There can be many facets to being a doctor beyond the obvious diagnosing and treating disease. During a typical week, I can be involved in clinical work yes, but also leadership roles, service evaluation and development, academic work and teaching.
Of all my roles, I think it is educator I enjoy the most. This can include formal teaching, such as in the lecture theatre at the medical school or in a group tutorial for trainee doctors, but it can be less formal ad hoc teaching as well, often known as bedside teaching (despite the fact I never actually see patients at the bedside in my job as a community psychiatrist). Often teaching will be given to medical students or junior medical colleagues. On occasion I will speak to other professions such as nurses and psychologists. Rarely, and most nerve-wrackingly (is that even a word…) I will teach other consultant peers. What might be less obvious, I also have a role teaching my patients, their families and carers.
Educating patients and families about their health and wellbeing can take a variety of forms. Most commonly it will in some way involve discussing healthy living choices, such as diet and exercise options. At other times, I might explain a medication to a patient, how it works and what the side effects are. On occasion, I find myself exploring what a mental illness is, how it can present in people and linking this to the symptoms they are experiencing which has led them to my clinic room.
Recently, I found myself in a discussion with a patient which explored even more fundamental issues, namely how the brain worked. The patient seemed curious of the underlying mechanisms of the brain, in his case with a particular focus on neurotransmitters and their role in brain function. Fortunately for me, he came from a position of only a basic understanding to begin with, so I did not need to attempt to recall too much of the intricacies and detail to provide him with a satisfactory answer.
After I had finished my outline of the brain, he asked me a follow on question which threw me; why does my brain work differently [to everyone else]?
Brain: the final frontier
At first glance, it might appear obvious why I would find this question so difficult. Despite a century and more of fantastic work in neuroscience and psychology, we have only begun to scratch the surface of understanding how the brain works. Yes, we can describe structures in the brain, neural pathways, cell functions and how the brain can go wrong, but we are far from being able to provide a complete model to explain the brain. And when it comes to illness, we have some understanding of risk factors for getting a disease, but why some people with risks develop a disease and others do not is currently beyond us.
Take Alzheimer’s dementia as an example. We know many of the risk factors for Alzheimer’s (age being the most important and unfortunately the one we can do nothing about), and we can describe some of the many changes seen in patient’s brains (shrinkage in certain areas and a build up of abnormal proteins for example). What leads to one older person with some brain shrinkage developing dementia while others do not is currently unknown. To make things more confusing, symptoms similar to Alzheimer’s dementia can be seen in people who are not necessarily old, or don’t have the classical features in their brain.
The brain is by far the most complex organ in the body. The vast number of connects between nerve cells make for a complicated machine for which we understand only the fundamentals. When a patient asks why their brain is working differently to other people, I can give vague answers about risk factors and neurochemical imbalances (a phrase so meaningless in my view I try my best to avoid using it at all). What I cannot give is a concrete understanding of the exact mechanisms in their brain which are working differently to lead to the problems they are experiencing. As a doctor, the gaps in our knowledge can be as interesting as the bits we do know. For the patient, I appreciate the vague answer is likely to be disappointing and frustrating.
I am me?
Everything I have said in the last section is true. What I failed to mention, it is not the actual reason I found myself stumped when the patient asked me why his brain worked differently. The implication in his question was his brain worked differently from everyone else. My problem in answering this, everyone’s brain works different from everyone else.
This statement might appear so obvious as to not be worth mentioning. Everyone has a brain which is slight different in its structure, has experienced slightly different life experiences and functions in slightly different ways from the person next to you. I wrote just last week about the similarities between us being vastly greater than the differences. This week, I want to contradict myself by talking about our differences. First, a (relevant, I promise) tangent.
The science of spheres in a vacuum
There is a cliché about physicists which suggests they will always simplify any calculation they are making to that of spheres in a vacuum. If you want to understand the forces acting on a plane in flight, for example, you first need to remove all the complicating bits of reality like the plane, air and even the Earth and consider a simple sphere moving through a vacuum.
Like all clichés, it is an exaggeration, but equally, there is a grain of truth in the idea. The universe is a complex place. Our hypothetical plane has thousands of moving parts, is travelling through a substance (the air) consisting of billions of molecules, while the complexities added by the Earth below are of another magnitude entirely. To have any hope of being able to describe, let along understand, the flight of the plane, it is important to simplify things as far as possible.
Simplification is done all the time in science. A set of assumptions are made, such as the plane being a certain shape, which might not exactly match with reality. What it does allow is the simplification of the mathematics needed to explain the phenomena being investigated. Oversimplify things, and the results become meaningless, but find the right balance and it can allow for profound and useful conclusions to be drawn.
The study of psychology is no different to physics in this respect. Decisions have to be made when it comes to an experiment to remove bias and what are known as confounders. Take for example an experiment looking at memory. A psychologist might want to test how someone remembers new information. To make this as fair as possible, they will need to choose something no participants will have seen before, so participants might be asked to learn made up words. Researchers will also want to reduce distractions, so the experiment will take place in a quiet room without other people around. Finally, the scientists will not want to give advantages to people who are good at learning by long periods of repetition, so they might limit the time participants have to learn the new words.
Everything I have described above would be the start of a perfectly good memory experiment, but clearly it is removed to a degree from the real world. When we learn new things in real life it is often in a busy environment, how long we have will vary, and the information we are learning will have some context or meaning to it. This experiment might be useful in helping psychologists determine a particular mechanism for how we remember, but how applicable the information is to people in the real world is debatable.
After completing the experiment, psychologists will then use a variety of statistical techniques to combine the data from all the participants involved, and derive an average participant (apologies to any statisticians reading this, I am aware I have over-simplified to the limit of acceptability). We could imagine our experiment above had two groups with one difference between them, say the words being printed in black or blue ink. At the end we could look at the number of words remembered by each group and determine whether black or blue ink is better for learning (in case you are wondering, it appears red ink is superior to both black and blue).
Our experiment would give us an indication of how well on average people do in each group, and with a big enough sample of participants you could tentatively suggest this applies to the general public. The problem, this approach does little to take into account outliers. Without going into too much detail about normal distribution here, in brief people’s abilities in any task will fall on a curve, typically a bell shaped curve. Some people will be really good at a task, some people will struggle, the majority of people will sit somewhere in the middle. In a psychology experiment, we have to try and combine this spread of people into a meaningful answer to the question we asked, and inevitably in doing so some of the variability between people is lost.
This happens all the time in science. Think back to our flying plane example. Every time a plane flies, it will follow a slightly different path to those before it. Some planes will have to travel much higher, others lower, some faster, some slower (sorry about the rhyming…). When doing an experiment in physics (or any other part of science) it is important to repeat it over and over and then combine the results for our average.
Doing this in a physics experiment is not controversial. Testing the same item over and over is important, and it does not matter whether the experiment uses the same plane each time, or a different plane depending on the needs of the researchers. Where things I think become controversial in psychology, is using individuals, combining their data together and coming up with an average person. Information about the individual is inevitably lost in this process, and I suspect for some people this invalidates the results entirely.
When I treat a patient before me, I am interested of course in their individual life story, the symptoms they are experiencing, and how this is impacting on their life. Knowing my patient as an individual is crucial.
At the same time, I also need to apply what I know about groups of people to the patient in front of me. Are the group of symptoms this patient is experiencing similar to a recognised group of symptoms (a disease) which others have experienced? From this, can I suggest a course of treatment which works for the majority of people, given the scientific evidence available? By understanding how a disease presents for the majority, and what treatments are likely to work for most, I can apply this to my patient while trying to take into account the individual and how they may respond differently to the average person.
Concerns that psychology (and by extension psychiatry) care little for the individual have been present as long as psychology has been a speciality. Differential psychology is an attempt by interested researchers to understand the individual and their thoughts and behaviours, at times at odds with the majority of psychology which is interested in the individual as part of a group. Within medicine, the hallowed goal of individualised medicine (medical treatments adapted to your particular biology, typically genetics, with a view to providing a more effective therapy with fewer side effects) is in its infancy, but will likely become more common in the next couple of decades.
Science, by its very nature, attempts to develop a generalised understanding of the world around us. Psychology and brain sciences are no different, yet find themselves coming up against the desire to consider ourselves an individual. The challenge for psychiatrists like myself, but also anyone with even a passing interest in their brain and how it works, is to balance our understanding of the average person gained through psychological research with the individual differences we see in each and every one of us.
Returning for the final time to our plane analogy, the situation is no different for the pilot flying the plane. Of course it is crucial the pilot knows how planes (in general) work, but more so it is important they understand the plane they are flying at the time. Whether the experiences of our brain are akin to a pilot flying a plane is probably stretching the analogy a little far (I’m not going to get into a mind-body debate with myself here…), but it has served us well in demonstrating the balance throughout science between the individual and the group.
Despite my difficulties in answering my patient’s question, answer him I must. I thought it would be fitting to end this post with a version of what I told him. He appeared satisfied with my answer. Hopefully you will find some benefit in it too.
Every brain works in slightly different ways. Every brain has things it does well, and things it finds more difficult.
While everyone is different in small ways, we also have lots of things in common, ways our brains work just like everyone else.
For some people, their brains can work in a similar way to a small group of others, but different to the majority of the population. Brains which work this way can often be grouped together and given a label. What this does not change is any one person within the group, and it does not change the fact they will have as many unique differences from this group as they have similarities.
Sometimes, our brain stops working the way it is supposed to. This might be in a small way, or it might be a bigger problem. When problems in our brain start to impact how our bodies work or how we live, we call this a disease. When we have a disease, we often need help to feel better again.
Fundamentally, no matter how our brain is working, how similar or otherwise we are to other people, and whether our brains have a problem or not, we are all individuals who are both similar and different to each other at the same time. Most of all, that is entirely OK!