Commentary

Incoherence


 

Two women came in for routine skin checks, one after the other, but as patients often prove, there was nothing “routine” about it.

I asked Doris about her overall medical condition.

“I’m feeling much better,” she said. “I had what I can only call a brain fog. I couldn’t concentrate, and I had no interest in doing any of the things I used to enjoy. I don’t know how I got it, but they diagnosed chronic Lyme disease. My doctor was at a loss. As you know, the American Medical Association doesn’t know what to do with that diagnosis.” (She said this with a smile.)

“I went to a chiropractor north of Boston. Then I found a practitioner in Vermont, and when she retired she sent me to someone else. Finally, I found an MD naturopath in Portland, Maine. He offered me two options. The first – long-term, intravenous antibiotics – didn’t sound very good, so I chose the second, a diet meant to boost my immune system. And it worked! I feel so much better. He wants me to avoid gluten, and I do, but I really love bread and pasta. So I still eat them sometimes, but not as much.

“Maybe it’s all in my head,” she mused. “Maybe I just want to think that boosting my immune system makes me feel better, but whatever the reason, the fog is gone, and I feel like myself again.” Her skin exam was normal.

The next patient was Irene, who listed her medications as etanercept and methotrexate. Seeing no obvious psoriasis, I asked what the medications were for.

“Arthritis,” she said. “I’ve been taking them for 3 years. Before that I was on adalimumab.”

“And that didn’t help?”

“It worked, I guess, but I thought maybe something else would work better. I’m not sure if the new treatment does, but I stay on it anyway. My legs are still very swollen, see?”

They didn’t look all that swollen to me.

“When I get achy, I also take ibuprofen” she said. “And I go to an acupuncturist and do yoga.”

You have to love people. (Actually, if you’re a physician you’d better.) People are so wonderfully insistent on interpreting their own symptoms and how they are doing. And they are so messy, so cheerfully incoherent.

Does Doris believe in Western medicine? Well, she’s in the office of someone who practices it. Does she believe in chiropractic medicine? Naturopathy? Yes, maybe, sometimes.

How about Irene? What is her position on acupuncture? Yoga? Does either patient know the theories behind any of these healing systems? Would pointing out the mutual incompatibility of these theories trouble Irene and Doris? Not for a moment.

This broad array of therapies is hidden from their many respective practitioners, all of whom are sure their own ministrations are working. Should they even find out their patients are using other therapies, they would probably dismiss the therapies as irrelevant.

Doris thinks she is on a gluten-free diet, sort of, but of course she does eat some bread and pasta. Practicing clergy will smile in recognition of this kind of behavior. How many of their flock have nibbled at the fruit of the gluten (it tastes good!) – only not that often and not so much (nobody’s perfect!) – without a trace of concern that backsliding implies they’ve resigned membership in the community of the faithful? Being incoherent means never having to say that noncompliance shows you’ve quit.

I love incoherence. People who insist on believing just one thing to the exclusion of all others tend to be humorless, self-righteous scolds, and are tough to deal with. I stay as far away from them as circumstances allow.

Our own medical world grows increasingly rational and bureaucratized. All is aimed at being neat, tidy, and objective: cataloging outcomes, research, and evidence-based therapies and developing meticulous, often pseudo-precise categories, such as one code for skin tags of the left eyelid and another for the right. There is something to applaud in this trend, which contributes to advancing science and discarding useless traditions.

Oh, but there is more! There has always been so much more to the practice of medicine than is dreamt of in rational, scientific pursuit of knowledge. And, whether or not anyone cares to admit it, there always will be.

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