Why Specialists Need To Understand the Entire Body

29 08 2010

I have no problem telling people that I want to become a psychiatrist, because even though my ambitions may change during my medical education, having a direction and being able to say it out loud helps keep me motivated to learn and it keeps me thinking about the relevance of what I learn.

In the near past, when I told someone that I wanted to become a psychiatrist, she questioned why I needed to learn about the other parts of the body.

It reminded me of when an old friend told me that her elderly mother had a heart condition that required medication.  The medication was not without side effects, but maintaining the heart trumps everything else, so she continued to take the medication.  Unfortunately, the edema (swelling) in her mother’s legs progressed to the point that she was no longer able to walk, so my friend took the day off from work and drove two hours (each way) to visit the cardiologist with her mother.  The cardiologist took a look at the EKG and other results that concerned him, and said that the medication was working fine, so there was no reason to change it.  He did not care about the edema, because the heart, in his eyes, is the only important organ to maintain.

It’s true that without the heart, we die, but what is the point of living without some quality of life?  Without the ability to walk outside or do anything independently, so that you feel trapped in your own home and have almost no choice but to become depressed?  With every stranger that passes by your wheelchair knowing that you have some debilitating illness, looking at you with pity and avoiding you (or at least that’s how you feel)?

Understanding the body as a whole allows for consideration of drug-drug interactions, side effects affecting other bodily systems, nutritional habits, hobbies, and individual patient desires that informs everything from how likely the patient will adhere to the prescribed medication to how well he or she will do on it.  Ultimately, I think that isolating organs or even entire body systems (circulatory, lymphatic, gastrointestinal, etc.) to treat risks the treatment being only a bandaid solution if it is not tailored to the individual’s life circumstances.  A patient may not take blood pressure medication if it means that she will not be able to play volleyball because of edema in her legs.  A mother of four young children may forget to take an HIV drug regimen that is three-times-per-day.  Someone who is homeless may not be able to travel two hours out of town per week to keep an appointment for a life-saving treatment.

Specialists exist because they are needed for in-depth study of the kidney, the skin, the eyes, etc. so that general theories of what can go wrong can be applied to the individual presenting with unique and rare signs and symptoms, but I think this specialized knowledge can never be taken out of the context of the intact human being.

But the question that was asked of me was specifically about why psychiatrists need to know about the other parts of the human body.  I think it’s a fair question, because psychiatrists tend to deal with what I always call the software of the human body (aka the mind or the intangible qualities of the brain that can distort personalities, create hallucinations, and debilitate memory).  Therapies in psychiatry include drugs, but drugs are meant to complement other therapies that may involve sitting in a chair and talking, like cognitive beahvioural therapy.  Most of the other fields in medicine are more concrete, requiring surgery and/or a cocktail of drugs, irrespective of trying to change how the patient thinks, so why should software specialists need to learn about the hardware?

The answer may be obvious to you, but other than inherent academic interest, it was difficult for me to come up with practical reasons for why a psychiatrist should have a firm grounding in how the rest of the body works, other than to avoid nasty drug-drug interactions and toxicities.

Originally, I thought perhaps the importance lies in understanding patients with co-morbidities (concurrent illnesses other than any psychiatric concerns), but then I thought that the patient’s subjective experience of the disease is probably more important, and I could always look up any disease that I didn’t know.

I then thought maybe the importance lies in increasing adherence, but the day-to-day factors that would affect adherence should be explored as part of the psych sessions anyway.

So as it turns out, that was the end of my extensive list of ideas.  So I decided to take a break from thinking, and that was when Dr. House came to the rescue.

In one particular episode, a young female CEO has intense heart failure with no indication of why, and it wasn’t until House considered her psychiatric symptoms that the underlying reason for her precocious illness was discovered: she was bulimic and using Ipecac to regularly induce vomiting, thereby destroying her heart.

The case woke me up from my naivety.  I realized that House is right: everybody lies.

While that may simply be truthiness talking, the reality is that if I become a psychiatrist, not all of my patients would be able to or want to open up to me and divulge all of their secrets right away.  Due to their circumstances, they may not trust me or perhaps they have the lost the ability to communicate coherently (as with some schizophrenic patients).  Medical training is one long course in pragmatic observation, and understanding the entire body allows me to notice clubbed fingers, a slight tremor in the arm, or jaundice in the eyes, and be able to infer details in the patient’s life (like bad habits or recent trauma) that he or she doesn’t want to tell me, didn’t know was important to tell me, or literally couldn’t tell me.

Essentially, knowing the whole body is critical to my becoming a good doctor and being able to successfully guide my patient’s treatment.  Who would have thunk it?

(P.S.: There is some recent evidence to suggest that optimism may alter immunological function, and possibly improve chances of survival and healing of any illness, so perhaps other medical fields can benefit from learning about how improving the mind literally improves the body, even beyond the placebo effect!)

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3 responses

29 08 2010
Eastwood

Just for laughs, check this out: http://scutmonkeycomics.blogspot.com/2010/01/blog-post_17.html … “His what?” 😀

And to follow up on your P.S., yes, there is a lot of exciting research taking place in the relatively young field of Health Psychology and Psychoneuroimmunology.

29 08 2010
June

I LOVE it! And thanks for the new blog to follow!

30 08 2010
Jocelyn Ling

Great post, and can I just point out that I love your analogy to House. awesome!

This is such a great reminder that in life, everything is linked to such an intricate network that it is absolutely necessary to understand how all the gears work. To put a name to what you just described, the term is Systems Thinking/Systems Theory and you might be interested in checking out a couple of models that they have. It’s actually the foundation of Chaos Theory…

Essential, one of the major breakthroughs in understanding the complex world of organizations is the field of systems theory. The field studies systems from the perspective of the whole system, its various subsystems and the recurring patterns in the relationships between the subsystems.

The application of this theory is called systems analysis and one of its major tools is systems thinking. Basically, systems thinking is a way of helping a person to view systems from a broad perspective that includes seeing overall structures, patterns, trends and cycles in systems, rather than seeing only specific events in the system and then leveraging that knowledge to offer different solutions to the problem as opposed to just one route.

Some resources:

http://managementhelp.org/systems/systems.htm

http://www.utwente.nl/cw/theorieenoverzicht/Theory%20clusters/Communication%20Processes/System_Theory.doc/

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