[MedGenMed, September 17, 2001. ©
Medscape, Inc.]
Under the Medical Gaze: Facts
and Fiction of Chronic Pain
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:
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:
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.
Copyright © 1994-2001 by Medscape
Inc
Reviewed by: Roman D. Jovey, MD
By Susan Greenhalgh
University of California Press
Copyright 2001
371 pages
ISBN 0-520-22397-7
$48.00 hardcover; $18.95 paperback
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.
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.
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.
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.