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95 pages

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For years after graduating from medical school, Dr. Clifton K. Meador assumed that symptoms of the body, when obviously not imaginary, indicate a disease of the body—something to be treated with drugs, surgery, or other traditional means. But, over several decades, as he saw patients with clear symptoms but no discernable disease, he concluded that his own assumptions were too narrow and, indeed, that the underlying basis for much of clinical medicine was severely limited.

Recounting a series of fascinating case studies, Meador shows in this book how he came to reject a strict adherence to the prevailing biomolecular model of disease and its separation of mind and body. He studied other theories and approaches—George Engel's biopsychosocial model of disease, Michael Balint's study of physicians as pharmacological agents—and adjusted his practice accordingly to treat what he called "nondisease." He had to retool, learn new and more in-depth interviewing and listening techniques, and undergo what Balint termed a "slight but significant change in personality."

In chapters like "The Woman Who Believed She Was a Man" and "The Diarrhea of Agnes," Meador reveals both the considerable harm that can result from wrong diagnoses of nonexistent diseases and the methods he developed to help patients with chronic symptoms not defined by a medical disease. Throughout the book, he recommends subsequent studies to test his observations, and he urges full application of the scientific method to the doctor-patient relationship, pointing out that few objective studies of these all-important interactions have ever been done.

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Publié par	Vanderbilt University Press
Date de parution	22 avril 2005
Nombre de lectures	0
EAN13	9780826591883
Langue	English

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Symptoms of Unknown Origin
A Medical Odyssey
Symptoms of Unknown Origin
A Medical Odyssey
Clifton K. Meador, M.D.
Vanderbilt University Press Nashville 2005
© 2005 Vanderbilt University Press
All rights reserved First Edition 2005
This book is printed on acid-free paper.
Manufactured in the United States of America
The prologue , “First Patient, 1952,” was originally published in part in Med School: A Collection of Stories, 1951 to 1955 (Nashville: Hillsboro Press, 2003). The patient in Chapter 1 was reported in abbreviated form in “The Person with the Disease,” Journal of the American Medical Association 268 (1992):35. A modified report of Miss Cootsie, Chapter 3 , appeared in “A Lament for Invalids,” Journal of the American Medical Association 265 (1991):1374–75. A version of the story of Vance Vanders in Chapter 4 appeared in abbreviated form in “Hex Death: Voodoo Magic or Persuasion?” Southern Medical Journal 85 (1992):244–47.
Library of Congress Cataloging-in-Publication Data
Meador, Clifton K., 1931–
Symptoms of unknown origin : a medical odyssey / Clifton K. Meador.—
1st ed. p. ; cm.
Includes bibliographical references and index.
ISBN 0-8265-1473-1 (cloth : alk. paper)
ISBN 0-8265-1474-X (pbk. : alk. paper)
1. Clinical medicine—Case studies. 2. Diagnostic errors. 3. Medical misconceptions. 4. Medicine—Philosophy. [DNLM: 1. Clinical Medicine—Anecdotes. 2. Diagnostic Errors—Anecdotes. 3. Philosophy, Medical—Anecdotes. 4. Physician-Patient Relations—Anecdotes.] I. Title. RC66.M43 2005 616—dc22 2004028858
Contents
Acknowledgments
Introduction
Prologue
1. An Unlikely Lesson from a Medical Desert
2. Texas Heat
3. Dr. Drayton Doherty and Miss Cootsie
4. All Some Patients Need Is Listening and Talking
5. Diagnoses Without Diseases
6. The Woman Who Believed She Was a Man
7. Mind and Body
8. Sweet Thing
9. New Clinical Interventions
10. Florence’s Symptoms
11. Symptoms without Disease
12. Looking Back on Fairhope
13. The Diarrhea of Agnes
14. Dr. Jim’s Breasts
15. The Woman Who Would Not Talk
16. The Woman Who Could Not Tell Her Husband Anything
17. Staying out of God’s Way
18. A Paradoxical Approach
19. You Can’t Be Everybody’s Doctor
20. In Tune with the Patient
Bibliography
Index
Acknowledgments
I appreciate all the help and encouragement I have received from my family, colleagues, and friends.
The following physicians reviewed earlier drafts of the book and made helpful suggestions and criticisms: Dean Steven Gabbe, Dean James Pittman, Dr. Jim Pichert, Dr. Kevin Soden, Dr. Taylor Wray, Dr. Eric Chazen, Dr. George Hansberry, Dr. John D. Thompson, Dr. Betty Ruth Speir, Dr. Kelley Avery, Dr. Eric Neilson, Dr. John Johnson, Dr. Norton Hadler, Dr. Ximena Paez, Dr. Julius Linn, Dr. Joseph Merrill, Dr. George Lundberg, Dr. Stephen Bergman, Dr. Abraham Verghese, Dr. John Newman, Dr. Albert Coker, and Dr. Caldwell DeBardeleben.
Colleagues and friends who helped me include Anita Smith, John Egerton, Fran Camacho, Cathy Taylor, Amy Minert, Joe Baker, Libbie Dayani, James Lawson, Stephen and Pamela Salisbury, Virginia Fuqua-Meadows, Lynn Fondren, Patty DeBardeleben, Diana Marver, Susanne Brinkley, and Jane Tugurian.
Dr. Harry Jacobson, Vice Chancellor of Health Affairs of Vanderbilt University, and Dr. John Maupin, President of Meharry Medical College have been constant sources of support.
Many of the patients were seen in the teaching clinic at Saint Thomas Hospital in Nashville. I am indebted to the staff and nurses in the clinic, particularly Joy Smith.
I am indebted to the love and support of my children and their families: Mary Kathleen Meador, Graham K. Meador, Rebecca Meador, Jon and Ann Meador Shayne, Aubrey and Celine Meador, David and Elizabeth Meador Driskill, and Clifton and Mary Neal Meador. My brother Dan has been a steady source of encouragement.
I especially value and appreciate the editing and other assistance from the staff of Vanderbilt University Press: director Michael Ames, Dariel Mayer, Sue Havlish, and Bobbe Needham.
Many physicians have shaped my thinking and have been personal mentors through the years: Robert F. Loeb, Tinsley Harrison, Grant Liddle, David Rogers, Carl Rogers, Joseph Sapira, Stonewall Stickney, Drayton Doherty, H. C. Mullins, and Harry Abram.
Others have shaped my thinking only through their writings. Much of this book comes from their thoughts and ideas. Michael Balint, George Engel, Thomas Kuhn, John Grinder, Richard Bandler, Milton Erickson, Jerome Frank, and Berton Roeuche.
Finally, I want to thank all the patients who taught me so much about people and illness.
Introduction
The overarching thesis of this book is that the prevailing biomolecular model of disease is too restricted for clinical use.
It took me many years to come to that conclusion. I was pushed to come to that view through my experiences with patients who did not fit the narrow model. Too many exceptions forced me to find an expanded model of disease. These are the stories of those patients and my interaction with them as a physician over a fifty-year period. I have selected patients and their stories that riveted my attention and changed my thinking about the nature of disease, about doctor-patient relationships, and about principles of caring for patients who came to me with symptoms of unknown origin. I have changed the names of the patients and certain other details to preserve their anonymity.
When I graduated from medical school in 1955, I adopted the model of disease then prominent, if not exclusive, in U.S. medicine. It has been called the “biomolecular” model. It is still the dominant model of disease among physicians today. Except for the patient presented in the prologue, the patients’ stories in the early chapters of the book illustrate exceptions and aberrations to the narrow biomolecular model. Each case (as I encountered the person and the facts) began to unravel my rigid views about disease and illness. Eventually, I found the biomolecular model of disease applicable only to a narrow segment of patients who seek medical care.
Despite its clinical weaknesses, the restricted biomolecular model remains a powerful biological research tool as we continue to explore the limits of molecular genetics, the genome, and proteomics at the cellular level. We need to draw clear distinctions between the reductionist research model and the need for an expanded clinical model that encompasses the psychological and social aspects of human beings. Human biology and clinical medicine overlap, but they are also quite different and are too often confused.
I did not read Michael Balint until the 1970s. When I did, I was heavily influenced by his writings and began to understand some of the clinical problems I was encountering. Balint studied general practitioners for several years in the United Kingdom as if they were pharmacologic agents. He was examining the correct dosage, underdosage, overdosage, and duration of action of physicians themselves as a drug. Balint developed the term “apostolic function of a physician” to describe the beliefs and teachings of physicians as these affected their relationships with their patients. By “apostolic,” he means authoritative teaching.
Of the apostolic function, Balint (1955, 684) writes: “We meant that every doctor has a set of fairly firm beliefs as to which illnesses are acceptable and which are not; how much pain, suffering, fears, and deprivations a patient should tolerate, and when he has the right to ask for help and relief: how much nuisance the patient is allowed to make of himself and to whom, etc., etc. These beliefs are hardly ever stated explicitly but are nevertheless very strong. They compel the doctor to do his best to convert all of his patients to accept his own standards and to be ill or to get well according to them.”
Balint goes on to explain the consequences of the doctor’s apostolic views.
The effect of the apostolic function on the ways the doctor can administer himself to his patients is fundamental. This effect amounts to always a restriction of the doctor’s freedom: certain ways and forms simply do not exist for him, or, if they do exist, somehow they do not come off well and therefore are habitually avoided. This kind of limitation in the way he can use himself is determined chiefly by the doctor’s personality, training, ways of thinking, and so on, and consequently has little to do with the actual demands of the case. So it comes about that in certain aspects it is not the patient’s actual needs, requirements, and interests that determine the doctor’s response to the illnesses proposed to him but the doctor’s idiosyncrasies.(Ibid.)
In 1976, Harry S. Abram and I jointly published a chapter in his book Basic Psychiatry for the Primary Care Physician . Physicians hardly ever express their beliefs explicitly; nevertheless, Abrams and I modeled our comments along the lines of Balint’s thinking and wrote a hypothetical statement in those terms to define and dramatize the narrow biomolecular apostolic function. It is this narrow version under which I had attempted to function during the early years after I graduated from medical school. The hypothetical statement says:
I believe my job as a physician is to find and classify each disease of my patient, prescribe the proper medicine, or recommend the appropriate surgical procedure. The patient’s responsibility is to take the medicine I prescribe and follow my recommendations. I believe that man’s body and mind are separate and that disease occurs either in the mind or in the body. I see no relationship of the mind to the disease of the body. Medical disease (“real” or “organic” disease) is caused by a single physicochemical defect such as by invasion of the body by a foreign agent (virus, bacterium, or toxin) or from some metabolic derangement arising within the body. I see no patients who fail to have a medical diseas