Guest Editorial Suffering, Science and Sabotage Journal of Musculoskeletal Pain, Vol. 12(2) 2004, pp.3-18 Muhammad B. Yunus Muhammad B. Yunus, MD, is Professor of Medicine, Section of Rheumatology, University of Illinois College of Medicine at Peoria [E-mail: yunus@uic.edu]. ABSTRACT. Objectives: The objective of this paper is to discuss suffering in general, the criti­cism against fibromyalgia and other central sensitivity syndromes [CSS], the deleterious effects of disease-illness dualism, a new unifying paradigm for this duality, and then to suggest a remedial model for better patient care. Methods: A review of the literature using Medline and other sources, and an amalgamation of known knowledge with author's own ideas and inquiry. Results: Bias against CSS are harbored by many physicians, thwarting the progress for a better understanding and treatment of these syndromes. Most physicians believe in disease-illness di­chotomy and pay more attention to the structural than the functional pathology, e.g., neurochemical endocrine [NCE] abnormalities. Both types of pathology are likely based on biology. Even psychosocial distress is mediated by neurochemistry. A model is suggested for proper care where patients and physicians work together with a common satisfying goal, each fulfilling their individ­ual responsibilities. Conclusion: Most physicians treat CSS with a negative attitude. The outdated model of dis­ease-illness dualism should be abandoned in favor of a fresh approach to medical education that fosters compassionate care irrespective of the disease label. KEYWORDS. Suffering, disease-illness dualism, phenomenology, biology, compassionate care Medicine, the only profession that labors incessantly to destroy the reason for its own existence. -James Bryce My first editorial in the first issue of this journal in 1993 was an imploration for science (1). Since then, the whirl of evidence-based medicine [EBM] has been gaining momentum, and most of us, including myself, were too willing to embrace it. This is not surprising since the basis of our medical training is sci­ence. But, now I think that EBM is not a pana­cea for all ills. Part of this essay will transgress the "sacrosanct" bounds of EBM, and talk about such abstract concepts as human phe­nomenology, e.g., mind, perceptions, feelings, and suffering, where EBM has scant relevance. I shall discuss suffering and some of its causes, medical profession's fixation on current rigid and restricted definition of science, and physi­cian apathy causing iatrogenic suffering. Fi­nally, I shall offer some suggestions that may help physicians to care for the patients as a whole. SUFFERING Cassell (2) states that modern medicine has, at best, an ambivalent attitude towards suffer­ing and that suffering is an embarrassment to currently practiced medicine. In Cassell's view, "suffering can be defined as the state of severe distress associated with events that threaten the intactness of person" [emphasis is mine]. Distress or pain per se, according to this definition, does not necessarily cause suffering. Many ailments cause much distress or pain, such as tooth extraction, a viral infection, or the fracture of a bone, but patients are able to rationalize that they are most likely to recover from these conditions, and their overall sense of intactness remain unchanged. The patients comfort themselves by thinking that these con­ditions are not serious in the long term, and they do not experience a sense of irretrievability. Thus, pain and suffering are not synonymous. It also appears that acute conditions are not necessarily immune from suffering, such as an acute attack of panic or anaphylaxis, when a sufferer feels quite helpless and fears that he or she may die. On the other hand, most chronic diseases cause continued anguish and misery in such a way that an individual feels hopeless and helpless. He or she feels out of control, and uncertain about the course of the disease. This individual is suffering, since the intact­ness as a person is threatened or lost. He or she cannot escape from an invisible shadow that haunts her or him every day and every night, and sometimes every existential moment. Here is a quotation from Abraham Lincoln during some of his darkest days, that has all the com­ponents of suffering: "I am now the most mis­erable man living. If what I feel is equally dis­tributed to the whole human family, there would not be one cheerful face on earth. Whether I shall ever be better I can not tell; I awfully forebode I shall not. To remain as I am is im­possible; I must die or be better, it appears to me" (3). Van Hooft (4) suggested an objective idea of suffering, perhaps as reconciliation with science. He argued that many persons who un­dergo poverty, lack of education, bitter up­bringing, unhygienic living, and drug addiction with potentially serious medical and psycho­logical consequences, are also suffering and may not be aware of this. These are thought to be measurable ways to assess suffering [you can measure poverty by earning, education by number of years in school, etc.]. Van Hooft further contends that such adversities of life thwart the fulfillment of a goal for happiness that every human strives for. The concept im­plies that treating the measurable factors will ameliorate suffering. As an example, by treat­ing the pathology [such as inflammation] one can also treat suffering. I think Van Hooft's concept of suffering is untenable. The examples given by Van Hooft above may cause suffering in some; but not in everyone. Many individuals go through severe adversities, but they adjust to their life diffi­culties, look at life positively, and take unfa­vorable life circumstances as healthy challenges to future achievements and fulfillment. Hu­mans can bear a lot of pain if they find a sense of purpose and meaning. Several years ago, one of my students shared his enormous life difficulties and the accompanying stress due to financial and family situations. He was one of our best students. I asked him one day what kept him going and doing well in his studies despite the hardship. His answer was rather simple: "I had always dreamed of being a doc­tor and I can see it happening." Gunderman (5) states that it is not distress that destroys people, but the misery without meaning. For a woman in labor, the horren­dous pain has a meaning and a noble purpose. Most women take the labor pain as a positive experience. Chronic pain has no meaning and no purpose. It promises no luminance at the end of the tunnel. In fact, the patient feels that she or he is constantly confined in a subterra­nean existence where the sun never penetrates. It is the feeling of an eternal and inescapable dark sphere that causes so much suffering among so many chronic disease sufferers for so long. Suffering by itself is an entity that goes be­yond structural pathology. I espouse Cassell's view that "Suffering is ultimately a personal matter-something whose presence and extent can only be known to the sufferer." I also agree with Cassell (2) and Edwards (6) that suffering is really a phenomenological condi­tion. It is based on feelings, perceptions, em­bodied sensations, and existential experience that a sufferer lives through irrespective of any objectivity to what she or he feels and suffer. Suffering does not have a visualized anatomy or physiology. In recent years, some physio­logical explanations of pain, its individual vari­ations, and genetic determinants have been demonstrated by functional magnetic resonance imaging [tMRI] or single-photon-emission computerized tomography SPECT (7-9). While findings of perturbed physiology by these tech­niques [and others to come in the future] are very helpful in achieving a better understand­ing of pain, they are not sufficient to fully ex­plain all of the depth and dimensions of an individual's distress. Despite our modern en­deavors to understand the colossal complexity of the brain and its functions, the mind's full depth, and dimensions are yet to be unraveled. SCIENCE Science can be simply defined as an exami­nation of the nature and natural occurrences through objective observation and experimentation leading to empirical evidence. Unlike faith or feelings, which ultimately belongs to the depth of a personal domain, the scientific evidence is based on information that is open for all to see, examine, accept or refute based on similar objectivity. Science has revolution­ized the way we live, do, and think. However, science so far failed to provide all the answers to life's intricacies, vicissitudes, emotions, and anguish. SCIENCE AND PHENOMENOLOGY: DUALISM IN MEDICINE The foundation of medicine, as practiced in the West, is the science of medicine, which is restrictively defined to mean "organic" pa­thology. In some cases, future medical stu­dents get interested in biology during the mid­dle school years; by the time they are first year medical students, the objectivity of science, and its essentiality are firmly engrained in their minds. From then on, the major, if not the only, focus remains on science in most physi­cians' practice of medicine. This is now vigor­ously reinforced by the incessant mantra of EBM. A fact is defined by measurement of classical [structural] pathology alone, and to qualify as a fact, it must successfully run the gauntlet of P values. Only a few medical schools offer a targeted course on immeasurable [or incompletely mea­surable], but vital areas of human feelings, sensibility, and existentialism. Examples in­clude: suffering, fear, want, frustration, unre­solved psychological conflicts, old psycho­logical trauma, hopelessness, despair, love, optimism, happiness, kindness, and empathy. We measure some of these things by having the sufferers fill out a questionnaire or rate them in a visual analog or similar scales. Such measurements have been useful in clinical practice and research, but all the dimensions of suffering are truly not measurable. Aristotle said that a physician should know when it is wiser not to measure (10). Mirowsky and Ross (11) state: "Psychological distress is probably one of the most difficult concepts to measure." To this, I will add that any distress, irrespec­tive of cause or pathology, is beyond true mea­surement. Structural pathology has a poor cor­relation with symptoms. For example, there is often a pain-pathology gap, as has been ob­served in rheumatoid arthritis [RA] (12). Many practicing physicians rate symptoms of their patients [they should]. But, they ques­tion the patient's rating if no structural pathol­ogy is present, saying that their symptoms are purely subjective and, therefore not depend­able as a basis for any action. The red flag of intentional misrepresentation and desire to achieve secondary gain springs up in a physi­cian's mind. Such thinking is still pervasive from the examination room to the courtroom. This kind of judgmental attitude is an iatro­genic cause of accelerated suffering. Despite a clear admonition, in recent de­cades, for treating patients as a whole, includ­ing an assessment of their psychosocial diffi­culties (13-16), little attention is being paid by most physicians to these vital elements of pa­tient care (11). There is a lot of lip service to the psychosocial issues, but this seems to be more of a current fashion statement, rather than any true attempt to understand, empa­thize, provide the necessary time, and help the suffering. A large number of patients com­plain that their physicians spent just ten min­utes with multiple interruptions and the real concerns of their patients were never addressed. The physicians hurriedly pull out a prescrip­tion pad before hearing the full history, scribbled Prozac [fluoxetine], or Elavil [amitriptyline], and asked the patient not to return. Scientists in other fields, such as physics, chemistry, and molecular biology, do not have to deal with the question of suffering. The rea­son for the existence of the medical profession is to uniformly serve the sick and the suffering without derogatory or prejudicial views. Such service is the mission of the profession. A dog­ged reliance on science of structural pathology will not help us to keep our promises of caring when we first espoused the Physician's Oath [commonly used oath is that of the World Medical Association, based on the Hippocratic principles]. Henceforth, the World Medical Association Oath will be referred only as "Oath." Because of the overwhelming influ­ence of the science of structural pathology that is emphasized in medical education, it is not surprising that most physicians focus on the classical or "organic" pathology of disease, since they have been taught to believe that such pathology provides the only rational ap­proach to treatment. There is only cursory at­tention to the mind, as if mind and structural pathology are two different and independent domains. All the attention goes to the latter. The first is regarded as not real and not worthy of time and effort. This is surprising in view of the fact that the nexus between mind and body, was fully appreciated in Ayurvedic medicine that taught that a person as a whole needs to be treated by a physician. Ayurvedic medicine was the first system of medicine-developed some 3,000 years ago in India (17), but even now a holistic approach to disease manage­ment, as advocated by Ayurvedic medicine, is not commonly practiced by the medical community. APATHY, ANTAGONISM AND SABOTAGE There are varying attitudes among physi­cians who ignore human suffering due to cur­rently defined illness, because they perceive no objective pathology in these conditions. Among these, I shall talk about a group of in­terrelated conditions, such as headaches, fibro­myalgia, irritable bowel syndrome, and chronic fatigue syndrome. They have been called "functional" syndromes [an intriguing term considering that their pathophysiology is based on a dysfunction of the neuroendocrine sys­tem]. Now it seems quite likely that these con­ditions share a common pathophysiology of central sensitization, hence the recently sug­gested term "central sensitivity syndromes," [CSS] (18,19). In this article, I shall refer to these "functional" syndromes as CSS. Some physicians simply ignore the suffer­ing of the CSS patients, telling them, directly or indirectly, that their symptoms are imagi­nary ["there is nothing wrong with you"] and making sure that no further appointment is given. They are often derisive and rude to their patients. Other physicians tell their patients that they are suffering from depression or an­other psychiatric disease [with no intention of finding out if this is the case] and ask them to see a psychiatrist. Often, psychiatrists fail to find any mental illness in such cases. Thus, pa­tients are left in the lurch and they have no­where to go for help. They suffer silently. The patients learn to distrust and hate the medical profession for what they view as its ignorant pomposity. Other physicians recognize the problem and genuinely want to help, but they have been the victims of the current medical education system (10) and are ill equipped to manage such patients. Empathy is an awkward emotion for them. There are still others [the passive aggressors] who are passively antagonistic though not actually abusive to the patients suffering from functional problems. They, too, quietly get rid of these patients. The worst type of physicians spew out their engrained and virulent bias against suffering patients who do not fit their definition of "or­ganic" pathology. They altercate in any forum [corridor, meetings, journals] to discredit and decimate the concept and science of CSS through their paralogism-an invented "logic." Many caring and well-informed physicians would regard such views as fatuous. The fact that the term CSS is based on a pathological mechanism, would nettle many of these biased physicians. Worse, some of them actively sab­otage (20-25) the service of others who devote their time to research and care of these unfor­tunate patients. The CSS opponents complain that if there is no "organic" pathology, the problems of the CSS sufferers do not exist. Some of them state that the symptoms are all psychosocial and that the misery is "all in the head" (24). One of the cardinal mistakes they make is that they put all the patients in the same basket (20-25), despite the well-accepted concept of subgroups in any disease or syn­dromes in modern medicine. My colleague Dr. Alfonse Masi and I have always maintained that in FMS, there are subgroups based on physical and psychological variables (25-29). Recent analysis of our data by cluster analysis showed that only 34% have high psychologi­cal distress (28), a figure similar to 32% re­ported by Giesecke using the same technique (30). To these physicians, when it comes to taking care of these patients, 'mind' is a sepa­rate domain for the psychiatrists only, and is far removed from bodily pathology. Some of them are self-declared FMS experts without much patient contact. They seem to be under a perpetual spell of Cartesian curse. They make no attempt to understand the agony of the suf­ferers ["it is all psychological"]. They have no intention to understand the pathophysiological basis of the CSS patients' symptoms. They ig­nore many properly conducted studies pub­lished in well-known journals that show ab­normal neuronal functions, neurochemicals, and neuroendocrine status (18,19,31-37). They can rarely read any scientific paper on the CSS conditions with an open mind, since in their biased minds they have already decided that these studies are no good. This reminds me of an old advertisement for Guinness [a dark look­ing beer that is perceived by many Britons to have bad taste] that I once saw in London, UK. It says, "I do not like Guinness, since I never tasted it." One of the insensate com­plaints of the saboteurs regarding FMS is that there is no adequate treatment for it (22). Was there any meaningful treatment for RA before the methotrexate era in the 1970s, despite the fact that it has been characterized for at least 200 years? FMS characterization and research barely began in the late 1970s and early 1980s (38,39). Why is there a quixotic expectation regarding FMS, particularly given the fact that it is a recently characterized condition and it received very meager extramural support com­pared with RA? Is there an adequate treatment for all cancers, connective tissue diseases or cardiovascular disorders? If there is to be a cure or satisfactory treatment for FMS [or other CSS members], it will not be achieved by a pure psychosocial approach. Treating depres­sion alone does not cure FMS and it is hardly surprising that cognitive behavioral therapy is ineffective in FMS when a proper study in­cluding attention controls is conducted (40-42). Research in both biological and psychosocial areas will be needed to adequately treat the CSS sufferers. It is good to recall the Oath of The World Medical Association, and read it aloud: "I sol­emnly pledge to consecrate my life to the ser­vice of humanity . . . I will maintain the utmost respect for human life." Charaka, a great phy­sician of ancient India [200-300 BC], who wrote six volumes of text books of medicine [called Charaka Samhita] on different disci­plines of medicine [including obstetrics/gyne­cology and psychiatry], had urged a similar oath for the graduating disciples: "Day and night, however thou mayest be engaged, thou shalt endeavor for the relief of patients with thy heart and soul . . . Thou shouldst speak words that are gentle, pure and righteous, pleas­ing, worthy, true, wholesome and moderate" (43). The Charaka oath exhorts physicians not only to relieve patient distress [irrespective of cause], but also to be devoted and compas­sionate in patient care. They should also be gentle and respectful in their interactions with the patients. An erudite patient of mine with both FMS and RA, who also teaches ethics in a college, complained that many physicians are reneging the Oath and are iatrogenically exacerbating the patient suffering. The callous actions of some physicians threaten the very reason for the existence of the medical profession-namely service of humanity and relief of distress. Part of the reason for the utter failure of our profes­sion is an overemphasis on science, the mean­ing of which has been taken to imply only the Virchow's dictum of structural pathology. Does anybody care that some of the physicians are destroying our trusted profession by their con­scious or unconscious abandonment of the Oath? CAN WE TREAT SUFFERING? Perhaps a more manageable question is, can we help to mitigate the suffering of our pa­tients? I shall address this question in several sections. First, I shall discuss certain barriers to our empathetic care of the suffering, and then offer a few suggestions for the manage­ment of suffering. Barriers in medical school: On the surface, the heading of this section in the context of suffering seems antithetical to the very pur­pose of a medical school, since its role is to prepare future physicians for mitigation and healing of suffering according to the Oath. Perhaps unintentionally, the schools got into a drumbeat of propagating science that deals only with swarming germs, deranged cells, and battered bones. In the obsession with or­ganic pathology, there is subtraction of the pa­tients as persons . We spend two hours discuss­ing a case and two minutes at the bedside, as if patients are just a number and totally detached from an interesting MRI or a renal biopsy that consumes our attention. At present, only a handful of educators think that there is some­thing terribly wrong and vacuous in such an approach. Also implied in the medical teach­ing is a dichotomy of mind and body, so that anything that does not fit into structural "or­ganic" pathology model [i.e., "truly" in the body] belongs automatically to the "soft sci­ence" of the mind, vis-a-vis psychiatry and psychology. Psychology does not belong to the psychologist alone. Seldom can the psy­chiatrist or the psychologist successfully sooth the suffering without knowing the full context of a disease. Only the treating physicians can bridge both aspects and treat the patient as a whole. They should be able to do so by them­selves in a vast majority of the cases despite a lack of specialty or subspecialty training, but sometimes they may need to work with other specialist colleagues who can help the patients with coping or other forms of psychotherapy. Nevertheless, the physician should remain in charge. Any fragmentation of the centrality of a treating physician's role will only compound a patient's suffering. Hippocrates and Charaka get a black eye everyday in many hospitals and clinics. In fact, we, the teachers, may be demonstrating hypocrisy while solemnly and ostensibly ad­ministering the Oath to our graduating stu­dents, since very few of us are really guided by the essence of the Oath in practice. Thus, hy­pocrisy becomes a norm in a resident's mind through the examples of the physician mentors. Someone mentions the term fibromyalgia syn­drome or chronic fatigue syndrome during a medical round, and the whole group gets in­volved in an orgy of jocundity and derision. This spectacle is, of course, led by the attend­ing physician. There are other barriers to understand suf­fering in a medical school environment. Eth­ics, empathy, listening skills, and literature are rarely part of the medical education. Disease-illness dualism: A dichotomy be­tween classification of disease and illness is such a destructive barrier that it deserves a greater discussion. A distinction between dis­ease and illness has been proposed by several authors, although their recommended approach to patient management has varied to some ex­tent with regards to an emphasis on psychol­ogy alone vs both psychology and biopathology (29,44-47). Despite good intentions, I think such distinction has not served our profession and our patients well. Esterson (48) defines ill­ness as follows: "Illness is experience . . . . It can not be investigated by methods of bio­medicine because its study ultimately depends directly on phenomenological analysis of ex­perienced suffering through individual self-re­ports and behavior." I find this definition rather perplexing since it states that symptoms of an illness are purely subjective without any underpinning biopathology. Disease, on the other hand "is demonstrable pathophysiology or pathochemistry, and is demonstrable by pathologic findings." In this definition, pa­thology means only structural [or organic] pa­thology. The pivotal point of disease-illness demarcation, according to its proponents is the lack of "organic" pathology in illness. Funny, they do not recognize the brain and spinal cord as organs. Many see an advantage to focusing on psy­chosocial issues in illness. It is as if all patients with CSS conditions and none with structural pathology suffer from psychosocial distress. These physicians ignore the subgrouping con­cept that applies to both types of disorders. Occurrence of psychiatric disease in CSS has varied between 20-60% (27,49-51). There are studies that showed no excessive psychiatric abnormalities in a CSS condition when com­pared with chronic "organic" disease (27,52). It also seems that psychosocial problems in CSS seen in a clinic are influenced by self-se­lection (53,54). What is clear, however, is that not all CSS diseases have psychosocial dis­tress, nor all patients with structural pathology are free from it. Depression, other psychiatric diseases, and other psychosocial difficulties are present in virtually all chronic diseases with structural pathology, e.g., coronary artery disease [CAD] (55,56), RA (57,58), systemic lupus erythematosus [SLE] (59,60), diabetes mellitus, and chronic pulmonary disease (61). It is known that depression is associated with worse outcomes in CAD (55,56). Psychologi­cal distress can also aggravate psoriasis (62). Instead of focusing on an individual patient's distinct problems with their own pathology and psychosocial issues, physicians treat their patients according to prefixed notions about illness and disease with a different attitude. Predetermined mindset creates a "genus of generalization" based on disease-illness dual­ism, such that everyone labeled to have illness is automatically a psychosocial "basket case," and others having an "organic" disease present a basket of fruits, wherein lies all the "sweet­ness" of structural pathology. Such divisive chasm is antipodal to person-centered care (29,46,63-65) where the approach is to focus on an individual patient's unique set of problems with differing pathology, etiology, contribut­ing factors, and symptoms with or without psychosocial issues. Let us define pathology and disease. The current manipulation of the word pathology has come to mean only those conditions that have been blessed by Virchow, i.e., the so­called organic pathology with anatomic ab­normality (66). A current medical dictionary defines pathology as "the medical science, and specialty practice, or concerned with all as­pects of disease, but with special reference to the essential nature, causes, and development of abnormal conditions, as well as structural and functional changes that result from the disease process" (67). The same source de­fines disease as "an interruption, cessation, or disorder of body functions, systems, or or­gans." This is exactly what happens in currently defined illness, where objectively demonstra­ble aberrations of the neurochemical-endocrine [NCE] system are present. The word disease derives from dis-ease meaning a lack, or oppo­site, of ease (67). By these definitions, one can argue that both structural and functional [NCE] pathology may cause symptoms and suffering. At this time, I shall interchangeably use func­tional pathology [unlike 'functional syndrome,' 'functional pathology' implies dysfunction] and NCE pathology. Actually, subgrouping pathol­ogy as structural and functional [or NCE] is ar­tificial and fragile. After all, symptoms due to structural or anatomic damage occur because of disturbed function. Moreover, disease and illness defy any circumscription. If there is a boundary, it is faint and abundantly porous. As stated earlier, patients with structural pa­thology may have functional pathology and vice versa. Since the NCE pathology has been better defined and has provided greater objec­tivity in recent years [see below], it may now be strategic to rethink and abandon the old and destructive doctrines of dichotomy between the so-called organic versus functional dis­eases. Such binary division is outdated, preju­dicial, pejorative, and pernicious. In this con­text, I find it odd that the term 'organic' is used only for structural damage, considering that spinal chord and brain are also organs. Some readers may like to see 'psycho' added before 'neurochemistry endocrine,' but NCE pathology does include that of psychologic or psy­chiatric problems. The proposed terminology 'functional' or 'NCE' pathology would in no way exclude the importance of psychosocial stressors and their appropriate management in an individual patient. However, objectively demonstrable biology is involved in both struc­tural and NCE pathology. For this article, I shall only refer to a few sources that discuss the neurobiology of common emotional disor­ders. Neurochemicohormonal mechanisms involv­ing serotonin, noradrenaline, dopamine, gamma­aminobutyric acid, hormones [corticotropic releasing hormone, glucocorticoids, gonadal hormones, thyroid hormones, growth hor­mones], neural sensitization [mediated by sub­stance P, N-methyl-D-aspartate, and a host of other neurotransmitters] are at play in variable combinations in anxiety (68), depression (69), stress (70), and other forms of emotions, e.g., adaptation and cognition (71). If "seeing is be­lieving," current neuroimaging techniques have accommodated that sense as well (72). The question arises, does emotional stress trigger biology or is biology responsible for the emo­tional upheaval? I think the answer is both. A given environmental stress does not necessar­ily elicit the same response in everyone. So, there is likely to be individual genetic or other endogenous predispositions. Once the process of emotional distress is set, it self-perpetuates and amplifies, most likely on the basis of cen­tral sensitization mechanisms (73). It is worth remembering that environmental factors, e.g., a microbial agent, can also trigger a structural disease in a predisposed host, e.g., Reiter's syndrome (74). Finally, even psychological coping mechanisms, that have been found to be helpful, are likely to have a neuroendocrine basis (75). The role of physicians is to encour­age and coach the patients to give a helping hand to biology. The point is that psychologi­cal difficulties or a lack of proper adaptation are not willful pretensions on the part of the patients, but have a biologic predisposition and perpetuating mechanisms. Functional syndromes, such as irritable bowel syndrome and headaches have been known for many years. The fact that they are intercon­nected, similar, and overlapping with a proba­ble common pathophysiological mechanism was first proposed in 1984 by Yunus, who de­picted the interrelationships of these syndromes using a Venn diagram (76). These syndromes [which now also include chronic fatigue syn­drome, temporomandibular dysfunction, rest­less legs syndrome, depression, and others] can now be explained, at least partly, byobjec­tive pathophysiology of central sensitization (18,19,34,36,37,77-79) and neuroendocrine dysfunctions, e.g., aberrations in serotonin, sub­stance P, and growth hormone (31-33,35,81-94). As an example, pain may be explained by low serotonin status (81,82) and increased sub­stance P (85), and hypersensitivity to physical, chemical, psychosocial and environmental stim­uli by central sensitization (18,19,73,87). This perturbed physiology [vis-a-vis pathology by my earlier definition] can also be "visualized" in different parts of the brain by current brain imaging techniques (9,95-100) and by abnor­mal sleep electroencephalogram [EEG] (101). Contrary to a fanciful statement (24), genetic contributions to the pathophysiology of CSS members have been demonstrated (103-113). In the context of CSS, the recently used ter­minology "medically unexplained symptoms" (114-116) has illogic and bias written all over it, given the extensive pathophysiological re­search in these conditions, as elaborated above. Even after more than 100 years of research, does the currently known pathophysiology fully explain the symptoms of RA, SLE, mul­tiple sclerosis, or Alzheimer's disease-to give just a few examples? If the pathophysiology of these diseases fully explains resultant symp­toms, why is there continued research for a better understanding and better treatment of these diseases? I think the disease-illness di­chotomy creates and perpetrates a double stan­dard. As always, the patients are the innocent by­stander victims of the firefights between the physicians. The real practical problem of the disease-illness chasm is that those with cur­rently defined illnesses are relegated to the sta­tus of a second class citizen and are not taken seriously. In medical training programs, the residents and their attendings trivialize illnesses and consider them benign, "all in the head," less important, and less real than disease. How­ever, CSS conditions, even excluding depression, are associated with increased morbidity and even mortality (117). We victoriously cure the structural pathol­ogy in the hospital and send patients home with suffering. An additional factor for patient suffering is the "reformed" health care system where cost saving is the king and the patient a peasant. I think it is the loud distinction be­tween disease and illness, and an unabashed emphasis on the former that got medical prac­titioners in the scandal of being "non-caring" in the experience of many of our patients and in the eyes of the society. Barriers of insurance and "the system": Many, but not all, patients in the CSS spec­trum of diseases as well as others with struc­tural pathology take more time than usual for the proper management of their symptoms. Some physicians are willing to give the needed time, but are discouraged by a lack of proper reimbursement by the insurance system. Pa­tients receiving a comprehensive, individual­ized care that addresses all the components of problems do significantly better than those having usual care (118). The non-autonomous system of medical practice we have today has put much stress on the physician and physician time because of much unnecessary paper work, bureaucracy, reduced reimbursement resulting in shortened patient contact, and shift of control from phy­sicians to the third party payers. Thus, many caring and non-judgmental physicians who want to treat their patients according to the Oath can not do so because of the hostile and harassing environment in which they must practice. It is time for physicians to speak in one voice and work with the health management, insurance establishment, and government organizations to ensure that patients are not the ultimate los­ers. Addressing the causes of suffering: From the above discussion, it is understood that both structural and NCE pathology along with psy­chosocial burden that may accompany them can cause human suffering. Thus, one needs to treat the underlying structural pathology of RA or SLE, as well as the NCE pathology of an accompanying disease, e.g., fibromyalgia syndrome, that is known to be associated with both conditions (119-122). Treatment of RA and SLE alone, in the example above, will not adequately relieve the pain or fatigue unless the concomitant NCE pathology is addressed by, for example, prescribing centrally acting drugs [e.g., amitriptyline, cyclobenzaprine, and! or tramadol] as well as patient education and support. Must a rheumatologist "dichotomize" a patient with both systemic lupus [or RA] as well as fibromyalgia syndrome and send one half to a fibromyalgia specialist and keep the other [lupus or RA] half? In terms of causative factor[s], most dis­eases emanate from multiple factors, which vary from patient to patient. Putting all pa­tients in the Procrustean bed does not work. A person/patient-focused approach has been ap­propriately emphasized (29,46,63,65,118). Listening and empathizing: Many physi­cians treat their patients with paternalism and are pretentious in their interaction with them. Compassion has been replaced by egregious disrespect. Recently, I observed an internist talking to a sick patient with one of his shoes haughtily planted on the patient's bed [he must have thought he had special germ-free shoes!]. The patient happened to be a close family member. He expressed his utter bitterness with such arrogance of a physician. Ten weeks later the patient died. A well-known academic physician with se­vere ankylosing spondylitis, coronary artery disease, and renal carcinoma expressed his de­plorable experience with his physicians (123). He described the treating physicians' impa­tience, insensitivity, poor communication skills, refusal to listen, and an "I know it all," attitude which apparently led to poor decisions. His is a troublesome account to read. I suspect that non-physician patients may have to endure worse attitudinal bahaviors. Treating struc­tural pathology alone does not cure the pa­tient. Careful listening without interruption not only illuminates a better understanding of var­ious symptoms, but also can disclose details about problems that have special meaning to a particular patient. A physician can miss an im­portant concern by not being an active listener. Once I saw a 68-year-old woman whose RA was active, but instead of focusing on her joint problems, she talked about her children who did not seem to care. I advised her to talk about this openly with them, and then try to accept the reality. This seemed to work, as she was less bitter about her children on the next visit. Schneiderman (124) eloquently describes a similar example of a male patient with conges­tive heart failure who repeatedly focused on his own inability to take care of his apricot trees. Giving undivided attention and empa­thizing with the patient are by themselves ther­apeutic. So, what is empathy and can it be taught? A well-written pithy essay by Howard Spiro (10) on this topic is worth reading. Spiro states that empathy is evident when I and you becomes I am you, or at least I may be you. Simply and proverbially speaking, empathy is putting one­self in a patient's shoes. Can it be taught? In a phenomenological study, Raingruber and Kent (125) subjected students and faculty of a nurs­ing school to real life traumatic experiences: a bloody crush injury; the helpless moaning of a teenage girl who lost her child; the terror in the eyes of a little boy with multiple fractures from the daily abuse and violence by his father; and a dying patient's last hour or minutes. All the participants later described overwhelming bodily sensations, such as sick stomach, and distress of sudden onset. They described trou­bling perceptions of suffering in their own mind through patients' descriptions and non­vocalized expressions, and developed a great desire to help them. The authors state that the embodied responses of the participants after such encounters help them to understand hu­man suffering at a personal level and to de­velop a feeling of empathy. Empathy can be trained by taking patient history with sensitiv­ity, focusing on all problems, including implied ones, and having a kind attitude and patience with all patients irrespective of pathology, so­cial standing, religion or ethnicity. It can be developed, says Spiro (10), through narratives of human life and its difficulties that are well expressed through paintings, stories, novels, and literature in general. I agree. The problem of physician arrogance and apathy cannot be solved unless we attack the root cause that has its inception in the early years of medical school or perhaps even be­fore that. This trait should be considered, along with academic achievement, in the process of choosing future medical students. Many can­didates may be brilliant in their science knowl­edge but would not make good physicians be- cause they lack genuine caring and compas­sion. However, this does not imply that we should accept a student who lacks a strong sci­ence aptitude. Both science and beneficence are important. Every medical school in the country must teach science [with structural as well as NCE pathology] and humanities with equal emphasis [although equal emphasis does not translate into equal time], so that a future physician is scientifically adroit and also learns to be kind, humble, sensitive, attentive, and re­spectful to a patient's complaints and con­cerns. Medical students should be emphati­cally taught that a patient's suffering lies not only in what is currently known as classical or organic pathology, but also in NCE pathology, both of which are interactive, and both may contain psychosocial elements. Such a goal can be met by implementing relevant courses, and more importantly, through inculcation by the physician teachers who themselves prac­tice medicine with gentleness, humility, and humanity in their daily practice, as advised by Charaka and Hippocrates. Finally, can we measure empathy and com­passion to assess these qualities in our resi­dents and medical students? Imperfect as such evaluation may be, I think it can and should be done. First, the evaluating faculty must al­ready possess these humane attributes. Empa­thy and compassion are hard to define, but one can spot it when it is seen. After all, we sponta­neously recognize kindness or malfeasance in other people. The role of literature: Once a responsible individual in an academic center asked me if writing prose and poetry was part of my job. Such an incredible inquiry epitomizes the ig­norance of many regarding an intertwined re­lationship between literature, medicine, and humanism. It should surprise no one to learn that a large number of physicians are also nov­elists, poets, philosophers, essayists, and short story writers. Past and present physician writ­ers include Oliver Wendell Homes, John Keats, William Carlos Williams, Sir Arthur Conan Doyle, Lewis Thomas, LJ. Schneiderman, John Stone, and Abraham Verghese. Several articles have discussed the relation­ship between medicine and literature, making a cogent case for teaching the latter to our stu­dents and residents (126-128). Literature reflects life as lived and experienced. Human sufferings, happiness, agonies, and death ex­periences echo in the pages of prose and po­etry. Reading literature helps us to understand these phenomena where a skilful writer makes the characters all too real and we laugh or cry with them. A good and commonly cited exam­ple is Tolstoy's Ivan Illych, a character who suffers relentless mental agony and pain be­cause his inability to extricate himself from dependence on others is destroying his self­autonomy. Illinois poet Lucia Getsi describes in "Intensive Care" her experience of profound love and sorrow for a daughter who was going through the uncertainty of life in an intensive care unit (129). The poems in this volume move us poignantly and make us empathize with the poet's torment as a mother. Every medical in­stitution should have a forum for literature, music, and art, and offer a course in these areas following the model of Schneiderman (124). Understanding human experiences through literature help us to take a good medical his­tory with sensitivity. Both history taking and literature are based on narratives. They help us to feel and describe an event in a more humane way that touches us, the listener or the reader. Plants, placebo and prayer: Through our inherent bias as physicians, complementary and alternative medicine [CAM] has simply come to mean quackery. In my recent critical review of CAM in FMS (130), I found that there is good evidence for the efficacy of electro­acupuncture (131), hypnotherapy (132), static magnetic therapy (133), S-adenosylmethionine [SAMe] (134,135), and many more are being properly investigated. Even if there is a pla­cebo effect of some of the products, does it matter if the patient feels better, provided the product is safe and not too expensive? I am not, of course, saying that we should abandon EBM, but I do maintain that data do not have a veto power. P values with the magic numbers of statistical significance do not tell us every­thing about patient care in a real world. P val­ues and human values are not the same thing. Many patients have tried endless mainstream pharmacologic products, only to be harassed by adverse reactions that compounded the suf­fering. They feel betrayed by the mainstream medical system, complete with the hostile atti­tude of their physicians. Can we quarrel with a patient who says she feels much better and functions better by taking a safe and moni­tored CAM therapy? Who are we to excoriate such a patient? Prayer and spirituality have been found to be useful (136-139). Although good control studies are lacking, can we ask patients to abandon their faith if that's where they find solace, healing and strength? A large number of patients believe in the power of prayer in healing. The important thing is to make sure that a patient does not depend on these mea­sures alone, but takes appropriate medications as indicated, and does not harm themselves. Faith is a personal matter and we should re­spect every patient's individual beliefs, irre­spective of our own. Remember, non-faith is also a faith, since both are based on the same belief system. However, our role is not to ser­monize or proselytize. The caveat: The ultimate responsibility of a physician is to heal without causing harm, as Hippocrates emphasized primum non nocere. Empathy and psychological support do not mean handholding and crying with a patient. It means telling a sufferer, irrespective of the type of pathology, that the physician is empa­thetic with his or her pain and suffering. The physician needs to reassure the patient that the suffering is real and based on a genuine pa­thology. Looking at the past when SLE was thought to be a psychiatric illness, one can pre­dict that a time may come when the research­ers will have a much better understanding of the CSS conditions based on NCE or struc­tural pathology [both being connected by biol­ogy], and will develop more effective drugs for these conditions. A patient should under­stand that his or her emotional stresses, irre­spective of the type of pathology, need to be addressed, since they may aggravate symp­toms and influence outcomes of diseases, in­cluding those with structural pathology (55,56). Aspects of management of emotional distress, if present, involve restructuring of thoughts and state of mind, changing behavior, and as­suming self-responsibility. The goal is to achieve functional independence and emotional and corporal well being. The physician should play the role of a caring, understanding and super­vising coach. In this capacity, the physician must guide the patient to accept that the ball is in his/her own court, and learn how to play it with a positive attitude. The physician should help the patients to help themselves, encour­age function and discourage disability. A few patients do deserve disability. However, the issue of disability is a separate topic and be­yond the scope of this essay. In summary, this discourse emphasizes the need for a physician to be both a scientist [with its broader definition] and a humanist. These humane qualities need to be taught and incul­cated from the very beginning in medical school and throughout the residency program. Charakan and Hippocratic oaths should be the burning flame to guide the professional mis­sion of young physicians. Suffering cannot be allayed unless we deal with the whole person. Our obsession with the old paradigm of sci­ence that deals only with structural pathology, and a distinction between disease and illness has been among the most destructive forces of our time in shaping the pejorative and reckless physician attitude towards patients. Disease­illness dualism has reinforced this attitude and such an outmoded paradigm should be aban­doned. In recent years, it has become clear that CSS conditions are based on demonstrable pathophysiology that promises to be deciphered better with continued and committed research. Referring to the epigraph of this article, many physicians are undermining, knowingly or un­knowingly, the very reason for the existence of our profession. Some are the renegades of the sacred Oath, and have embraced a destruc­tive faith of CSS bashing. I implore upon them to become "born again" physicians and retake their badge of honor as a true devotee of the Oath. Followers of the oaths will truly enjoy the profession of medicine, as Hippocrates said, "where there is love of man, there is also the love of the art." (140). We need a national debate on the quintessence of the medical pro­fession and to embark on major reforms be­fore it is too late. REFERENCES 1. Yunus MB: Research in fibromyalgia and myo­fascial pain syndromes: current status, problems and fu­ture directions. J Musculoskeletal Pain 1: 23-4,1993. 2. Cassell EJ: The Nature of Suffering. Oxford Uni­versity Press, Oxford, 1991. 3. Depressed? 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