In my long and winding journey as a physician there have been a few books and papers that have really informed or changed how I interact with patients.
Patient Centered Medicine, by Stewart et al, is one such book. And the first chapter of Balint’s The Doctor the Patient and his Illness, when he speaks about how true healing can only happen when the doctor and the patient agree on the diagnosis, is another.
Now, at the ripe old age of seventy, I have added a new “must-read” book to my list: A Body Made of Glass, A cultural history of hypochondria by Caroline Crampton.
This book, part memoir, part history of medicine, part literary analysis, explores the issue of hypochondria through the ages. It explores how patients and physicians navigate the murky waters of caring for patients whose conditions do not yield to our clinical tools and seem to manifest mental distress through bodily symptoms.
In other columns, (see Numerators and denominators) I have discussed what I believe are the most common forms of medically unexplained symptoms: the subtle or early manifestation of an physical diagnosis, the complicated interaction of multiple diagnoses and their treatments with the patient’s psychosocial context, and finally the emergence of a brand new diagnosis.
In this book, Crampton explores these ideas in fascinating depth. She examines the enduring appeal of quackery, the ethical use of placebos and most importantly, humans as meaning making creatures. This book has changed my practice.
Being a physician is itself a risk factor for health anxiety. We develop what is called in French, “la deformation medicale,” the anxiety which is the result of our medical perspective. This is a pun on “formation medicale,” or medical education, because it is a direct result of knowing too much and worrying in technicolor.
Crampton discusses how her experience of lymphoma and its treatments set up her enduring problem with hypochondria. Before I started in medicine, I had the general obliviousness towards health which is the natural state of the average 22-year-old. Early in first year, I had my first encounter with what is called in English, Medical Student Disease, and I came down with a virulent case.
My new husband came to me with a story that he had been bitten by a wasp. He had a few very painful lesions on his forehead, felt feverish, and had rock hard swollen lymph nodes. I immediately concluded that he had lymphoma. I was seized with fear and started to imagine his illness and death. I panicked about how I would cope with being a widow at age 22. I sent him off to the Emergency Room. Tellingly, I found out that while I was right to be afraid, I was afraid of the wrong thing! He had trigeminal V1 Shingles and after being cleared by the ophthalmologist, and given pain killers—since anti-virals were not a thing back then. He and I were reassured that he was not dying.
Later, as an intern and pregnant with my first child, I was doing a neonatology rotation. The phenomenon of caring for tiny premature babies was disconcerting, giving me the feeling of having a “wombs eye view” as I fussed over the 26-weeker who was the exact gestational age of my own fetus. One night I was told to attend a C-section of a baby who had been found on ultrasound to have massive deformations, including anencephaly, and complete abdominal eventration. “Please collect heart blood for genetics after the baby dies,” I was instructed. Once that gruesome task was accomplished, the image of that baby haunted my nightmares all through my pregnancy. No ultrasound could remove that image from my brain or assuage the fear.
As I grow older these moments of panic have become rarer, but more intense. Once you are of an age when worrying that you might have cancer or heart disease is not a laughable foible but a realistic fear, symptoms that would have been ignored take on heightened meaning. Sometimes, however, logic and observation can trump the illness paranoia of our “deformation medicale.”
This is a TMI story but I cannot resist telling it. In the past several months I have noticed black flecks floating in my toilet bowl. I was also diagnosed with anemia. Having had a gastric bypass, I have reasons to have a small amount of GI blood loss and iron deficiency. I started brooding. Maybe something ominous was cooking. My anxiety grew despite having a benign colonoscopy and gastroscopy two years ago. I worried my doctor, by nature a minimalist, which I generally appreciate. She obligingly resent a consultation to my gastroenterologist. Then I went on vacation.
Staying for a week in our B&B, I noticed that those ominous black flecks never showed up. “How could that be,” I wondered. When we returned home, the coffee ground flecks were still there. In fact, they seemed to have accumulated even though I was away.
Suddenly, my gnawing anxiety and growing fear was relieved. Like the good diagnostician I believe myself to be, I dumped some CLR down the toilet tank. Magically the rust flecks from our old pipes were removed! Both the toilet and I were cured.