and naming the disease. Ultimately, asking the right questions is more important than giving a label to a set of observations.

What does that mean, doctor? “You learned that….” Did it really take you thirty years to learn that treating diseases involves more than naming them? Congratulations. So what is behind your revelation?

This is because most if not all chronic problems, from heart disease to arthritis, migraines to irritable bowel syndrome (IBS), depression to fatigue, usually have multiple factors that need to be addressed – this is called the total load. The total load is the sum of the factors that influence a person’s life and health, including diet, exercise, job stress, relationships, state of mind etc. Individually, each of these elements might not cause a problem, but their cumulative effect can overload our normal functioning and cause harm. Everyone’s tipping point is different and each of us manifests or experiences overload in our own unique way.

That’s clever! You invented a new word–”total load”. You also “discovered” that every patient experiences health and disease in a unique way. Good for you.

There are two types of idiocy going on here. First is the usual altmed co-optation of standard medical practice, in this case prevention. The recognition that prevention is important is not revolutionary—it’s standard of care. The second is the delusional belief that you have actually discovered something new and revolutionary.

It’s sad in a way, but also dangerous. Doctors who abandon the model that has served us well for so many years to adopt a new, made up, and invalid approach to practice are dangerous. There’s plenty in medicine that could stand some improvement, and smart, compassionate doctors are always needed. Cranks, not so much.

Comments

  1. #1 Dianne
    June 25, 2009

    this is called the total load

    Sorry but I can’t resist saying: This statement is a total load of…

  2. #2 Denice Walter
    June 25, 2009

    This could potentally be as inspiring to the woo-centric world as was the “myth* of mental illness” .*(which is itself, mythical)

  3. #3 daedalus2u
    June 25, 2009

    He right about systems biology being important and the correct way to look at physiology, but he is doing it all wrong. Traditional Chinese Medicine has nothing to say about systems biology because it knows nothing about systems biology. To do systems biology right, you have to have all the details right. Those details only come from science.

    You can’t tack “systems biology” stuff onto the false hierarchical structure of TCM or chi, or naturopathy and get something correct. You have to start with the scientific details and build the hierarchical structure from the bottom up, not from the top down. It is very frustrating to me that they are now mucking up systems biology too.

    Some of what he is saying is true, but because he doesn’t understand what he is talking about it is just empty words. Those systems are all connected; not through diet and exercise but through nitric oxide.

  4. #4 The Perky Skeptic
    June 25, 2009

    Oh, there’s a “total load” in Lipman’s assertion, all right… darnit, Dianne beat me to it! ;)

    I am curious. How does Huffington Post choose its articles? I mean, do they have a team of people who are paid to find the really top-of-the-line utter crap?

  5. #5 Kim
    June 25, 2009

    I can see the clear problem with abandoning the concept and process of diagnosis, but it seems to me the systems biology concept is probably relatively sound (whether he’s just invoking it to give credence to his methods rather than genuinely looking at evidence coming out of legitimate systems biology lines of inquiry is not clear to me from this essay). And I’m sure some people with chronic illness probably could use a social worker…again, not that that is more important than a proper diagnosis.

    In any case, it sounds like he is mostly concerned with the worried well and other not-very-sick people, who probably will feel better for following his advice.

  6. #6 PalMD
    June 25, 2009

    this whole invocation of systems biology in re clinical medicine seems like a little kid throwing around a big word that he doesn’t understand and is irrelevant.

  7. #7 titmouse
    June 26, 2009

    I criticized Dean Ornish for his assertion that stress management was somehow novel or controversial among mainstream MDs. I said, “I was trained to develop a bio-psycho-social formulation summarizing all the significant variables in the patient’s presentation. So talking with patients about social supports, time management, and so on, is nothing new to me.”

    Ornish replied that I was unique, that the average doc spends only 9 minutes with a patient…

    Well. Average amounts of time are meaningless. Some patient encounters are 90 minutes long while some don’t involve direct contact with the MD at all.

    More face-to-face time isn’t the ideal; it’s efficient use of time that matters. A mechanic who spends two hours fixing your flat isn’t necessarily more caring or involved or “holistic” than a mechanic who gets the job done in 30 minutes.

    I could not have passed by oral Board exam without presenting a bio-psycho-social patient formulation. So clearly, I am not unique.

    In a room filled with my bio-psycho-social colleagues, Dr. Ornish got a standing ovation. “EAT UR CARROTS AN CHILL AN U WONT GIT DE CANCER OR MI!!” is a message that seems to hit a nerve.

    It’s getting old, this dominance of popular culture by Boomer issues. The 1960′s had their entertainment value, as we all lived through the hyperdramatization of adolescence. But now we’re looking at 10-20 years of “OMG I DON’T WANNA DIE!!!1!!” all day long, playing on every feckin’ channel.

    Meh.

  8. #8 BaldApe
    June 26, 2009

    The reasons that we diagnose diseases rather than taking some other approach to human disease is because it works.

    It works as long as you don’t stop with naming the syndrome and then acting like you’ve finished. ISTM that identifying a syndrome is a useful tool along the path to understanding what is going on, but not the end of the path.

    Otherwise, you wind up with “It hurts when I do this” syndrome, with the medical advice “Don’t do ‘this’” That’s what I object to when someone diagnoses fibromyalgia, for instance. Yes, there is a syndrome, but somewhere under that syndrome is one or more causes.

    My wife came within months of dying from a kidney tumor that had grown up her vena cava nearly to her heart because the doctors she was seeing were willing to see her symptoms as part of the “syndrome” (if I may call it that) of obesity. I understand that kidney cancer can be hard to diagnose, but her symptoms were not taken seriously, because when she complained of a bloated stomach, they saw a fat woman.

  9. #9 rob
    June 26, 2009

    sad face.

    Dianne and The Perky Skeptic beat me to the “Total Load” quip.

    sniff.

  10. #10 The Perky Skeptic
    June 26, 2009

    LOL– I know how you feel, rob! Seriously, that “total load” line, which he seems to use in utter seriousness, nearly makes the whole article seem like a Poe! What does one call an alternative medicine Poe, anyway?

  11. #11 Kim
    June 26, 2009

    @titmouse: I agree, re Boomer issues. And I particularly do not like the mean-spirited flip side of the “if you follow the ‘right’ guru and do things ‘right’ (and are appropriately smug about it) nothing bad will ever happen to you” BS.

  12. #12 antipodean
    June 29, 2009

    Dammit!

    Now I’ve got the Beatles in my head…smug 60′s bastards…

  13. #13 Larkspur
    September 28, 2009

    Oh, bite me. So very sorry I was born in 1952. I am trying to live a decent life, and I am not trying to oppress you with my existence, and I hope you all are fortunate enough to get as old and annoying as I am.

    Jeebus. Not all of us are wealthy and self-indulgent and intent upon consuming everything we’re supposed to leave to you. A lot of us grew up.

    If I had a fucking lawn, I’d tell y’all to get off of it. But you probably saw that coming.

  14. #14 Larkspur
    September 28, 2009

    This is so embarrassing. It is September. Y’all are back in June. Senior fucking moment, eh?

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