Toward the stars: On humility and pain in medicine

Your brain is a three-pound hunk of biological tissue. And though it’s nothing more than a conglomeration of specialized cells, it generates the taste of cheesecake, the ecstasy of enchantment, and the misery of suffering. Amazing, right? I certainly think so, though I find myself among a shrinking minority. Whereas the eyes of our medical forefathers were turned toward the heavens in search of answers to seemingly unknowable questions — how does blood move around the body? — my eyes, and those of my colleagues, are focused intensely on computer screens.

We’re preoccupied not by concepts or theory, but data analysis and randomized controlled trials. In an age of cardiac catheterizations and endoscopic ultrasound, we’ve become so firmly rooted in the objective, the concrete, that we’ve lost our sense of wonder for the subjectivities in our world and their biological underpinnings.

Never do we declare in amazement: “My patient, a physical person made of physical bones, organs, and muscles, reports feeling pain: an invisible yet real and deeply private experience appreciated within his person. I have no idea on the means by which this is happening, and my ignorance alarms me greatly.”

Of course, how could we expect such a realization to materialize? When were we prompted to question with sincerity how blobs of biological protoplasm could possibly intersect with rich, invisible, and deeply vivid feelings? When has any standardized exam or attending physician asked us to stop and think about how duloxetine might work downstream of chemistry: How up or down regulation of chemicals in our heads could make us feel any differently, or really — do anything at all?

We are trained not in the pursuit of wonder, but the pursuit of data and its regurgitation. We are rewarded not for humility or the quest for clarity, but for being correct and couching our correctness in the correct evidence. Concepts not rooted in objective data have become less true. I fear that our research has come to focus exclusively on the biomedical and the concrete.

This becomes problematic for doctors and patients concerned with pain. No matter how far down the rabbit-hole we go in terms of neurotransmitters, neuroanatomy, and randomized control trials, our conceptual knowledge on the mechanism of pain will continue to be arrested by the absence of a big-picture concept. The problem, coined the hard problem of consciousness, represents what might be the most impressive gap of knowledge in modern medicine, conspicuous by its absence from every doctor’s lounge conversation.

I am beginning to see the consequences of its neglect every day in the clinical management of pain. The distance between glowing pixels on brain MRI scans and my patient’s pain is reflected in the absence of effective drugs. The epidemic of opiates we read about every day is spurred in part by our collective ignorance on the physiology of pain. This ignorance is driving our embarrassing and continued dependence on the sap of the poppy plant (opium) spanning now over five thousand years.

Despite its relevance, the man-from-meat paradox has fallen on deaf ears. The hard problem has collected dust in the dark dungeons of academia. It’s not spoken about in the hospital. It doesn’t lend itself to scientific investigation, measurement, and evidence: it’s simply too fluffy to be taken seriously. Our dismal understanding of pain has not mobilized a generation of young physicians to seek reform to our education — reform that promises ideological and economic commitment to interdisciplinary inquiry; reform that reclaims consciousness and pain as legitimate sources of awe and academic study; reform that values the vulnerability of asking big questions not immediately amenable to randomized controlled trials.

In a culture demanding objectivity, it seems as though there’s no room left for the subject or his pains. And this, I believe, is a shame. The hard problem of consciousness deserves a place in our core medical curriculum as paradox in need of urgent resolution. We need physiologic theory, one that explains with elegance and simplicity the generation of pain from the biological body. We need data though we also need to acknowledge the limitations therein. We need a new generation of general medical physicians, one acutely aware of and disillusioned by our inadequacy at understanding the basics of how we feel anything at all. We must partner with colleagues not just in the so-called hard sciences, but also those in philosophy, psychology, architecture and the arts as we begin to approach this monstrous riddle. We need to take subjectivity seriously.

It is time to become a bit less certain and a bit more humble. It is time to cast our gaze back towards the stars.

Michael Kaplan is an internal medicine resident.

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