by Atul Gawande
By contrast, one thing that has been shown is that human beings commonly imagine patterns (whether good or bad) where really there are none. It’s just how our brains work. Even totally random patterns will often appear non-random to us. The statistician William Feller described one now classic example. During the Germans’ intensive bombing of South London in the Second World War, a few areas were hit many times over while some others were not hit at all. The places that were not hit seemed to have been deliberately spared, and people concluded that those places were where the Germans had their spies. When Feller analyzed the statistics of the bomb hits, however, he found that the distribution was purely random.
This propensity to see nonexistent patterns has been called the Texas-sharpshooter fallacy. Like a Texas sharpshooter who shoots at the side of a barn and then draws a bull’s-eye around the bullet holes, we tend to notice unusual occurrences first—four bad things happening on one day, for example—and then define a pattern around them. It seems to me we could just as well have feared Thursday the thirteenth, or Friday the fifth, as Friday the thirteenth. Nonetheless, phobia about Friday the thirteenth is widespread. Based on surveys, Donald Dossey, a North Carolina behavioral scientist, estimates that between seventeen million and twenty-one million Americans suffer mild to severe anxiety or change their activities because of paraskevidekatriaphobia (which is Greek for “fear of Friday the thirteenth”). They perform rituals before leaving the house, call in sick to work, or postpone flights or major purchases, causing businesses to lose seven hundred and fifty million dollars annually.
Superstitions about the moon appear to be taken even more seriously. A 1995 poll found that 43 percent of Americans believed that the moon alters individual behavior. And, interestingly, mental health professionals were more likely to believe it than people in other lines of work. The full moon has been thought to be linked to madness for centuries—hence the term “lunatic”—and in disparate civilizations across the world. Certainly, the idea of lunar human cycles seems more plausible than a Friday-the-thirteenth effect. Scientists once dismissed the idea of biological cycles, but now widely accept that season can affect mood and behavior and that we all have “circadian rhythms” in which time of day affects body temperature, alertness, memory, and mood.
In a computer search, I managed to find some one hundred studies that attempted to identify “circalunidian” cycles. The most intriguing one I looked up was a five-year study of self-poisoning at a hospital in New South Wales, Australia, published in the Medical Journal of Australia. From 1988 to 1993, the hospital admitted 2,215 patients for overdosing on drugs or poisoning themselves with toxic substances. The researchers checked to see whether peaks in such events occurred not just according to the phase of the moon but also according to one’s zodiac sign or numerological readings (as “calculated according to the formulas contained in Zolar’s Encyclopedia of Ancient and Forbidden Knowledge,” the authors reported). To no one’s surprise, self-poisoning rates were not affected by whether a patient was born a Virgo or a Libra. Nor did Zolar’s “Name Number,” “Month Number,” or “Birth Path Number” for a person make any difference. However, women (but not men) were about 25 percent less likely to overdose around the time of a full moon than around a new moon.
Strangely enough, this decrease in self-poisonings actually correlated with the results of other studies. If any link between psychology and the full moon exists, it would seem to be protective. The authors of a 1996 study of ten years of suicides in the Dordogne region of France concluded, in charmingly ungrammatical English, that “the French dies less in Full Moon, and more in New Moon period.” Studies in Cuyahoga County, Ohio, and Dade County, Florida, also found a drop in suicides at the full moon. These studies didn’t quite clinch the full moon’s happy effect, however. Far more studies failed to find any lunar correlation with suicide.
As for other forms of craziness, the moon seems to play no role. Researchers have reviewed logs for calls to police stations, consultations to psychiatrists, homicides, and other records of our daily burden of madness—including, I noticed, emergency room visits. They found no consistent relationship, one way or another, with the moon.
Reassured by this, I was finally able to leave the library convinced that neither the full moon nor the inauspicious date threatened my night on call. A couple of weeks later the appointed evening arrived. I walked into the ER at 6 P.M. sharp to take over from the daytime resident. To my dismay, he was already swamped with patients for me to see. Then, just as soon as I began to get caught up, a fresh trauma came in—a pale and bloodied twenty-eight-year-old knocked unconscious in a high-speed head-on collision. The police and paramedics said he had been stalking his girlfriend with a gun in hand. The cops then arrived and he fled in his car, leading them on a chase that ended in the massive crash.
The rest of the night went no better. I was, as we say, “slammed”—running hard, unable to get two minutes to sit down, hardly able to keep the patients straight.
“It’s full moon Friday the thirteenth,” a nurse explained.
I was about to say that, actually, the studies show no connection. But my pager went off before I could get the words out of my mouth. I had a new trauma coming in.
The Pain Perplex
Every pain has a story, and the story of Rowland Scott Quinlan’s goes back to an accident that happened years ago, when he was fifty-six. A Boston architect and avid sailor with a shock of white hair and a predilection for bow ties and Dutch cigarillos, Quinlan headed a thriving Beacon Street firm in his name and had designed such buildings as the University of Massachusetts Medical School. Then, in March of 1988, he fell off a plank at the construction site of one of his commissions—a pavilion at the Franklin Park Zoo. His back was fine, but he dislocated and fractured his left shoulder, and it required several operations. In the fall, he returned to his drafting table, and there he was hit by a spasm of pain like a writhing snake in his back. The attacks recurred, and although at first he tried to ignore them, they soon became unbearable. More than once, while he was standing with a client the back pain suddenly burst forth and it was all he could do to keep from crying out while the client caught him and helped him to a seat or to the floor. Sitting in a restaurant with a colleague, he was overcome by pain so severe that he vomited right there at the table. Soon he wasn’t able to work more than two or three hours a day, and he had to give up the firm to his partners.
Quinlan’s orthopedist had taken numerous X rays. They revealed little—perhaps a bit of arthritis, but nothing out of the ordinary. So Quinlan was sent to a pain specialist, who injected a long-needle syringe full of steroids and local anesthetic into his spine. The first few of these epidural injections worked for days, sometimes weeks, but subsequent shots provided steadily diminishing relief, until they didn’t work at all.
I had seen his CT scans along with a sheaf of other tests and medical images. Nothing in them would have led me to expect the severity of his back pain: there was no fracture, no tumor, no infection, not even a sign of arthritic inflammation. The vertebrae were aligned perfectly, like checkers in a stack. None of the soft gel-like disks that sit like cushions between the vertebrae had ruptured. In the lower back, the lumbar spine, two disks bulged a bit, but that is common in men of his age, and the bulges didn’t seem to be pressing against any nerves. Even an intern could see that there was no cause for operating on this back.
When doctors encounter a patient who has chronic pain without physical findings to account for it—and such patients are exceedingly common—we tend to be dismissive. We believe the world to be decipherable and logical, to come with problems we can see or feel or at least measure with some machine. So a pain like Quinlan’s, we’re apt to conclude, is all in the head: not a physical pain but a different, somehow less real, “mental” pain. In fact, Quinlan’s orthopedist recommended that he see a psychiatrist as well as a physical therapist.
When I visited Quinlan at his home, in a se
aside town outside Boston, I found him at what turned out to be his usual perch: a worktable in the kitchen facing a wall-length window with a view of a small garden. Blueprints of unfinished projects were curled up in rolls on the table. A telephone headset lay to one side. A dozen different kinds of drawing pens, along with small rulers and a protractor, sat in a holder. He grimaced as he rose to greet me. I thought about his thorough medical workup and those clean images of his spine: Was he faking it?
When I asked him, he smiled wanly, and told me he sometimes wondered that himself. “I’ve got it pretty cushy here,” he said. Quinlan has handicap license plates, financial security, and none of the pressures of running a business, and if he doesn’t want to do something he merely has to say his back is killing him. But, despite a patch on his arm that infuses high doses of the narcotic fentanyl through his skin twenty-four hours a day, he can’t do even the simplest thing—stand in a line, walk up stairs, or even sleep more than four hours at a stretch—without the acute sensation that, as he puts it, “someone is wringing out a muscle in my back.”
I asked his wife, a tall woman several years younger than him with fine features and sad eyes, if she ever thought he fakes the pain. She told me that day in and day out for a decade now she has seen the pain and lived with the increasing limits it places on his life and hers. She has seen the pain defeat him in ways that she knows he is too proud to fake. He’ll try to carry the groceries, and then, shamefaced, have to hand them back a few moments later. Though he loves movies, they have not been to the cinema in years. There have been times when the pain of movement has been so severe that he has soiled his pants rather than make his way to the bathroom.
Yet there are aspects of the pain that puzzle her and make her wonder whether it is in some respects in his head. She notices that when he is anxious or irritable, the pain is worse, and that when he is in a good mood or is simply distracted, the pain can disappear. He has bouts of depression which seem to bring on terrible spasms almost regardless of what he is doing physically. Like his physicians, she wonders how a pain can be so incapacitating yet arise from no identifiable physical abnormality. And what about the circumstances that tend to bring on an attack—a mood, a thought, sometimes nothing at all? These traits strike her as unusual, as needing explanation. But the disturbing truth is that Roland Scott Quinlan isn’t unusual. Among chronic pain sufferers, his case is altogether typical.
Dr. Edgar Ross, an anesthesiologist in his forties, is the director of the chronic-pain treatment center at Brigham and Women’s Hospital in Boston, where Quinlan is seen. Patients come to Dr. Ross with every imaginable kind of pain: back pain, neck pain, arthritic pain, total-body pain, neuropathic pain, AIDS-related pain, pelvic pain, chronic headaches, cancer pain, phantom-limb pain. Often, they have already seen numerous doctors and tried multiple therapies, including surgery, to no avail.
The center’s waiting room looks like any other doctor’s office. It has the flat blue carpet, the dated magazines, the row of expressionless patients sitting silently against the wall. A glass case displays thank-you letters. But when I visited Dr. Ross recently I noticed that the letters were not quite the typical testimonials that doctors like to put up. These patients did not thank the doctors for a cure. They thanked the doctors merely for taking their pain seriously—for believing in it. The truth is that doctors like me are grateful to the pain specialists, too. Though we want to be neutral in our feelings toward patients, we’ll admit among ourselves that chronic-pain patients are a source of frustration and annoyance: presenting a malady we can neither explain nor alleviate, they shake our claims to competence and authority. We’re all too happy to have someone like Dr. Ross to take these patients off our hands.
Ross led me into his office. Soft-spoken and unhurried, he has a soothing demeanor that fits perfectly with his line of work. Quinlan’s kind of problem, he told me, is the one he sees most frequently. Chronic back pain is now second only to the common cold as a cause of lost work time, and it accounts for some 40 percent of workers’ compensation payments. In fact, there is a virtual epidemic of back pain in this country today, and nobody can explain why. By convention, we think of it as a mechanical problem, the result of misplaced stress on the spine. We therefore have had some sixty years of workplace programs, and now there are even “back schools,” which teach the “correct way to lift,” among other things. Despite the fact that the number of people who engage in manual labor has steadily declined, however, more people have chronic back pain than have ever had it before.
The mechanical explanation is almost certainly wrong, Ross noted. It’s true that lifting something the wrong way can cause a muscle pull or a slipped disk. But that sort of strain occurs in almost everyone at some time, and in most people it never becomes a persistent problem. Scores of studies have looked for physical factors that can predict which acute back injuries will evolve into chronic back pain, but they haven’t found any. For instance, doctors used to assume that damaged disks were associated with pain, but recent findings have not borne this out. Spinal MRI scans show that most people without back pain have disk bulges. Conversely, a large percentage of patients with chronic back pain, like Quinlan, are found to have no structural lesion. And even among those with abnormalities there is no relation between the severity of the pain and the severity of the abnormalities.
If the condition of your back doesn’t predict whether you’ll get chronic back pain, what does? Well, it’s the mundane stuff that neither doctors nor patients much like to consider. Studies point to such “inorganic” factors as loneliness, involvement in litigation, receipt of workers’ compensation, and job dissatisfaction. Consider, for example, the epidemic of back pain in the medical profession itself. Disability insurers once saw doctors as ideal customers. Nothing stopped doctors from working—not years of stooping over operating tables, not arthritis, not even old age. Insurers used to try to outbid one another with cheap rates and generous benefits to attract their business. In the last few years, however, the number of doctors with disabling back or neck pain has risen dramatically. Needless to say, doctors aren’t suddenly being required to carry heavy packages around. But one known risk factor has been identified: with the growing role of managed care, job satisfaction in the medical profession has plunged.
The explanation of pain that has dominated much of medical history originated with Rene Descartes, more than three centuries ago. Descartes proposed that pain is a purely physical phenomenon—that tissue injury stimulates specific nerves that transmit an impulse to the brain, causing the mind to perceive pain. The phenomenon, he said, is like pulling on a rope to ring a bell in the brain. It is hard to overstate how ingrained this account has become. Twentieth-century research on pain has been devoted largely to the search for and discovery of pain-specific nerve fibers (now named A-delta and C fibers) and pathways. In everyday medicine, doctors see pain in Cartesian terms—as a physical process, a sign of tissue injury. We look for a ruptured disk, a fracture, an infection, or a tumor, and we try to fix what’s wrong.
The limitations of this mechanistic explanation, however, have been apparent for some time. During the Second World War, for example, Lieutenant Colonel Henry K. Beecher conducted a classic study of men with serious battlefield injuries. In the Cartesian view, the degree of injury ought to determine the degree of pain, rather like a dial controlling volume. Yet 58 percent of the men—men with compound fractures, gunshot wounds, torn limbs—reported only slight pain or no pain at all. Just 27 percent of the men felt enough pain to request pain medication, although such wounds routinely require narcotics in civilians. Clearly, something that was going on in their minds—Beecher thought they were overjoyed to have escaped alive from the battlefield—counteracted the signals sent by their injuries. Pain was becoming recognized as far more complex than a one-way transmission from injury to “ouch.”
In 1965, the Canadian psychologist Ronald Melzack and the British physiologist Patrick Wall proposed that
the Cartesian model be replaced with what they called the Gate-Control Theory of Pain. Melzack and Wall argued that before pain signals reach the brain they must first go through a gating mechanism in the spinal cord, which could ratchet them up or down. In some cases, this hypothetical gate could simply stop pain impulses from getting to the brain. In fact, researchers soon identified a gate for pain in a portion of the spinal cord called the dorsal horn. The theory explained such ordinary puzzles as why rubbing a painful foot makes it feel better. (The rubbing sends signals to the dorsal horn that close the gate to nearby pain impulses.)
Melzack and Wall’s most startling suggestion was that what controlled the gate was not just signals from sensory nerves but also emotions and other “output” from the brain. They were saying that pulling on the rope need not make the bell ring. The bell itself—the mind—could stop it. Their theory prompted a great deal of research into how factors such as mood, gender, and beliefs influence the experience of pain. In one study, for example, researchers measured pain threshold and tolerance levels in fifty-two dancers from a British ballet company and fifty-three university students using a standard method called the cold-pressor test. The test is ingeniously simple. (I tried it at home myself.) After immersing your hand in body-temperature water for two minutes to establish a baseline condition, you dunk your hand in a bowl of ice water and start a clock running. You mark the time when it begins to hurt: that is your pain threshold. Then you mark the time when it hurts too much to keep your hand in the water: that is your pain tolerance. The test is always stopped at a hundred and twenty seconds, to prevent injury.
The results were striking. On average, female students reported pain at sixteen seconds and pulled their hands out of the ice water at thirty-seven seconds. Female dancers went almost three times as long on both counts. Men in both groups had a higher threshold and tolerance for pain—as expected, since studies show women to be more sensitive than men to pain, except during the last few weeks of pregnancy—but the difference between male dancers and male nondancers was nearly as large. What explains the difference? Probably it has something to do with the psychology of ballet dancers—a group distinguished by self-discipline, physical fitness, and competitiveness, as well as by a high rate of chronic injury. Their driven personalities and competitive culture evidently inure them to pain: that’s why they are able to perform through sprains and stress fractures, and why half of all dancers develop long-term injuries. (Similar to other nondancing males, I started to feel pain at around twenty-five seconds; but I had no trouble keeping my hand in for the whole hundred and twenty seconds. I will let others speculate on what this says about the submissiveness inculcated in surgical residents.)