22. What Every Doctor Should Know but does not Learn in Medical School

What Every Doctor Should Know but does not Learn in Medical School*

The hundred year period (ca. 1850-1950) was a period of spectacular achievements in medical sciences. It was during this period that the 'microbe hunters' demonstrated, one by one, the organisms responsible for the most dreaded communicable diseases, as also discovered the vaccines or antibiotics which could control them. During the very same period were discovered all the major micronutrients, and in them were found the specific keys to cure scurvy, beriberi and pellagra. Finally, the same period saw the discovery of insulin and other hormones which could provide effective and rational treatment for some enigmatic diseases. These achievements had an overwhelming, almost intoxicating, effect on medical scientists. It seemed that the body could be treated like a mathematical proposition. Diseases were the result of entry into the body of something undesirable, or absence in the body of something desirable. All what medical science had to do was to find in each case the agent or the right replacement. The complacency, however, did not last long. It was soon realized that besides the agent, the host and environment also played a pivotal role in the natural history of disease. The attention therefore was no longer concentrated on the agent, but was shared also by the host resistance, and the environment - both physical and biological. This paved the way for public health and community medicine. These developments were admirable in that they overcame the tendency to look at the patient as a diseased organ or a defective molecule, and placed him in the right perspective as an integral part of an interdependent ecosystem. However, even the concepts or community medicine did not question or challenge the mechanistic model of biological systems, which was given to modern science by Rene Descartes in the seventeenth century. But some developments during the last 50 years have now matured to a stage where the mechanistic model is itself facing a serious challenge. An interesting way to get a glimpse into the developments which are likely to change radically the way medicine will be practiced in the near future is to take a look at the life and works of some of the individuals who have ushered in the revolution.

Norman Cousins

In 1964, Norman Cousins, a highly educated, intelligent and wise man, but not a doctor, got a serious collagen disease, ankylosing spondylitis. The disease was serious, and his doctors told him that only one in five hundred patients recover fully from it. The disease was also painful, and at one point, he was receiving in the hospital 26 tablets of aspirin and twelve tablets of phenylbutazone a day. On reading up about his disease and the drugs he was taking, he came across few disturbing facts. First, the pain killers exhaust the adrenal glands. Second, adrenals are a store house of vitamin C. Third, vitamin C is important for the synthesis of collagen and other chemicals in the connective tissue. Finally, patients having collagen disease get deficient in vitamin C, possibly because the body uses up large amounts of vitamin C in the process of combating the disease. Putting these facts together, he suspected that pain killers, while giving him symptomatic relief, were actually depleting his capacity to combat the disease. Vitamin C might do him much more good than pain killers, he argued.

Another factor, which Norman Cousins had a hunch, was important to his illness was his trip to Russia (then USSR) shortly before he fell sick. He had gone there as chairman of an American delegation to consider cultural exchange. During the meetings, paper work had given him late nights. The last night there was particularly strenuous. After making it just in time to the airport and boarding an overcrowded plane, he had had more than 24 hours without proper sleep by the time he reached USA. A week later he was hospitalized. In the 1960s, psychoneuroimmunology was still in its infancy, but some hints were available to Norman Cousins from Hans Selye's work. Could emotional stress have exhausted his adrenals and deranged his immune system, Cousins wondered. If so, that might have contributed to his ankylosing spondylitis, an autoimmune disease. Based on this hunch, Cousins asked an apparently simple but ingenious question - if negative emotions affect the body negatively, can positive emotions not affect it positively? Based on the assumption that the mind-body relationship could work both ways, and the age-old adage "laughter is the best medicine", Norman Cousins had a talk with his doctor.

With the permission of his doctor, Norman Cousins shifted from the hospital to a hotel, which he found both more comfortable and less expensive. In the hotel, he stopped all pain killers, and instead started taking vitamin C and watching comedies on the video to make himself laugh. He discovered that ten minutes of laughter gave him at least two hours of pain-free sleep (possibly due to release of endorphins!). Further, each episode of laughter brought down the erythrocyte sedimentation rate by at least five points: the fall was sustained, and cumulative.

Based on his experiences, Norman Cousins wrote a book, Anatomy of an Illness, which has now become a classic. His book stimulated much research, which has now emerged as the field of psychoneuroimmunology.

Herbert Benson

In the 1960s, Maharshi Mahesh Yogi made vigorous efforts to popularize a meditative technique, which he called transcendental meditation (TM). Realizing that we live in the age of science, he was very keen on getting some studies done on the physiological effects of TM, which, he was confident would be favourable. In today's environment, scientific validation of a practice can enhance its credibility enormously. With this in view, in 1968, practitioners of TM went to Herbert Benson's laboratory at the Harvard Medical School, and requested that their ability to lower the blood pressure through TM may kindly be studied in the laboratory. After initial reluctance, the scientists finally relented. The result was a series of classical studies which led to the description of the relaxation response and identification of meditation as a unique hypometabolic state (Chapter 17.4). Subsquently, Bension applied the relaxation response in combination with nutrition, exercise and stress management, and demonstrated the package to be effective in the management of hypertension , cardiac arrhythmias, chronic pain insomnia, anxiety, mild or moderate depression, and premenstrual syndrome. These studies contributed immensely to ancient wisdom becoming a part of modern medicine, and culminated in the establishment of the Mind/Body Medical Institute at Harvard Medical School.

Deepak Chopra

Deepak Chopra graduated in medicine from the All India Institute of Medical Sciences in 1969. Soon after that, he left for USA and specialized there in endocrinology. His deeper contact with ancient Indian wisdom and certain observation on his patients, particularly those having cancer, revealed to him certain truths for which his training in scientific medicine had not prepared him. What he realized was that there is an enormous amount of intelligence packed into the living organism which medical science has missed because of its rather predominantly material-based approach. To illustrate, a molecule of adrenaline released in the body as a neurotransmitter is not the same as adrenaline injected by a doctor. The endogenous adrenaline is released at the right places at the right time in the right dose to engage in a dialogue with some cells in the body which have, depending on the needs of the body at that time, multiplied their receptivity to the molecule. On the other hand, injected adrenaline shouts at all cells in the body with a single-minded insistence. The fine-turning of the endogenous molecule is the result of the intelligence of the body, which is of such a high order that no scientist has been able to duplicate it. According to Deepak Chopera, the intelligence is encapsulated in DNA, as a result of which a finely regulated synthesis of several enzymes at several places in the body ensures that appropriate neurotransmitters are released at the right places and lead to just the right effects. Thus the intelligence (which he translates, in this context, as knowhow) encapsulated in DNA is disseminated in the body by neuropeptides, which act as messengers. This intelligence is not confined to the brain because DNA is the same in all cells, which have a great chemical kinship with nervous and endocrine systems. What triggers this intelligence is thoughts, which are a non-material entity. THus non-material thoughts are translated into and transported by chemical molecules, which are a material entity. How this happens is a gap which modern science, rooted firmly as it is n a matter-based approach, cannot bridge. To bridge this gap, one needs to take a quantum leap which takes one beyond the ordinary level of consciousness, which is based on sensory perception. This was the leap the rishis of ancient India (and mystics in several other traditions too) took which enabled them to see the creation of the universe from an infinitesimally small part of creation, which they termed the Brahman. Thus the process of creation of the universe is duplicated, albeit on a small scale, in our body every time a thought is transformed into an 'intelligent' molecule.

What is the relevance of all this to medicine? Deepak Chopra uses it to help induce in the patient the process of, what he calls, quantum healing. He defines quantum healing as the ability of one mode of consciousness (the mind) to spontaneously correct the mistakes in another mode of consciousness (the body). Taking cues from Ayurveda, he encourages the patient to expand the boundaries of his consciousness during meditation, 'drown' himself in an Ocean of awareness (the 'bliss technique'), and then focus attention on the diseased area (the 'primordial sound technique').

Bernie Siegel

Bernie Siegel, an American cancer surgeon, realized after a few years of practice that each patient has a unique biology and so has each tumor, and the histopathological diagnosis ignores both. Therefore the prognosis based on such a diagnosis gives only the probability, not all possibilities. A few individuals who defy all statistics and survive cancer are not necessarily miracles, misdiagnosis or slow-growing tumors. What is common to virtually all cancer survivors (and this applies also to those who survive AIDS, lupus or multiple sclerosis) is a set of the same basic qualities: peace of mind, unconditional love and the courage to be themselves. Previous literature on the subject and recent studies by Siegel as well as other groups of workers have only confirmed that cancer develops more commonly in those whose personality is characterized by denial and repression, and who have on top of that recently experienced more than their share of traumatic life events. Further, in these patients disease can be turning point. The patient may develop a more positive, healthy and constructive approach to life, and try to do in what remains of his life whatever he always wanted to do but could not. Interestingly, that makes not only the remainder of life better, but also longer. Some patients may effect this change of attitude on their own, but many more can be helped to bring about such a change by appropriate guidance from the doctor. In that sense, the doctor's role is merely to facilitate self-healing. What is noteworthy is that the approach not only heals the disease but life itself.

The evidence in favour of the mind-body approach has gone beyond anecdotes, and has the support of several large studies. What lends further credibility to it is the evidence also for a plausible mechanism. As Bernie Siegel says, love, hope, joy and peace have physiological consequences are mediated by the neuro-endocrine-immune interactions and have been examined variously in studies by change in neuropeptide levels, cytokine levels and changes in number or activity of immunocompetent cells, particularly the NK cells.

The essence of Bernie Siegel's prescription to the doctors is not to take away hope from the patient on the basis of statistics. Since 'miracles' do occur, there is nothing like 'false hope'. What doctors have to beware of is giving false 'no hope'.

Dean Ornish

Dean Ornish, an Americal Cardiologist known today for his lifestyle program for management of heart disease, did not stumble on his program by chance. The origins of his program go back to his premedical days. As a premedical student at an extremely competitive university, he started feeling inadequate and convinced himself that he could never make it to medical school. On the other hand, he also received a flash of spiritual insight which told him that no achievement was going to bring him lasting happiness. These two ideas dominated his thoughts to such an extent that he got depressed and decided to end his life. However, an attack of infectious mononucleosis forced him to go home for a few days. During his stay at home, he heard a discourse by Swami Satchidanda wherein he learnt that while it is true that nothing we get from outside can bring us lasting happiness, the true source of happiness is within us. This proved a turning point. Instead of being outwardly defined, he became inwardly oriented. He recovered from the illness, returned on his work, and it goes without saying, made it to medical school.

In view of this background, it was not surprising that he was struck by the paradox of cigarettes and hamburgers being sold in the lobbies of the very same hospitals that were doing bypass graft. There was far too much reliance on drugs, angioplasties and bypass surgeries instead of attending to the root causes of coronary artery disease. While still a medical student, he discovered that although there were several studies showing individually the relationship of coronary artery disease with diet, exercise, smoking or mental stress, no single study had examined all these factors together. He decided to take a year off between his second and third year of medical school (in the year 1977), and having the benefit of 'inexperience', embarked on his first study to investigate whether attending to all the lifestyle factors together could reverse the chain of events which had, in the first place, led to coronary artery disease. The results were clear: after just one month of a new lifestyle, the patients not only felt better, they were better, as assessed by the exercise thallium scan. The results were received with a great deal of skepticism, flaws were found in the study design and blamed for 'wrong' conclusions. However, Dean Ornish was convinced in his heart about the validity of the study, and did a few more progressively better designed studies, finally culminating in the classical study published in the Lancet in 1990. The study demonstrated through a randomized through a randomized controlled trial that lifestyle changes do bring about an angiographically demonstrable reduction in coronary artery stenosis. The results, based on a one-year follow-up, were confirmed in the four-year follow-up published in 1995 in JAMA.

Dean Ornish prefers to call his program the ‘Open your heart’ program because although diet, exercise, meditation, and quitting smoking, are all there in it, the greatest emphasis is on making the patient look life differently. For achieving the transformation, the patient is guided to open his heart to himself, to others, and to a Higher Self. The patient may enter the program as a miserable, helpless person to himself whom a life-threatening illness has compelled to choose between a life that is interesting but stressful and short, and another that is long but boring. He is expected to leave a happy, empowered person whom the illness has provided an opportunity to discover to discover a way of life that is more productive and delightful than he ever thought possible. If the transformation is actually achieved, the patient makes a conscious choice in favour of a new lifestyle. He fallows the diet-exercise-meditation regimen not out of fear but because he enjoys it. Moreover, the transformation is not limited to the regimen: it spills over into his daily life which he now lives and looks at with an open heart. The transformation is not easy, and cannot be achieved by preaching or pressurizing. Moreover, it is not an all or none process. The program only enlightens and empowers the patient: the choice of how much to change ultimately depends on the patient. Once he starts enjoying the change, he voluntarily progresses further in the same direction. But the space and extent of change are left to him; the doctor’s job is only to provide the facts and show the path.

Larry Dossey

Larry Dossey, an American physician, developed as a medical student an extraordinary receptivity for spiritual philosophies of the east, specially Buddhism and Taoism. Therefore, it was not surprising that when he saw a positive study on the healing effect of prayer, he was prompted to make a search for other similar studies. He started with the belief that there would not be many, but was pleasantly surprised to find that there were more than 100 studies, exhibiting criteria of good science, which suggested the therapeutic efficacy of prayer. His reactions to this discovery were two-fold. First, he was amazed that scientific medicine had ignored these scientific studies. Secondly, he felt uncomfortable because he was not sure how he should use this knowledge, if at all. In spite of his background of being educated in modern medicine, he felt that denying his patients the benefits of prayer would be akin to withholding from them a potent drug, and would therefore be unethical. Starting with praying for his patients, it was a natural corollary for Larry Dossey to take special interest in mond-body relationship and non-local healing.

Research and reflection have convinced Larry Dossey that what we are witnessing is a major paradigm shift in scientific medicine. He has pointed out that the period 1860-1950 was marked by spectacular achievements such as vaccines, antibiotics, imaging techniques, radiotherapy and advanced surgical techniques. The effect of these achievements was so overwhelming that it came to dominate our thinking completely. But once the spell cast by these miraculous advances started wearing out, the limitations of looking at the body as a machine became obvious. Around 1950, the era of physical medicine started giving way to the era of mind –body medicine. While retaining the enormous gains of the previous era, we have started adding another dimension to scientific medicine based on mind body interactions. It is an era of synthesis, not one of replacing one system of medicine by another. The synthesis is embodied in psychoneuroimmunology, a rapidly growing discipline. However, our heritage rooted in a material-based approach continues to restrain us. As a result, in the era of mind-body medicine, we tend to localize the mind in a physical structure- the brain. Hence the era may probably be better described as that of brain-body medicine. However, Larry Dossey feels that we are gradually coming out of that shell. Therefore he predicts that the next era will look at mind as an entity not constrained by time and space. That will be the era of non-local medicine. While retaining the gains of physical medicine and mind-body medicine, we will add another dimension to scientific medicine in which there will also be room for healing across barriers of time and space. Not only the patient’s mind but also the healer’s mind will be used for influencing the patient’s body. In this approach, since the patient and the healer don’t have to be physically close, the distance between them does not matter.

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All those named above, except Norman Cousins, are physicians trained in scientific medicine at some of the finest medical centers in the world. While remaining firmly rooted in scientific medicine, they have made a perceptible shift in the way they practice their art. The shift they have made has nothing to do with what they learnt in medical school. Another thing they all have in common is their deep abiding interest in eastern philosophies, mysticism and spirituality. Some would consider them to be a few inconvenient individuals whose eccentricities will make no difference to mainstream medicine. But in fact they are the leaders of a wave that is sweeping the world as never before. For the first time in recent history, science has embraced spirituality, leading to union that has all the signs of a perfect synthesis. The synthesis is all set to shift the basis of scientific medicine from a material-based approach to a consciousness-based approach. Mind-body medicine is a transitional stage in this process of a radical shift in approach. What mind-body medicine does is to use the thought process of the patient to bring about self-healing. The mechanisms of self-healing are inherent in the body. What we are doing is merely to give those mechanisms their best chance. Homeostasis, or correcting deviations from normal through physical mechanisms is a time-honoured concept. What mind-body medicine has revealed is that the scope of these mechanisms is much wider than hitherto assumed; second, that the mind can influence these mechanisms; and finally, that the patient can be guided to use the mind-body relationship to his advantage.

It has taken about 50 years of research for mind-body medicine to emerge as a potentially powerful component of scientific medicine. It is understandably still too early for these developments to be reflected in medical curricula. But a student studying medicine today may well be practising medicine for the next 50 years. He may find himself woefully inadequate if he is not aware of this new dimension of modern medicine, and does not keep pace with it through his own efforts.

Bibliography
1.    Benson H. The Relaxation Response. New York: Avon Books, 1976.
2.    Chopra D. Quantum Healing: Exploring the frontiers of mind/body medicine. New York: Bantam Books, 1989.
3.    Cousins N. Anatomy of an Illness as Perceived by the Patient. New York: W W Norton, 1979.
4.    Dossey L. Healing Words. New York: Harper Collins, 1993.
5.    Gould KL, Ornish D, Scherwitz L, Brown S, Edens RP, Hess MJ, Mullani N, Bolomy L, Dobbs F. Armstrong WT, Merritt T, Ports T, Sparler S, Bilings J. Changes in myocardial perfusion abnormality by positron emission tomography after long-term intense risk-factors modification. JAMA 1995; 274: 894-901.
6.    Ornish D. Dr. Dean Ornish’s Program for Reversing Heart Disease. New York: Ivy Books, 1996.
7.    Ornish D, Brown SE, Schewitz LW, Billings JH, Armstrong WT, Ports TA, McLanahan SM, Kirkeeide RL, Brand RJ, Gould KL. Can lifestyle changes reverse coronary heart disease? Lancet 1990; 336: 129-133.
8.    Siegel BS. Peace, Love and Healing: The path of self-healing. London: Arrow Books, 1990.

Taken from:
Book: Understanding Medical Physiology: A Text-book for Medical Students, Third Edition, Page 913 to 917
By: RL Bijlani (Department of Physiology, AIIMS, New Delhi)
Published in: 2004
Publisher: Jaypee Brothers Medical Publishers (P) Ltd.

(* An earlier version of this essay was published in the magazine of the magazine of the student's Union of the All India Institute of Medical Sciences, Hybrid Hues in 2002, and an expanded version has appeared in New Approaches to Medicine and Health (NAMAH) 2003; 11(1): 28-40.)

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