It starts with the story: Listening to patients Radwan Banimustafa MD The university of Jordan...
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It starts with the story:It starts with the story:Listening to patientsListening to patients
Radwan Banimustafa MDThe university of Jordan medical school
"The good physician will treat
the disease, but the great physician will treat the patient."
Sir William Osler, M.D.
What are the connections?What are the connections?
MindBrain
Body
?
?
?
Early understandingsEarly understandings
The soul is in the very likeness of the divine, the immortal, the intellectual…. The body is an enclosure or prison in which the soul is incarcerated. – Plato (Cratylus)
The seat of the soul and the control of voluntary movement - in fact, of nervous functions in general, - are to be sought in the heart. The brain is an organ of minor importance.
Aristotle (De motu animalium, 4th century B.C.)
It seems to me an acceptable assertion that the soul itself resides within the brain
where the activity of thought is produced, and the memory of sensorial images is
stored there.
Galen (129-199 A.D.)
For the next 1600 years…..For the next 1600 years…..
Respect for the body as “created in the image of God” precludes systematic scientific investigation
Gradually the church permits the body to be studied by the scientists
The soul is left to the theologians and philosophers
The soul and body are separate…The soul and body are separate…
“If the filaments that compose the marrow of these nerves are pulled with force enough to be broken and thus are separated from the part to which they were joined, so that the structure of the whole machine is less intact, the movement they cause in the brain will cause the soul to experience a feeling of pain.
Treatise of Man
"Pain in the hand is felt by the soul not because the soul is present in the hand but because the soul is present in the brain."
Principles of Philosophy
…but the soul is present in the brain.
The mind (soul) and body connectionThe mind (soul) and body connection
Pineal gland was the interface, connecting the animal spirits and the bodily sensations
Cartesian dualism has had a profound effect on medicine:– emphasis on biology– reductionism– tissue damage, disease and symptoms are
proportional
The mind – brain connection
After the accident, “… the equilibrium or balance, so to speak, between his intellectual faculties and animal propensities, seems to have been destroyed. He is ... irreverent, indulging at times in the grossest profanity (which was not previously his custom), manifesting but little deference for his fellows, impatient of restraint or advice when it conflicts with his desires ... obstinate, yet capricious and vacillating, devising many plans of future operation, which are no sooner arranged than they are abandoned in turn for others.…”
Harlow, John M. Recovery from the Passage of an Iron Bar Through the Head, 1868, Publication of the Massachusetts Medical Society, 2:327
The mind and the mind-body connection: The mind and the mind-body connection: Sigmund FreudSigmund Freud
Obtained MD in 1881, worked as a neurologist Couldn’t explain common and important clinical
phenomena using neurological models alone Hypothesized an inner world: the mind The mind had a structure similar to the brain, and “rules”
of operation Discovered the “talking cure”: discussion of the onset of
certain symptoms (phobias, paralyses, pains) frequently led to their abatement
Example: a soldier who became blind in battle regains his sight when he talks of “no longer wishing to see the trauma of combat”.
Freud’s model of the mindFreud’s model of the mind
SUPEREGO(conscience)
EGO(awareness)
ID(impulses)
PRECONSCIOUS(memory)
CONSCIOUS(awareness)
UNCONSCIOUS(the closet)
structure topography
repression barrier
The brain-body connection:The brain-body connection:Hans SelyeHans Selye
Stress: the inability to cope with a physical or emotional threat
3 stages:• Alarm: fight or flight response (nervous and endocrine
systems activated for defense against stressor)• Resistance: continued high alert (hormones helpful in
alarm stage now become counterproductive increasing risk for disease)
• Exhaustion: body no longer able to cope Showed that the brain could, literally, kill the body
Brain environment
Endocrine glands Immune system
Physiology and Behavior
NervesHormonesAction
That was then…That was then…
MindBrain
Body
Gage and head injury
Selye and stress Freud and mysterious symptoms
… … this is nowthis is now
MindBrain
Body
The biological basis ofPsychiatric disorders
Psychoneuro-Immunology
Medically unexplainedphysical symptoms
Biopsychosocialmodel
So, what does it mean to be a patient?
Becoming a patientBecoming a patient“Patients are human beings with very human
hopes and fears. In the hospital, they have been removed from their accustomed environment. Their valuables and their clothes have been taken away from them, and they feel “miserable, scared, defenseless, and, in their nakedness, unable to run away”.
Francis W. Peabody, MD in a 1927 lecture to Harvard Medical Students.
Signs and symptomsSigns and symptoms Signs: ‘objective’ manifestations of a disease
process (e.g., a rash, high blood pressure) Symptoms: ‘subjective’ experiences (pain or other
form of distress) Healthy individuals develop a new physical
symptom every 5 - 7 days 95% of these symptoms are never brought to the
attention of a doctor. Question: What are symptom characteristics that
might make you go to the doctor?
Why symptoms lead to medical visitsWhy symptoms lead to medical visits
Intensity Duration Change in presentation Family history Previous experience Unfamiliarity Perceived threat Loss of control
Disease and IllnessDisease and Illness
Disease: an objective pathological process or injury
Illness: a subjective sense of one’s state of health
Usually these happen together. But not always…….
Your first night on callYour first night on call
You are the medical student in the ER tonight.
Two patients have been admitted with chest discomfort
Your job is to interview them and find out what’s going on
Mr. KMr. K
Patient: 53 year old man with no history of heart disease. Came to the ER reluctantly at the insistence of his wife because of chest discomfort
Findings: abnormal EKG, cardiac enzymesDiagnosis: Myocardial InfarctExpectation: Patient wants to leave ER
now to go back to work, states discomfort is “not that bad”. Asks that you discharge him immediately.
Mr. SMr. S Patient: 48 year old man with no history of heart
disease. Ninth ER visit this month for complaints of chest pain, no previous findings. Patient has had multiple thorough workups including cardiac catheterization as well as pulmonary and gastroenterology consults (all normal).
Findings: normal exam, EKG, cardiac enzymes Diagnosis: not clear Expectation: Patient wants to be admitted again.
Says the pain is “worse than ever”. Feels he cannot go home. He’s pulling on your sleeve.
How do people become patients?How do people become patients?
A symptom is recognized and its associated functional impairment is experienced
The symptom is interpreted and attributed to some health problem (i.e., the symptom has meaning)
The person becomes a patient and uses health care (forms a relationship with a health care professional)
He or she may remain a patient until the symptom remits.
Patients vary greatly in their Patients vary greatly in their reactions to common symptomsreactions to common symptoms
Genetic or constitutional predisposition
Biological factors
Personal experience, learned patterns of attribution and response
Psychological factors
System of medical care, health benefits, financial incentives, family and peers, environmental stressors and resources
Social factors
How can we keep track of all How can we keep track of all this information?this information?
Case #1Case #1
Mary is a 45 year old woman with diabetes who presents with a 1-month history of “not feeling herself.” She states that she has difficulty sleeping, poor appetite, poor concentration and constant fatigue.
Case #1Case #1
Mary is a 45 year old woman with diabetes who presents with a 1-month history of “not feeling herself.” She states that she has difficulty sleeping, poor appetite, poor concentration and constant fatigue.
What would you do about these symptoms?
Biopsychosocial formulationBiopsychosocial formulationBiological (brain-body)
What we see
Sleep, appetite, concentration fatigue
What might be the cause
Diabetes or Major Depression (a neuro-chemical imbalance)
What we might do ?
Biopsychosocial formulationBiopsychosocial formulationBiological (brain-body)
What we see
Sleep, appetite, concentration fatigue
What might be the cause
Diabetes or Major Depression (a neurochemical imbalance)
What we might do
Medication
Progress of treatmentProgress of treatment
0102030405060708090100
1 2 3 5 6 7 8
Prior level of function: busymother of 3, preschool teacherMedications:
Insulin adjustedProzac started
Blood sugar now normal
Case #1Case #1Mary is a 45 year old woman who
presents with a 1-month history of “not feeling herself.” She states that she has difficulty sleeping, poor appetite, poor concentration and constant fatigue. She rarely goes out anymore with her friends and spends most of her time with her alcoholic husband who is physically abusive.
What do these new data tell us?
Biopsychosocial formulationBiopsychosocial formulationBiological (brain-body)
Social(environment)
What we see
Sleep, appetite, concentration, fatigue
Isolation, abuse
What might be the cause
Diabetes or Major Depression (a neurochemical imbalance)
Domestic violence relationship
What we might do
Medication ?
Biopsychosocial formulationBiopsychosocial formulationBiological (brain-body)
Social(environment)
What we see
Sleep, appetite, concentration, fatigue
Isolation, abuse
What might be the cause
Diabetes or Major Depression (a neurochemical imbalance)
Domestic violence relationship
What we might do
Medication Women’s Shelter, social support
Progress of treatmentProgress of treatment
0102030405060708090100
1 2 3 5 6 7 8
Goes to women’s shelter
What happened here?
Case #1Case #1 Mary is a 45 year old woman who presents with a
1-month history of “not feeling herself.” She states that she has difficulty sleeping, poor appetite, poor concentration and constant fatigue. She rarely goes out anymore with her friends and spends most of her time with her alcoholic husband who is physically abusive. She has little interest in fun activities, has a negative view of almost everything, and feels that she is a failure as a mother.
What do these new data tell us?
Biopsychosocial formulationBiopsychosocial formulationBiological (brain-body)
Psychological(mind)
Social(environment)
What we see
Sleep, appetite, concentration, fatigue
Boredom, poor self-image, negativity
Isolation, abuse
What might be the cause
Diabetes or Acute Major Depression (a neurochemical imbalance)
Childhood abuse and neglect
Domestic violence relationship
What we might do
Medication ? Women’s Shelter, social support
Biopsychosocial formulationBiopsychosocial formulationBiological (brain-body)
Psychological(mind)
Social(environment)
What we see
Sleep, appetite, concentration, fatigue
Boredom, poor self-image, negativity
Isolation, abuse
What might be the cause
Diabetes or Acute Major Depression (a neurochemical imbalance)
Childhood abuse and neglect
Domestic violence relationship
What we might do
Medication Psychotherapy Women’s Shelter, social support
Progress of treatmentProgress of treatment
0102030405060708090100
1 2 3 5 6 7 8
Medication
Social support
Psychotherapy
WorldCountryVillageFamily
RelationshipsPATIENT
Organ systemsOrgansTissues
CellsCell components
Molecules
The systems-orientedview of theBiopsychosocialModel
Engel GL: The clinical application of the biopsychosocial model. Am J Psychiatry. 1980 May;137(5):535-44
ANTHRAX
What have we learned today?What have we learned today?
Symptoms are commonOccasionally their meanings change
and individuals seek health careIllness and disease are differentThe bio-psycho-social model is the key
for organizing the story
"It is more important to know what kind of a patient has a disease
than what kind of disease a patient
has."
Sir William Osler, M.D., 1891