Managing the Emotional Factor in Medicine
A New Approach to Diagnosing and Treating Patients (Part I)By Michael Mannion
Virtually every medical condition – from the common cold to cancer – has meaningful emotional components. These can promote the development of disease, convert its course, and significantly influence how patients respond to treatment. Few physicians today are trained to explore and explain these complex interrelationships.
The great interest in complementary medicine in America today is patient-generated. Patients feel—often correctly—that they do not have a relationship with their conventional doctors. Very few Americans anymore have “a doctor” because of the vast changes brought about by managed care medicine. Physicians are under the financial gun and as a result cannot spend enough time with many patients. Both conventional doctors and patients feel this keenly.
Increasingly, Americans are looking for alternatives to impersonal, technology-centered bioscientific medicine. They are turning to alternative practitioners. Many would prefer a physician trained in Western medicine but one of the major obstacles facing patients is the great lack of physicians interested in, or trained in, any of the complementary approaches to health.
It is unlikely that a sizable proportion of new physicians are going to be interested in practicing complementary or integrative medicine. For one thing, the money is just not there. However, if physicians were encouraged to interact on an emotional level with their patients, they would be surprised to discover that they were better able to educate and inform patients in such a way as to save time for themselves, enhance doctor-patient relationships, and improve treatment results. Treating the emotional factor in medicine could bring allopathic physicians financial as well as personal rewards in their practices.
Family practitioners and internists in private practice need the most up-to-date, authoritative information on relevant research on emotions and health, with an emphasis on practical applications. They need to know how, when and why emotions, personality and stress can contribute to certain disorders (and, conversely, how physical illness impacts emotional life). Emotional factors that can contribute to the development or aggravation of complaints and illnesses that are frequently encountered in primary care practice, but most physicians do not recognize them or handle them effectively.
Can “Regular Doctors” Begin to Focus On Emotions and Health?
Treating the “whole person,” body and mind, is not new. It is the oldest tradition in medicine. It has always been a basic precept of ancient Asian and Ayurvedic medicine—and Western medicine as well. Allopathic physicians (“regular doctors”) since Hippocrates have emphasized that “It is more important to know what kind of patient has the disease, than to know what kind of disease the patient has.”
Emotions, personality, behavioral traits and the ability to cope with stress, can have a crucial effect on the clinical course of most diseases. A century ago, physicians were apt to be more aware of such relationships because they had more time to study and observe their patients. In the forerunner of The New England Journal of Medicine, the 19th century physician Putnam wrote “No argument is needed to show what transforming power the mind can exert...We cannot really know the man we are called upon to treat, without going far beyond his outward relations and penetrating in imagination deep into his mental life.”
Sir William Osler, a keen observer, accurately described the relationship between Type A behavior and coronary heart disease when he depicted his typical heart attack patient as "a keen and ambitious man, the indicator of whose engines are set at 'full speed ahead.' " Osler also wrote that it was more important to know what was going on in a patient's head, than his chest, to predict the outcome of tuberculosis.
Numerous 19th and early 20th century physicians, including Albert Schweitzer, believed that cancer was primarily due to emotional factors, and particularly, an inability to cope with the stress of rapid psychosocial changes. As the noted physician Berglas commented, “...everyone of us is threatened with death from cancer because of an inability to adapt to present-day living conditions.”
But where will today’s primary care physician find the latest information on emotional and mental factors that both contribute to and result from physical illness? There are no professional journals for mainstream physicians devoted to this topic. Yet, it has become increasingly evident that such influences need to be acknowledged and addressed to achieve optimal treatment results.
It is tragic that cutting-edge breakthroughs and state-of-the-art clinical strategies dealing with all aspects of the role of emotional, cognitive and behavioral factors in disease are not made available to conventional physicians. Knowledge in this exciting area of medicine is developing at a rapid rate, because of psychophysiologic research results that now demonstrate relevant mechanisms of action that are understood and accepted by Western-trained practitioners. These new scientific findings confirm the validity of what were previously considered only “anecdotal reports” and old wives' tales about relationships between stress and illness.
Physicians' Attitudes
Most American physicians agree that the patient's ability to attain and maintain a positive attitude and strong sense of control can be a critical influence in the treatment and prevention of illness, as well as in the enhancement of health. In a recent survey, 97% of physicians said they try to get an emotional sense of their patients. The main obstacle to achieving this, the doctors reported, was a lack of time. Half of the physicians surveyed, particularly younger physicians, were dissatisfied with the overall amount of time they were able to spend with their patients. More than four out of five blamed lack of time for their inability to deal with the emotional aspects of their patients' problems. (An added obstacle reported by physicians was the lack of reimbursement from third-party payers for time spent discussing emotional factors with patients.)
Almost all of the physicians surveyed said they believed a patient's emotional state could adversely affect the course of disease by reducing the body's resistance and defense mechanisms. And 65% said that a patient's emotions were a crucial factor in maintaining good health; 35% believed that a patient's emotions were at least somewhat connected to good physical health.
When asked to evaluate why their patients came to see them, 60% of physicians said that from 25-75% of their patients’ complaints are psychological. About 30% physicians said that more than half of their patients' complaints have a psychological component. And nearly 90% of the physicians said they tried to get at the emotional root of their patients' complaints and recommended various non-medical interventions to address these complaints. The most common recommendation that doctors gave their patients was to "slow down" and reduce the sources of stress in their lives.
To reduce stress, 89% of physicians recommended that their patients exercise regularly. A vacation was the recommendation of 49% of physicians. Relaxation exercises were recommended by 44% of doctors and meditation was suggested by 31% of physicians. Talking with close friends, family; massage therapy; prayer; support groups; biofeedback; and self-help books were also recommended by physicians.
Physicians seem to take at least some of their own advice. To reduce stress levels in their own lives, 73% report that they exercise regularly; 48% take vacations; 23% employ relaxation exercises; and 22% of physicians meditate. Many physicians also reduce stress levels in their own lives by engaging in activities that bring them pleasure, such as listening to music or playing an instrument; reading literature; golfing; spending time in nature; enjoying free time with spouse and family; shopping; and attending church.
Many primary care physicians may not fully appreciate the important role of stressful emotions in the genesis of their patients' problems. And even when they do recognize this, they frequently don't know what to do or how to do it. It is obvious that conventional physicians need professional education devoted to correcting such deficiencies in their training, continuing education and practices.
Pharmaceutical vs. Psychological Prescriptions
Physicians were evenly split with respect to prescribing pharmaceuticals for the treatment of emotional and psychological problems. About half of those surveyed said they used very few drugs, while an equal number reported resorting to this frequently. In any given week, 17% of prescriptions were for anxiety; 16% for depression; and 10% for insomnia. The medical literature clearly indicates that combined medical and mental treatment is more effective than either one alone. However, the pharmaceutical industry—through advertising, financial incentives for physicians to use certain drugs, sponsorship of physician conferences and seminars and office visits to physicians by “detail men”—gets the doctor to focus on drug therapy as the primary treatment in these and other disorders. Conventional treatment along with appropriate complementary approaches can achieve a synergistic effect, but few physicians are knowledgeable about complementary medicine. This does seem to be changing somewhat with younger doctors.
In recent years, the important reciprocal links between emotions and illness increasingly have been confirmed by advances in neurochemistry and neurophysiology, as well as by the development of sophisticated imaging techniques. The burgeoning new discipline of psychoneuroimmunology (PNI) has also provided important insights into numerous interrelationships among cognitive activities, emotions, and immune system responses. Mechanisms of action have been uncovered that may explain why an inability to express anger, and passive self-effacing attitudes, may contribute to crippling rheumatoid arthritis and cancer in certain patients. The stress-buffering effects and other positive effects of strong social support have also been confirmed by scientific research. A study which was originally undertaken to show the absence of any relationship between stress and breast cancer surprisingly concluded that those women who were involved in stress-reducing social support groups lived twice as long as non-participating controls. If the average physician were educated in findings such as these and shown how they can help to improve conventional therapy, many might be more open to a holistic or complementary approach.
Basic Change Is Needed
Basically, what medicine needs is an entirely new approach to diagnosing and treating patients.
In the past, the mind was the domain of the psychiatrist; the brain belonged to the neurologist; the endocrine system was the realm of the endocrinologist; and the immune system was the purview of the immunologist. But there are no such artificial divisions in the living human being who walks into the doctor's office asking for help. The biosystems of each patient are constantly interacting in complex but integrative ways, to maintain homeostasis, especially during stress. Most physicians understand that stress can contribute to disease by lowering the body's immune defenses; helping to produce excessive secretion of hormones that cause cardiovascular damage; disturbing brain neurotransmitter activity; and disrupting a variety of other physiologic functions affecting the skin and other organs. However, many physicians are less aware that a significant number of these stress-related problems can now be evaluated with objective measurements.
Americans Are Stressed
A variety of polls confirm that job stress is a major problem for American adults. In many cases, increased job stress is clearly correlated with a higher incidence of heart attacks and hypertension. Structured Personnel Interview evaluations, the Jenkins Activity Survey, and other Type A measurement gauges, can forecast the likelihood of a variety of future coronary events, as well as sudden death. The Holmes-Rahe Social Readjustment Rating Scale, which assigns a numerical value to life change events, has demonstrated that their aggregate magnitude over the preceding 12 months is a strong indicator of the likelihood of increased illness during the following year. The loss of a close emotional relationship – through death, divorce or other separation – is at the top of the list. The Hassles Scale, devised by Lazarus, which measures the number of minor irritations of daily life (e.g., arguments with neighbors or customers; broken shoelace; lost wallet or keys) may have even greater prognostic significance.
When surveyed, about 81% of physicians said that a lack of time interfered with their ability to deal with the emotional aspect of their patients’ problems. (Some physicians also mentioned the obstacles managed care placed in the way – psychiatric problems are reimbursed at half the rate of medical problems.) Recently, in The New York Times, Dr. Robert Spitzer, a psychiatrist at Columbia University in New York, agreed that lack of time is a major obstacle for primary care physicians when treating their patients’ emotional problems. And yet, increasingly, the emotional care of patients is falling to primary care physicians who are under great time constraints.
Why Are There No Publications For Primary Care Physicians on Emotions and Health?
There is no available publication for the primary care physician that focuses on managing the emotional factor. A review of the journal holdings at a large New York medical library; the current publications lists of the Index Medicus; Gale's Directory; Burrelle's Media Directory; and Vol. 4 (Controlled Series) of the Ulrich's Directory failed to disclose any publication devoted to this critical topic. Journals aimed at psychiatrists, publications for those interested in psychosomatic medicine, or some corporate-sponsored “throw away” newsletters may on occasion contain material that might be relevant. But busy doctors don't have the time to cull scores of publications for pertinent information that could be of considerable value to them and to their patients.
As the burden of detecting and managing the emotional problems of patients increasingly falls on the shoulders of primary care physicians, they will require high-caliber resources to help them sharpen their diagnostic skills in this area; stay abreast of the latest research in the field; and learn how to use this knowledge to achieve better patient communication and provide better patient care. Who will provide such knowledge?
The emotional life of the patient can no longer be ignored, affecting as it does the etiology of disease and illness; the response to diagnosis; the patient's prognosis; response to treatment; and the patient's long-term outcome. For example, research shows that women with a “fighting spirit” have better cancer survival rates than women who express “stoic acceptance.” (The same phenomenon has also been observed in experimental mammary cancer in animals.) Improved survival in melanoma patients is associated with assertiveness and an ability to express emotion. Increased illness and early death is linked with loneliness and isolation. High levels of stress can reduce the effectiveness of many vaccines (e.g., for Hepatitis B) probably because of an increase in anti-inflammatory glucocorticoid hormones which depress immune system response.
Emotional problems are responsible for fully half of the top ten reasons patients consult physicians. When these are identified and addressed, the vast majority of patients go on to lead productive lives. However, only 20% of patients with symptoms and signs that are due to mental or emotional problems are recognized. Intervention by an enlightened primary care physician could be crucial for the proper care of these individuals.
There is increasing physician interest in the areas of stress and the rapidly developing field of psychoneuroimmunology (PNI). PNI grew out of decades of scientific research into the area of stress. A recent survey of physicians indicated that 40% of American doctors have heard of PNI or are familiar with it. Of the physicians familiar with this new discipline, 98% consider it to be a legitimate field of study and a worthwhile endeavor.
Improving Physician Education
Primary care is comprehensive care, integrating the biomedical and psychosocial sciences. Primary care physicians work at the intersection of caring and curing. They incorporate the body and the mind (i.e., the patient's total life situation) into their practices everyday. However, the physician-patient relationship is a complex interaction and many physicians do not feel they have the skills needed to handle the mental/emotional aspects of their patients' complaints. They do not see themselves as qualified to be “therapists” for their patients. However, according to Marion R. Stuart, PhD and Joseph A. Lieberman III, MD, MPH, authors of The Fifteen Minute Hour – Applied Psychotherapy for the Primary Care Physician, physicians are more qualified than they might think.
Although it is often by default that primary care physicians handle the mental/emotional factors patients present with, surveys show that 95% of patients find it helpful to talk about their problems with their physicians. For a majority of patients, the personal physician is the primary source of mental health care. In fact, patients with psychosocial problems turn to their personal physicians for help more often than to any other type of professional. Patients feel the therapeutic benefits of talking with and listening to their physicians.
Among the qualifications and skills that physicians already possess (and can build on) that enable them to handle the mental/emotional aspects of primary care, Stuart and Lieberman list trust; continuity of care; nurturance; power to influence; and essential interviewing techniques.
Primary care physicians need assistance learning how to use what they already know about the emotional and mental factors in patient care more effectively. They need information on developing effective patient communication skills; new techniques that physicians can learn and incorporate into practice (e.g., behavioral techniques; cognitive therapy techniques) and effective preventive health measures they can teach to their patients. The medical literature clearly indicates that combined medical and mental treatment is more effective than either one alone.
According to Stuart and Lieberman, there is impressive and growing evidence on the necessity and cost-effectiveness of managing the emotional factor in medicine if comprehensive primary care is to be successful. Further, the authors believe that managing the emotional factor saves the physician time (e.g., by preventing many problems) and can even offer economic benefits to the physician (e.g., making him or her more competitive and relevant in our changing health marketplace.)
To improve conventional medical treatment, continuing medical education for primary care physicians, and medical school education, need to:
- Focus on what works in actual practice
- Help physicians put knowledge into action
- Explore health promotion and prevention
- Examine effective methods of physician-patient communication and provide physicians with time-saving, cost-effective patient information
- Primary Care Physicians and Patient Education
Patient education materials could focus on a specific ways that the physician and patient, or patient alone, can work to promote health; prevent disease; and mobilize the patient's own inner healing powers to enhance treatment results. Primary care physicians can provide a great deal of help that will allow patients to put knowledge into action. Physicians who undertake this patient education effort will find that it a actually a significant time-saver, and helps make their practices more effective.
Conclusion
The time is right for primary care physicians to begin managing the emotional factor in medicine more effectively. The role of emotions in health is increasingly recognized by patients, physicians, third-party payers and businesses. A recent survey of personnel officers found that 90% of human resource professionals believe that “mental health” will be the critical health care issue of the next decade and 70% said that their companies will soon need to provide "mental health days" for their employees.
It is becoming more evident that optimists are healthier than pessimists; that emotions influence etiology, prognosis, treatment and outcome; that factors such as stress can cause physical damage to the brain, heart, digestive tract, reproductive organs, etc.; and that emotional healing techniques can be learned and taught.
Physicians who learn and teach (the word “doctor” comes from the Latin “docere,” which means “to teach”) healing techniques to their patients are practicing the most ancient and most advanced medicine simultaneously. In addition, they are practicing an extremely effective form of preventive medicine, invaluable in these days of cost-containment and limited access to health care for millions.
The mind plays a decisive role in health. Although a focus on the emotional factor in medical practice goes against many past biomedical views, it is the path that leads to the future of successful patient care. The physical and chemical reactions that occur in the body do not occur in a vacuum. They take place in an environment that consists of complex interactions within the “bodymind.”
The medical drugs we use are introduced into the complex physical and emotional environment of the patient's bodymind. For many years, it has been known that some drugs can cause unwanted emotional reactions in patients at times (e.g., steroids). In recent years, a growing body of evidence suggests that a patient's emotional state can profoundly influence the effectiveness of many pharmaceuticals in treating such conditions as arthritis, hypertension or cancer. Both physicians and patients need to learn how emotions can limit the necessity of some forms of treatment and enhance the effectiveness of other therapeutic regimens.
Few any longer question that the mind contributes to the maintenance of physical health, the development of disease, and to the cure of disease or that physical processes in the body influence and alter mental states. Many disagree, however, about how this takes place and to what degree in which patients and under which circumstances.
The information gathered by those exploring this new area of medicine provides exciting and unique new medical opportunities for the primary care physician. Part II of this article, which will appear later in The Journal of the Mindshift Institute will look at specific topics that primary care physicians can explore to enhance their abilities to manage the emotional factors in their patients’ health care.