Jarrod Shapiro, DPM
The Mind Body Connection

For those of us practicing modern medicine and surgery, we like to think that the outcomes we attain with our patients are completely under our control. Do the correct work-up, identify the appropriate diagnosis, apply the correct treatment, and our patients will resolve their complaints. Right?

Maybe not.

One of the most mysterious aspects of treating other human beings is the deep visceral connection between the mind and the body. In more instances than I like to admit, this connection has been a major player in the overall success or failure of the treatments I've provided to a good number of my patients.

Here's an example. A long time ago, I treated a patient for a foot problem. Psychologically, this patient was highly anxious at all visits, including our first encounter. The number of questions asked and the level of detail required to answer these questions was much greater than the average patient. Additionally, the patient's affect was relatively flat without so much as an occasional smile. In actuality, the "smile" looked more like a grimace. At the time, I was too young and dumb to realize I shouldn't come near this patient with a scalpel, but I was overly confident, her problem seemed in itself straightforward, so I performed a surgical procedure. Despite the objective success of the surgery (all radiographic and physical signs demonstrated reduction of deformity and improved function), the patient continued to have pain.

In a contrasting example, I had a patient with a similar foot diagnosis but was completely different from a psychological standpoint. This patient was gregarious, happy, active, and nothing ever seemed to bother her. I surgically repaired her foot problem, and within two weeks of her surgery was – against my advice – hiking up and down mountains for 20 miles, three times a week. And she was completely pain free with no significant affects on her healing! I'd like to say this was all due to my amazing world-class surgical techniques, but we'd all know that would be me blowing smoke.

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I've come to the conclusion after my almost nine years of practice that both of these patients are highly indicative of the importance of the mind as it connects with the body. These patients healed or didn't heal in large part due to their own internal relationship. Of course, I had a major role to play – the particular foot problems were there and not created by their minds – but their response to therapy depended greatly on their overall demeanor and outlook.

Today, I feel I am able to predict to a great extent which patients are going to heal after my interventions and which ones will either have complications or not heal at all.

Here are a few of my personal (highly nonscientific) criteria for the red flag mind/body patient.

Red Flags to Watch Out for:

	•	Prior diagnosis of fibromyalgia.
	•	Flat or negative facial affect.
	•	Highly anxious personality type.
	•	Asking excessive questions requiring detail beyond the "average" patient.
	•	History of seeing a large number of prior doctors for the same problem.
	•	Having more than 3 or 4 "allergies", especially when those allergies are actually adverse drug reactions. For example, stomach pain after taking opioids.
	•	Highly nonspecific and nonfocal complaints that cannot be otherwise identified.
	•	Anyone with a history of risky behavior (ex, alcohol, tobacco, or other drug abuse).
	•	ANYONE who asks for pain or behavior modifying drugs on the first visit.

Anyone having one or more of these characteristics causes me to become wary.

Is there any scientific evidence about this mind-body connection? The medical literature is, in fact, increasingly pointing to a relationship here. For example, the field of psychoneuroimmunology has noted empirical findings demonstrating the following about stress¹: Alters white blood cell function, diminishing their response to infection and cancer, vaccinations are less effective, and wounds heal slower.

Similarly, studies have shown a negative response of preoperative fear and distress to postoperative recovery with both a decline in wound healing function, as well as adverse effects of pain on endocrine and immune function.² There's actually a body of literature that goes far beyond the scope of this article.

With the research evidence pointing toward a real connection between the mind and the body, what can the average practicing physician do to mitigate their own pain when dealing with the higher risk emotional patient?

Pay attention to the red flags. Watch for those patient signs that tell you trouble may be ahead.
Manage your patient's expectations. Patients should have a clear understanding of what chance of success a particular treatment will bring. Work hard to lower your high-risk patients' expectations. This will protect both them and you.
Manage your own expectations. You're not a god. If five other doctors saw this patient and none of them could help, what makes you think you're so different? Watch out.
Refer. Don't be shy about referring this type of patient to another physician, either for a second opinion or an "evaluation and treat" consultation.
Be honest and balanced at all times. All patients, regardless of anxiety or risk level, deserve your honest assessment of the situation as you see it in your professional opinion. Brutal honesty might not work, but a sincere, balanced, and caring discussion that may include the statement "I don't think I can help you" will always be in your patient's best interest.

Medical science is at the infancy of understanding the connection between the brain/mind and the body/physiology. Until more research is done, with a focus on outcomes of various interventions, we in the field will be somewhat blind and have to rely to a great extent on our own judgment, with our own flaws. The first steps are to be vigilant, learn from mistakes, and do our honest best for all of our patients. Good luck with your next patient.

Best wishes,

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
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