WELCOME to the 3rd SURGERY WITH SOUL newsletter!

My hope with this little monthly note to patients and practitioners is to not only provide valuable information but a also a spark of inspiration! If you find this newsletter useful, please feel free to share it with patients, family or friends.

This month’s note starts with a warning – it is largely an opinion  and philosophical piece on a topic I find interesting and fascinating and is not necessarily suited for the conservative thinker.It is written more for practitioners than patients but I think that patients will find it helpful too. It definitely asks for an open and curious mind – if left of center ideas does not appeal to you, this is not for you. Give it a skip and join us again next month when we look at the evidence for and advances made in breast conserving cancer surgery.

I would like to reassure you that most of the things that I will talk about this month has in fact been published by quiet reputable journals like “Nature” , “Science”,   “The New England Journal of Medicine” and their counterparts.

As a surgical practice that follows many of the principles of integrative and functional medicine while practicing evidenced based medicine, we always remain curious about and patient with the deeper underlying causes and implications of disease and pathology. We do this while we utilize the full spectrum of international standardized care: adhering to the guidelines for surgery, chemotherapy, radiotherapy, endocrine therapy etc. and decision making by a multi-disciplinary team. In my practice it is not a case of allopathic OR other health care modalities but rather allopathic AND alternative health care modalities ( in the form of nutritional counselling, Body talk therapy and TRE) — the very definition of an integrated approach to encourage the best results. Hence this brief introduction to mind-body medicine – a hot topic well worth exploring.

I got curious about this emerging view of healing a few years ago. My fascination has grown to such an extent that I completed a post-graduate certificate in Integrative Medicine. I am now convinced that everyone inside the four walls of a hospital should at least be aware of the incredible new ways science are presenting to us to think about healing. But I am getting ahead of myself.

I think there is no better place than a practice dealing with cancer patients to be amazed and perplexed by the strength and complexity of the human body. Despite our best efforts and mountains of knowledge, it really sometimes feels as if we are mere observers – watching our patients getting better or worse, unable to explain the events that pushes them one way or the other. It confuses us, presents us with exiting challenges and gives us the opportunity to openly and publically be dumbfounded. Besides our patients, we are also presented with a tsunami of fast changing information – we think we understand, only to find out that what we worshiped today as truth may be a complete fallacy tomorrow. So how do who cope? Does it even matter that we cope? How do we continue to do what we do and more importantly, how can we do it better? So I thought I’d invite you all to put on your philosophy hats, unlock a little curiosity and be inspired.

What is mind-body medicine?

Mind/body medicine, also known as behavioral medicine, is the field of medicine concerned with the ways that the mind and emotions influence the body.It examines the physiological consequences of thoughts, feelings, emotions and behaviors on health and well being and acknowledges psycho-social and spiritual factors as fundamental prerequisites to understanding the illness-wellness dynamic. This article published in the Journal of General Internal Medicine is a useful read, shedding some light on just how common the use of these modalities have become and highlights some important emerging evidence for it’s use. For a local article published in the CME, click here.

Another term that is often used interchangeably used with mind-body medicine is psycho-neuro-immunology (PNI) which is defined as an investigation of the implications of clinical disease manifestation, progression and inhibition as a result of the bidirectional relationship between the mind (thoughts and emotions), the physical brain and neurological system and the immune system. For me, this term provides a very helpful framework, especially when viewed from an integrative medicine perspective.

What do I mean by Integrative medicine?

The most important thing to understand is that the integrative model is not an alternative medicine model. It is very much allopathic medicine but it aims to provide us with an evidence based framework that is more inclusive and more flexible in an attempt to rediscover the human behind the human body. It asks of us to revisit our definitions of health and healing, to ask the question (and there is no right or wrong) whether it is time for western medical practitioners to acknowledge that we are in the business of improving cellular functioning and that a doctor is no longer  necessarily a healer.  But it also empowers us to reclaim the title of healer should we choose to, to bridge the divide that has come to separate us from our patients.

The most elementary place to start with would then be to revisit our definition of health as defined by the World Health Organization:

” A state of complete physical, mental and social well being, not merely the absence of disease or injury.”

The WHO definition is what we grew up with but is it clear and is it enough? Do we even realize what it means? Integrative medicine suggests that we expand our minds and also consider the following definition as put beautifully by Dr Maria Christodoulou:

“Healing represents an expansion of consciousness and a movement in the direction of wholeness and health. We can be healed by our illness but not cured of it or we can be cured of our illness but not healed by it. Healing may or may not result in cure”

At this point we may want to peek at functional medicine – finding root causes

The tree of the integral model of functional medicine provides a helpful metaphor and hopefully you will be able to see throughout this blog how we have evolved in understanding the tree.

Leaves – expression of symptoms and signs of disease/health

Branches – underlying system dysfunction/function

Tree trunk – underlying organ dysfunction/function

Larger Roots – underlying cellular and molecular dysfunction/function including genetics

Smaller Roots – interior environment of the patient (includes emotional, spiritual and psychological states)

Air and ground – external environment of the patient

Groundbreaking work  are currently happening  at the bottom of the tree where our finer and finer microscopes and research technology has served us very well in understanding cellular, molecular and genetic advances as well as the influence of the external environment. The one area where we seem to get stuck is the small roots of the tree: the internal environment of the patient. Most of us have always sensed (even if we did not speak about it) that it influences the health of the entire tree. The problem up and till recently was the how. How do we express the influence of our thoughts, beliefs and emotions on our bodies and health in scientifically sound terms? I believe that the  field of psycho- neuro -immunology (PNI) are increasingly providing the language to do this.

In its very essence PNI explores the cross-talk of the hypothalamic-pituitary axis and the sympathetic nervous system, with the immune system looking closely at the role of neuro-peptides , neuro-peptide receptors and neurotransmitters throughout the body.

We are going to literally skim the surface of Psycho-neuro-immunology. It is impossible to give you an in depth overview and I considered simply presenting one or two landmark studies. But after some thought I decided to really get you curious and reading, I am going to opt for the more scenic route and give you some historical background as to how we arrived where we are today in this interesting field.

Let us depart from the thought that true wisdom has an ancient heart. That there is indeed nothing new under the sun, starting with the guy that we all consider the father of modern medicine: Hippocrates. He opened a world for us where medical knowledge could finally be separated from superstitions and myths. Yet, despite finally starting to popularize the idea that very earthly tangible factors lead to disease as opposed to the punishment of the gods or the village witch, among the many quotes attributed to Hippocrates is this:

“It is far more important to know what person has the disease than what disease the person has.”

Around the same time and even earlier (600BC) was written many of the Hindu Holy Scriptures – yogic instructions and other tenants that has come to be known as Aurvedic medicine. For those of you not familiar with the term – this is the first historic notion of energy and food based medicine and forms the foundation of most eastern healing modalities. Incidentally, just to stir the pot a bit, these ancient chakras and energy meridians closely corresponds with our endocrine and more recently neuro-endocrine system. Which off course was only described in the 2^nd century by Galen Claudius Galenius.

Galenius was the first to identify the 12 cranial nerves, concluded that the kidneys produced urine and postulated in about 200 AD that women of the melancholic blood type were more prone to develop breast cancer.For those who chuckle at the thought that we ever based medicine on your sanguine or phlegmatic blood type… does the notion that type A personalities are more prone to heart disease sound familiar?

On to Descates, father of reductionism who, along with Newton, would shape our world view for centuries. Descartes was torn between 2 forces: the teachings of the church and the new science and philosophies. Unable to explain the human condition in any other way, Descartes proclaimed that the only reality lies in measuring things objectively. That human thought is a non-physical entity and the body a machine purely acting on material influences. He was however soon struck by the difficulties caused by the mind – now referred to as a “meddling ghost” in the well-designed machine. Although this Newtonian reductionist world view has brought us far, we now realize more than ever the limitations of this model of thinking – or rather we should. Unfortunately it would seem that a lot of us is still trying to get rid of “the ghost in the machine.”

This brings us into the 18^th and early 19^th century which gave us the first documented placebo controlled trial and off course, the germ theory – and mentioned these two together because I find some synchronicity in these events. The following quote is attributed to John Hagen after performing the first placebo controlled trial in 1799:

” An important lesson in psyche is here to be learnt: the wonderful and powerful influence of the passions of the mind upon the state and disorder of the body”.

Taking nothing away from the incredible gift the germ theory brought us, I came across a very interesting article published in Science in 2003. The germ theory was substantiated in the late 19^th century by Robert Koch, a German bloke , who injected anthrax into healthy sheep and noticed that they too contacted the disease and died. So from this Koch, together with Pasteur, theorized that every disease had a simple scientific cause: germs. As all new ideas go, it was off course considered very controversial. One of their critics was a strong and outspoken scientist, fixed in his belief and so convinced that they were wrong, that, genius that he was, he wolfed down a glass of water laced with cholera. To everyone’s astonishment, the man was completely unaffected by the virulent pathogen. Koch’s official response to the events was:    “ For unexplained reasons he remained symptom free but never the less wrong.” An interesting tale of the power of belief and John Hagen’s statement indeed!

Shortly after followed the discovery of nerve endings on the lymphoid tissues of the body – one of the anatomical foundations of neuro-immunology.We’ll jump ahead to the 1920’s when Harvard professor Walter Canon coined the term homeostasis with various studies looking at the relationship of perception on the autonomic nervous system and the recognition of the fight or flight response.

Following Cannon’s work was that of Hans Seyle, student of both John Hopkins and McGill universities and researcher at the university of Montreal who experimented by exposing animals to different physical and mental adverse events. He noticed that under these circumstances the body consistently adapted to heal and recover. Several years of experimenting formed the empiric foundation of what came to be known as the General Adaptation Syndrome. The syndrome consists of enlargement of the adrenal gland, atrophy of the thymus, spleen and other lymphoid tissue often accompanied by gastric ulceration. Seyle described 3 stages of adaptation including an initial brief alarm reaction, followed by a prolonged period of resistance and terminal stage of exhaustion and death. This foundational work lead to a rich line of research on the biological functioning of glucocorticoids that is still continuing today and is one of the corner stones of psycho-neuro-immunology.The late 1940’s and 50’s would subsequently deliver the first research articles explicitly linking psychological factors to immune response. Although the study population could be criticized one of the first of these studies reported a decreased number of circulating lymphocytes and poorer antibody response in psychotic and/or depressed patients when immunized against pertussis when compared to a control group.

In 1964 George Solomon from the University of California finally coined he term psycho-neuro-immunology and published a landmark paper called “ Emotions, immunity and disease: a speculative theoretical integration.”

In 1975, Robert Ader and Nicholas Cohen, who is more often referred to as the fathers of psycho-neuro-immunology, was investigating conditioned responses (much like Pavlov’s dogs) in rats. To condition the rats, they used a combination of saccharin laced water (the conditioned stimulus) and the drug Cytoxan which unconditionally induced a brief period of nausea, taste aversion and immune-suppression. Ader was surprised to discover that after conditioning, just feeding the rats the saccharin water was associated with the death of some animals and proposed that they have been immune-suppressed  purely by receiving the conditioned stimulus. Ader, a psychologist, and Cohen, an immunologist directly tested this hypothesis by immunizing conditioned animals and unconditioned animals as a control group. They went on to expose both groups to the conditioned stimulus (the sugar water) only and measured the antibody response to immunization. Their theory was confirmed and these highly reproducible results was one of the first widely recognized experiments showing an explicit link between the nervous system, perception and immune system.

Enter Candice Pert, a brilliant but difficult Nobel prize nominee who first discovered opioid receptors and a few years later was part of a team that isolated neuro-peptides and neuro-peptide receptors. In 1985 this PhD neuro-pharmacist at the National Institute of Health at Georgetown University also revealed that neuro-peptide specific receptors are present on the cell walls of the brain including the hypothalamus and pituitary gland as well as all the organs of the immune system. She continued to subsequently publish various articles suggesting mechanisms through which emotions (intentional and unintentional) and the immune-response are deeply interdependent. She affectionately referred to her staggering discovery of neuro peptides as the discovery of the molecules of emotion and the term mind-body came to be widely recognized. If you are interested, I would strongly recommend reading her book “Molecules of emotions”.

Psycho-neuro-immunology was well on its way and the first metanalysis of PNI studies was published in 1993 by Herbert and Cohen. Looking at 38 studies examining immune function in healthy adults exposed to a psychological stressor, they found a consistent increase in total white cells and decrease in the number of T-helper cells, B-cells and natural killer cells. They also reported  stress related decreases in Natural killer cell and T-cell function. The 2^nd metanalysis was published in 2001 by Zorilla et al, analyzing 75 studies and yielding the exact same results with regards to circulating neutrophils, T-cells, cytokines and Natural killer cells.

That, in a nutshell and very simplified gives us some of the ingredients of this beautiful system called psycho-neuro-immunology.It is clear that we are finally beginning to get a glimpse at understanding the “how” in the roots of the tree.Pharmacological intervention is where the money is, so the largest body of research in the field is currently looking at manipulating the process pharmacologically specifically neurotransmitters like dopamine and serotonin as well as cytokine modulators. There is however also a growing support for research into the psychological manipulation of the process.

One of the fastest growing fields of research is indeed into an entity well known to all of us since med school: the placebo effect.Now this might be a controversial statement, but given all that we have spoken about today, one could probably argue that healers through-out the history of medicine might in actual fact have been partially depending on this phenomenon. I mean, if you look at the obscure treatments that we have subjected patients to over the years from the extremes like bloodletting to the administration of certain drugs – patients actually got better in spite of us. Although recognized for centuries, it is only now that we are really turning our attention to the possible therapeutic insights and benefits might be offered by the placebo effect as well as nocebo effect. And it is now well-established that even the most concrete of medical interventions can foster a placebo effect. I present to you, orthopaedic surgery and probably one of the post published and talked about placebo trials.

A well respected UK orthopaedic surgeon, Dr Mosely, tackled a simply study in 2000 looking at the benefit and specific therapeutic value of knee arthoscopy and surgery for patients with debilitating knee pain. 180 patients were selected and scored exactly the same in terms of pain, functionality and radiological findings. They were randomly divided into 3 groups – the patient and the final post surgical assessors all blinded as to which procedure the patient was undergoing. The three surgical treatment options were:

1. Athroscopic lavage
2. Athroscopic debridement
3. “Fake” surgery – simulated theater environment, receiving anesthetics and two incisions made as for the laparoscopic ports and just sutured closed without any procedure done.

The results were published in the New England Journal of medicine in 2003 and has subsequently been reviewed and discussed on various panels. The results: there was absolutely no difference in outcome – the placebo group regained as much function as the groups receiving lavage and debridement and in a few individual cases even more function.

And then there is the quantum leap that I am not even going to attempt to explain. But there is mathematical geniuses out there that is using the quantum zero effect to explain the energetic charge of thought and its subsequent stimulation of neurotransmitter and neuro-peptide release and giving us a glimpse of that last little bit of scientific language that we need to get to the roots of the tree.

If you are interested in understanding more I suggest reading “The mindful universe: quantum mechanics and the participating observer” by Dr.Henri Stapp , “Quantum Healing” by Deepak Chopra and “The Biology of Belief” by Prof Bruce H Lipton.

Medicine is science but it is also an art.  If you remember nothing about this very long post but maybe the following few philosophical points:

1. That true wisdom has an ancient heart, that just because we don’t always have the up-to-date language to explain something, it does not mean that it is necessarily wrong.
2. That saying that we worship at the altar of science is no longer an excuse to avoid the human and softer qualities of healing that we find so difficult to quantify. Science is now providing the language to explain miracle and myth as fact. We cannot stick our heads in the ground. We are obliged to read more, to remain curious, to at least attempt to understand what this quantum world offers beyond the Newtonian one that we are so damn comfortable in. Otherwise we will surely fall behind and no doubt be called fools by future generations.
3. That the only solution to a health care system that has lost public trust is health care workers that are well enough to care.
4. To always keep an open mind, to constantly revisit our clinical decisions by asking is it ethical, is it humane, is it evidence based? To maybe be more mindful of what we say around a patient’s bed and how we say it and finally, to look after ourselves so that we can look after others.
5. As a young and impressionable student at UP I was once told by our head of surgery: Liana, the surgeon is the captain of the ship! So naturally I wanted to become a surgeon. Even though I love surgery and I don’t for a minute believe that my scalpel will become redundant any time soon, I have learned that whether we like it or not, whether our patients like it or not, the only captain of the ship is in actual fact the patient. And the best first mate to help get the ship through stormy waters in the future is not going to be the surgeon or physician or intensivist or GP but the integrated practitioner who, regardless of his/her specialty, can recognize the intricacies of the tree called a human life. Who can mobilize a team to support this tree, who are comfortable with the discomfort of a fast evolving science and who are capable of looking after him/herself.

I sincerely hope you enjoyed this little dive into the murky but marvelous waters of mind-body medicine and that you have been inspired to explore more! We would love to hear your comments – let us know what you think.

Until next month.

Liana