May 27, 2009

Ramachandran's Mirror

And I don't like what I see.

For three years I had been seeing her for  "Major Depressive Disorder" and been treating her with Effexor and Restoril and thought I was doing a good job of it, too.  Proud of myself, you see, that I had reduced her symptoms AND managed to keep the number of pills she was on to well under the psychiatry average of 19.  I rule.

Also and by the way, she had an above-elbow amputation from a bus accident ten years ago.  She had phantom limb pain, in this case feeling that her missing hand was bunched up into a fist, cramping.  Occasionally, she'd even get a charlie horse in the forearm which wasn't there.

Sometimes if she was distracted, or if she distracted herself, the pain would go away.  Other days, it was terrible.

etc, etc, you get the idea.

The New Yorker had a recent article on Ramachandran, the neurologist famous for discovering that phantom limb pain wasn't the result of damaged nerve endings in the stump, but of a brain malfunction: the brain had rewired itself to think that a stump was there.  What needed to be done was to teach the brain that it wasn't there; or, more immediately, trick the brain into relaxing the fist that isn't there.  

He did this by putting a large mirror in front of the person, facing/reflecting the good arm.  Looked at from that side, it looked like you had two good arms.  You would then clench and unclench your "two"  fists, and you/your brain would "see" the other hand (that wasn't really there) also unclenching.  You'd feel as if the fist was relaxing, and the cramp would go away.   Apparently, the results were sudden and profound.



I was a little nervous, I don't mind telling you this up front.

I set up the mirror just as Ramachandran had described.  At first she didn't really get it, she wiggled her fingers, and nothing was happening.

"What I want you to do," I ad libbed, "is look in the mirror, and imagine that your left hand is doing the exact same thing as your right, simultaneously."  I showed her by opening and closing my fists.  "In other words, open and close both of your fists."

I barely finished my sentence when her eyes popped wide.  "Oh my God.  Oh my God."

My eyes popped open, too-- it actually worked!

We did that for a minute, and I asked her to then play a scale on an imaginary piano, 1-2-3-4-5-4-3-2-1, with "both hands."

She started crying.  This isn't an exaggeration.   "I can't believe this.  I can actually feel my hand..."

This, I thought with immense pride, is awesome.


Well, it's a wonderful story, I guess, and if this was the end of it it would be suitable for Good Housekeeping or maybe one of the medical journals that we pretend to read.  Maybe I could sell the story to TV. A Lifetime Original Special: Reflections Of A Physician.

But it's not the end, there are some hard questions to be asked that no one will ever ask:

Sure, it worked, sure, she feels better, sure, she thinks I'm awesome.  Why did it take me three years to try something I had known about for ten years with her?

Ramachandran's mirror technique is medical school stuff.  Everyone knows it.  Everyone.  If you don't know it children on the street kick you in the shins.  If you were in a coma during medical school then you still would have picked it up from a trillion other places, from Scientific American to Discover to Time Magazine.

Of course I knew the significance of the mirror.  Of course I knew how to do it.  I just never did.  It never even occurred to me to do it.

The mirror occurred to me; doing it never occurred to me.  I'll tell you that every single time I saw her stump, the theoretical implications of Ramachnadran's mirror immediately came to my mind, I imagined the mirror.  But I never tried it.

Not just me, but it also never occurred to the ten years of doctors she'd seen in her life.  Absolutely every single doctor knows about the mirror.  Not one tried it.

And it wasn't that I was lazy or didn't care-- I had tried Elavil, Neurontin, Lyrica, Cymbalta-- no, I didn't expect much from them, but I tried them, I thought, why not?  Maybe it could help?

But I never even considered using the mirror.

I can't understate this: I was thinking about the mirror in her presence, but never thinking about using the mirror.  I wasn't asleep, I wasn't drunk, I wasn't inattentive, I wasn't bored.  I was just too much in my world.

So I ask you: did I help her?  Or did I make her suffer needlessly for three years?


Without ducking responsibility, what's wrong with medicine today is that it is predicated on providing treatment, not on reducing suffering.  Not on solving problems.

The reason it never occurred to me to use the mirror is because the mirror is not something doctors do.  Never mind it is fairly safe.  What we do is offer treatments.  Medications.  Procedures.  Not maneuvers.

Do you know what every single one of my patients who lives in Flavor Country have in common?  They're on Lipitor.  That's what doctors do when confronted with the results of smoking.  Not nicotine patches or wellbutrin or talking them through becoming a different person.  They treat the results.  The smoking is an afterthought.

Think about how much controversy there is over using medications that are already approved off label for something else.  Where, then, is the cognitive strength to do something that isn't even considered a treatment?

Most residents fantasize about doing something like the mirror on a patient, partly because it sounds cool, but unfortunately really because it puts them on an equal footing with their supervisors.  They'll never know as much about Treatment Guidelines For Bipolar XVI as their supervisors, but they can know more about this.  This is how they can distinguish themselves.

Once they grow to the point where they are knowledgeable about the Guidelines, then there's no reason to use mirrors.


Also-- and again not to minimize my own responsibility-- part of the problem with all of the popularizers like Oliver Sacks, NPR, The New Yorker, is they trivialize the information to the point of uselessness.  "So that's why the Kurds hate the Sunnis!  I'll have a latte."  There's a sense among doctors that if it appeared in, say, Wired, it's not real medicine.

When I was a resident I tried the Sacks insights. None of them ever worked.  It wasn't either of our fault: there's a big gap between practicing medicine and watching Awakenings.

What I didn't do, of course, is watch Awakenings and then go back and research how I might actually apply it.


Now, all you patients, think about this: there is more than a slight chance that your doctor knows how to help you, but isn't trying it.  Maybe it's another medication, maybe it's an intervention, maybe it's information he's simply not telling you.  Not on purpose-- it doesn't occur to him to tell you.

Not because he's bad, of course.  I don't think I'm bad, not a bad doctor anyway.  But hell, if I had to sit with every patient and think out of the box on every issue with them, and individualize the treatment while still maintaining scientific rigor-- drawing not just medicine but from all possible fields that might be applicable to the current problem, being "conscious of the patient's spirituality" not because that's what doctors are supposed to pay lip service to, but because I might be able to use it in a clever manner to obtain results, spending time proportional to what is actually going to matter (like smoking) and less on treatments I am conditioned to provide reflexively--

-- then what kind of a doctor would I be?