Bmj Usa: Editor's Choice

Mind over matter

BMJ 2003; 327 doi: (Published 19 November 2003) Cite this as: BMJ 2003;327:E128

From BMJ USA 2002;August:421

Medicine perpetuates a dichotomy between the mind and “organic” disease, but by now we should know better. Clinicians recognize the role of psychology, emotions, and mental illness in countless physical complaints—back pain, headache, and fatigue to name a few. They know that it is smarter to address these root causes than to order x rays and blood tests. More often than not, these tests generate normal or false-positive results and do little to confront the real problem.

Yet the mind gets little attention in practice (except when patients present with overt symptoms of depression, anxiety, or confusion). The subtle psychological ferment behind chief complaints is often unexplored. Most doctors lack the time and inclination to ask the probing questions that would expose the link between chest pain and the upcoming anniversary of a father's sudden death; to truly understand how patients perceive their disease; and to study what the patient is not saying and why.

The standard refrain is that there is too little time and reimbursement for such counseling. Is there a deeper problem lurking behind this excuse? Are doctors uncomfortable or unqualified in exploring the patient's emotional world? Every doctor would affirm the merits of open-ended questions and empathy, but how many are good at it? Patients who encounter the clumsy bedside manner predictably report, in dozens of studies, that they feel unheard and dissatisfied with the quality of their encounters with doctors.

One solution is to sharpen our skills. Gask and Usherwood (BMJ USA p 459) help with this task, summarizing the principles for communicating well with patients. Another solution is to remember the clinical circumstances affected by the psychological life of patients. Kroenke (BMJ USA p 429) reviews the physical symptoms that often herald underlying mental disorders. Another solution is to enlist the mind as a tool for healing. For example, people work through grief more rapidly if they have strong spiritual beliefs (BMJ USA p 445).

Entrenched medical dogma artificially segregates the mind from the body. The historic divide between neurology and psychiatry, described by Baker et al (BMJ USA p 430), grows obsolete with mounting evidence that “organic” brain disease and mental illness are interrelated. Brain scans reveal abnormal cortical structure and function in mental illness, and mental illness pervades organic disease.

What is on the patient's mind is pivotal in determining which test or treatment is “best.” What doctors prefer, in their surmise of benefits and harms, may be the wrong choice for patients with different values. Findley and Baker describe “a lack of congruence between what patients and doctors value in terms of the impact of disease on quality of life and what should be done about it” (BMJ USA p 434). Hart gives a historical example of doctors ascribing pathology to behaviors that patients consider normative (BMJ USA p 463). Hopefully the future will bring greater interest in the patient's perspective.

Articles cited in Editor's choice are listed below, beginning with their BMJ USA page number:

BMJ USA p 459 The consultation (Gask),

BMJ USA p 429 Psychological medicine (Kroenke),

BMJ USA p 445 Spiritual beliefs (Walsh),

BMJ USA p 430 The wall between neurology and psychiatry (Baker),

BMJ USA p 434 Treating neurodegenerative diseases (Findley),

BMJ USA p 463 Sexual behaviour and its medicalisation (Hart),

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