I’d never really thought about how to respond in an ethically sound and humane way to a demand for medical treatment for a “non-medical problem”. The situation is very common, with Jane the extreme example. Take the 68-year-old woman who has experienced an intense and sleep-disruptive burning in her breasts since the death of her husband. Or the young man with a paralysed leg and tingling lips. They have each seen a number of specialists, all the tests are normal, but the patients feel real symptoms in their bodies. Do I reassure and dismiss? Recommend a psychiatrist the patient will not accept? We tend to split our understanding down a Cartesian line: it’s all in your body (but we just don’t know where yet), or it’s all in your mind (but you just don’t accept that yet). If belief in a sugar pill – or in your physician – can lower your blood pressure, your heart rate, or make your brain produce extra dopamine, when words can alter physiology, this famous line must be like the Milky Way: vast and shattered and spread. Where’s the book that bridges Harrison’s Principles of Internal Medicine (the physician’s bible) and the latest Diagnostic and Statistical Manual of Mental Disorders?
“I know you think there’s something terribly wrong with your body.” Mike puts his hand on Jane’s forearm and squeezes. “I believe you, but you have to believe me: we’ve looked and we can’t find it.” She turns to him, the first time I have seen her eyes in the light. They are the palest blue. “And I’m scared that if we keep looking we’re going to cause you real harm.”
Jane closes her eyes and lies back on the pillow: “I understand.”
Mike squeezes her arm again. “We’ve got some work to do, my friend,” he says.
Medicine and the Mind–Body Problem
I was recently asked to give a presentation about “what makes us sick”. Thinking about that question nearly made my head explode. It’s more like, “What doesn’t make us sick?”
My big inner-city hospital is overflowing with the sick. There are people who are in the orthopaedic ward because they got up for a glass of water and snapped their hip. The psychiatry ward is full of near suicides and patients whose phantom voices are drilling holes in their heads. The cardiac lab is full of heart attacks. The burns unit usually has one or two people a year who tipped a bucket of petrol over their head and struck a match. We house the frail and the elderly, the drunken and the overdosed. Organs are plucked from the brain-dead and sewn into the diseased. People crowd the emergency department, suffering because their organs are slowly failing their bodies. What made them sick? What is sickness, anyway?
Besides looking after inpatients, I also work in three public outpatient clinics at the hospital. One is for patients – mostly elderly – who have multiple health problems. Another clinic is for the morbidly obese, and the third is a fatigue clinic.
A doctor’s job is to treat and protect diseased and threatened organs – those beautiful, intricate, faithful organs that pump and squeeze and metabolise away, mostly quietly, keeping us alive. Sick organs. Just treat them, doc, and go home. How hard can it be? But doctors don’t sit in their chairs facing livers and hearts. We encounter complex, conflicted, imperfect, suffering people with their specific histories, needs, cultures and understandings of sickness and health.
Being alive has its difficulties. Even for those who are relatively wealthy, with access to all the physical necessities, living demands payment of an existential debt. We live with the knowledge that we are going to die. We suffer unbearable losses. We hurt in all sorts of ways. And because we are alive, we do things that damage our bodies and make us sick. I have had patients who can barely breathe because of their lung disease tell me they cannot quit smoking as it’s their only friend. We smoke, we drink, we overeat. We engage in all manner of risky activities, trading aliquots of our life in exchange for things that give us pleasure or make life bearable.
A registrar once told me that her PhD topic was the appetite of rats. The results, she claimed, were applicable to humans. “Their brains are almost exactly the same as humans’!” I looked around our ward. In medical research we are rats, we are robots, we are a bunch of organs bound by skin. We have no mind, no unconscious. We have no dreams or hopes or existential pain.
But we are more than organs bound by skin. We are more than rats in cages. We have gigantic mental lives – conscious and unconscious. We each bear our sickness in our particular way. Suffering, for each person, has different meanings and manifestations. Most of the patients who come to the fatigue clinic have been seen by many, many doctors. They’ve had every part of their bodies probed, scoped and scanned. They’ve been cupped, pricked, starved, and infused with harmful megavitamins. They have pain, fatigue, paralysis. They can’t get out of bed. They’ve abandoned their dreams because they are sick. But they are not “clinically depressed”. And their organs are intact, pristine.
“But, doctor, there is something wrong with my body and no one can find what it is.” Approximately 30 to 50 per cent of patients attending specialist clinics have symptoms that have no organic cause. That is, they are psychosomatic in origin, “all in their head”. In medicine we call these unexplained debilitating symptoms “functional”. The patient, we say, has a “functional” disorder.
Unfortunately, in medicine, in theory, in popular culture and society, we’ve disconnected the mind or psyche from the body and chucked the psyche part away. So if you are sick, the thing making you feel that way must be in there somewhere – a bug, an intolerance, a toxin, a lump of rot – and you go to see doctors who scan you and sample you and test you and find nothing. Your symptom is then labelled “functional” and you are sent home. A lot of terrible disability, sickness and wasted life remains untreated or maltreated because everyone – except that ever-dwindling enclave of psychoanalysts – has abandoned an understanding of the human being as more than robotic, more than animal, more than genes plus protein and water.
Modern psychiatry has reduced the wonders of our mental life to the mush of the brain. For treating the brain, the organ, is prestigious. Having something wrong with your body is prestigious, because the psyche’s been relegated to the bin. We have lost – in medicine and everywhere else – the understanding of the human as a complex, language-bound mix of consciousness and unconsciousness whose bodily suffering may have meanings and functions we cannot interpret via a blood test. We call these illnesses “functional” but have stopped questioning what exactly the “function” of them may be for the patient.
There’s an epidemic. We can’t name it or see it or treat it because we no longer have the language we’d need to do this. And so we can’t help these people. And so we hand out a barely-better-than-placebo antidepressant. We’ve let ourselves be reduced to lab rats. But don’t blame the doctor (though it’s evidently a fun sport), because the patients don’t want a psychoanalyst, they want a physical diagnosis and a pill. Don’t blame medicine, for it is all of us who have decided that dreams are debris, that a symptom generated “in your head” is merely counterfeit and that sickness is always caused by a thing.
The Art of the Body
When I started medical school, the hospital library had a collection of jars and perspex boxes containing preserved fleshy anomalies: gigantic bulbous kidneys, a lung with a galaxy of rot, an ovary fat with tumour. The jars lined the topmost shelves and I would wander the aisles, fascinated. One jar contained a tiny foetus all scrunched up like a purple and white fist, a chaos of teeth, skin and hair sprouting in the wrong places. At first, I would avert my eyes as I passed. After I read about fetiform teratomas – apparently the little thing was a tumour, not a baby – I’d take it down for a closer look, hardly believing that I had a right to stare.
I felt the same thing in the wet lab, a steel-lined room where pre-dissected body parts swam in enormous vats of formaldehyde. We’d drag out an arm, a leg, a torso-with-neck – all dripping and grey – and sling them onto steel trolleys. We’d prod and pull tendons to learn the names and attachments of the muscles, follow the great v
essels, run our fingers along the vasculature of a heart still clinging to its aorta.
Our lecturer in anatomical pathology was a short-tempered, scary man who was usually boiling with disgust at the degree of our ignorance. I remember only one of his lectures. He was standing beneath a massive projection of a microscope slice of sick kidney, pointing out the anomalous cells, when he turned to us and, with a kind of desperation, said, “Isn’t that just the most beautiful thing? I wanted to study art but did medicine and now this.” He raised his arms towards the kidney. “This is my job. I spend each day gazing at and interpreting aesthetically pleasing images. It’s virtually the same thing.”
I felt glad for him that he’d found a way to come to terms with his life choices. And the dots and lace of pink, purple and blue were pretty. But I was quite sure this mishap of human physiology, sliced and set and stained to protocol, all for the purpose of diagnosis, was not art.
I thought of him during a recent presentation on immunological disorders of the skin. The doctor showed slides stained with immunofluorescent markers, lit and magnified hundreds of times. The abnormal cells glowed green and the rest remained pitch-black, the particular pattern of green determining the diagnosis. They looked like photos of the northern lights. Throughout medical training you get good at recognising which information you definitely need to memorise, or vaguely retain, or let gently go. “The light gleams an instant, then it’s night once more,” wrote Beckett. I sat there wondering if I’d ever see the northern lights, and the disease classifications drifted by.
I had actually studied art history for a few years, inoculating myself against the pathologist’s kind of regret by discovering I wasn’t any good at it. I could never fully erase the aesthetic forged during my youth in an Arkley-esque suburb where the highest forms of art were twelve-dollar Chinese landscapes, handpainted in front of your eyes at Sunshine Plaza, and the animals Dad shot, stuffed and then hung on our walls.
Animals were originally preserved for science, to classify and order, by men like Darwin and Banks. Later they became signifiers of wealth and power for aristocrats, then the bourgeoisie, then those in the classes below. In the past few decades, galleries have embraced the form: animals, as well as the closest things to human taxidermy outside of hospitals and wet labs. In the gallery, human remains are preserved, refashioned and elevated. Our bodies are spun into dreams; animals are stuffed with ideas. Every five years British artist Marc Quinn uses 9 pints of his own frozen blood to sculpt a self-portrait bust. Damien Hirst’s shark is suspended in a gigantic tank of formaldehyde and titled The Physical Impossibility of Death in the Mind of Someone Living. Melbourne artist Julia deVille’s baby goat, encrusted with pearls, graces a silver platter. We are chaotically, painfully alive, and we are dying.
Hobart’s MONA is full to bursting with lived and imagined bodies, and last month I took my young daughters. There were two exhibits I particularly wanted to show them: the poo machine (Wim Delvoye’s Cloaca Professional) and the wall of 151 porcelain vaginas (Greg Taylor’s Cunts … and Other Conversations). These two works say more than any textbook could about our bodies. I wanted them to see that it takes a gigantic, stinking machine to perform the most rudimentary part of a task your body carries out within your tiny abdomen. And that what we insist they hide and wash and don’t touch too much is neither uniform nor hideous nor disgusting.
There are certain undeniable facts about the anatomy and physiology of bodies you dutifully memorise in medical school. And then there is the lived body, the imagined body, where those facts verge on irrelevancy. A beautiful girl on my ward considers food in her stomach an invasion. A football player faints at the prick of a needle. One of the most effective treatments for pain in a phantom limb is to set up a mirror that reflects the intact limb in the place of the one lost. Living – too fleetingly – with, through, in your imagined body: science doesn’t tell this story.
I have an old box that contains a slowly disintegrating skeleton, bequeathed to me years ago by a retired doctor who thought medical students still had to memorise each nook and cranny of the 206 bones that reinforce our sack of skin. I took the box down, wondering if I should display them. I could string them together so they hang like a ghoul. One of my daughters asked in horror, “Is that a real person?” I stared at the tangle of brittle yellow sticks. Yes. And no.
Sick Day
I once slipped while running on a treadmill. It was eight years ago, but I still clearly remember the sickening feeling of my right foot gliding backwards instead of connecting with the belt. I landed palms, shins and knees on a strip of rubber that continued to rotate at 12 kilometres an hour, taking my skin with it. I fell to the side, surveyed my energetic bleeding and the pink patches that would soon bloom deep purple. I started to cry, not in pain but in anger: at the machine, my stride, my runners, but most of all because I couldn’t keep running. The next morning I stood at the side of the pool, my legs plastered in bandages, asking my coach if he thought my ruptured skin posed an infection risk to the rest of the squad if I was allowed in. One of the guys from my lane looked up and said, “I wish I got cut up like that. It’d be a good excuse to have a week off training.” We weren’t professional athletes. We were engaged in a voluntary (albeit slightly mad) activity (training for ironman). If we didn’t turn up, no one would give a damn. For whom did he need a sick note?
I thought of him last week as I developed a head cold. You know how it announces itself: first your throat gets prickly, then it hurts to swallow and your cervical lymph nodes swell up like ripening plums. Throughout the day the virus spread its havoc. Heavy head, aching limbs, blocked ears, litres of snot. I ran through the things I had on for the rest of the week and thought, Good. It’d been a while since I’d spent three days drinking sweet tea, in my pyjamas, in bed. I went home, made a few calls, swallowed two paracetamol and picked up a novel.
So the next morning I was lying in bed thinking that as long as there was milk in the fridge, analgesics in the cupboard and a babysitter to get my girls from school, I’d be happy to do this sick thing for a while. I was thinking, Why do I really do all the things I would have been doing had I not inadvertently inhaled some no-name airborne virus? One needs money, of course, and for most of us that means we must work. But there are many other drivers that fuel our activities in the world. In countries that offer a guaranteed income to all of their citizens, the entire population doesn’t down tools and take to their beds. Outside of doing enough to ensure our basic material needs are fulfilled, it’s a grab bag of imaginary stuff that fuels our work. That night I watched a recording of American stand-up comedian Ali Wong. She was heavily pregnant. Mid-show she said, “I think feminism is the worst thing that ever happened to women. Our job used to be no job.” I laughed so hard I almost choked.
I’ve heard it said that the alcoholic drinks hard not for the pleasure, abandonment or oblivion it brings them, but for the depression they’ll suffer the following day. The enforced downtime. Getting sick in a temporary, non-life-threatening way offers us the opportunity to pause, to reflect, to assess what the hell it is we’ve been doing and wonder why. Flung off the treadmill, lying broken, do you look at its incessant rotation in horror, or in desire?
Athletes often have a potent and complex relationship with their coach. Nothing fuels hard work as effectively as love can. But the coach is as much a fantasy as a real person, and has to pull their charges back as often as push them. I no longer have a coach, but were I to fall running today it would be in a park, and I’d let my skin heal before soaking it in chlorine or sweating in some absurd display of dedication to an indifferent audience.
Getting sick has its advantages: time off work, the presence of doting loved ones, fiscal compensation, identity solidification, sympathy, attention – the list is endless. In medicine these advantages are called “secondary gains”. Sometimes illness is all about secondary gain. There are people who pretend they’re sick in order to garner these benefi
ts. Sometimes – through some trick of the mind – they actually do experience symptoms of illness although their body is perfectly well and should function smoothly. Push yourself (or be pushed) long and hard enough, without reflection or any way out, and the sickbed might feel like bliss, the thought of leaving it seem terrifying and you may not be able to haul yourself out. Sometimes, being sick may be your only escape.
I once saw a young man who’d been tired for a few months and had been sent to my clinic because his GP had failed to find a clear cause. I flicked through his old medical notes before I called him in. He was a retired competitive sprinter and had been heavily investigated a few years back for an unusual symptom: as he crossed the finish line at the end of each race (races he often won), he’d pass out cold. He’d had every cardiac, respiratory and neurological test known to medicine and the conclusions were consistent with what anyone’s eyes could see: he was a fine-tuned Formula 1 machine. The specialists were stumped. It was either that (unlike all other human beings) he didn’t stop before he surpassed his physiological limits, or the pass out was psychosomatic. A trick of the mind. An unspoken internal protest that this racing business was intolerable. Although no pathology had been detected, one of the cardiologists’ letters contained a recommendation that he stop running, given the risk of serious head injury. I brought him in. He shrugged when I asked him about the end of his running career. Nope, he didn’t really care. And neither did his father, who had been his coach.
Performance Check-up
Christmas Day, early morning, and I’m walking deserted streets to my PO box to collect a few weeks of mail. I was in my first year as a fully qualified specialist, working in a large city hospital, and I was neither on call nor responsible for any patient on any ward. So unburdened did I feel at that moment that I may have been humming an off-key carol. The first year is the toughest: eye-squinting anxiety by day, phone calls at midnight kicking your heart up into your throat. But here was a day off, my only responsibility to boil the hell out of a drunken pudding. I flicked through the envelopes. Among the pile was a letter – Important Confidential – from the medical board. Maybe I’d forgotten to pay my registration. I opened it and kissed goodbye to any peace, joy or pudding the sunny day had promised.
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