It starts with the story: Listening to patients Radwan Banimustafa MD The university of Jordan medical school

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.

http://www.medicalarchives.jhmi.edu/portlarg/osler.jpg

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 ?


What we see

Sleep, appetite, concentration fatigue


Diabetes or Major Depression (a neurochemical imbalance)

What we might do

Medication

Progress of treatmentProgress of treatment

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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?


Social(environment)

What we see

Sleep, appetite, concentration, fatigue

Isolation, abuse



Domestic violence relationship

What we might do

Medication ?


Social(environment)

What we see


Isolation, abuse




What we might do

Medication Women’s Shelter, social support


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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?


Psychological(mind)

Social(environment)

What we see


Boredom, poor self-image, negativity

Isolation, abuse


Diabetes or Acute Major Depression (a neurochemical imbalance)

Childhood abuse and neglect


What we might do

Medication ? Women’s Shelter, social support


Psychological(mind)

Social(environment)

What we see


Boredom, poor self-image, negativity

Isolation, abuse


Diabetes or Acute Major Depression (a neurochemical imbalance)

Childhood abuse and neglect


What we might do

Medication Psychotherapy Women’s Shelter, social support


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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

http://www.medicalarchives.jhmi.edu/portlarg/osler.jpg

Documents

It starts with the story: Listening to patients Radwan Banimustafa MD The university of Jordan medical school