An Uncritical Approach to Behavioral Medicine

PsycCRITIQUES - An Uncritical Approach to Behavioral Medicine Page 1 of 4 PsycCRITIQUES February 9, 2011, Vol. 56, No. 6, Article 8 An Uncritical Approach to Behavioral Medicine A Review of Behavior and Medicine (5th ed.) by Danny Wedding and Margaret L. Stuber (Eds.) Cambridge, MA: Hogrefe, 2010. 351 pp. ISBN 978-0-88937-375-4. $59.00, paperback doi: 10.1037/a0022269 Reviewed by Stuart W. G. Derbyshire The major aim of Behavior and Medicine, now in its fifth edition, is to educate U.S. medical students and help them pass the behavioral science portion of the U.S. Medical Licensing Examination (USMLE). The Foreword includes a useful distinction of disease and illness: Disease is defined by pathological abnormalities of the normal function or structure of organs and cells, whereas illness is defined by the economic, cultural, and social abstractions of disease. Medics may prefer to confront disease, but they are forced to confront illness. Behavior and Medicine is an attempt to convince medical students that understanding human behavior and experience is critical to their future understanding and treatment of illness. The book includes discussion of several major themes that interlock and contrast: life transitions (including growing up, growing old, and dying) and the continuity of identity through those transitions; the interaction of behavior, such as smoking, diet, and exercise, with health outcomes; and the practical problems of delivering equitable and adequate health care. The book is divided into five major sections that tackle mind–body interactions, patient behavior, the physician’s role, physician–patient interactions, and social and cultural issues. Possibly the best chapter in the book is that by Howard Brody addressing the physician–patient relationship. Brody documents the various psychological mechanisms known to influence good patient outcome. These include the knowledge that treatment is being given with the expectation of improvement, the perception of being listened to, patient–physician agreement on the nature of the problem and treatment, and an acceptable meaning associated with the problem. As Brody explains, Benedetti and colleagues devised a new method for assessing the specific effects of drugs called the overt–covert or open–hidden paradigm (Colloca, Lopiano, Lanotte, & Benedetti, 2004). In this paradigm, all patients receive the active drug, but half the patients receive the drug openly and half the patients receive the drug covertly. Covert or hidden delivery is possible because postsurgical patients are typically fitted with an intravenous (IV) line connected to a computerized pump that delivers necessary drugs to the patient at intermittent periods. Fluid consistently flows through the IV such that the patient cannot know when the drug is being added unless he or she is explicitly informed. Not informing the patient that the drug is being added, therefore, means that the drug is being delivered covertly. http://psycnet.apa.org/index.cfm?fa=fulltext.printReview&uid=2011-00607-001&lang... 27/07/2011 PsycCRITIQUES - An Uncritical Approach to Behavioral Medicine Page 2 of 4 In Benedetti’s experiment, postsurgical patients either had morphine delivered covertly or observed a health worker directly inject the medication into the IV line while being told that they were receiving a painkiller that would soon take effect. The results were dramatic. Analgesic medication delivered openly provided about twice the pain relief of the same medication delivered covertly. Subsequent research has demonstrated that these effects of expectancy are naloxone reversible, indicating that the effects are mediated by the endogenous opioid system (Amanzio & Benedetti, 1999). The conditioned association of health workers, medical centers, and medical paraphernalia with pain relief, in contrast, is not naloxone reversible. The pain relief associated with conditioning is mediated by hormonal changes. Treatment effects are also enhanced by other mechanisms peripheral to the pharmacological action or other direct effects of intervention. Treatment provided by a warm, supportive, and attentive individual yields more positive outcomes than does the same treatment delivered by someone cold and impersonal. Patients who feel involved in their treatment and have a satisfactory understanding of their symptoms report a better sense of control over their illness and respond better to treatment. Brody nicely suggests that the right combinations of treatment delivery, physician concern, and patient involvement optimize activity of the patient’s “inner pharmacy” to provide benefits for patients and doctors. Given these facts, it is perhaps not surprising that Brody, consistent with the authors of most chapters in the book, advocates patient-centered medical care. Certainly it is difficult to argue with the suggestion that doctors should recognize their patients as human beings rather than as diseased specimens, but Brody fails to acknowledge any problems with a more patient-centered approach. One problem is the large amount of time that patient-centered medical care takes. Listening to the patient is only the beginning. Diagnoses often require elaborate description and education to communicate. Then there is the requirement to explore a range of treatment options, evaluating their respective merits. Reaching an understanding about the impact of the disease and treatment upon a patient’s life can be exhausting and is often impossible. Another problem is trying to decide what will help a given individual patient. Some patients value honesty, frankness, and directness, but others experience that as brutal and crass. Some patients value concern for their emotional well-being, but others perceive that as intrusive. In response to these difficulties, medical institutions and organizations produce lengthy guidelines and instructions that are burdensome, detract from other medical training, and often reduce to a series of check boxes that can be as impersonal as the brusque doctor they were meant to improve upon. The general lack of critique is a serious problem throughout the book. The chapter by Brenda Bursch on managing difficult patients, for example, offers the following advice: The key to working effectively with patients with functional disorders is to avoid the temptation to dichotomize patients as either physical or mental, and to become highly adept at understanding all illness within a biopsychosocial context. The biopsychosocial model posits that illness is the product of biological, psychological, and social subsystems interacting at multiple levels. (p. 251) The advice is not wrong but is overly vague and general. The biopsychosocial approach is more descriptive than directive; it doesn’t provide mechanisms of disease or assist with a specific patient diagnosis. The concept is so broad that almost any diagnosis and almost any illness behavior can http://psycnet.apa.org/index.cfm?fa=fulltext.printReview&uid=2011-00607-001&lang... 27/07/2011 PsycCRITIQUES - An Uncritical Approach to Behavioral Medicine Page 3 of 4 be subsumed under the biopsychosocial label without any obvious advance in understanding. Moreover, insistence that a biopsychosocial framework be adopted denies the possibility that some patients may benefit from a more binary approach. A patient who uses a physical illness to mask an emotional problem, for example, might benefit from being dichotomized as having a mental rather than a physical problem. Sometimes the lack of critique leads to advice that, if followed, may encourage patients to question the credibility of their doctors. The chapter by Timothy Fong on addictive disorders, for example, repeats without embarrassment the National Institute on Alcohol Abuse and Alcoholism (NIAAA) guideline for drinking “no more than 7 standard drinks per week for women and no more than 14 standard drinks per week for men” (p. 123). Women are allowed only half the alcohol of men because, explains Fong, “women metabolize alcohol less efficiently, and therefore they are more affected by a given amount of alcohol” (p. 123). No evidence is provided, however, to substantiate the huge metabolic deficiency of women relative to men. Fong continues with the advice to ask patients, “During the last year, has there ever been an occasion where you had more than 5 drinks in a single day?” (p. 123). He suggests following any “yes” answers by taking a more detailed alcohol use history. Every year brings celebrations (weddings, birthdays), national holidays (Thanksgiving, Independence Day), and numerous family reunions or other social gatherings. It’s hard to imagine anyone who is not a teetotaler honestly being able to deny drinking more than five standard drinks on any single day during the past year. British guidelines allow women to drink twice as much (14 standard drinks per week) and men to drink 50 percent more (21 standard drinks) than their American counterparts. There is no evidence that the metabolism of the British is superior to that of the Americans. In reality, drinking limits are imposed arbitrarily according to political and moral rather than medical concerns. Medical professionals who earnestly pursue patients for details of their drinking habits because they exceed arbitrary (and largely unrealistic) limits will encourage dishonesty amongst their patients, undermine the credibility of medical advice, and waste a lot of time. The book also includes details that are inadequately substantiated and sometimes clearly incorrect. The chapter by William Lovallo and Margaret Stuber on stress and illness, for example, mentions a series of interesting studies documenting health responses to the 1994 Los Angeles earthquake, England’s traumatic loss in the 1998 World Cup, living in New York City, and caring for a spouse with Alzheimer’s disease. Not one of those studies is referenced. Returning to the theme of alcohol, the chapter on treating psychopathology in primary care states that alcoholism “is the third leading cause of death in this nation [America]” (p. 239). No citation is provided to substantiate that claim, and the claim is clearly undermined by U.S. national statistics that cite cardiovascular disease as the leading cause of death, followed by cancer and stroke (readily available from the Centers for Disease Control and Prevention website and also cited on page 79 of Behavior and Medicine). The failure to be critical means that Behavior and Medicine adds to changes in the practice of medicine that cause tension between patients and doctors. Tension is created because medicine is defined so broadly that medical professionals become embroiled in almost every life decision and event. Behavior and Medicine covers families and relationships, birth, childhood, early adulthood, middle age, old age, death, dying, grief, stress, sex, communication, and social inequalities. Such an all-encompassing approach to medicine means that medical professionals are empowered to question and interfere with the most intimate and personal of behaviors and decisions. Patients may rightly protest that their doctor has no business enquiring about their ability to grieve. Tension is also created because medical advice increasingly moves out of step with the realities of patient’s lives and sometimes just moves out of step with reality. It is perhaps reasonable to inform http://psycnet.apa.org/index.cfm?fa=fulltext.printReview&uid=2011-00607-001&lang... 27/07/2011 PsycCRITIQUES - An Uncritical Approach to Behavioral Medicine Page 4 of 4 people of the risks and dangers associated with their habits and behaviors, but encouraging people into conforming with some ideal model of behavior is something else altogether. The chapter on behavior change by Adam Aréchiga cautions that “successful treatment . . . requires lifestyle modification on the part of the patient” (p. 145). Unfortunately what the patient and doctor consider as “successful” is not always the same. Successful for the patient might mean being able to live the life he or she enjoys for as long as possible rather than making changes that make his or her life less enjoyable if slightly longer. The zealous pursuit of health can too easily become a crusade against the patient’s lifestyle. Instead of being helpful, this oppressive approach can undermine the life goals of the patient and supplant them with more petty concerns of bodily welfare. Behavior and Medicine probably does achieve one of its central goals, which is to help medical students through their exams. All U.S. medical students must pass the USMLE before being permitted to practice medicine. The USMLE assesses a physician’s ability to apply knowledge, concepts, and principles, and to determine fundamental patient-centered skills that are important in health and disease and that constitute the basis of safe and effective patient care. About 10 to 15 percent of the USMLE Step 1 final exam concentrates on behavioral science: Students should be aware of developmental markers, the potential influence of personality, problems associated with addiction, risk factors for divorce, and so on. All of these issues and the other issues needed for the USMLE are covered in Behavior and Medicine. Nevertheless, I cannot recommend that students read the book and even worry about what kind of student, and what kind of professor, would be satisfied with a book that fails to critique the material, provides inadequate citations, and tends toward safe and general positions. I expect my students to write essays that are searching, challenging, and powerful, and to exit the university with a deep respect for the importance of argument in establishing a position. In that regard, Behavior and Medicine sets a poor example. References Amanzio, M., & Benedetti, F. (1999). Neuropharmacological dissection of placebo analgesia: Expectation-activated opioid systems versus conditioning-activated specific subsystems. The Journal of Neuroscience, 19, 484–494. Colloca, L., Lopiano, L., Lanotte, M., & Benedetti, F. (2004). Overt versus covert treatment for pain, anxiety, and Parkinson’s disease. The Lancet Neurology, 3, 679–684. doi:10.1016/S1474-4422(04)00908-1 Footnotes Note. Nicole Thomson served as the action editor for the selection and processing of this review. http://psycnet.apa.org/index.cfm?fa=fulltext.printReview&uid=2011-00607-001&lang... 27/07/2011