11 Oct Frames and how they Shape Us.
Pause for a moment and think about how you think about healthcare. Do you trust doctors in white coats more than doctors who dress more casually. When you hear the word “alternative practitioner,” do you think of quacks or healers? Do you think about how your emotions affect your health?
For the most part, we go through life without paying attention to the frames that shape our thinking. This is especially true if we have the same, or similar, frames as the people around us, which is very likely as we tend to congregate with people who think like us. This can easily be seen in the liberal vs. conservative frames that shape much of our political discourse. Conservatives tend to listen to one radio station and liberals another, they read different newspapers, and watch different channels; leaving themselves with fewer reasons or opportunities to confront ideas that crash up against their own.
As filmmakers we saw this very clearly as we made “Battle for Brooklyn,” which chronicles a community’s fight to keep their homes and businesses from being seized via eminent domain. No one likes to see property seized, but liberals tend to look the other way because the seizure is presented as being “for the public good”. Conservatives tend to have more questions about it, but it doesn’t seem to be a priority. In the fight we chronicled, the land was being taken to hand over to a private developer so he could build an arena, housing, and office buildings. Urban planners who actually looked at the plan savaged it, but the developer pushed hard with a mantra of jobs, hoops, and housing, winning him support from most government officials and the public. Still, those who were paying attention, or who stood to lose their homes, fought tenaciously to make it clear that what was being promised could not be delivered. They further argued that it was unconstitutional to take their homes and give them to someone else. Nine years later, the land has been seized, an arena has been built, but very few jobs were created and there is no housing built or being built. Still, for the most part, people who should be lambasting the government have largely kept quiet and accepted the new mantra of “hoops will save Brooklyn”.
The same kind of unseen frames have a profound affect on the way in which we as a society approach medical care. Our next film is tentatively titled “Story of Pain”, and it takes a hard look at the pain epidemic that is bankrupting America, largely though an examination of the work of Dr. John E. Sarno.
Dr. Sarno, who wrote “Healing Back Pain”, is an 88 year old orthopedist who realized that the back pain patients he was seeing rarely had a structural problem, but instead a stress based one. After having little success treating patients with the conventional care that he has been taught, he pored over his patients charts and found that the vast majority of them had a history of known psychosomatic disorders such as ulcers, excema, migraines, and colitis. He developed a frame which views the pain problem as being based on repressed emotions rather than “slipped discs” or “tennis elbow” or torn rotator cuff. When he presented this frame to patients who were open to the idea that their pain might be caused by a mind body interaction he found tremendous success. He developed a treatment program based on examining patients to rule out structural abnormalities, talking with then to find out what was going on in their lives, and an education and study process to help them understand the process that was causing the pain. When he presented his findings to other physicians he was seen as a quack because a lot of what he discusses had not been thoroughly tested.
However, the vast majority of standard care practices for back pain have no studies to prove their efficacy either. Those that have been vetted have been proven to be ineffective both in terms of diagnostic testing and in terms of healing. Jonah Leher, wrote about this in Wired magazine, where he pointed out that there have been many studies that show no direct correlation between “herniated discs” seen on an MRI and pain. There have been none that prove a causal correlation. Still the imaging tools lead to billions of dollars of surgery a year, for which there is no data to prove efficacy. In general the 636 billion dollars spent on pain care this year were spent on chasing symptoms rather than solving the problem. Hence the codification last year of pain as a disease in and of itself.
I have my own personal history with Dr. Sarno’s work which gives it credence in my mind. As such when I read other stories of pain and failed treatments I view them through a frame that considers stress and situations that might cause unconscious rage. I have been following the meningitis scare caused by tainted steroids for the last few days. I know from looking at the literature that steroid injections for pain do not lead to a cure for the problem. The NIH, led by Dr. Dennis Turk, studied the pain situation in 2011 and came to the conclusion that none of the pain treatment modalities currently in use work. Studies show that steroid shots work no better than a placebo.(see below 1*) Knowing this it has been very difficult to understand how a treatment that clearly can cause harm or even death, yet works no better than a placebo, is being used as widely as it is. One lab, out of at least a thousand in Massachusetts alone produced over 17,000 doses in a week.
Dr. Sarno refers to the type of patient that is likely to have the kind of repressed rage induced back pain as a “goodist”. A classic example might be a doting husband in son-in-law who doesn’t particularly like his wife’s mother, but will do whatever he is asked to do for her. Perhaps she asked to live with them for a couple of months while her house was being repaired. She likes it so much she stays for 6 months. The part of him that always does the right thing wouldn’t even think of complaining, but the child like part deep inside is enraged. “How could she do this!! I haven’t had a moment alone with my wife for months!!” his subconscious screams. His conscious mind is so afraid of these unthinkable thoughts escaping that it slows the blood flow to his neck, depriving the muscles of oxygen. The neck spasms and his attention is diverted to the pain and the unthinkable thoughts stay unthought.
Reading the first paragraph of today’s NY Times cover story on one woman who died from a cortisone shot through this frame makes certain words jump out.
Diana Reed tried massage and acupuncture, but neither eased her neck pain. She may have injured herself while helping her husband, Wayne, who has Lou Gehrig’s disease, in and out of his wheelchair.
Her neck hurts but it’s unclear why. Perhaps she injured it performing a task that she couldn’t possibly consciously resent. However, I imagine it can become frustrating to live one’s life constantly having to take care of the needs of someone else. When one reads further the reasons she might be repressing stress and rage get even more clear.
“Diana kind of became Wayne’s arms, legs and voice,” her brother, Bob Bergeson, said.
Mrs. Reed, 56, a healthy, vigorous woman who ran or swam every day, decided to try a series of epidural steroid injections for her neck trouble. She had been laid off from her job at a nonprofit group and wanted the treatments before her health insurance ran out.
It was a decision that ended her life. She died on Oct. 3, one of more than 130 people to have contracted meningitis in a national outbreak from a tainted drug used in spinal injections for back and neck pain. So far, 12 have died.
She was laid off from her job and was losing her health care coverage. Lots of reason for stress, rage, and pain. No reason to have had the shot. I have experienced debilitating pain first hand. It is torture. The only thing I wanted when I was in that pain was to be away from that pain. Pain makes us desperate. When we are desperate we cannot make rational decisions. As such it is imperative that the medical community act with extreme rationality. When one looks at the exponential rise in the cost and incidence of chronic pain and couples it with the expansion of pain care it becomes clear that something is out of whack. It is obvious that conventional care is not solving the problem. Invariably when I read a story of pain I see plenty of details that point towards unrecognized stress and repressed rage. While my conclusions are clearly not scientific, the data clearly shows that conventional care is not addressing the issue.
1*Journal of the American Board of Family Medicine; “Overtreating Chronic Back Pain; Time to Back off” July 2008
The efficacy of spinal injections is limited. Epidural corticosteroid injections may offer temporary relief of sciatica, but both European and American guidelines, based on systematic reviews, conclude they do not reduce the rate of subsequent surgery.57,58 This conclusion is based on multiple randomized trials comparing epidural steroid injections with placebo injections, and monitoring of subsequent surgery rates.59–62 Facet joint injections with corticosteroids seem no more effective than saline injections.57,63
Despite the limited benefit of epidural injections, Medicare claims showed a 271% increase during a recent 7-year interval (Figure 1C).2 Facet joint injections increased 231%.2 Earlier Medicare claims analyses also demonstrated rapid increases in spinal injection rates.12,64 For patients with axial back pain without sciatica there is no evidence of benefit from spinal injections57; however, many injections given to patients in the Medicare population seemed to be for axial back pain alone.2
Charges per injection rose 100% during the past decade (after inflation), and the combination of increasing rates and charges resulted in a 629% increase in fees for spinal injections.2 During this time, the Medicare population increased by only 12%.