07.14.14 9:45 AM ET
Why Smart People Are Dumb Patients
People who otherwise seem educated and rational continue to refuse vaccinations for their children due to a long-discredited study falsely linking vaccines to autism. They choose herbal remedies instead of well-researched medications and operations to treat serious illnesses like cancer. They flee from modern medicine to visit any other guru possible. But at what cost? What is fueling the mistrust?
Steve Jobs is a classic case in point. In Jobs’ 2011 biography, author Walter Isaacson highlighted a tragic mistake fueled by hubris. Jobs could have been very fortunate; a medical exam for something else incidentally picked up an early pancreatic carcinoma. Although pancreatic cancer is usually deadly, Jobs’ tumor was felt to be curable with immediate surgery. Yet this brilliant inventor, who revolutionized modern technological society, refused the recommended surgical procedure. He chose herbal treatment instead. By the time he noticed nine months later that he wasn’t getting better, it was too late. His tumor had spread, and the next six years became a painful game of catch-up, one that he ultimately failed.
Isaacson muses, with good insight, that Jobs’ tendency toward “magical thinking” was what did him in. In psychology, magical thinking is a term referring to a type of primitive rationalization used by children, before maturity brings about abstract thinking. This thinking can seem innocent and endearing in children; if you will it, it will be. There is a simple optimism in the notion that anything can happen if you want it to. It’s only the brick wall of logic that brings the fantasy ride to a bracing halt; adulthood teaches us that there are laws to the world around us that we, for better or worse, have to adapt to. There is no Santa Claus. The Earth isn’t flat. People die. Science becomes the lens through which the adult brain peers at life; and the view isn’t always pretty.
Yet even as adults, many of us still cling to the wishfulness of childhood wonder. In some cases, it can be a magnificent and inspiring force. Not unlike the mantra of the movie Field of Dreams—build it and they will come—the power of the human imagination can be transformative. Jobs was willing to think outside the box, literally and figuratively; he combined elements of intuitive playfulness with the usually dry complexity of computer science. He made adult-level toys for the masses, because he believed in his own dreams.
But sometimes one needs to sober up. In particular, the area of modern medicine seems particularly feared by people who otherwise employ reasonable amounts of logic to the world around them. It’s perfectly normal—important, even—for people to be anxious about health and illness. Life and death are nothing to joke about. Yet the hardest thing about illness for people to face can be the lack of control, the uncertainty around one’s fate. People notoriously avoid the doctor for this reason; magical thinking pops in. If no one tells you you’re sick, you’re not sick. So don’t let the doctor tell you you’re sick. Never mind that it’s the doctor who can cure you.
Say one does finally go to the doctor, gets the bad news, and then gets the doctor’s recommended advice on treatment. A typical physician goes through 14 credits of tough pre-medical science and mathematics college courses, takes a difficult admissions exam, and only 5-10 percent of these hardworking candidates get accepted to medical school. After two years of intense advanced-level biology and biophysics courses (likened by many to “drinking from a fire hose”) and two more years of rapid-fire clinical rotations, one enters residency for another four to seven years, and often an additional fellowship after that.
Still, many patients fall into the rut of “noncompliance,” or “nonadherence” as it has more recently been termed: the refusal, intentional or not, to follow a doctor’s medical recommendations. Skipping visits, medications, lab work, and procedures.
It’s a tricky topic to bring up. Sure, people are eager to mention the nightmare stories, the malpractice suits, the Conrad Murrays of the medical profession playing Russian roulette with people’s lives out of profiteering and arrogance. And of course doctors are human. Errors happen more frequently than not, and each person carries an individual set of clinical skills and acumen and knowledge that can benefit some more than others. In the past, perhaps too much faith was put into physicians, leading to paternalism and poor physician-patient communication, which could also create mistakes.
There’s also no denying that the pharmaceutical industry has made major missteps, in the name of profit or the limitations of research protocols. Case in point: the COX-2 Inhibitors debacle where Vioxx and Bextra—pain medications designed to provide the benefits of medications like ibuprofen without the stomach irritation—were later found to increase mortality in patients. The uneasy alliance between Pharma and medical research has also resulted in major scandals. Dr. Charles Nemeroff, the former chairman of Emory University’s Psychiatry Department and a major figure in depression research, didn’t report millions of dollars from drug company research and speaker talks to the university, which has strict limits on such private-sector profits. He subsequently resigned after his scandal appeared on the front page of The New York Times in 2008.
With the vast majority of American physicians trained with almost brutal intensity to serve their patients above all else, it seems the skepticism they face is still disproportionate to their potential for failure. The pendulum has swung too far in the other direction from physician paternalism towards willful ignorance by patients.
A particularly worrisome indicator of this mistrust has been the booming alternative medicine industry. Millions of dollars are spent by people on methodologies and substances that, by and large, have not been researched with the same scientific rigor as those used in modern medicine. Herbs, vitamins, acupuncture, and healing touch are presented in the soothing alterna-med culture, where “holistic” looks at the whole person and healing incorporates all aspects of one’s consciousness and mind-body-spirit notions. A 2007 survey conducted by NIH’s Center for Complementary and Alternative Medicine of 38,000 people indicated that 38 percent of them used alternative medicine.
The appeal of this holistic medicine culture does need to be understood better by the modern medical establishment. There is some scientific merit to some alternative modalities, such as the well-documented placebo effect. And few of us can deny the benefits of a good massage or yoga session. Beyond the individual treatments, there is a nature-mother quality to the alternative movement, where the focus on gentle comfort, on non-invasive therapies seems much less threatening than cold clinical medicine.
Modern medicine badly needs an image makeover. Hospitals often still look like the stereotypical cold, monolithic concrete building, with harshly lit linoleum hallways, noisy monitors, and uncomfortable beds. Staff members can be rough and impersonal at times, particularly in high-stress areas like emergency rooms. Everything is meant to be utilitarian and efficient, at the expense of relaxation or comfort. Accordingly, patients’ already heightened fears of modern medicine get amplified; their paranoiac visions are fulfilled in these icy clinical rooms, where people get poked and prodded like guinea pigs. For those unfamiliar with this world, it can create abject terror.
The idea of “research” settings in our popular culture tap into this phobia. Clinical research debacles like the Tuskegee experiments, and wartime ones done by Nazis and Japanese scientists, also showcase the worst-case scenarios—the notion of scientific rigor trumps humanity. As a result, clinical research remains strictly regulated in many countries with regard to ethical treatment; in most American hospitals, an Institutional Review Board (IRB) must approve studies.
Nonetheless, to conceive alternative medicine as childhood fantasy and Western medicine as childhood nightmare is too drastic and hysterical a reaction. There is too much irrational self-preservation going on. The concept of the ego and the self (classically outlined by Sigmund Freud) is another problematic roadblock in the acceptance of modern medicine. Steve Jobs specifically noted that he avoided surgery because he didn’t like the idea of being invaded, of no longer being whole. He rather concretely spells out the core fear behind most people’s views of medicine: the idea that somehow one will come out of an operating room or after a psychotropic medication as fundamentally altered, no longer oneself, no longer in control of one’s own identity.
In an individualistic culture like our own, this potential loss of self seems like the worst possible outcome. It seems that self-preservation would involve accepting the recommendations of medical experts; yet for many, it feels like the opposite. It means acknowledging that one is sick: that one isn’t perfect, is mortal, and may need to be altered. It frightens the psychological concept of oneself that all of us rely on to maintain our dignity and overcome uncertainty in life. After all, death means that we disappear, and this is the ultimate thing we fear. So, when faced with something as terrifying as death and illness, some of us jump to the reassurance of holistic concepts outside of ourselves, be it naturopathy, spirituality, or religion.
The dark side of alternative medicine is the rejection by otherwise rational human beings of basic scientific principles and safety. During medical school, I often felt fatigued, and needed more energy to get through the brutal call schedules and studying. Even coffee wasn’t enough. Another student said he had started selling herbal supplements on the side and offered me a free sample. I took the seemingly harmless capsule. Shortly after, I felt my heart pounding out of my chest. I felt dizzy and sick. The main ingredient was ephedra, which was shortly after taken off the market for causing heart attacks. In a similar vein, kava kava, advertised as a natural anti-anxiety supplement, was taken off the market for causing liver failure. Worst of all, my medical school classmate’s mother passed away after mixing an Asian herbal medicine with her own sleep medications.
Yes, alternative medicine can help in some cases. It can emphasize preventive and holistic practices like exercise, healthy eating, and relaxation training, all of which are crucial to general health. Yes some alternative practices can be a viable option when the limits of Western medicine have been reached. But one shouldn’t ignore the hours and rigor spent toward the research and development of what many know is the best medical care available in the world out of fear, even out of simple stubborn egotism. Modern medicine needs to remain the first-line option.
The tragedy of Steve Jobs’ premature death is that it likely robbed the world of future ingenuity, because he felt he knew what was best for himself. But sometimes, we need to have faith in science.