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“Are you saying it is in my head, doc?”
The patient is in front of me. I want to explore the possibility that my patient’s varied and inexplicable symptoms might be psychogenic. The panic, palpitations and abdominal spasms might just be related to stress. Or anxiety. Look, I have done the full history, the full examination and the bloods. The symptoms and story are just not coming together in a way that suggests any diagnosis known to me, after 30 years’ experience.
But there is always the risk that introducing the words ‘stress’ or ‘anxiety’ into any medical conversation will make patients feel that they are being fobbed off. Maybe there are better ways, like asking about the context: “What was going on in your life around the time that these symptoms started? How are things at work/school/home?”
These questions might open up possibilities. But many a man, usually a man, still thinks you are not dealing with the nuts and bolts of their problem. We men are culturally able to split problems into different categories. Physical problems, which really and honestly, no ‘real’ man should have. And then there are the psychological things that everyone knows do ‘not’ really exist.
‘Now, really! If the doctor is talking about my psychological problems, then he is no good as a doctor. Furthermore, he does not have the courage and audacity to say that he does not know what he is doing and does not know what is wrong with me. Saying it is stress, like I caused this problem myself — what a put down.’
I stop my daydreaming because there is a real patient in front of me. The facts are that in my experience, his problem is going to turn out to be a stress-related enigma. But I can’t be sure and half of Blackhall Place would love to make a fool of me in court, showing, in retrospect, how right they themselves would have been if only they had studied medicine and not law. I often wonder if the legal profession feels jealous of us in some strange way. Not of equal status, having to prove themselves.
You see, it is obvious to me in my madness that everything is in the head. The pain of a broken femur is felt in the head. No head means no pain.
Panic attacks are the great proof of the body-mind connection.
And yet many men feel it is some sort of insult when we begin the conversation about stress. This is surely because of the ‘either/or’ hypothesis: It is either a physical problem or a psychological problem. It can’t be a mix of both. It can’t be an emotional problem because we have the lingering fear that emotions are really ‘only for women’, our male historical culture tells us. Men are, of course, more enlightened now, but not to the core of our belief systems. Not quite yet.
The cosy certainty of the ‘either/or’ thinking we were brought up with deludes us into believing that many of our problems (and solutions) are either physical or psychological. The facts are that everything is ‘both/and’. Every medical condition and every condition of man and beast is both physical and psychological.
So we need to assume this in all of our conversations, not just the difficult diagnosis, where we are a struggling. Then patients will know that we ask the same questions for all conditions, not just the challenging ones.
Sore throat. What are the physical symptoms? Physical response: ‘Pain localised to the throat.’ The psychological and emotional symptoms: ‘I’m worried because Google tells me my throat may close over. I am stressed because I am singing in an opera tomorrow.’
Blood in the bowl with no physical pain. The physical symptoms suggest piles. ‘But red blood alarms me and tells me I might die or have cancer.’
So in future, I am going to ask about the psychological and emotional aspects of every apparently physical diagnosis and see where that brings us. Maybe I have always being doing this without a structure. And in the future, patients, even men, will expect this as the norm and won’t assume I am a useless doctor just because I ask about emotional intelligence and the stressors in their lives.
And whether the illness is common or rare and perplexing, I will investigate the physical and the psychological at the same time. No longer will I investigate the physical to the nth degree before I investigate the psychological. I will do both, side-by-side, with equal status.
I will tell the patient: ‘Next visit, I want to do bloods and an ultrasound to explore the purely physical side of your illness, and I also want to spend an equal amount of time exploring the equally important psychological part of your illness. That’s our best chance of a successful solution.’
Not ‘either/or’. Hand-in-hand, psychological and physical, because that’s just the way it has got to be. Equality in principle and equality in practice.
A long time coming. A lot of work to do.