Dr. Jeff Kane: On taking a history
My most memorable medical school professor, Dr. Elsie Giorgi. advised me, “Listen to your patients well enough, and they’ll tell you exactly what’s going on.”
Indeed, sometimes docs actually do listen that well. Take Vincent Felitti, a doc at Kaiser Permanente in San Diego. After almost 300 people dropped out of his obesity clinic, he interviewed them to learn why, and discovered in the process that a majority had experienced childhood sexual abuse. He wondered whether weight gain might be a coping mechanism for depression, anxiety, and fear. So he and colleagues devised a much larger study in which they interviewed seventeen thousand people about their childhoods.
They asked them specifically about Adverse Childhood Experiences (which they called ACEs). These included emotional, physical, and sexual abuse, household dysfunction like family violence, alcoholism, imprisonment, and mental illness, and emotional and physical neglect. Patients were assigned a point for every ACE in their history. Then they were monitored over the next fourteen years for medical visits, hospitalizations, drug use, death, and other factors.
High ACE scores (that is, more adverse events) correlated perfectly with increased incidence in adulthood of drug and alcohol abuse, liver and lung disease, cigarette use, depression, suicide, memory impairment, number of prescriptions filled, and, fascinatingly, number of unexplained symptoms. The study is being continued. At this point the oldest patients in the study—the ones who’ve lived longest—have the lowest ACE scores.
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Numerous other studies confirm that trauma at any age can dent well-being. The American Psychological Association, for example, published a study showing that employees who enjoyed collegial support and positive social interactions at work were less likely to die over a twenty-year period than those who reported a less friendly work environment.
It’s widely recognized that experiences can affect health. We don’t often discuss it, though, since it raises uncomfortable issues about our personal involvement, like: You mean I somehow helped create my illness? Why on earth would I do that? Are you saying I’m faking or crazy and need to see a shrink?
Hopefully in this twenty-first century we’ll recognize that every illness is real, and that the mind isn’t just an innocent bystander. Sure, some illness might occur randomly, but the entire history of science amounts to teasing patterns from apparent randomness. We can’t learn whether an instance of illness expresses previous experiences like ACEs though, unless we ask patients about their lives. If we docs were to value their histories as skillfully as we assess their chemicals—that is, if we attended to their minds as thoroughly as their bodies—we’d develop more effective ways to understand and treat them.
Jeff Kane is a physician and writer in Nevada City.
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