Certainty
This is Western Coffee—notes on building the creative body. Last time: Pain, Part 2. The whole series is here. Please share this email; you can sign up free below.
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This is the second installment in a discussion of emotional factors in chronic pain.
American medicine professes certainty all the time, even when the work itself is probabilistic: “Most people get this parasite from drinking untreated water or traveling to certain foreign countries, not hanging out in New York City.” “The X-ray shows a bone intact, but there’s an outside chance the fracture is too small to see without more sophisticated imaging.” “This bacterium has an indeterminate level of resistance to the following list of antibiotics, and any of them may or may not treat it.” “The pain in your foot could be attributable to degenerated disc material in your spine, or local inflammation, or something else.” (As it happens, these are all examples from my own medical history, and in each of them the initial diagnosis and treatment were off the mark.)
My pain journey did begin with one of the most binary diagnoses in medicine: I had a broken femur, classically symptomatic (I couldn’t walk and was consumed with pain) and easily visible on an X-ray. As I understand it, there was some leeway in treatment approach—and, in fact, when I broke the other femur in a similar place and fashion six months later, that surgeon elected a different one—but the problem itself was unambiguous.
A few years and several other bone breaks later, I found myself with persistent pain and a fog of medical mystery. “Do you think of yourself as an achey person?” my rheumatologist asked. She’d been the one to diagnose the excessive calcium excretion that explained my fragile bones. Since then, she’d ordered dozens of tests to try to account for the pain that had trailed me since my most recent crash—suspecting but not finding an autoimmune condition—and one of them indicated a low count of some complement proteins in my immune system. She prescribed an antimalarial drug called Plaquenil, which later achieved note as a debunked remedy for Covid and whose mechanism as a treatment for autoimmune conditions is, like so much else, unknown—and said rheumatologists joked that some patients simply suffered from “Plaquenil deficiency.” In other words: There’s no real diagnosis and we don’t know how this drug works, but maybe it will help you.
I appreciated my rheumatologist for two things: She was avidly curious, and she didn’t jump to conclusions. She’s one of the only health-care practitioners I’ve met who never seemed to run out of questions. That was the opposite of my experience with a number of orthopedists and pain doctors, who would take one look at an X-ray or an ultrasound and issue an unwavering diagnosis or whip out the epidural. What I began to realize was that the latter group didn’t actually have grounds for more confidence about what they were seeing or how to treat it; they just acted like they did, perhaps even believing so. Fake it till you make it has certain virtues as a life philosophy, but it’s not a sound basis for medical diagnosis. And yet, over and over again, I’ve encountered specialists who quickly conclude that whatever condition they are best versed in, so long as it loosely fits the symptoms, is the one presenting before them.
The idea that an instance of chronic pain could originate in the inner workings of the mind, even parts of it to which we have no conscious access, is unsettling because it makes an almost opposite assumption from those orthopedists about what we can know. The symptoms are the certainty; the diagnosis gets hazier, and the ultimate cause is almost definitionally unknown. John Sarno believed that in most cases the repressed emotions that were driving the brain to generate pain as a distraction would never be experienced by the patient, because the unconscious mind had simply deemed them too threatening. In therapy, some of his patients would gain access to memories of severe trauma and go through a turbulent processing of emotions that eventually freed them of their symptoms. For others, simply embracing the idea that the brain could work this way—and that for it to do so is a completely normal feature of being human—was somehow enough to ease their pain. And that has been my own experience.
Sarno worked from inside the establishment, but I think he had an insight that has eluded many of his colleagues: Certainty is a bad match for medicine. As a patient, it was both difficult to unlearn the expectation of certainty and tremendously freeing, because it meant that I was a meaningful participant in figuring out what was going on. In fact, if this was originating inside my mind, no one would ever have more authority on what was happening than I did.
Kindly send me your thoughts, questions, and provocations: dmichaelowen@gmail.com. And say hi on Instagram, or let’s Peloton together: @leggy_blond.