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This article was downloaded by: [University of Tasmania]On: 13 November 2014, At: 10:28Publisher: Taylor & FrancisInforma Ltd Registered in England and Wales Registered Number: 1072954Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH,UK
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Chemophobia, FamilyMedicine, and the Doctor-Patient RelationshipWilliam M. Simpson Jr., MD & Clive D. Brock MDPublished online: 30 Sep 2008.
To cite this article: William M. Simpson Jr., MD & Clive D. Brock MD (2003)Chemophobia, Family Medicine, and the Doctor-Patient Relationship, Journal ofAgromedicine, 9:1, 7-16, DOI: 10.1300/J096v09n01_02
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Chemophobia, Family Medicine,and the Doctor-Patient Relationship
Some things change with the times; some things remain the same. Pa-tients still hurt, healers still try to diagnose, treat, and prevent illness.Symptoms and signs of illness still come in rational, scientifically un-derstandable syndromes and patterns. These can be lab-tested, clini-cally confirmed with agreed-upon treatment plans, and peer-reviewedby medical professionals. Skilled doctors can communicate to their pa-tients the most likely outcomes of healing or chronicity, with caring andcompassion.
Some things change in medical practice, especially with new diag-nostic methods, including MRI technology, and enhanced serology andbiopsy information. Pharmaceuticals are increasingly potent, disease-specific, and capable of dramatic cures as well as serious deleteriousside-effects.
What is unchanging in medical practice? It is the doctor-patient rela-tionship, so eloquently defined in the 1960s by Dr. Michael Balint, in aclassic called, “The Doctor, His Patient, and The Illness.”1,2 Unchang-ing is the need for a fundamental level of trust between patient and doc-tor which begins with the first encounter at the bedside or in the clinic.The relationship may continue over time, through the ups and downs ofthe course of acute and chronic illnesses, until either the patient or thedoctor dies. Continued trust requires continued observation, nurturedby caring, competence, and commitment on the part of the healer andhis staff. Differential diagnosis by the clinician requires a delicate bal-ance between defining the “organic” (pathophysiologic) basis of symp-toms and recognizing the “functional” (subjective, stress-related) basisof the patient’s very real symptoms.
In the past, continuity of care in the smaller community of rural prac-tice was a given. Over the years, the cumulative wisdom of the generalpractitioner became legendary and revered by generations of grateful
Journal of Agromedicine, Vol. 9(1) 2003http://www.haworthpress.com/store/product.asp?sku=J096
2003 by The Haworth Press, Inc. All rights reserved.10.1300/J096v09n01_02 7
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patients. They could count on the skills of the dedicated, tenured clini-cian to help sort out the trivial from the serious, and to recognize thefear-component as distinct from the telltale early sign of serious pathol-ogy in the apprehensive and often baffled patient. The balanced practi-tioner was scientist, counselor, teacher, and steadfast family friend. Heknew, not only the books, but the patient, the household, the neighbor-hood, and the community. He knew the biological, the physical, and thechemical etiologic factors at work in his community.3-6 These couldrange from brucellosis in the dairy herd infecting handlers to contami-nation of the water supply by industrial run off.
How times have changed in the new century! Progress has acceler-ated in telecommunication, in pharmaceuticals and vaccines, in sur-gery, genetics and preventive medicine. Most importantly, as Sir ColinBerry7,8 points out, the gains in health and longevity among residents ofdeveloped nations, are based on advances in agriculture and nutrition,as well as sanitary measures to protect water, sewage disposal, andspread of communicable disease, including rodent control and insectvectors. The question now is, what has happened to the doctor-patientrelationship? To ordinary continuity-of-care? To citizens’ trust in themedical and public-health community?
The disturbing answer is that the average citizen trusts the eveningTV news with its latest environmental, food, or health scare more thantheir local personal physician who may be hard to reach, too busy treat-ing patients, or “away” on vacation or for continuing education. Thepower of the media to inform has gone from print to electronics, withthe shift from reading and deliberation to instant impressions, and irra-tional feelings of “good” news and “bad” news. The average TV viewerrarely experiences feelings of “oh, hum, no news” toward the nightlybroadcast; if he did, the network ratings and market-share would suffer.In the meantime, nutrition can be better than ever if persons choosewisely at the supermarket, exercise can benefit us enormously with reg-ular self-discipline, and aging can actually be enjoyed as never before.This good news cannot compete for media attention with the latest foodscare (parts per billion of organochlorine residue in Lake Michigantrout) or global warming alarms from futuristic meteorologists.
This all leads the thoughtful citizen to appreciate the argument for areturn to reason and rationality in the new century posed by Sir Colin.How can we let ourselves be led so far astray from sound risk percep-tion, balanced reasoning, common-sense, and trust in credible sciencethat is the foundation of our standard of healthful living? Of course,death still carries a probability of 1.0, but certainly birth and delivery
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and infanthood and childhood freedom from communicable diseases re-main a cause for increasing optimism, not pessimism in our complex so-ciety.
Yet, Berry points out, consider how an unconfirmed, speculative me-dia report of an association between childhood immunizations and au-tism frightened many parents in the U.K. to deny their children theprotection of essential vaccines against several dangerous pathogens.Give the credit to the media and its ever present need to maintainviewer-ratings and stockholder profits (see Table 1).
What has changed and what has not, is never more clear than in theongoing case of chemophobia, or environmentally-linked human ill-nesses that cannot be medically or epidemiologically defined, con-firmed or understood. Popular names are coined to describe thesepoorly defined “syndromes” (lay persons adopting the jargon of medi-eval physicians). The new name for old-fashioned “neurasthenia” maybe chronic fatigue syndrome, or multiple chemical sensitivity (allergyto everything man-made), or environmental hormone disruption (explain-ing cancers, neurotoxicity, sterility and birth defects of most planetaryspecies, including humans). Individuals and society, in technologicallyadvanced countries, seem to have adopted the concept of a no-risk en-titlement to good health and freedom from any sign or symptom ofill-health which might be conceivably linked to “involuntary exposure”to man-made chemicals detectable in our air, water, soil, crops, or pro-cessed food supply. Forget about pandemic influenza viruses, soil-bornegangrene, zoonoses, or deadly mosquito-borne yellow-fever. After all,these are organic and natural in origin, according to such distorted per-ceptions of health risks.
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TABLE 1. Highlights Adapted from Sir Colin Berry’s Article on “Risk, Scienceand Society” http://www.spiked-online.com
1. In the United Kingdom, the public has “become highly adverse to risk.” This irrational fearfeeds the media’s appetite for publicizing the latest so-called health hazard.
2. By exaggerating the health risks of low-dose chemical exposures in the environment, ac-tivists invoke “the precautionary principle” to overrule balanced, cost-benefit, scientificjudgment and to pass unnecessarily restrictive laws and regulations.
3. Unrealistic expectations for the health benefits of improved life-style lead many to expect“to live forever.” In fact, ordinary signs and symptoms tend to be “somaticized” to anever-increasing level. This leads to irrational demands on the medical care system.
4. Despite enormous progress in life expectancy, nutrition, agriculture, public health, andmedical technology, the public tends to take such advances “for granted.”
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In terms of bedside diagnosis of distressing and disabling illnesses,there is a linkage between several influential changes in society, affect-ing the formerly tenured and trusting doctor-patient relationship. Thesecontemporary changes operate far beyond the sciences of statisticalprobability, pathology, physiology, and toxicology.
CASE STUDY OF CHEMOPHOBIA
The foregoing discussion of changes in our society impacting a sin-gle individual’s perception of illness and how it affects the way an aver-age patient seeks help can be illustrated by a recent case of a disabledyoung worker.
A thirty-two year old worker is on total disability and has receivedstate-mandated worker’s compensation for the past three years. Herpromising career as a civil servant in a state agency was abruptly inter-rupted by a single incident of alleged acute toxic chemical exposure.The worker routinely operated an assigned government vehicle as partof her job. One day, however, the interior of the automobile was de-odorized with a “powerful chemical” to remove noxious odors. Fromthat single day’s acute exposure, the alleged fumes irritated the mucusmembranes of her eyes, nose, throat and respiratory system to such anextent that she sought emergency help at a nearby hospital. After com-plete examination she was assured that her symptoms were self-limited,related to temporary chemical irritation with no long-lasting effects.However, one conscientious physician expressed his concern to the pa-tient that a form of arrhythmia (extra-systoles) was noted in her EKG.
This episode began a series of cardiovascular tests and referrals,which led to a diagnosis of a congenital, not acquired, electrical conduc-tion abnormality. Not rare or life threatening, the doctor explained, itwas merely worth noting for future reference and future caregivers.
Consequently the worker became obsessed with the toxic theory thatany exposure to noxious fumes could trigger acute heart failure. Pre-sumed cumulative cardiovascular and circulatory damage was also asource of dread.
This led her to accept a diagnosis of “multiple chemical sensitivity”and to seek various prolonged expensive diagnostic tests and detoxifi-cation treatments by clinical ecology specialists. Everything in her diet,water, housing and life-style was considered a possible triggering toxin,and required constant vigilance. Prescriptions included tonics, vitamins,purifying saunas, a light beam generator, masks, filters, and oxygen to
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protect her from further illness. Periodically, her workers’ compensa-tion guarantors require medical opinions to justify continuation of herexpensive treatments and disability payments. Her health and disabilityclaims are backed by toxic tort lawyers.
In another age, not too long ago, this case would be categorized assomatization disorder, severe, bordering on psychiatric illness.9-14
Schuyler and Brownfield15 describe the painful disability of these pa-tients as “viewing one’s body on a screen in which every sign or symp-tom of pain or weakness is projected and cannot be controlled oralleviated in any way” (see Table 2).
In summary, the confluence of current forces in society are at work,not only at political, cultural, and economic levels, but at the level ofdiagnosis, treatment, and prevention in the forces also influence the in-dividual doctor-patient relationship (see Table 3). At the root of thepatient’s problem is a growing culture of scientific naivete bordering onsuperstition, unrealistic expectations of entitlement to everlasting, dailygood health, free of pain or discomfort, and the perceived need for gov-ernmental protectionism. There is a trend to increasing activism on thepart of the patient.16 Patient activism, gone awry, can lead to suspicionof any source of possible chemical risk. Heightened awareness of symp-toms requires greater access to medical resources, tests, treatments,more tests, and more treatments. Prevention, in their view, requires ac-cess to “pure” air, water, food, and housing on a permanent basis toachieve a risk-free environment.17
As Shakespeare warned us in “Julius Caesar,” “the fault, dear Brutus,is not in the stars, but in ourselves.” The trends in society, past and pres-ent, are listed in Table 4. The trends in the primary care physician’s roleare listed in Table 5. Trends in the patient’s role, past and present, arelisted in Table 6.
When will our society correct its self-delusional perception of arisk-free environment and symptom-free personal life? When will wetake a critical look within our all-too-human bodies, at our distorted per-ceptions, our flawed reasoning? When will we begin to question biasedstudies with obvious foregone conclusions? When will we begin tocome to terms with our own mortality and tolerable signs of morbidity,without seeking “better living through non-chemistry,” instead of try-ing to ban the benefits of essential petrochemicals and their derivativeswhich we now take for granted?
The good news in the U.S. is that the academic community at theHarvard School of Public Health began a center in 1989 devoted to pro-motion of “reasoned responses to risks to public and environmental
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TABLE 2. Some Characteristic Features of the Somatization Syndrome
• Defined: “the propensity to experience and report somatic symptoms that have nopathophysiological explanation, to misattribute them to disease, and to seek medicalattention for them.”8
• Defined: “the pathological end of a spectrum of phenomena that overlaps normal experi-ence.”9
• May be acute or chronic, moderate or severe.
• Coincidental mental illness may or may not be present (anxiety, depression, post-trau-matic stress).
• Multiple diagnostic tests and procedures are likely, especially if covered by some form ofinsurance.
• Distinct from malingering and conscious simulation of illness.
• Not consciously used as a tool to control or manipulate others.
• Prevalence rates estimated at 0.2 to 2.0 percent for women, and 0.2 percent for men.
• Carries a high risk for over-referral to specialists including unnecessary surgery.
• Many medical specialties tend to label patients with current syndromes with poor medicaldefinition. These syndromes include fibromyalgia (by rheumatologists), irritable bowelsyndrome (by gastroenterologists), chronic fatigue syndrome (by infectious diseasespecialists).
• Anxiety and depression may be co-morbid features, but their successful treatment doesnot alter the course of the severe form of somatization disorder.
• Emergency room visits, doctor-shopping, self-medications, and unproven alternativemedicine therapies should be discouraged.
• The relationship of the patient to a single, caring, and committed caregiver is the singlemost likely factor in long term successful management and prevention of diverse, distress-ing symptoms.
• Additional research is needed in the relationship of somatization, its underdiagnosis, itsmismanagement, the patient’s demand for services, and the role of third-party reimburse-ment policies, which exert pressure for more disease-oriented tests and procedures thanare wise or necessary.
• Overinformation and disinformation from the media and websites tend to increase anxietyand raise false hopes for cures in the dissatisfied patient. Trust is eroded in the essential,hopeful, therapeutic doctor-patient relationship which can lead to healing and return to anormal life.
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health and safety.”18 While trying to improve risk analysis methodolo-gies, the center works with industry, consumers, government and pri-vate foundations to address current health issues in terms of prudentpolicy. For example the Harvard Center assisted the U.S. Department ofAgriculture in strengthening safeguards against the importation of bo-
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TABLE 3. Comparison of Two Types of Doctor-Patient Relationships, Functionaland Dysfunctional
CHARACTERISTIC FUNCTIONAL DYSFUNCTIONAL
• Communication Collegial (adult-adult) Authoritarian (adult-child)
• Empathy Appropriate, flexible, open,non-judgmental
Inconsistent; either over-sympathetic, or rejecting
• Case management MD orders tests andprescribes objectively;educates patient
MD, pushed by patient,over-tests, over-treats, andover-prescribes
• Continuity of care Tenured care and patientresponsibility
Excessive-referrals to otherspecialties; “dumping” ofpatient
• Patient’s acceptanceof illness
Learned to accept symptomsand time-scale of healing
Impatient, angry, feelsabandoned, unrealisticdemands on self andproviders
• Patient’s acceptanceof uncertainty
Gradual and cumulative trustin MD’s skills, honesty andcounseling
Distrustful of MD, lacksconfidence in medical system,seeks popular cures againstadvice
• Early diagnosis oforganic disorders
Alert and vigilant monitoring ofchanges indicating pathology
Danger of mistaking earlysigns of pathology as moresubjective symptomatology
TABLE 4. Trends in Society’s Perception of Chemical Risk, Past and Present
SOCIETY’S ROLE PAST/PRESENT
Scientists’ judgement Trust/Distrust
Government regulations Limited/Big brother
Media influence Limited/Global
Media alarms Infrequent/Daily
Legal damages Unlikely/Frequent
Patient support groups Therapy/Political action
Scientific uncertainty Accepted/Rejected
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vine spongioform encephalopathy, so-called “mad cow disease.” Otheraccomplishments in recent years include evaluation of hazardous childseating in passenger motor vehicles, and screening for colorectal can-cers in the general population. The interdisciplinary university centerwelcomes visits to its website at www.hcra.harvard.edu. Its centralmotto is to “use decision science to empower informed choices abouthealth, safety, and environmental risks.” This is not too different fromthe informed choices that are required between the caring clinician andthe help-seeking patient in the context of the average ambulatory visitfor diagnosis, treatment, and prevention. The alert family physician ofthis century needs to be aware of chemophobia and sensitive to other
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TABLE 5. Trends in the Primary Care Physician’s Role, Past and Present
PHYSICIAN’S ROLE PAST/PRESENT
Patient’s perception Trust/Tentative trust
Continuity-of-care Often/Less often
Legal liability Slight/Major
Ability to reassure Strong/Weakened
Diagnostic tests Few, simple/Many, complex
Psychosomatic management Supportive/Refer to specialists
Managed care Unlikely/Dominates practice
TABLE 6. Trends in the Patient’s Role, Past and Present
PATIENT’S ROLE PAST/PRESENT
Entitled to health, longevity Unlikely/Assumed
Diverse symptoms Accepted/Intolerable
Daily micro-exposures Trivial/Hazardous
Protecting children Easy/Eternal vigilance
Access to medical care Assumed/Complicated
Self-medication, herbals Slight/Growing
Medical tests, doctor-shopping Slight/Growing
Victimization, compensation Rare/Growing
Alternative medicine, health fads Rare/Growing
Self-diagnosis, peer pressure Limited/Expanding
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equally distressing somatic disorders which can be disabling and un-necessarily stressful.
The patient whose case is described above will likely not do wellwith traditional medical practices, and is often “written-off” as a malin-gerer or “crock.” If, instead, through the empathic process we were ableto view the patient’s inner world, albeit delusional, we might be able toform a management plan from such a perspective. This might require usto give up our cherished allopathic ideals and apply complementarymedical strategies or perhaps refer the patient to a practitioner trained inintegrative medicine.
After all, the art of medicine is in finding a way to make the patientfeel better through the “magic” of healing.
William M. Simpson, Jr., MDClive D. Brock, MD
REFERENCES
1. Balint M. The Doctor, His Patient, and the Illness. London, UK: Pitman Pub-lishing Company, 1964.
2. Brock CD. Multiple chemical sensitivities: A presenting complaint in two pa-tients. Journal of Agromedicine 1994; 1(1):47-55.
3. Pickles WN. Epidemiology in Country Practice, 1939; John Wright, Bristol, UK.4. Pickles WN. Research in General Practice. BMJ 1948; 2:469-477.5. Schuman SH. Practice Based Epidemiology, 1986; Gordon and Breach Science
Publishers, NY.6. Francis T, Jr. The family doctor: An epidemiological concept. JAMA 1949;
141:308-311.7. Sir Colin Berry. Risk, Science, and Society. November 1, 2001, spiked-online.
com.8. Berry CL. Bellmanism: The distortion of reason. Journal Roy. Coll. Phy. 2000;
34:486-491.9. Barsky AJ, Borus JF. Somatization and medicalization in the era of managed
care. JAMA 1995; 274:1931-1934.10. Sharpe M, Carson A. “Unexplained” somatic symptoms, functional syndromes
and somatization: Do we need a paradigm shift? Ann Int Med 2001; 134:926-930.11. Kuch JH, Schuman SH, Curry HB. The problem patient and the problem doctor.
J Fam Practice 1977; 5:647-653.12. Schuman SH, Jebaily GC, Samuelson DC. Life events in a family with
life-threatening illness. Psychosom. 1977; 18:34-39.13. Rainsford GL, Schuman SH. The family in crisis: A case study of overwhelm-
ing illness and stress. JAMA. 1991; 246:60-63.
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14. Sicherer SH. Psychological reactions to foods: Case study of a 16 year old withan asthmatic panic attack. Food Allergy News 2002; 11(2):9-11.
15. Schuyler D, Brownfield E. Somatization: A disorder about “Nothing.” J SCMed Assn. 2002; 98:21-24.
16. Rosenfeld I. Power to the Patient: Treatments to Insist on When You’re Sick,2002; Warner Books, NY.
17. Pitts L. Attempting to create a risk-free life misses the whole point of life,Charleston Post & Courier, 3/5/02.
18. Gray G. The Harvard Center for risk analysis: Past, present, and future. Risk inPerspective 2002; 10(1):1-6.William M. Simpson, Jr. MDClive D. Brock, MD
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