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David Katz, M.D. Headshot

The Limit to What Doctors Understand

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As reported August 17th in The New York Times, a fascinating study published in the Journal of Neuropathology and Experimental Neurology -- suggests that even Lou Gehrig may not have had Lou Gehrig's disease. Rather, it's possible that Gehrig had progressive, neurological deterioration mimicking amyotrophic lateral sclerosis (ALS) due to head trauma (among other things, he was hit in the head by a fastball).

The obvious implication of this report is that the head trauma to which many athletes (and soldiers, and to a lesser extent, others) are subject may have serious long-term health consequences not previously recognized. If some ALS is, in fact, due to trauma, perhaps quite a bit is. Perhaps many other conditions of the brain were caused by, or at least propagated by, injury.

This is only novel thinking up to a point. Muhammed Ali's Parkinson-like condition is widely recognized to be a consequence of his many years of suffering blows to the head. Boxers have also long been known to be subject to a form of dementia named for their trade: dementia pugilistica.

But for me, a doctor who these days specializes in the care of the hard-to-treat, the implications run much deeper. If physical trauma can cause the nervous system to fail, what else can it do? Can it cause chronic inflammation we don't know how to measure? Can it lead to chronic pain we can't detect on any scanner?

And if physical blows can take a toll we have overlooked until now, what of psychological blows? Can emotional and psychological trauma induce failures in the immune system, the endocrine system and/or the nervous system, resulting in chronic pain, chronic fatigue, fibromyalgia?

And what of low-level exposures to toxins? While many of us may be resistant to adverse effects of chemical residues, traces of pesticides or air-borne solvents, isn't it possible that some are more sensitive than others? And if so, might not this 'trauma' also exact a toll?

Each time medical knowledge and understanding advance by even a single step, it tells us something we neglect at our peril, and certainly the peril of our patients: our knowledge and understanding are incomplete. They are subject to such advances. We will know something tomorrow we simply don't know today.

Such ignorance is a potent goad to humility for anyone paying attention. How much easier it is when the source of a patient's pain or fatigue can't be traced to its origins with a blood test or MRI ... to blame the patient, rather than our own ignorance. How much easier it is to imply that it must be "all in the patient's head," rather than concede it is knowledge that isn't yet in ours! How easy, and how wrong.

In general in medicine, the term 'syndrome' is used for conditions we understand imperfectly: complex regional pain syndrome, chronic fatigue syndrome, fibromyalgia syndrome, irritable bowel syndrome, premenstrual syndrome. Alas, we tend to respect them quite imperfectly as well! The legitimacy of a condition is in question when modern technology can't elucidate its etiology, or pinpoint its pathogenesis.

But we have more and more evidence that the traumas of life -- the slings and arrows of outrageous fortune -- can cause the body to fail in ways we don't yet understand. Confronting the patients who are victims of such unkind fate with cynicism adds, in the most literal sense, insult to injury.

Good medical practice is comparably undone by such cynicism as by vapid gullibility. Our patients, and the complexities they present, warrant our most thoughtful reflection, our deepest thinking, and often, even, our open-minded skepticism. But cynicism? Blaming the victim for our own limitations? Never that. Patients who happen to have what we don't yet understand are not to blame for such precocity.

The patient deserves the benefit of any doubt, and there is ample cause for us to doubt. The inexplicable pain, headache, limp, fatigue that tempted us today to roll our eyes, may be the breakthrough reported in tomorrow's New York Times; may be the basis for next year's Nobel Prize.

Dr. David L. Katz;

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