A cross-sectional observational study by S. Todd Stolp MD and Chandler W. Stolp PhD
May 2009

©April 2008

Perhaps the most important part of practicing medicine is to gain the capacity to see through your patient’s eyes.  To fully comprehend the experience of a patient as expressed in a chief complaint is often the most important clue to a diagnosis, no matter whether the goal is to understand the subtle characteristics of pain, to visualize a rash according to the patient’s description, to empathize with the distress of a spouse during a partner’s illness, or to anticipate the reluctance of a patient to take a medication as prescribed.  It is for this reason that the words of a patient are necessarily accepted, at least initially, as a basic truth.   But it is not often recognized how destructive it can be when a health care provider is deceived, either purposefully or inadvertently, about the best interests of the patient.  Perhaps the most serious example of the breakdown of the physician-patient relationship is the abuse of prescription drugs and the temptation to over-prescribe medications designed to relieve suffering.

First, it is important to emphasize that the recognition and treatment of pain is a critical responsibility of physicians and providers.  In 2001, California passed a law requiring all physicians to receive 12 hours of pain management education because of a perception that there was a gap in general knowledge of the subject.  However, since that time there has been a well-recognized increase in prescription drug abuse paralleled by an unprecedented increase in the prescribing of narcotics.

Pain is actually our friend.  It turns out that when the first protozoan recoiled from a hot object, the nervous system was born.  Responding to noxious stimuli only requires the memory of this event to inspire learning.  As memories of positive and negative experiences accumulate, the capacity to understand Shakespeare is only a few million years away.

A complex nervous system is designed not only to pull the strings that operate our machinery, but also to protect our bodies from injury.  Several disorders can cause individuals to lose the capacity to experience pain.  The end results of such conditions include joint destruction, bed sores, and infections, any of which can be life-threatening.  Indeed, there are many maladies that one should prefer to the loss of the ability to experience pain.

Prescription drug abuse is only encouraged by technological progress that has made it possible to both mass produce and market pharmaceuticals.  Every culture on earth has discovered substances that either relieve suffering or provide temporary pleasure.  If there is any doubt about the capacity of substances to place the brain on autopilot, simply observe a cat indulging in a patch of catnip.  In the past, pharmaceutical production was limited by the ability of farmers to grow and harvest poppies, plants and the like.  However, it is relatively recently that synthetic narcotics have become available in a wide array of doses, formulations and colors to pharmacies throughout virtually every corner of every community in the country.

Except for marijuana, tobacco and alcohol, prescription narcotics are now the most commonly abused drug in the local student population.  Most of these either come from prescriptions that have been diverted from the intended user, or are “extra” medications that were salvaged from previous prescriptions.

Tuolumne County had the second highest rate of drug-induced deaths in California during the period 2003 to 2005.  We simply must begin the process of re-educating ourselves and future generations to be comfortable with the idea of sometimes being uncomfortable.  While we must validate and treat pain when it is a part of illness, we must not substitute the illness of an anesthetized society for pain – both physical and mental anguish – that is serving a healthy purpose.

©December 2007

New brain imaging discoveries are surfacing each day, providing us with astonishing new insights into our thinking machines.  One of those insights has to do with how we communicate.  It turns out that many of our perceptions are constructed automatically from data that is collected and analyzed even before we realize that our brains have actively participated in the act of interpretation.  Creatures have an uncanny capacity to interpret body posture and facial expressions as an integral part of our communication skills, even before we realize that we have drawn conclusions from our observations of each other.  It might be worthwhile to consider this compulsion for practicing amateur sociology as we prepare to join our family members over the holidays to share meals and revelry.

As is often the case, our understanding of our capacity for communication has been boosted by our observations of individuals in whom this capacity has malfunctioned or been delayed.  Recent attention has been focused upon the condition of autism, in which there is a deficiency in the ability to interpret social cues from the faces of other people.  In severely autistic patients, the ability to recognize a human face is diminished even in infancy.  While the cause of autism remains a mystery, brain imaging has clarified that autistic patients have abnormalities in how social information is physically processed by the brain.

If any doubt exists about the magnitude of our drive for gathering social signals, consider the success of televised game and reality shows.  The camera seems to linger for entire seasons on the magnified faces of preoccupied game show participants to satisfy our voyeuristic interests.  While maintaining vigilance in our interpersonal data-gathering can be exhausting, ratings for televised international poker championships remain high.

Consider the mind boggling success of Facebook, YouTube and the multitudes of other social media networks.  The notion of employing electrons to facilitate interactive written communication was agonizingly simple.  However, our hard-wired compulsion to communicate has required the remodeling of a bewildering network of satellites and the commitment of some of our most sophisticated technology.  It is perhaps a positive commentary on humanity when we do so for the sake of communication rather than for other less constructive purposes.

Even the smorgasbord of downloadable music on the internet is further evidence of our insatiable appetite for communication.  As musical tastes become increasingly intercultural and international in scope, boundaries between peoples stand to be blurred and mutual understandings at least potentially facilitated.  The biological roots and community benefits of rhythm and music are undeniable, even among species other than humans.

And so it seems that given such an innate ability to communicate, and with such a demonstrated devotion to facilitating conversation, we ought to attempt to make our interactions worthwhile.  While some degree of our ability to communicate effectively across the dinner table is learned and some inherited, maximizing our enjoyment takes some effort – sometimes considerable effort.  A secret among clinicians is to verbally acknowledge perceived social cues, so that misinterpretations have an opportunity to be corrected.  Ultimately, holiday gatherings provide one of our greatest opportunities to exercise our talents for listening, singing, laughing, asking questions, challenging, debating, and simply expressing ourselves.  Here is to hoping we all do so with joy.

©July 2007

To question what it means to be human may not sound like a public health issue.  However, suicide, as narrowly defined, is a behavior that is distinctive only to humans.  Therefore, to scrutinize what it is about humans that accounts for this uniquely human tragedy may bring us to a better understanding of the phenomenon of suicide and contribute to minimizing its occurrence in our communities.

It is clear that other creatures will engage in behavior that results in the self-imposed death of the individual.  A scorpion will sting itself, a spider may lose its life upon mating, a mammal may die defending their young against impossible odds, and higher animals may die of starvation after the loss of a mate or die as a result of self-injury upon captivity.

However, as far as science can determine, none of these examples represent actions by otherwise healthy individuals that are chosen with the specific purpose of ending the life of the individual.  So what singularly human capacities make such a decision possible?

It is generally accepted that humans enjoy intellectual powers that provide us with unique perceptions.  This includes the ability to conceive of life span, life expectancy, and mortality – most notably our own.  People understand abstract concepts like taboo behavior, popularity, ethics, and cultural norms.  We inevitably construct some sort of self-image of ourselves by measuring how we perform against the norms that regulate the societies in which we live.  Unfortunately, when our own self-assessment leads us to perceive ourselves as falling far short of our own expectations or society’s expectations, mental anguish is a frequent outcome and the mechanisms of mental illness frequently follow.  Self-awareness of the factors that influence our behavior provides the basis for widely embraced and successful forms of psychological treatment, such as Cognitive Behavioral Therapy and Dialectical Behavioral Therapy.

To maintain a healthy mental state, one must have an adequate supply of socially acceptable coping mechanisms (rational arguments, self-confidence, meaningful employment, a sense of humor, spiritual beliefs, etc…) with which to manage the negative or positive self-perceptions one encounters, to greater or lesser degrees, during life.  One theory considers that the abyss of suicide in an otherwise healthy individual represents a breakdown of these coping mechanisms relative to one’s negative self perceptions and/or world perceptions.

A recent article in the New England Journal of Medicine points out that it is possible to detect in young people when the failure of coping mechanisms begins to push a young person towards a sense of hopelessness.  There are even indications that physical, genetic factors may in some instances influence our ability to develop and exercise adequate coping skills.

Herein lays the public health message.  Prominent risk factors for suicide include Native American and White ethnicity, residence in a rural community, access to firearms, substance use disorders, male gender, sexual assault victimization and recent personal loss.  “Red flag” trigger factors include recent exposure to personal tragedy, intoxication, loss of interest in favorite pastimes, ease of access to a suicide method or legal problems.  If you or someone you know displays such behavior and admits to thoughts of suicide when you ask, call or have them call 1-800-273-TALK immediately.  For a local number to access emergency mental health care for thoughts of suicide, call your local Behavioral Health Department.

Self-perceptions are naturally distorted by our own biases.  Recognizing early when those perceptions – guided or misguided as they may be – are leading us to thoughts of hopelessness may be all the incentive we need to seek professional counseling services.  Such services can and do save lives.

©December 2008

Recently Americans have shared an identity crisis of extraordinary proportions.  Without dwelling upon the confidence-rattling events of the past several years, the emergence of a national state of depression seems to threaten one of the great strengths of our nation: a sense of humor.  Therefore, in the interest of taking a break from the fury of the battle, it appears to be a timely opportunity to explore the mysteries of laughter.

If we stick with a scientific dissection of laughter as a behavior, we discover that it actually involves very complex neurophysiologic mechanisms.  First, there is the cerebral recognition of irony in the joke itself.  Then there is the contraction of the oral muscles which bears the teeth, the spasms of the diaphragm which cause brisk movements of air, the array of sounds generated by contraction of the vocal chords, and in a real guffaw, gasping for air and closure of the eyes!

In many forms of dementia, the sense of humor is one of the first cognitive functions to go.  A very revealing test that a doctor can do in the course of a physical exam is to tell a joke, and see if the patient responds.  Of course, if the physician is a biostatistics professor this test is nearly impossible to conduct.

Through neuroimaging techniques and mapping of the cerebral cortex, scientists have pointed out that laughter is generated from the same anatomical sites in the brain that produce growling in other primates and lower mammals.  The consequential behavior – bearing of the teeth accompanied by the emission of guttural sounds – certainly is reminiscent of laughter, although true laughter is curiously unique to humans.  On the other hand, a certain amount of satisfaction might be achieved by growling while watching the evening news, since giggling might be socially unacceptable.

The recognized health benefit of laughter has led to the development in India of “Laughter Clubs”, in which individuals join in communal laughter without the benefit of comedy.  Like yawning, laughter has a subliminal infectious quality.  Ergo, “sit com” producers saturate the sound tracks of their shows with tracks of laughter which in real life would warrant referral for group psychotherapy.

In this country, one can only speculate about the consequences if the pharmaceutical companies, recognizing the health benefits of humor, were to obtain patents on the latest jokes.  Would it be necessary for companies to prove the positive effects of certain jokes by performing controlled studies, in which the control group would be forced to listen to ice skating commentary?  Would certain jokes only be available by prescription, accompanied by warnings for patients suffering from incontinence?  Would there be certain jokes that should never be told together to a particular patient because of the risks of interactions?  Would insurance companies deny coverage to Comedy Clubs that were not Preferred Providers?

While our health care system is plagued with many problems, we should console ourselves that some of the healthiest things we can do are free, and within our reach.  A walk in the woods, a swim in the ocean, or a reminder to not take oneself too seriously may all be on that list.  It’s a funny thing.

©September 2007

When was the last time you took time away from work to enjoy a vacation?  While taking time off, did you relax?  It might actually be a very astute public health recommendation to advise our friends and families to “go fly a kite.”

According to a study by the International Labour Organization, Americans take fewer days off of work each year than any other industrialized country.  Twenty five percent of Americans do not receive paid vacation.  In addition, those employees in the U.S. who are provided the benefit of paid vacation days typically fail to take an average of one to two of those days per year.

Workers in Germany average 30 days of paid vacation time per year, and in France it averages 38 days.  Americans average about half that.  Even among the industrious workers of Japan, vacations are more extensive than in the U.S.

Now, it should be made clear that there is nothing wrong with dedication to work and a strong work ethic.  This is the classic parental montra.  However, it is also dangerous to accept the notion that we can maintain maximum health and benefit to our families when we forfeit every last morsel of free time in favor of work.

Research has explored the characteristics of work that contribute most significantly to work related stress.  It turns out that the occupations that generate the most anxiety on the part of employees are those jobs in which the employee has the least ability to influence their work responsibilities.  Such an insight may help explain why work within the U. S. Postal Service or in positions with repetitive mundane responsibilities are so hard on some employees.

Literature is rife with speculation about why Americans are so obsessed with work.  Economic pressures, Puritanical roots and corporate influences have all been suggested as major contributors.  However, Websters Dictionary alludes to the fact that the Latin root of the word “vacation” includes references to the cocept of “freedom.”  Restraints are equally effective, whether they be physical or self imposed and economic, and neither is conducive to good health.

Consider planning a vacation this next year.  And remember that a vacation does not have to be expensive.  Time off to go camping, or a bike trip might be just the ticket.

It is worth reminding ourselves that spending restful time with our families and friends is an important way to keep a healthy perspective on the trials of work.  Such an outlook makes for a more enjoyable life and ultimately a more productive employee.