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Robert C. Smith is best known for arguing medicine lost its mind. This episode he explains why he is still proud to be a doctor. Primary care physicians deliver 75 percent of the nation’s mental health care without training for it, and Smith has spent his career trying to fix that. But before the fix, he makes a case that may surprise his own readers: modern medicine has been astonishingly effective at what it was built to do. This episode is based on his article “How the mind-body split in medicine shaped modern clinical care,” published on KevinMD. You will hear how 2,500 years of four humors and bloodletting gave way to a physical-disease framework that doubled life expectancy from 40 to 80. You will also learn why that same framework now leaves psychiatry stalled. Hear why the reformer who wants to overhaul mental health care still says medicine has never been better at the thing it was built to do.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Robert C. Smith. He’s an internal medicine physician. Today’s KevinMD article is “How the mind-body split in medicine shaped modern clinical care.” Robert, welcome back to the show.

Robert C. Smith: Kevin, thank you. Nice to be here.

Kevin Pho: All right, so tell us why you decided to share this particular article on KevinMD.

Robert C. Smith: We’ve talked, you and I and others, and in my book “Has Medicine Lost Its Mind,” have talked lots about the problems of mental health care and the fact that medicine has not trained people like you and me and all the other primary care doctors in mental health care. It’s not our fault.

So what I want to emphasize today is what medicine has done for us that has been quite effective. That is how skilled we have become in physical diseases. And to kind of go through some of that backdrop, we can be justifiably proud of our heritage in physical diseases, and I think it’s worth emphasizing that. We hear a lot on the other side these days, but medicine has been incredibly effective.

Kevin Pho: So you wrote in your article that there’s a mind-body split. So we are great at diagnosing and treating physical disease, but I infer from what you’re saying that the mental part, the psychological part, is still lacking.

Robert C. Smith: That’s right. The psychological part is still lacking and we have a major mental health crisis. And as we talked in one of our earlier shows, it is not getting any better, and simple reason is that medicine does not train the doctors who provide the care. That’s primary care docs like you and me. We provide 75 percent of all mental health care. But we weren’t trained to do it.

Kevin Pho: So in your article you talk about the history of the mind-body split in medicine. So for those that don’t get a chance to read your article, tell us more about that.

Robert C. Smith: Sure. Backtrack now to Hippocrates in the fifth century BC, some two and a half millennia before modern medicine began. The guiding theory for that two and a half millennia, this is now up until the 16th, 17th century scientific revolution, the guiding theory of medicine was a so-called four humors: black bile, yellow bile, blood, and phlegm. And the idea was that if these four humors, I’m using my fingers to demonstrate it, but these four humors, basically if they stayed in balance, that was health, like my fingers. On the other hand, if one of them went out of whack like that, that was disease that caused symptoms, disability, and death. And that was their understanding for two and a half millennia of disease and death.

And of course, as everybody knows, the treatment was bloodletting. And the idea was that if that humor is out of whack, let’s say that’s black bile causing depression, if that was out of whack, they had to draw blood off to redress the imbalance. Of course, everybody knows it didn’t work and they killed literally millions of people doing this, some of our famous presidents, in fact.

And so that was the basis of all medicine up until the 16th century, and at that point, science was starting to get some traction. Prior to that, over the entire preceding 1000 years or so, the Catholic church had ruled medicine with an iron hand, as well as all of society, and they had prohibited anatomic dissections of human bodies. They thought it was blasphemous, but science at this point was gaining some traction. They wanted to get going. This is happening in physics and chemistry elsewhere as well. And so medicine was insisting they do human dissections. And finally, in 1537, Pope Clement relented and allowed human dissections.

This is what led Andreas Vesalius in his famous book, “De Humani Corporis Fabrica,” it’s also known as just the Fabrica, where he described his findings in human dissections. And this turned over thousands upon thousands of years of prior misinformation that was gained from dissecting goats, pigs, and the like. And so this was a dramatic change at this time.

Now that was the beginning of modern scientific medicine, but that was just basic science. Come along now, moving up to the middle of the 1700s, middle 18th century, clinical medicine now started to pick up this isolated focus on physical diseases that stems from the mind-body split. And I need to emphasize that up until the turn of the last century, till the 1900s, the treatment never did change from bloodletting. And we’ll talk more about that. But so far with anatomy, we have only the advances in basic science focused on physical diseases.

Now comes Giovanni Battista Morgagni in the mid 1700s. He made some interesting observations. He did 700 autopsies and correlated them with clinical findings. He had clinical notes, people he’d seen and others, and he starts scratching his head. And remember at this time, they now knew they were doing human anatomy, so they knew what a normal liver or a normal lung looked like. And they were scratching their head and they say, “Oh my gosh, that liver doesn’t look normal. It’s big. It’s got growth on it and it’s bloody. This patient had pain right there in that right upper quadrant of the abdomen where the liver is, and they were sick to their stomach and vomiting. That must be the disease.” He deduced that’s causing the symptoms, disability, and death of these patients.

We know this today as clinical pathological correlation. It’s old hat to us, but at that time it was revolutionary. That was where the concept of the four humors was laid to rest. Notwithstanding that people continued bloodletting after that, but this was where it was first laid to rest and replaced by clinical pathological correlation, which is the basis of medical education today.

And so at that time also, clinicians, now realizing that symptoms led to an underlying physical disease, started focusing just on physical symptoms. They started scrapping their interest in what job you had or how your life was going or your emotions, and they focused just on physical symptoms to get to the underlying physical disease. And physical examination became quite prominent at that time too, understandably.

So with that, medicine is now progressing diagnostically but still not therapeutically. And so bloodletting continued up until the 1900s, and many people may be surprised, but in William Osler’s 1912 textbook, it still says something to this effect: “For people with pneumonia, the extraction of 20 to 30 ounces of blood is in every way beneficial.” This is from Sir William Osler, who I’m sure Kevin agrees that most of us would view as the most eminent clinician of all time. And so he is still in 1912 advocating bloodletting.

But perhaps for good reason. There was no other treatment at that time. There had been no effective treatment in the history of medicine up until this time, and it’s now transitioned to what happened at the end of the 1800s. The chemical industry, not physicians, started discovering drugs like various opioids, and aspirin, and soporifics. And so medicine started to have some traction then with these medications.

But the real change came in the early part of the 1900s. Chloroform, ether were discovered. This led to dramatic changes. Surgery: people could now be operated on, have a leg amputated, a tooth pulled without being overdosed on alcohol and held down. Penicillin was discovered, sulfa was discovered. People were now living who previously had died in three or four days of, say, sepsis or something like that. So this was strange, but this was just the beginning.

Following that through the entire 1900s, just a cornucopia of dramatic changes took place that many of us experienced. Medications, beta blockers, statins, we now have GLP-1 agonists. Look in diagnostics: X-ray. OK, now we’ve got MRIs. We’ve got genetic analyses, surgical advances. We’re transplanting hearts, livers, kidneys, lungs, pancreas. All of these dramatic advances in the last century led to the first ever impact of medicine on health. Life survival doubled from 40 years of age to 80 by the end of the last century. That is an absolutely dramatic improvement that we had never seen before.

And so it is in this sense that medicine can be justifiably proud of what we’ve done. Sure, we’ve got problems yet to do, and we’ve shown with our capacity to address physical disease this effectively that we have the capacity to now expand our scope into mental health and prevention. And so Kevin, I think we need to understand this. Medicine’s coming under attack from all directions these days. But medicine has done a good job, and at least I feel quite proud to be a physician and to have been trained so well and being simply a small part of all of the success of physical disease medicine.

Kevin Pho: So historically, as we’ve had so many advances from the physical medicine standpoint, have there been any advances from the behavioral and mental health side, or has that section been completely ignored?

Robert C. Smith: That’s a good question and a painful one to answer. Thomas Insel, I’m sure you know, he’s the former director of the National Institute of Mental Health. He says, and I agree, there have been no significant improvements in mental health care in the last 25 years. And this largely stems from the fact that psychiatry has this disease focus that we’ve just talked about that’s been so effective in physical diseases. But psychiatry has had the same idea that some disease in the brain is causing mental disorders, and it is still, that is still the predominant direction of psychiatry. The problem is they have found no diseases causing mental disorders.

And so psychiatry has lagged behind, and the idea is probably that, well, physical disease medicine benefited tremendously from this disease direction, we need to expand our scope to start including the psychological, the social dimensions, to explain why we have psychiatric disorders, because they’re not due to diseases. For example, among psychiatric disorders, there’s a tremendous history of trauma. Childhood trauma, a history of social factors like crowding, poor housing, lack of finances. And so these psychological and social factors have to be addressed. Many people are starting to view the brain not as a source of disease, but as simply an information processing system where all of these things come together, but they, including the physical, are also going to have to be put together to better understand psychiatric disorders.

Kevin Pho: So as we move forward, and hopefully we can shift more of our focus onto the psychiatric realm, what do you envision that looking like?

Robert C. Smith: Yeah, what has to happen, and we can kind of link this to what we were just talking about in physical disease. The Flexner report in early 1900s established that medical education would focus on clinical pathological correlation for physical diseases. That unfortunately led to simply 2 percent of total teaching time addressing mental disorders and other psychological and social factors, and that persists yet to this day.

So the thing that has to happen is to change that. We need to bring psychologists into medicine. They right now are outside medicine. We need to train vastly more psychiatrists, and especially we need to train the doctors who are providing 75 percent of all mental health care. That’s primary care docs like you and me. We’re not trained.

And so this is the next step that is yet to come. And as we’ve talked before, Kevin, medicine is pretty resistant to this. They are locked into this physical disease, clinical pathological correlation mindset. We need to keep that, for sure, but we need to expand it from a physical disease focus to integrate psychological factors and social factors, and then bring them all together. This will provide better mental health care for certain, as well as better physical health care.

Kevin Pho: We’re talking to Robert C. Smith, internal medicine physician. Today’s KevinMD article is “How the mind-body split in medicine shaped modern clinical care.” Robert, as always, we’ll end with some take-home messages you want to leave with the KevinMD audience.

Robert C. Smith: Yeah, my book “Has Medicine Lost Its Mind” has two chapters on what we’ve been talking about today, on what you might call the glories of physical disease medicine. Medicine has been incredibly successful and we must never forget that.

Kevin Pho: Robert, as always, thank you so much for sharing your perspective and insight. Thanks again for coming back on the show.

Robert C. Smith: Kevin, thanks for having me.