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The All Of It

The All Of It

A woman asked me the other day, "What makes diagnosing a medical illness so difficult?" She was evaluated by a number of physicians in the local and regional area, each time they came up with the same conclusions; she was not remotely ill. She just was suffering from depression. Each of her six physicians offered her some form of antidepressant medication and told her to follow up with her primary care provider. The frustration oozed from her pores. She was ill. As a result of her chronic ailments, she was a little depressed because she could no longer do the things she did before she was ill. Fatigue, hair loss, constipation, brain fog, weakness in her legs and arms, back and stomach pain, headaches, loss of libido, irregular menstrual cycles, shortness of breath on exertion and blurred vision were her symptoms. Most physicians are overwhelmed with two or three symptoms, but after hearing about eleven, they just shut down. They have no idea where to begin.

When I was in medical school, we had a class called Focal Problems. This was a small group class which met three times a week and our internist professor would walk us through the evaluation of one or two symptoms to find a diagnosis that fit the symptom(s). The first class we had focused on a sore throat. It was a simple journey to find the answer, all the while looking at the physiology, anatomy, and non-organic attributes which could cause a sore throat. We discussed laboratory testing, imaging techniques (no CT Scans back then) and physical diagnosis. I was one of the few student doctors that absolutely loved the class. Most of my classmates disliked the course because they had to think through a problem and apply Bayesian statistics to each test result whether it was positive or negative.

Although the class was simplified and primitive at the time we were taking it, it was a challenge to think outside of our personal worldviews of medicine as we knew it. I think our hardest focal problem was anemia. It was difficult because anemia could be a result of so many different possibilities. Although I enjoyed the class and did very well, that focal problem almost took half of my small group down. My fellow classmates just did not possess the skill sets to investigate a symptom like anemia and fatigue. If the diagnosis was not apparent within the first or second rounds of testing, they gave up. I enjoyed the mystery of looking beyond the veneer of the of the symptoms and getting into the deep disturbances related to the fatigue. I realized I was not really a member of our student class in this regard.

In the last thirty plus years, basic science research has exploded in the fields of neuroscience, physiology, biochemistry, microbiology, genetics, epidemiology, pharmacology, toxicology and other areas of medicine. These areas of research provide the foundations for understanding the human condition in all of its manifestations. Sadly, these research findings rarely reach the medical journals as pertinent information to the practice of medicine. Furthermore, the pioneers of stress research have shown that chronic unrelenting stress is profoundly detrimental to our bodies and minds. There is no telling what it will do to our Souls.

Another area of research that has changed the shape of diagnosing and treating illness is the theories associated with the phenomenon of emergence. Most people in our world including doctors and scientists believe that there is a pace maker cell or founder cell that influences an entire organism. This concept extends in the deep fabric of the oral tradition of medicine. The heart is an organ that has a couple of pacemaker cells which when acting in synchrony ignites a rhythmic consistent heart beat. Regardless of the rate of the heartbeat, it tends to be uniform when healthy. And there are gastrointestinal specialists who believe that pacemaker activity initiates gastrointestinal motility and emptying. Some specialist advocate the use of pacemakers for those patients who suffer from gastroparesis (profound delay in stomach emptying). But these two examples are not only exceptions to the rule, they are not exactly correct or in accord with modern accepted biological research.

Emergence is a phenomenon of organizing from the ground up. It is a collective phenomenon. Cells form collective communities and operate based on environmental factors associated with cell function. Humans are nothing more than a collection of cells, organized into organ systems, glands, appendages and a brain. The brain does not make the body act, it integrates the body's environmental factors and gives our bodies’ direction through chemical and nervous system messaging, allowing us to adjust to the environment, to maximize our responses in the safest, most efficient way. The theme behind the unconscious mind: survival and harmony.

What's frustrating to me is that physicians have been taught theories that are absolutely antiquated and they have become closed to novelty as soon as they receive a piece of paper citing that they have completed medical school, residency and fellowship in some area of medicine. The piece of paper states they have the qualification to be a specialist and subsequent passing of their certifying board examination degenerates their desire to seek any new basic science information influencing the practice of medicine. In addition, our industrial medical system has completely abolished the possibility that any physician can take care of any disease if they are competent to do so. No one assess competency in the field of medicine, they assess merit badges and certifications. Good test taking skills does not translate to good medical practice habits.

In addition, it is very hard for physicians to embrace the idea that the collective (all the cells in the body) greatly influences the behavior of the whole (patient). The human body is a system that enjoys complex behavior: a system with multiple organ systems, glandular functions and immune activities dynamically interacting in multiple ways, following local rules and oblivious to any higher-level instructions. Our brains do not instruct our bodies, our brains instruct us on how to adapt to the environment as the body's environment changes. The reason humans are emergent is because the local interactions result in an obvious discernable macrobehavior: survival in our artificial man made world which has been planted smack dab in the middle of nature.

This may seem a bit esoteric to most of you who read my blogs, but it is not. The foundations of my medical practice are based on learning the fundamental laws of emergent systems and applying them to the infirm. It is the all of it that matters. Food plans, hormones, cognitive patterns, worldviews, structural body integrity and alignment, rituals for staying healthy, medications that relieve symptoms, drug interactions, social relationships, stress and internal environmental changes such as infections, hormone insufficiencies, immune reactions, autoimmune reactions and circulating chemical messengers referred to as cytokines all impact each of my patient's individualized therapeutic adventure. Everything matters. What's ironic about my physician path is I started out in Emergency Medicine. I had no idea what I was yearning for, but I found a path to the phenomenon of Emergence.

Perhaps the Specialty of Emergency Medicine should be changed to Hospital Based Accident and Acute Care Medicine and leave the Emergency label to those of us who get it. The All Of It.

Doc
Posted by Amanda Sanders at 10:12 AM
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