2.6 The doctor as witchdoctor - allaying anxiety

Anxiety is a normal reaction to disease or the possibility of disease, and anxiety usually, but not always, leads the individual to seek professional help to resolve the uncertainty. If no disease is found, anxiety is usually, but not universally, allayed and the person continues with their life (Figure 8).

However, anxiety of different types can persist and aggravate the patient's problems.

2.6.1 Anxiety generated by disease

For some people the diagnosis of a disease comes as a relief. They feel empowered by the knowledge and look forward with confidence to treatment and cure. For others, even when an effective cure is available, diagnosis does not end anxiety, and the emotional response to illness is determined by a number of different factors such as:

• the severity of the disease
• the effectiveness of available treatment
• the side effects of available treatment
• the confidence that the patient has in their clinician and health services
• the patient's personality - some people are more disposed to anxiety than others

When anxiety persists it can aggravate the symptoms of disease (Figure 9).

2.6.2 Medically unexplained physical symptoms can cause, and be aggravated by, anxiety

When no diagnosis is made - that is, no disease is found, because failure to diagnose is no guarantee of absence of disease - most people are relieved, but for a proportion of people anxiety persists, and can maintain or even increase the severity of the symptom (Figure 10).

The probability of this happening is determined by a number of factors including:

• fear of a particular disease, fear of cancer being a major cause of anxiety
• the personality of the individual
• the way in which the symptoms, the diagnostic process, and the giving of information, have been managed

2.6.3 Anxiety alone may be the cause of the patient's symptom

Some symptoms are actually caused by anxiety, and if the symptom which led the individual to consult the clinician in the first place was the result of anxiety, then failure to resolve their anxiety will tend to aggravate the symptom. Furthermore, anxiety itself can produce physical changes in the body. Psychosomatic diseases are those in which anxiety can actually cause a disease or, more commonly, aggravate the severity of the condition; asthma is an example of such a condition (Figure 11).

2.6.4 The management of anxiety

The management of anxiety, whether or not the diagnosis is known and whether or not the individual has a disease, is of central importance in healthcare and clinical practice. The best approach is, of course, to deal with all the underlying issues: accurate diagnosis, clear communication, and effective treatment, all carried out in a competent, caring way, are effective means of managing anxiety but it is also important to recognise that the organisation of healthcare and the style of the clinician can increase, as well as allay, anxiety. Anxiety arises from uncertainty, and modern medicine, although increasingly accurate in its diagnosis and more confident in the probability that treatment will be beneficial, is actually based on scientific methods in which the testing and refining of uncertainty are of central importance.

• Research produces conclusions which are statements of probability, not statements of certainty
• What a modern clinician knows are not facts but probabilities

The problems that uncertainty pose are vividly described in a doctor's account of his encounter with uncertainty:

We are encouraged these days to have more patient centred consultations, to share out thought processes and decision making with our patients, and to build therapeutic alliances. However, sharing uncertainty is not something I always find to be straightforward.

Six months ago, my perspective on uncertainty was radically changed and my ability to cope with it questioned like never before. I was diagnosed with non-Hodgkin's lymphoma. This was uncertainty of an entirely different order. This was me, for God's sake! I'm only 41. I've got a wife and children! This isn't how it was meant to be.

From the beginning, the rollercoaster of emotions that accompanies such a diagnosis and the progression through chemotherapy has been paralleled by the need to grapple with facts and figures. And how many times have I mulled over the discovery of that solitary cervical lymph node? It's probably nothing, I thought. Oh God, it's getting bigger - I need to do something. The histology shows low grade follicular lymphoma - good, that has longer survival rates. Bad - it's generally considered to be incurable. A scan reveals abdominal nodes. But wait - the bone marrow is clear! I pore over complex classifications of lymphomas and their seemingly endless revisions. I devour the recent publications on the treatment of follicular lymphomas. I scour the internet for that elusive article that will reveal all and restore hope. The doctor in me looks coldly at the statistics and is overcome with pessimism. What is the five year survival rate for a 41 year old man without lymphoma anyway? The patient in me prefers to look at the bottle and find it half full. There are a lot of promising developments in treatment, I tell myself

Tom Cuddihy (14)

In shared decision-making, these probabilities or uncertainties are shared with the patient, but not all patients welcome that: some wish to have an authoritative figure, preferring the certainty that the traditional clinician exuded so well.

2.6.5 Clinical practice - science or magic?

Anthropologists have defined the function of magic as the management of anxiety when no effective intervention is available. Scientifically, it is known that rain dances do not bring rain, but the rain dance provided a useful, apparently purposeful, activity for the community waiting for rain. Rain, of course, ultimately falls, reinforcing belief in the rain dance and thus increasing its effectiveness as a means of relieving anxiety still further.

• The 19th century clinician relied principally on magic
• The 20th century clinician used science consciously and magic unconsciously, although many clinicians were aware of the need to allay anxiety and used the power of the drug doctor frequently and with beneficence
• The 21st century clinician is less willing to do so, and some regard the practice as unethical and paternalistic

From the perspective of the patient, however, the need for magic may be greater than ever before.

2.6.6 The growing need for magic

If magic is a means of managing uncertainty, this need is determined in part by the amount of uncertainty in life in general - and life is becoming increasingly uncertain. As Ulrich Beck has described graphically, the world of work is changing, with decreasing job security, in what he calls the 'Brazilianisation of the West'. Furthermore, he pointed out in his monumental work The Risk Society that everyone was at risk in an increasingly uncertain environment. Faced with increasing uncertainty, individuals need reassurance and support, and if they do not find it from a clinician perhaps understandably unwilling to act as a witch doctor, they may turn to alternative medicine.

2.6.7 Alternative medicine

The complementary or alternative sector of the healthcare industry is growing faster than any other. The definition of complementary and alternative, and even conventional or orthodox medicine, can be subdivided into four types of care:

• necessary
• appropriate
• inappropriate
• futile

2.6.7.1 Necessary care

Necessary care is that which is universally agreed as being necessary. Even Ivan Illich, who first articulated a criticism of mainstream medicine in his polemic The Limits of Medicine accepted the need for someone to deal with severe toothache or a broken leg. Necessary care is:

• defined by society as a high priority
• recognised as a need by all doctors
• funded in almost every developed country.

Pain control would be regarded as necessary care.

2.6.7.2 Appropriate medical care

After necessary care, it is possible to define appropriate care on the spectrum. This is care in which:

• there is a good probability of doing more good than harm
• it is regarded as a reasonable standard of care in the context of the society.

Coronary artery bypass grafting and hip replacement, for example, are regarded as appropriate care in every developed country for people with, respectively, myocardial ischaemia or osteoarthrosis of the hip. Failure to provide such care would be seen as a serious dereliction of duty on the part of the individual clinician or the health service.

2.6.7.3 Inappropriate care

Inappropriate care is that deemed unreasonable in a particular context or for a particular individual.

For example, teflon fibre grafts to replace the cruciate ligaments of the knee are appropriate for a professional ice hockey player whose income and career depend upon a stable knee joint, but could be deemed inappropriate for the person who finds knee instability irksome and wishes to play tennis once every couple of months without the feeling that a knee will collapse.

It is important to distinguish between inappropriate care for the individual and an inappropriate use of finite resources.

In societies in which resources are finite, the definition of inappropriateness is made with respect to the opportunity costs of providing such services, namely what else could be done with the money. If, for example, there were a waiting list for coronary artery bypass grafting, it would not be appropriate to spend limited resources on an elaborate orthopaedic intervention to facilitate occasional mild physical exercise as a leisure pursuit.

For the individual, however, what is regarded as inappropriate by society as a whole may be highly desirable. This applies to aesthetic surgery, for example straightening or reducing the nose, or enlarging or reducing the breasts. If an individual is demonstrably severely depressed by some aspect of their appearance, perhaps suicidally so, then it may be appropriate to use finite resources to help that individual, but if the main wish of the individual is to increase their sexual attractiveness, many people would regard that as being an inappropriate use of resources.

2.6.7.4 Futile care

At the other end of the spectrum from necessary care is futile care, which:

• does not accord with the patient's wishes, and
• would be regarded as inappropriate by most clinicians

Radical surgery, intended to be curative but with no evidence of benefit, for a patient with advanced cancer who has requested control of symptoms, is an example of futile care.

2.6.7.5 Complementary medicine

There is no universally agreed definition of complementary medicine but one definition is that it consists of care of which many - perhaps most - physicians approve, and to which they would refer patients, but which is not automatically paid for by the state or insurance companies.

Examples of complementary medicine include:

• homeopathy
• osteopathy
• chiropractic

Aesthetic surgery, which people can now access online, could, of course, also be added to this list and the definition is determined to a degree by the extent of state funding. For example, thirty years ago the National Health Service provided basic foot care to all older people free of charge. However, as the population has aged, services have not expanded and older people now only receive podiatry if they have some particular condition, for example, diabetes or vascular disease. Those who are unable to give themselves basic foot care, for example because of osteoarthritis of the hips, are required to pay for it or are referred to private chiropodists by primary care professionals. Thus basic foot care can now be regarded as a form of complementary medicine.

2.6.7.6 Alternative medicine

Alternative implies that individuals should choose either standard healthcare, with or without complementary medicine, or the alternative. There is, however, evidence that patients use both simultaneously. Increasingly the distinction between complementary and alternative medicine is blurring and one proposal is to consider the two as a single entity of Complementary and Alternative Medicine (CAM). (15)

A pragmatic definition of alternative medicine is that it is a form of care, usually based on an alternative biological paradigm, which some physicians actively encourage, whereas an increasing number of others are sympathetic towards it as long as it does not lead the patient to refuse conventional treatment for a disorder for which conventional treatment exists. Acupuncture, Chinese medicine, and vitamin therapy are examples of alternative medicine.

In addition to these generic types of alternative medicine there are a multitude of specific systems, sometimes linked to one individual, such as, for example:

• Dr Andrew Weil's methods
• Dr Gerson's cancer therapy

2.6.7.7 People use alternative medicine for different reasons

The fact that people use both mainstream medicine and alternative medicine indicates that at least some of the people who use alternative medicine do so not simply because they have become dissatisfied with conventional health care, but because they find additional value in the alternative approach.

Four types of reason are given by those who use alternative health care.

1. Certainty. Part of the approach of empowering patients in mainstream medicine is to involve them in shared decision-making. In explaining options fully, uncertainty is usually clearly described, namely the fact that there is a probability of benefit and a probability of harm and (if more detail is asked for) that the evidence on which these probabilities are calculated is itself derived from research which can only produce an estimate of the extent of the good or bad effect. Alternative medicine is usually less uncertain medicine and for those who wish certainty, alternative medicine is a better option

2. Personalisation. Mainstream medicine uses knowledge derived from the studies of groups, and decisions are made on the basis that, for example, aspirin has been shown to reduce mortality among people with cerebrovascular disease. Thus people with cerebrovascular disease should be considered for aspirin treatment. The patient is compared with the group and decisions are based on how other people with the same disease have been treated. Increasingly the weakness of this approach, applied uncritically, has been exposed, for example, by the evidence-based medicine movement. A closer examination of the benefits of aspirin illustrates the need to tailor knowledge to the individual patient.

In contrast, many forms of alternative medicine focus on the individual, not only in terms of the time and personal attention given to the patient but also in terms of basing decisions on the constitution of the individual, rather than the similarity of the patient to the group. Homeopathy, for example, is based on the principle that the constitutional type of the individual has to be established as a basis for all intervention.

3. Evidence. There is evidence that alternative medicine is beneficial. Some people, particularly those with health problems that do not fit neatly into conventional systems of classification, report tremendous benefit. Their testimony encourages them to continue using alternative medicine, usually a particular type which they have found beneficial, and also encourages those to whom they describe their success to do so also.

Those in mainstream medicine usually attribute these successes either to the placebo effect or to the reduction in anxiety that certainty brings, or some combination of these factors, but for the individual the evidence of benefit is evidence enough.

4. Alternative 'Weltanschauungen'. The 'Weltanschauung', or world view, of most people in mainstream medicine is firmly rooted in a certain view of reality, one that sees reality from the perspective of

• a reductionist approach to science
• a split between mind and body
• a dualism that also emphasises the distinction between self and other, between subjective and objective

This is, however, only one way of looking at the world, and there are many others. A natural consequence of this approach has been the belief that science is good and progress is good, although this is now no longer held so simply as it was in the confident days of the early 1960s when it seemed that science could solve all problems. In the new world, most clearly described by the sociologist Ulrich Beck, science is seen as having adverse as well as beneficial effects and alternative world views are recognised as having their own validity. There is some evidence that some people choose alternative medicine because they prefer the world view, the Weltanschauung, offered by Buddhism or Taoism or by an individual clinician whom they regard, in the appropriate use of the word, as a guru.

2.6.7.8 Integrative medicine

Attitudes towards complementary and alternative medicine are changing within mainstream medical care and increasingly the value of these other approaches is being recognised not only by patients but also by clinicians.

One formulation developed by Dr Andrew Weil, alternative medicine's first superstar, who topped the New York Times best-seller list and appeared on the front cover of Time magazine, is that we should be using what he calls 'integrative medicine'. This is using mainstream medicine for what it is good at doing - such as fixing broken legs, bypassing narrow arteries and treating childhood leukaemia - while recognising that other approaches can help alleviate the suffering that many patients find not only unrelieved by conventional health care but also actually aggravated by the loss of power that they experience by becoming 'just a number' in a huge machine as awesome and impersonal as the Metropolis of Fritz Lang.

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