Did you ever have a teacher who changed your course of your life? Someone whose habits, actions, insights and integrity made you want to follow in their footsteps? Members of Dell Medical School share personal stories of profound influencers in this blog series.
I started doing research as a medical student and loved the idea of identifying gaps in knowledge and adding useful evidence. That interest brought me to national meetings, starting as a junior resident. I remember sitting in on a symposium about workers’ compensation at the annual meeting of the American Society for Surgery of the Hand. There were energetic debates about whether specific hand uses could damage the hand and about mitigation tactics. The word used to describe those mitigation tactics was “ergonomics.” As I followed the debate, it became clear to me that this was more religion (belief) than science. It was eye-opening to see a science-based profession focus so intensely — and, in my view, waste so much time — on the persuasiveness of different belief systems.
The following year, the president of the American Society for Surgery of the Hand and host of the national meeting was one of the co-chairs of the workers’ compensation course I had attended. His presidential guest speaker was Dr. Arthur Barsky, a psychiatrist from Brigham and Women’s Hospital and Harvard Medical School, and an expert in functional somatic syndromes. That was his term for illnesses characterized by notable symptoms without detectable pathophysiology. From the podium in a large venue, Dr. Barsky advised hand surgeons on how to best guide people with somatoform disorders.
What I remember most is a surgeon who came to the audience microphone to ask a question: “Why can’t I tell them there’s nothing wrong?” Dr. Barsky’s sharp answer was, “Because you’d be wrong.” That moment marked the start of my awareness of the biopsychosocial paradigm of human illness behavior. Illness is the state of being unwell. As Dr. Barsky was pointing out, human illness does not require that some part of the body be damaged or degenerated. Human illness can exist without any detectable pathophysiology. The idea that people with illness but without detectable pathophysiology have “nothing wrong with them” represents misdiagnosis, underdiagnosis and undertreatment. Conversely, focusing health and care primarily on aspects of pathophysiology — rather than on a person’s inner narrative about their body and its sensations — often leads to overdiagnosis and overtreatment of pathophysiology, including, in many cases, the pathophysiologies of normal human aging.
“Because you’d be wrong” was the spark that opened my eyes to entire lines of evidence that are often disregarded by surgeons. Over time, others helped me understand how to measure thoughts and feelings about bodily sensations, alongside emerging measures of illness. What we found was that levels of musculoskeletal discomfort and incapability were explained not by the severity of pathophysiology — such as the degree of arthritis on a radiograph or limitation of motion — which showed only modest correlation. Instead, the associations with one’s inner narrative about the sensations caused by that pathophysiology were much stronger and more consistent. A large part of my journey in academic orthopedic surgery has been an effort to discover ways for surgeons to think and talk about this evidence without feeling threatened or devalued in their work.
After more than a decade, I overcame my introversion, reached out to Dr. Barsky, and visited him in the city where we both worked. He was gracious, supportive and collaborative. We wrote several pieces together, and he helped guide me toward more accurate and effective ways of expressing these concepts. I sometimes wonder what my career in hand surgery would have been like if there had not been a Dean Louis to interject unfamiliar — and sometimes unwelcome — topics into hand surgery discourse, and an Arthur Barsky to elaborate on the evidence that human illness is far more than pathophysiology.