More MS news articles for Sep 2001

Book Review: Under the Medical Gaze: Facts and Fiction of Chronic Pain

[MedGenMed, September 17, 2001. © Medscape, Inc.]
Reviewed by: Roman D. Jovey, MD

Under the Medical Gaze: Facts and Fiction of Chronic Pain
By Susan Greenhalgh
University of California Press
Copyright 2001
371 pages
ISBN 0-520-22397-7
$48.00 hardcover; $18.95 paperback

The recent movement to incorporate evidence-based medicine into clinical practice has made doctors aware that the gray and murky areas in patient care far outnumber the black-and-white ones. We have solid evidence for only a small portion of the day-to-day tasks we perform in medicine, and new knowledge is evolving at an exponential pace. Clinicians must try to incorporate this rapidly changing information (the science of medicine) into their daily interactions (the art of medicine) with patients who prefer simple explanations and easy cures.

Under the Medical Gaze: Facts and Fiction of Chronic Pain, by Susan Greenhalgh, PhD, is the author's account of her experience as a patient whose life is dramatically altered by diagnosis of fibromyalgia -- and deeply affected by the uncertainty surrounding the management of this painful rheumatic condition. Greenhalgh, a Professor of Anthropology at the University of California - Irvine, produces an academic treatise that actually has less to do with chronic pain than with "the workings of power and culture in the biomedical domain." Through the vehicle of one patient's journey, it explores the effects of the doctor/patient encounter. It also allows the author to vent her anger over her perceived misdiagnosis and mistreatment.

This book is not light reading. After a lengthy introduction, the actual story is written in a dissociative, third-person style. The patient ("S.") is also the author ("I"), and the narrative flips back and forth from one to the other. This is followed by a detailed, extensively referenced analysis of the roots of the problem. Although the author states early on that this is not a "doctor-bashing" book, most of her writing criticizes modern "biomedicine" as represented by her doctor, ("Dr. D."), a rheumatologist with a special interest in treating patients with fibromyalgia. The patient/author discovers, 8 months after first seeing Dr. D., that she does not meet all of the American College of Rheumatology criteria for fibromyalgia. Given this patient's intelligence, education, and means, as well as the access to information that our age affords, it is surprising that it took her so long to decide to obtain a second opinion.

One clue may come from the patient's relationship with her doctor:

For S., interacting with D. came to be something of a game, something fun. It was a new intellectual challenge... it was this element of intellectual sport as well as S.'s sense that there was a special bond between them based on the sharing of knowledge that kept her in the relationship with her doctor.
S. writes at great length in her diaries about her doubts regarding the diagnosis, the disabling side effects, and the decreased quality of life she was suffering on the prescribed medication. At the same time, she was writing glowing letters of praise to her physician. When patients cannot be straightforward in communicating with their physicians, it makes the practice of medicine unnecessarily complicated.

The author suggests another external explanation for her problems when she describes her "gender theory of chronic pain." In the struggle between her feminist and feminine side, she "was able to see how larger social forces had worked to create in her -- and probably in many other women -- a syndrome of somatization or symptomization of gender-based psychosocial stress." She advances a theory that her condition is a physical manifestation of the pressure associated with being a woman in North American society.

On her journey, the patient explores alternative-medicine approaches. She explains: "They counter the objectifying discourses of biomedicine with theories of mind-body connections and lessen physician power with self-help programs for the patient." Initially, complementary therapies seem to place healing power in the hand of the patient. Unfortunately, S. becomes disillusioned with this path as well:

If biomedicine reduces illness to the body, some new age medicines reduce it to the mind and promote "mind cures" that are no more effective in healing chronic illness than the body cures of biomedicine. Both new age and self-help manifestos present only successful cases, conveying false hopes of improvement, when in reality the likelihood of success of a given therapy is unknown.
For Greenhalgh, even practice that does not fall under the rubric of doctor-mediated medicine presents problems. In her conclusions, the patient outlines her suggestions for better medical practice:
Better medical practice means practice that treats the patient not as an object of the "medical gaze" but as a subject who is knowledgeable about important aspects of her health and capable of making informed and good decisions about her treatment. Better practice is not authoritarian but democratic, enlisting the patient's help in a collaborative quest for healing. Better science is inclusive rather than exclusive, embraces the mind and heart as well as the body, and looks for sources of pain not only in the body physical but in the body politic as well. Finally, better science acknowledges the presence of human error and the imprint of personal values and interests on medicine.
Readers should note, however, that a collaborative approach that attempts to put the doctor on equal footing with the patient will fail if the patient is not prepared or is unwilling to take responsibility for him- or herself.
Both the language and style of the book make it a difficult read. The lengthy introduction could have been abbreviated or skipped altogether. The audience for this book will most likely be limited to academics and physicians who have a special interest in studying the doctor/patient relationship -- especially involving female gender issues. By shortening her book considerably and writing her story in the first person, using more simplified language, the author could have carried her message to a wider audience.

For physicians, this book illustrates the importance of considering the psychosocial contributors in all patients with chronic pain and encouraging patients to communicate openly regarding their medical concerns.

Good clinicians have known all along that medicine is not an exact science and that there is more unknown than known. As the science of medicine continues to evolve, the art of practicing good medicine will involve explaining this uncertainty to patients in a way that still gives them confidence and does not take away hope.

Roman D. Jovey, MD, is a Complex Pain Consultant at the Credit Valley Hospital in Mississauga, Canada.

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