An Outstanding Paper on Atrial Fibrillation

 

I have been fascinated by atrial fibrillation since I was a third-year medical student. I was doing a Medicine rotation and examining a middle-aged man.  Listening to his heart sounds was the first time I heard the irregularly irregular heart rhythm characteristic of atrial fibrillation. It was such an outrageous and unexpected sound compared to what I was used to that I felt a little panicky. Why wasn’t this patient experiencing more symptoms and even more unexplainably – why doesn’t he sense that there is something wrong with his heart beat?  Since then, I have treated hundreds of patients with atrial fibrillation.  I ask them all if they can sense the irregular heart beat and in the people I see about half of them can.  Being a psychiatrist, diagnosing and treating atrial fibrillation is technically not my “job”.  But it is currently such a prevalent condition that a brief examination typically triggered by vital signs and noting a pulse irregularity followed by an electrocardiogram is all that is needed. Atrial fibrillation has considerable mortality and morbidity associated with the most feared complication of stroke. A good friend of mine developed renal failure from a combination of atrial fibrillation and atrial flutter and required ablation procedures to restore normal sinus rhythm.  Two relatives had strokes associated with atrial fibrillation resulting in disability and ultimately death. Both had atrial fibrillation for about 30 years.  One of them was 92 years old, using digoxin for rate control, and not on anticoagulants. The other was 92 years old, using diltiazem for rate control, and on warfarin at therapeutic doses. He had two strokes about 10 years apart on the warfarin and multiple episodes of nuisance bleeding or excessive bleeding from minor injuries due to anticoagulation that did not require medical attention.   Another friend had pulmonary complications from an antiarrhythmic drug that he was taking for a new onset of atrial fibrillation and died as a result of those complications. Sixteen years ago – I developed lone atrial fibrillation while speedskating and have been on antiarrhythmics since that time.

When you see all of those problems associated with a condition and have had it yourself, you tend to read more about it than the average person.  Reading about atrial fibrillation is generally a frustrating task. The evidence base for treating the condition seems to be in a state of flux. For years the research seemed to say that rate control and rhythm control led to equivalent outcomes. When life style measures were included, the rhythm control strategies seemed superior. Even the question of anticoagulation with novel oral anticoagulants of NOACs for stroke prevention based on a scoring system has been called into question recently.

That brings me to the topic of this blog post and that is the single best summary of information about atrial fibrillation that I have seen anywhere - at least for nonspecialists in that area.

The paper was written this year in the New England Journal of Medicine (1). It starts out with a case description of a 63-year-old man with a new onset of atrial fibrillation. The authors discuss the disease in detail and treatment recommendations consistent with their discussion. What I really like about this paper is that they are discussing phenotypes of atrial fibrillation and I do not see that happening very often in real clinical situations. The phenotypes they discuss are paroxysmal atrial fibrillation, persistent atrial fibrillation, and long-standing persistent atrial fibrillation.  They have an excellent figure in their paper that was unfortunately prohibitively expensive for me to try to post here, but the basic idea is that there are distinct anatomical and electrophysiological substrates for each of those phenotypes. In the paper the phenotypes are labeled as “clinical profiles”. His phenotypes have prognostic considerations since the authors make the point that there is a gradation in the likelihood of conversion to normal sinus rhythm and maintaining that rhythm with paroxysmal atrial fibrillation being the most likely to convert and maintain a normal sinus rhythm and long-standing persistent atrial fibrillation being the least likely to convert. Just knowing that much about atrial fibrillation is a significant advance compared with most of the clinical discussions that I hear.

The second feature in this paper that I really like is that atrial fibrillation is not necessarily a benign condition. For years the discussion has been controlling the rate or rhythm and in most cases they have been considered to be equivalent. Many clinicians have their first experience with atrial fibrillation like I had. They are doing a physical examination outpatient for another reason and they notice they are in atrial fibrillation. Depending on physiological factors that patients irregularly irregular heart rate may already be rate controlled. I have talked with many people over the years who knew that their heart rate was irregular because their spouse noticed it and they did not do anything about it for years. Atrial fibrillation is a risk factor for embolic strokes as well as dementia, death, and heart failure. Persistent tachycardia can cause cardiomyopathy and reduced cardiac output can lead to renal failure.  The authors suggest that a heart rate of 110 bpm or greater might lead to cardiomyopathy but they also suggest it can occur at a lower rate. This is an interesting observation because the most recent review in UpToDate on sinus tachycardia suggests it is generally a benign condition, however an irregular tachycardia because of reduced cardiac output is likely a different matter.

In addition, the patient can be symptomatic from reduce cardiac output with lightheadedness, dizziness, fatigue, decreased exercise tolerance, palpitations, hypertension, and an exacerbation of symptoms of underlying coronary artery disease. The lesson for psychiatrists is if you notice that a patient has atrial fibrillation it cannot be approached casually. Atrial fibrillation is associated with significant medical comorbidities such as underlying structural coronary disease, obesity, sleep apnea, hypertension, hyperlipidemia, and diabetes mellitus. If the patient has had limited contact with primary care physicians the comorbid conditions may have gone unnoticed. It makes sense to ask about additional symptoms in the review of systems as well as family history and whether that patient is seen primary care physician or cardiologist recently.  I would have no problem referring a patient with tachycardia, expected symptoms, or risk factors to an emergency department for acute stabilization if I could not get them seen in a primary care clinic.

The authors go into treatment of atrial fibrillation as basically a rate control strategy, a rhythm control strategy, and a strategy to address comorbid medical conditions.  They review rate control with beta-blockers and calcium channel blockers and prefer beta-blockers. They consider a number of antiarrhythmics and the risks and benefits of those medications.  They consider catheter ablation - either radiofrequency pulmonary vein isolation or cryoablation as being more effective for treating and preventing recurrent atrial fibrillation. The recurrence rates are relatively high even after the ablation procedures, so continued antiarrhythmic medications may be necessary.

Once a patient has stable treated atrial fibrillation, the main task for the psychiatrist is to make sure that any prescribed medications do not interfere with the cardiac medications at either the pharmacokinetic or pharmacodynamic level. QTc prolongation is a primary consideration since several of the agents used prolong the QTc interval or affect other cardiac conduction.  At the pharmacokinetic level there is the possible risk of decreased metabolism of beta-blockers and increasing bradycardia and hypotension. If I have any doubts all about medication combinations I am usually in touch with the patient’s cardiologist or primary care physician before making those changes. All of the patients I see with atrial fibrillation also have their blood pressure and pulse taken at every visit along with the description of symptoms and potential medication side effects. That means I never practice in an environment where I can't do that. I will also review how well their comorbid conditions are being treated particularly hypertension, sleep apnea, and diabetes mellitus. I will provide them with concrete advice on how to approach those problems and whether or not they need to be seeing their primary care physician sooner than scheduled.

This is also an opportunity to discuss any comorbid substance use problems. Alcohol is a definite precipitant of atrial fibrillation. I have had patients never experience another episode by stopping alcohol. I have also had patients report that they can tell when their alcohol level reaches a certain point because they will go into atrial fibrillation for several hours until that alcohol is metabolized. Stimulant medications are also a risk because they increase sympathetic tone, increase heart rate, increase blood pressure. All three of those changes can trigger an episode of atrial fibrillation.  Cannabis can have a fairly potent sympathomimetic effect by acutely lowering blood pressure leading to a reflex tachycardia. Atrial fibrillation has been reported as one of several cardiac arrhythmias associated with cannabis use (2). Interestingly, the authors of the NEJM article state that caffeine is not a precipitant. There are no qualifiers on that statement and I think it is based primarily on epidemiological evidence. Caffeine intake is always important to quantify because of its wide variability across the population and general reputation of being a benign compound. There are segments of the population that consume large quantities of caffeinated beverages every day and experience the expected side effects of anxiety (in some cases panic attacks), agitation, insomnia, and hyperadrenergic effects but they seem unaware that these symptoms are related to their caffeine consumption. Certainly consumption at that level can directly or indirectly precipitate an episode of atrial fibrillation.

That is my brief review of the NEJM article in atrial fibrillation. I encourage all psychiatrists to get a copy of this paper, read it, and keep it for reference. I am not suggesting that psychiatrists treat this condition.  I am suggesting that they recognize it - even if it has not been diagnosed and know what to do when that occurs. The reality is that in adult psychiatry no matter what your practice setting there will be a significant number of people with atrial fibrillation and other arrhythmias as well as all of the known comorbidities. You cannot treat those people unless you know about these conditions, the comorbidities, and how to avoid complications.

 George Dawson, MD, DFAPA

 

References:

1:  Michaud GF, Stevenson WG. Atrial Fibrillation. N Engl J Med. 2021 Jan 28;384(4):353-361. doi: 10.1056/NEJMcp2023658. PMID: 33503344.

2:  Richards JR, Blohm E, Toles KA, Jarman AF, Ely DF, Elder JW. The association of cannabis use and cardiac dysrhythmias: a systematic review. Clin Toxicol (Phila). 2020 Sep;58(9):861-869. doi: 10.1080/15563650.2020.1743847. Epub 2020 Apr 8. PMID: 32267189.

Supplementary:

Common and uncommon medications listed in this article used in atrial fibrillation for rate control, antiarrhythmic properties, and anticoagulation.  I added additional warnings and general type of medications that might require avoiding based on pharmacokinetic or pharmacodynamic considerations. Important to keep in mind that all medications vary in their ability to affect these mechanisms as well as therapeutic mechanisms. That includes significant differences between medications in the same class. That leads to qualifiers like "all possible mechanisms leading to complications or serious adverse effects may not be listed" (in this package insert or computerized drug interaction program). Almost every time I am seeing a patient on these medications - it requires a study of the medication combination, even if they are taking a psychiatric medication that appears to be working. Baseline cardiac symptoms related to the arrhythmia also need to be established as well as the patient's plan to obtain assistance if they worsen.

Additional qualifier (if it is not obvious). Psychiatrists prescribe beta blockers (metoprolol, propranolol, pindolol, etc). Psychiatrists can diagnose atrial fibrillation. Psychiatrists do not manage atrial fibrillation but need to know what to do acutely and how to avoid complications of the following medical therapies from drug interactions with psychiatric medications. Practically all of the antiarrhythmics in the following table are prescribed by Cardiologists and subsequently managed by primary care physicians although many patients continue to see Cardiologists in follow up. Like all areas of medicine the limits of technical expertise need to be recognized.  I worked with Cardiologists who became psychiatrists and they restricted their practice to medications prescribed by psychiatrists.  

Graphics Credit:

Bunch TJ, Cutler MJ. Is pulmonary vein isolation still the cornerstone in atrial fibrillation ablation? J Thorac Dis 2015;7(2):132-141. doi: 10.3978/j.issn.2072-1439.2014.12.46

Open Access per this Creative Commons License: https://creativecommons.org/licenses/by-nc-nd/4.0/     

The Spiritual Journey From High School Football

About 2 years ago my wife said to me one morning “who is this guy who keeps texting me?” I looked at her phone and recognized the name immediately. He was the quarterback from my high school football team. More correctly it was the high school football team I was on when I was a sophomore in high school. I had the immediate association to his physical appearance and considerable athletic ability. To this day he probably was the most gifted high school athlete I had ever seen. He didn’t look like a high school player - more like a college player. He was also an excellent basketball player and sprinter on the track team. He was the fastest man over 100 yards in high school. Why was he suddenly texting my wife?

He was going to be inducted into the local athletic Hall of Fame. He was trying to organize a reunion of our 1966 undefeated high school football team. His plan was to get as many of us back there as possible - details to follow. There were 2 or 3 subsequent postponements of the reunion due to the pandemic. But yesterday on 6/26/2021 it finally happened. Twelve of the 22 players reunited for about 3 hours at a local bar. As far as I know three of my teammates are deceased and the remaining players could not be located or decided not come. The head coach was also in attendance. The assistant coach is deceased.  All of the attendees got baseball caps with their name and numbers embroidered on the back. The front of each cap simply said “Undefeated 1966 AHS Football”.

Unlike my high school reunion, I had the opportunity to say something to all my teammates. I remembered who they all were and details from our past. I know that many had significant problems in life including life-threatening health problems. I learned about their relatives who had similar problems. But most of all I learned about what that football season meant to the people who made it back to the meeting. I know that memories from over 50 years ago can get complicated and distorted. As we all sat around a table there was a collection of newspaper articles and photographs from 1966 to provide partial corroboration. There were some intense memories from the past that haunted some of the players. There was also active feedback from the coach about a few incidents where he realized that the plays he was calling were being ignored. My intention in writing this post is not to identify people with problems or criticize people, but to look at an event with obvious meaning as well as the meaning that may have been missed at the time.

Our quarterback started out with some self-disclosure of mistakes he had made during the championship season. Other players who were involved with those mistakes corroborated them immediately. Our center for example recalled a fumble on the opponents 1 yard line and the fact that it occurred on a silent count. For 5 decades our quarterback was thinking the fumble was his mistake, but our center let him know that he forgot the count. There were several other incidents involving typical football mistakes that people had been thinking about since 1966.  Resilience came up as an outcome of the coaches role in helping us overcome adversity.  

A significant injury was discussed. From the description it sounded like a traumatic brain injury, but back in those days any head injury with partial or significant loss of consciousness was referred to as a concussion. There was no grading system but persistent confusion or memory loss might eliminate a player from the game although that was certainly not guaranteed. More than one concussion led to a medical evaluation but again there was limited medical expertise in traumatic brain injuries. It led me to recall a lot of headaches from playing football. We would practice twice a day in hot weather hitting a blocking sled and doing full contact drills. There were days where the headaches just did not clear up.  I was also reminded of the only significant traumatic brain injury that I sustained when I ran into one of my teammates playing in a touch football league. In fact, I approached him at this reunion and joked that the last time he and I met - I was out of it for the next 24 hours. I had to explain that we were both defensive backs running full speed and I ran into a shoulder after diving for the ball. He did not recall the incident.

There was a strong underdog theme. At one point in the year, we did not have enough players to scrimmage so the coaches had to play defensive half backs. Many of the teams we played against had much larger players and significant depth.  That led me to recall our coaches quote to the press: “We are not big - but we’re slow”.  Our coach recalled that in some of the venues we were ridiculed for looking raggedy and not having many players. We were accused of running up the score against some teams to improve our overall ranking.  The coach found this humorous because there was no second team to put in.  At one point during the discussion, one of our receivers took over and talked about how he and one of his friends in the offensive and defensive line got psyched up for the game. He gave an inspiring and expletive filled speech about his love of football, how he liked physical contact, how he liked playing offense and defense. He presented it with such vigor that it seemed like he was ready to play - right then.

For some reason, I had forgotten how tough these guys were. We were almost all working class.  Half of us were from the East End and half from the West End of town. Some played with significant physical disabilities. It was the height of the Vietnam War and many would go into the Marines and the Army after graduation. Many would go on to play college football. I would just catch glimpses of their lives from time to time.  Everyone had a unique trajectory from that winning football season to where they were on June 26.  At one point a small group asked me what my trajectory was and I told them a variation of a story I have been telling for the past 10 years:

The only reason I ended up going to college was to play football, be a football coach, and teach physical education.  I had a football scholarship to a small college in the area, but within a few weeks, I developed a gangrenous appendix and was hospitalized for a week.  The coach came in and told me that the scholarship was mine even though I could not play anymore (I had a healing surgical scar in my side that was still healing after a drain was removed). I probably was headed to be a version of a hippy anyway. Another professor visited me and told me to forget about Phy Ed and football and concentrate on something else.  I had excellent chemistry and biology professors and knew that I wanted to be like them and know what they knew.  From there it was a change to biology and chemistry, the Peace Corps, a plant tissue culture lab and medical school.”

That’s the short version.  There are embellishments for comedic relief and more details if anybody wanted to hear it.  I leave out the heavy parts about being depressed to the point my grandfather showed up one day to encourage me to stay in college and not knowing what was wrong with me until I developed severe abdominal pain. I leave out the part about not taking a student deferment during the lottery for the draft.  A high lottery number rather than a conscious decision kept me from being drafted.  All part of the lack of a coherent plan. Nobody wants to hear about all of that. I never played college football.  The point is – I would never have stepped into that sequence of events culminating in medical school and psychiatric residency without that football scholarship. I never would have had that football scholarship without playing with this team and being coached by this coach. Some people will tell me that sequence of events would have happened anyway. That I would have made it happen through another channel. Whenever I mention being lucky on this trajectory, I encounter aphorisms like “Luck is just preparation meeting opportunity” and others.  But I really was not prepared to do anything at that point.

The only thing I was prepared to do in high school was play football. The teaching and guidance side was totally lacking. I can not recall a single piece of good advice that I received from a teacher or guidance counselor in those years. And the teaching was atrocious. You showed up, put in the time, did not create any problems and graduated from high school. The blue-collar ethos of education.  You did not have a plan until you got to the next stage. The modern-day stories of high pressure on high school kids to get into an Ivy League schools and parents going to extraordinary and in some cases illegal lengths to get them in - is lost on me. I am the poster child for getting into whatever college wants you and establishing goals after getting there.

Football was the initial pathway.  At the Reunion, the coach discussed some of his initiatives including the first strength training program at the school along with associated competitions. I remember summer training sessions including agility drills.  I excelled in agility drills and back and forth sprinting drills. In my senior year, I could equal or beat the fastest running back in the agility drill even though he would beat me by a mile in 100 meters. These summer sessions were something we all looked forward to and it was the only planned activity in my life for the 3 years of high school.  The Coach gave us a glimpse of what it took for him to implement these plans and all of the resistance he met along the way.  That resistance came in the form of administrators claiming that he was running afoul of certain regulations, personality conflicts, and suggesting that he should work the pre-season for free even though he was already undercompensated for the amount of work he was doing. Providing me with some structure to start to get my life together came at a considerable cost to the only guy who was doing it.

Several of my teammates provided additional stories about the immediate benefits of coaching. How to play against a much larger man with limited lateral movement.  How to make adjustments during the game, based on observations by coaches who were at ground level on the side lines, attending to the injured on the sidelines, and changing overall game logistics. High school coaching is a multi-tasking job and school districts get their money's worth from coaches.

One of the most important aspects of my life trajectory has been identifying with teachers along the way.  Most of that emphasis was in college at the conscious level. But did it occur in high school football?  I was never encouraged to play any sports by my father. I learned after his death that he was quite accomplished in baseball and softball in his early twenties. By the time I knew him well, he had been working a thankless job for twenty years. The only sports advice he ever gave me was: "Look - if you want to play sports be clear that you are playing it for you and not for me." He did live to see this football team and attended the end of season banquet prior to his death in 1967.  I never got the chance to completely understand his sports advice, but speculate that it was from having to fish every day during The Depression to supply food for his family of origin - whether he wanted to or not.  

Both of our coaches were young men, accomplished athletes, and had unique personas. I remember the head coach bench pressing a significant amount of weight even though he was a quarterback in college. For the rest of my family, sports were something you did into your early 20s and then you settled into a fairly sedentary lifestyle. Out of college and then again out of med school I embarked on a lifelong schedule of rigorous training for no reason other than being able to do it.  That continues to this day. Would I have logged all of this activity if I had not played high school football with this coach? Probably not. Was there a degree of unconscious identification with this coach?  Probably.

The developmental aspects of high school football are undeniable and the stage we were all at during the reunion was undeniably different from high school. High school male athletes are competitive either by choice or necessity. It was probably the most significant motivator. I can remember thinking about the difference between competing with myself and competing with others as I was running a long sprinting drill in the 90 degree heat that occasionally happens in northern Wisconsin. In that drill 5-10 players spread out across the field and run out to the 5 yard line and back and then the 10 yard line and back until they have reached the 50-yard line and back.  At some point during that drill you realize that competition is irrelevant because it really comes down to survival and in that sense you are competing against your own physical limitations.  That familiar mind set was with me for the next several decades of cycling and speed skating. With a single exception - I preferred to do both activities alone – just me and the rhythmic breathing and sweating of that familiar sprinting drill.

The competitive aspects of high school sports also play out in other ways. Clique formation, hazing, bullying, sarcastic comments, and various forms of acting out that are expected of teenagers who we now know don’t have fully developed brains for another 10 years. That was moderated to some extent by the shared suffering of football.  At the Reunion it was fairly clear that there were many accomplishments over the course of these lifetimes but also much suffering. We were all grateful to have survived so far and saddened by the loss of our teammates who did not.

55 years had passed and, in some ways, we were a better team.

 

George Dawson, MD, DFAPA

Postscript: 

If I am correct in my analysis (or not) - I am grateful to have had this experience in high school.  I am grateful for my teammates many of whom I consider to be friends but also the Coach and Assistant Coach who clearly did not get enough credit for what they did. I made the common mistake of also taking that coaching for granted until I realized that my entire career may have been based on it.

The commemorative cap:

Supplemental Qualifier:

I don't want to give anyone the impression that this is an endorsement for football or other contact sports.  Football is a collision sport and there is an expected morbidity associated with collisions. Chronic traumatic encephalopathy is one outcome that has received a lot of press. My speculation is that spinal problems also occur as the result of spinal compression and hyperextension movements that are harder to detect due to the high prevalence of spinal problems in the general population that does not play contact sports.  One of my teammates sustained a cervical spine fracture from football but it did not result in paralysis.  As a psychiatrist, I have seen a significant number of people with traumatic brain injuries and severe musculoskeletal injuries from collision sports.  The number of women with those injuries has increased as their exposure to these sports (soccer, lacrosse, ice hockey) has increased.  I have seen young men and woman in their early 20s with significant disabilities from these injuries. In some cases they have also had severe post-traumatic stress disorder (PTSD) from either the injury or the subsequent course of treatment. 

 

How Physicians Think

One of the more interesting aspects of my career has been contemplating how physicians make decisions on both the diagnostic and therapeutic side. Early in my career there was an explosion of activity in this area. Much of it had to do with internal medicine. There were computerized programs that were designed to assist physician decision-making. There were also entire courses taught at the CME level by experts in the field. At the time those experts included Jerome Kassirer, Stephen Pauker, Harold Sox, Richard Kopelman, Alvan Feinstein, and others.  The New England Journal of Medicine has a long-standing feature entitled Case Records of the Massachusetts General Hospital that showcases both diagnostic reasoning and the associated clinicopathological correlates. They added additional articles and a long standing feature on diagnostic decision making. After studying the subject area for about 10 years, I started to teach my own version to 3^rd and 4^th year medical students. It was focused on not mistaking a medical disorder for a psychiatric one.  It included a complete review of cognitive errors in that setting and how to prevent them. I taught that course for about 10 years.

There are a lot of ideas about psychiatrists and how they may or may not diagnose and treat medical disorders. Systematic biases affect the administrative and environmental systems where psychiatrists work.  Many psychiatrists are very comfortable at the interface of internal medicine or neurology and psychiatry. The most common bias about psychiatrists is that other medical conditions need to be “ruled out” before the patient is referred to a psychiatrist. From a psychiatric perspective the real day-to-day problems include inadequate assessment due to an inability to communicate with the patient and considerable medical comorbidity. Psychiatrists who work in those problem areas need to be competent in recognizing new medical diagnoses and making sure that their prescribed treatment does not adversely affect a person with pre-existing medical disorder.

Against that backdrop I decided to read 2 relatively new books. Both of them have the same title “How Doctors Think”. One book was written by Jerome Groopman, MD hematologist-oncologist by clinical specialty. The other book is written by Kathyrn Montgomery, PhD – a professor of Bioethics, Humanities, and Medicine. As might be expected from the writers’ qualifications Groopman is writing more from the standard perspective of a physician with an intense interest in medical decision making and Montgomery is describing the clinical process and analyzing it from the unique perspective of philosophy and the humanities. It follows that even though the titles are the same these are two very different books.

Groopman’s approach is to use a case-based style of looking at medical decision-making from the perspective of several clinicians-including his own work. The mistakes that occur are teaching moments and are explained from the perspective of heuristics or common cognitive biases. It is the approach I used in my course on preventing cognitive errors associated with psychiatric diagnoses. To cite one example, he describes an athletic forest ranger in his forties. The kind of a guy an internist might say: “I am not worried about his heart – he does his own stress test every day.”  He noticed increasing chest discomfort for a few days without any associated cardiopulmonary symptoms. He presented for an assessment on a day when the pain did not go away. He was seen and thoroughly examined.  There were no physical symptoms, exam findings, or laboratory finding to suggest a cardiac problem and he was released from the emergency department.  He returned a few days later with a myocardial infarction.  Discussions with the attending physician indicate that there were two issues associated with the missed diagnosis of cardiac chest pain – the generally healthy appearance of the patient and a lack of any positive tests indicating coronary artery disease.  Groopman discusses it from the perspective of representativeness bias (p 44) or being affected by a prototype – in this case the patient’s apparent level of fitness and attributing the chest pain to musculoskeletal pain rather than pain of cardiac origin. 

This case also allowed for a discussion of attribution errors especially if the patient fits a negative stereotype.  In the next case, a 70 yr old patient with alcohol use presents with and enlarged nodular liver on exam.  The presumptive diagnosis is alcoholic cirrhosis and the team’s plan was to discharge him back home as soon as possible. Closer examination confirmed that the patient was not drinking that much and searching for other causes of liver disease resulted in a diagnosis of Wilson’s disease.  For most of the book, Groopman uses this technique to illustrate substantial errors, the kind of cognitive bias that it reflects, and corrective action. The reality of “making mistakes on living people” comes though.

He recognized the importance of pattern matching and pattern recognition in clinical practice. There is an initial conversation with a physician that collapses pattern recognition to stereotypes and their associated shortcomings.  He elaborates on the concept and quotes a cognitive scientist to illustrate that pattern recognition may not require any conscious reasoning at all.  An expert can arrive at a diagnosis in about 20 seconds that may take a medical student or resident 30 minutes. Experts begin collecting information about the patient on contact and are immediately considering diagnostic possibilities. I have personally had this experience many times, typically for acute neurological syndromes (strokes, cerebral edema, encephalitis, meningitis) in patients who were referred for me to see in a hospital setting. Pattern matching clearly occurs in the diagnostic process, but it is more difficult to write about and discuss than verbal reasoning.

A major strength of the book is a fairly detailed look at uncertainty in medicine. The diagnoses are not etched in stone and no outcomes are guaranteed based on the accuracy of the diagnosis or not. He introduces a pediatric cardiologist who advances the argument that most of his cases are novel and that there are no set guidelines for what he treats. Even more complicated is that fact that what may appear to be sound science-based treatments like closing an atrial septal defect with a 2:1 shunt in kids it can be an illusion.  Many of those children do well without the surgery and many have had unnecessary surgery. The cardiologist also points out that study of this kind of problem is impossible because of the length of time it would take to do a randomized study.

Another major strength is advice to patients about how to keep the doctor they are seeing thinking about their case.  Numerous examples are given ranging from seeing large number of healthy patients where abnormalities are rare to seeing patients with real problems who have been stereotyped for one reason or another. Groopman is very specific in coaching prospective patients in how to overcome some of the associated biases.  This advice centers on the fact that biological systems are complex and don’t necessarily support logical deductions.  The astute doctor needs to be systematic, evaluate the data for themselves including the elicitation or more history, and question their first impressions. The patient aware of these limitations can ask the correct questions along the way to assist their physician in staying on track. He advises the patient to express their concern about the worst-case scenario to get that out there for discussion and to keep their doctor focused.  The patient is informed of how their history, review of systems and exam may need to be repeated along with some tests that have been previously done. The physician may have to ignore common aphorisms or maxims that are designed to focus on common problems and consider the complex – like more than one diagnosis being suggested. Business management of the medical encounter is seen to impair and obstruct this interactive process.

Groopman’s book is very good both as a guide to patients and a review for physicians who have been educated in diagnostic thinking. In the body of the book technical jargon is avoided and the case scenarios thoroughly explained. There is an excellent list of references and annotations for each chapter at the end of the book. 

How Doctors Think by Kathryn Montgomery takes the unexpected form of a philosophical argument against medicine as a science. She qualifies her criticism by being very clear that she is considering Newtonian or positivist science and not biological science. She recognizes several features of biological science that make it an integral part of medicine, but also not at all like the criteria for science that she sets as the premise for her argument. This is problematic at two levels. First, deterministic and reductionist physicists like Sabine Hossenfelder are very clear that everything is reducible to known subatomic particles and that particles in a brain are deterministic.

“Biology can be reduced to chemistry, chemistry can be reduced to atomic physics, and atoms are made of elementary particles like electrons, quarks, and gluons.” (5)

So for at least some scientists – reductionism is not a problem and the boundaries are not very clear between physical science, biology, and medicine.  Second, it is now known that biological organisms have a wide array of stochastic mechanisms that by virtue of their own nature produce apparently random results. With that range of possibilities, it is not very clear if the standards of physical science are that much different than the biological science necessary for medicine.

Montgomery makes the argument about science and the damage that the idea of medicine as science does to both medicine and its practitioners at several levels.  First, she describes science in medical training. Medical students encounter the basic science curriculum in the first two years of medical school. It is not physical science but biological sciences relevant to understanding pathophysiology, pharmacology, and epidemiology/evidence-based medicine.  She suggests this exposure to science is less relevant as the student transitions to a clinician with adequate clinical judgment – almost to the point that the basic science is an afterthought. This aspect of training is also used to point out that medical students are not being trained as scientists and the remainder of their formal education is spent learning clinical judgement.  At places she describes the preclinical years as fairly bleak period of memorization peripherally related to clinical development.  Second, the uncertainty of biology and medicine is part of her argument.  She extends the argument from the patient side to the side of the doctor. Patients want and need certainty and therefore they want doctors who are schooled in the best possible science who can provide it. Patients want an answer and all they get is statistics. Third, she suggests that the moral and habitual practice of medicine although dependent on human biology and the associated technical advances is not really science.  Physicians are taught to practice medicine and the don’t question “the status of its knowledge” (p. 191). She describes medical practice as a set of rational procedures that are shared with many other professions in the humanities and social sciences.  Fourth, the notion of medicine as a science is “clinically useful” in that it reassures the patients that physicians are engaged in a rational process like they were taught in science classes rather than a contextual, interpretive, narrative process used by non-scientists.  She cites numerous examples of maxims and aphorisms used in medicine to guide this process like Peabody’s famous: “The secret of the care of the patient is in caring for the patient.” 

 Montgomery’s writing is as sophisticated as you might expect from a bioethics professor with a doctorate in English and extensive exposure to medical training. Her critique depends a lot on verbal reasoning and the application of that model to numerous disciplines. Philosophical critiques of medicine and psychiatry that I have responded to in the past are typically presented as arguments with the premises being set by the author. As I read through these arguments being repeated across chapters there were clear points of disagreement.  Here is a short list:

1:  The argument about medicine not being a physical science – that is a good starting point if you want to be able to attack the scientific aspects of medicine, but does anyone really accept that premise? No physical science is taught in the basic science years of medicine.  The basic sciences are focused on human anatomy and physiology. An associated argument is that biological sciences have no overriding laws like physics and that is given as further evidence that medicine is not a science. There is an entire range of science within the basic science of medicine that cannot be explained by physical science but it is necessary for clinical medicine and innovation in medicine.  Finally science is a process that is subject to ongoing verification. That is as true for biological science as it is for physical sciences. While there appear to not be as many absolutes for biology progress is undeniable even within the boundaries of medicine.

2:  Uncertainty in biological systems and medicine - the author makes it seem like defining medicine as a science gives the false impression of certainty. I don’t think that certainty is misrepresented or minimized in clinical medicine.  Every physician I know experiences the uncertainty during informed consent and prognosis discussions. It is built into surgical consent forms and in situations involving medical treatment or testing – the discussions are even more complex. In a typical day, I will advise patients on side effects that occur at rates varying from 4 out of 10 patients to 1 out of 50,000 and tell them what to look for and when to call me.  I have had patients tell me after those discussions that they would prefer not to take a medication or do the recommended testing. I will also discuss life threatening problems with patients, and let them know I cannot predict outcomes but can advise them on how to reduce risk. The only way medicine can practiced is by having appropriate informed consent discussions that fully acknowledge uncertainty and the associated biological heterogeneity.  From the patient side, everyone has a friend, acquaintance, or family member who was healthy until the day there were not. The uncertainty of physical health and medical outcomes at that point are widely known by the general public.

An additional and lesser known aspect of the effect of uncertainty on physician behavior is encouraging the correct answer or treatment as soon as possible. Montgomery attributes some of this to the moral dimension of the physician-patient relationship and doing the right thing for the patient.  But a critical part of uncertainty is that physicians eventually learn to project their decisions out into the future. Those projections are all taken into account in developing the current treatment plan. The outcome of an idealized plan can be viewed as the direct result of the uncertainties involved.  

3:  Physician detachment is a likely consequence of characterizing medicine as a science – At points Montgomery makes the point that physician can emotionally protect themselves by assuming the detached rationality of science. It follows that abandoning medicine as a science would result in a more realistic emotional connection with patients. She has a detailed discussion of the physician-patient relationship being more as a friend or a neighbor.  She concludes that neighborliness has a number of virtues to recommend it as the relationship for the 21^st century. Two concepts from psychiatry are omitted from this discussion – empathy and boundaries. Empathy is a technical skill that is typically taught to physicians in their first interviewing courses in the first year of medical school.  It is a technical skill that allows for a more complete understanding of the patient’s emotional and cognitive predicament. In my experience what patients are looking for is a physician who understands them. That is generally not available from a friend or neighbor.  The basic boundary issue is that it is very difficult to provide care to a person who is emotionally involved with the physician. There are degrees of involvement, but any degree is important. A physician who is empathic, had a clear awareness of the relevant boundaries, and has a solid alliance with the patient is far from detached.  But I would not see them as neighborly or a friend.  The physicians job is the be in a position where they can provide the best possible medical advice. That can only happens from a neutral position where they can give a patient the same advice they would give anybody else.  That also does not mean that physicians are not emotionally affect when bad things happen to their patients or when their patients die.

4:  Do ancient Greek concepts still apply? – The author uses Aristotelian definitions of episteme and phronesis several times throughout the text. Episteme is scientific reasoning and phronesis is practical reasoning.  Aristotle’s view was that since there are no “fixed and invariable answers” to questions about health, every question must be considered an individual case.  In those cases, practical reasoning that considers context and additional factors or phronesis applies.  That allows the author to compare medicine to a number of social science disciplines that use the same kind of reasoning.  The question needs to be asked: “What would Aristotle conclude today?”  In ancient Greece there were basically no good medical treatments and medical theory was extremely primitive. Over the intervening centuries medicine has become a lot less imperfect. Uncertainty clearly exists, but the scientific advances are undeniable.  It is possible to say today that there are now fixed and invariable answers to large populations of people. Medicine has always been a collection of probability statements – but those probabilities in terms of successful outcomes have significantly improved.  One the corollaries of  Aristotle’s work is that there can be “no science of individuals” and yet the current goal is individualized or personalized medicine.

5:  Is science relevant to clinicians on a day-to-day basis? -  I think that it is.  I have certainly spent hours and even entire weekends researching patient related problems to find the best solution to a problem and to be absolutely sure that my recommended course of treatment would not harm the patient. All of that reading was basic or clinical science.  On the same day that I received Montgomery’s book, I got my weekly copy of the New England Journal of Medicine.  I have been a subscriber since my first year of medical school based on the recommendation of my biochemistry professor. Our biochemistry class was designed around research seminars where we read and critiqued basic science research. There was also the assumption that you were reading the text cover to cover and attending all of the lectures.  He encouraged all of us to keep up on the science of medicine by continuing to read the NEJM and in retrospect it was a great idea.  In that edition I turned to the Case records of the MGH (6): An 81-Year-Old Man with Cough, Fever, and Shortness of Breath. It was a detailed discussion by an Internist about the presentation and differential diagnosis of the problem. And there on page 2336 was a diagram of the ventilation perfusion mismatch that occurs with a pulmonary embolism and acute respiratory distress syndrome. I have seen this science at the bedside in many clinical settings.  

The clinical competency of pattern matching, pattern recognition, and pattern completion is left out of Montgomery’s description of how doctors think and it is an important omission.  It is a good example of non-verbal and unconscious reasoning that can be a critical part of the process. The answer to the question: “Is this patient critically ill?” and the triage that follows depends on it.  Pattern matching is also experience dependent with experts in their respective fields being able to more rapidly diagnose and classify problems that physicians who are not experts. Biases affecting verbal reasoning can negatively impact the diagnostic process, but so can the lack of experience in seeing patterns of illness and an inadequate number of cases in a particular specialty.

I consider both of these books to be good reads, especially if you are a physician and have had no exposure to thinking about the diagnostic process.  Both authors have their own ideas about what occurs and there is a lot of overlap. Both authors have the goal of stimulating discussion and analysis of how physicians think and educating the general public about it. Physicians will probably find Groopman a faster and more relatable text. Physicians may find the references and vocabulary used in Montgomery to be less recognizable. I would encourage any physician who is responding to initiatives to change the medical curriculum or critique it to read Montgomery’s book and work through her criticisms.  Both books have excellent references and annotations listed by the chapter for further reading. Non-physicians especially patients who are working with physicians on difficult problems may benefit from Groopman’s tips on how to keep those conversations focused and relevant.  As a psychiatrist who is sensitive to attacks (even philosophical ones) from many places – you may find my criticism of Montgomery’s work to be too rigorous. I tried to keep that criticism down to a level that could be contained in a blog post.  I encourage a reading of her book and formulating your own opinions. It is an excellent scholarly work.

Finally, the area of expertise in medicine and the associated clinical judgment of experts is still a current research topic.  The research has gone from basic experiments about who can properly diagnose a rash or diabetic retinopathy to a clear look at brain systems responding during that process. Those changes have occurred over the past 30 years. At the descriptive level it remains important to be aware of the possible cognitive biases and what can be done to overcome them.

 

George Dawson, MD, DFAPA

 

References:

1:  Groopman J.  How Doctors Think. Houghton Mifflin Company, New York, 2008.

2:  Montgomery K.  How Doctors Think. Oxford University Press, New York, 2006.

3:  Kassirer JP, Kopelman RI.  Learning Clinical Reasoning. Williams and Wilkens, Baltimore, 1991.

4:  Sox HC, Blat MA, Higgins MC, Marton KI.  Medical Decision Making. Butterworths, Boston, 1988.

5:  Hossenfelder S.  The End of Reductionism Could Be Nigh. Or Not.  Nautilus June 18,2021 (accessed on June 18, 2021) https://nautil.us/blog/the-end-of-reductionism-could-be-nigh-or-not

6:  Hibbert KA, Goiffon RJ, Fogerty AE. Case 18-2021: An 81-Year-Old Man with Cough, Fever, and Shortness of Breath. N Engl J Med. 2021 Jun 17;384(24):2332-2340. doi: 10.1056/NEJMcpc2100283. PMID: 34133863.

 

The Current Moral Crisis In The United States

 

It is fashionable these days to talk about moral crises that really aren’t moral crises. The level of rhetoric is at the point where disagreements can be spun as moral crises, while people are dying in the streets. The best examples I can think of are the long-standing epidemics of gun violence and racism. New examples are cropping up every day. There are current trends in violence against Asian Americans and Jews against the backdrop of long-standing trends. Discrimination and violence against black Americans is finally acknowledged as being widespread and is the basis of an activist civil movement and hopefully systematic reforms.

All of the statistics to back up my statements in the first paragraph are easily available and I am not going to post all those references here. Since I started writing this blog one of my concerns has been gun violence and how to stop it given the level of interference with common sense gun law reforms by one of the major parties and major lobbying concerns. I saw the attempt to counter that political interference as being futile and focused more on public health interventions and possible psychiatric intervention. The latest good review of that approach is available in a review by Knoll and Pies (3).  For many years I have advocated that homicidal ideation should be seen as a public health intervention point and that it should be part of the strong public health message. To this day nothing has happened. Public health organizations do have research-based suggestions such as locking up firearms and common-sense gun laws like banning large capacity magazines, banning assault rifles, and universal background checks, but the general lack of progress in that area is not reassuring. There has been some movement in allowing more research on gun violence, an area that was previously blocked by gun lobbyists.

What is the connection between gun violence, racism, and violence toward our fellow Americans?  I think there are all based on the same interpersonal dynamic. That dynamic is seeing another person as being significantly different from you, attributing negative characteristics to them, and using both of those premises for treating them different from you up to and including perpetrating violence toward them.  In psychiatric jargon, we use the term projection to capture this process or in the extreme projective identification. These are not psychiatric diagnoses, but defense mechanisms that are distributed across the population even though they may be more likely in people with specific psychiatric diagnoses.

In my readings over the years I have been looking for a likely origin or at least first sign of this kind of thought pattern. In other words, have people been thinking like this since the beginning of recorded time, or is this a new phenomenon?  In the course of that reading, I came across a book written by the anthropologist Lawrence Keeley called War Before Civilization. In this book, Keeley explores the idea of the noble savage from prehistoric times.  In other words, were pre-historic people inherently peaceful as some had suggested or were there early signs of violence and aggression. A review of the evidence suggests that the majority of human prehistoric civilizations engaged in frequent warfare and total warfare – in other words attacks not limited to combatants and decimating the opposition’s infrastructure and ability to make war.  Keeley reviews the motivations and consequences of primitive warfare in great detail including tactics (surprise attacks, slaughter of noncombatants, and general massacres) and specific practices like mutilating dead bodies. There is clear evidence the latter functioned in part to dehumanize and humiliate the enemy and send a message to the survivors. These dynamics were not limited to prehistoric man and have continued through modern times and modern warfare.

A recent report referencing Keeley’s book appeared on Scientific Reports (2) this week.  It was a reanalysis of a Nile Valley burial site of 61 people from about 13,400 years ago. It is thought to be some of the earliest evidence of Homo sapiens interpersonal violence.  In that analysis over 100 lesions were identified in the skeletal remains from what appeared to be projectile weapons.  Examining the mortality curve of the individuals in the cemetery showed that it was consistent with multiple burials rather than a single event.   The stone artifacts examined were consistent with spear or arrow heads. Some we designed to kill by lacerating and causing blood loss. Some were discovered embedded in bones, but others were discovered within the area where the body was discovered and that was viewed as being consistent with the ability to penetrate the body.  The authors conclude that the majority of people in the cemetery died of blunt or sharp force trauma and that there were multiple episodes of interpersonal violence.  Some of the combatants had been wounded multiple times prior to death.  They also concluded that these episodes were most likely the result of “skirmishes, raids or ambushes” likely related to territorial disputes that may have been affected by the weather. (p. 9).

What can be inferred from this long history of human violence and aggression? First, groups of humans have been perpetrating violence against one another since prehistoric times. Second, during these episodes total warfare was very common and the human cost of war is always high. The estimated percentages of deaths in ancient society were generally higher than in modern society for a number of reasons. That was not a deterrent to ancient humans.  Third, the psychological states during these episodes of violence show a potentially broad range of thinking leading to aggression.  Very limited incidents such as the theft of livestock or a rumor of a sexual affair between members of different tribes or villages may be all that was required to start a series of retaliations leading to all out war.  Once a violent conflict ensued – there were thought patterns and rituals in place to justify the killing, prevent bad outcomes for the killers, humiliate the dead, and embarrass their families.

The current moral crisis in America seems to have a direct link with prehistoric behaviors. It is enacted by aggressive behavior that is described as racism, antisemitism, and gun violence, but the dynamic is the same one described in ancient man.  In other words, once a person can be seen and characterized as an enemy (for whatever reason),  it is very easy to vilify them, attribute the worst possible motivations to them, and use that as a basis for rationalizing aggressive behavior. In the past weeks, I saw two elderly Asian American women attacked at a bus stop by a man wielding a knife. The attack as so violent that the large blade of the weapon broke off inside the body of one of these women. In a more recent event, a heavily armed long time employee shot 9 of his coworkers and then killed himself when he was surrounded by police.  In both cases, the “motivation” for the violent behavior is unknown.  There is a suggestion of mental illness, but the majority of people with diagnosed mental illnesses and even the same diagnoses are not violent or aggressive. The sheer volume of mass shootings in the United States suggests it is more of a cultural phenomenon here than anywhere else but that is confounded by the easy availability of firearms.  The main difference between modern and ancient times is that we have a societal structure that is designed to contain violence and aggression and prevent larger outbreaks.  It is clearly ineffective at this point in preventing violence.

I am suggesting a common thought process here that does not require any psychiatric diagnosis and one that can be intervened upon and self-monitored.  In order to perpetrate discrimination, hate crimes, and even homicidal violence toward others 3 conditions have to exist.  First, the potential victims of violence need to be seen as sufficiently different from the perpetrator so that he can attribute unrealistic negative attributes to them and rationalize his aggressive action.  Second, the attacker can see himself as sufficiently different from the potential victims that he feels threatened by them and can rationalize attacking them for that reason alone.  A common example is that the attacker feels victimized by his coworkers and feels the need to strike out at them.  And finally, the attacker must have a plan to either seriously injure or kill the victim(s). All of these thought patterns can be considered derivative of thoughts present in ancient man leading to the wide ranging aggression and warfare described in the references.

I think there is much to be said for intervention based on the observations in this post.  For the time I have written this blog, I have advocated for intervention based on homicidal or aggressive behavior. When I worked as an acute care psychiatrist – treating violence and aggression was easily half of my job.  If we can suggest that persons with suicidal ideation or self-injurious behavior contact a crisis intervention service or hotline – why don’t we have a similar suggestion for people with homicidal thinking?  And further what about general education about the primitive origins of these thought patterns.  Just the other day I posted the following:

“Ridiculing people who died of C-19 and were antivaxxers and anti-maskers is bad form - plain and simple.

Bring civility back and restart civilization.

It starts with recognizing the value of a single human life.”

There was much agreement with the post, but also several people who suggested that I was naïve for not being able to recognize enemies or that I was a “better person” for being able to overlook the behaviors of a group of people who were potentially dangerous to others.  My post was not about moral superiority or not recognizing enemies – it is all about the fact that disagreement should not lead to enmity and beyond that we are all members of the same tribe.  We all came from Africa. And seeing differences between us that do not exist is probably ancient thinking that obscures the fact that we are all a lot more similar than we are different.  As I explained to some of the critics of my post, they seemed to be focused on the exceptions rather than the rule.  They also seemed to be making arbitrary exceptions based on seeing more differences than similarities. 

We are currently at a crossroads in this country.  People are making money and generating political capital by emphasizing differences and exploiting the primitive thinking that I have outlined in this post.  Much of the aggression plays out at a symbolic level in social media, but the Insurrection at the Capitol building and the increasing levels of physical violence illustrates that it is far from always symbolic. Americans have traditionally left ethics and morality up to religious institutions where it may be presented at an abstract level.   

It is time to get back to the basic premise of why every person is unique and needs to be treated with respect by virtue of being a member of the human race. It seems like an obvious but untested approach to reducing interpersonal violence at all levels in a society that is not currently equipped to prevent it.

 

George Dawson, MD, DFAPA

 

References:

1:  Lawrence H. Keeley. War Before Civilization. Oxford University Press, 1997.

2:  Crevecoeur I, Dias-Meirinho MH, Zazzo A, Antoine D, Bon F. New insights on interpersonal violence in the Late Pleistocene based on the Nile valley cemetery of Jebel Sahaba. Sci Rep. 2021 May 27;11(1):9991. doi: 10.1038/s41598-021-89386-y. PMID: 34045477 (Open Access).

3:  Knoll JD, Pies RW.  Moving Beyond "Motives" in Mass Shootings.  Psychiatric Times 36(1) Jan 13, 2019. Link

Permissions:  Graphic above is from reference 2 per the following Creative Commons license. 

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News From Africa

 

 

Some readers of this blog may recall posts in the past about human origins from Africa. I first became aware of the migratory pathways of early humans and the archaeological and genetic evidence from participating in a National Geographic test. That test looked at haplotypes and how modern humans migrated from East Africa to essentially around the world. The test also estimated the percentage of Neanderthal heritage. Since that original sample I have been tested at 2 other laboratories. One of them confirmed the National Geographic analysis and the third test is pending. My original intent was to highlight the fact that all Homo sapiens are from East Africa, and that the distinctions we like to consider “race” mean a lot less than most people think. Genetically human beings from different races are much more similar than different.  If we all share common ancestors, similarities would seem to be intuitive, but the events that have occurred since my original post suggest otherwise.  Racial and tribal biases have been with her since prehistoric times and continue in modern societies.

Despite those biases, evidence continues to flow from Africa. In the may 6 Nature there was a research paper on the discovery of a 78,000-year-old gravesite in Panga Ya Saidi, Kenya that contained the body of a 3-year-old child. The body and gravesite had evidence of burial practices including intentional placement in an excavated grave, specific positioning of the body, and wrapping of the body in a perishable material.  The authors exhaustively review the evidence for those conclusions. They and the author doing the commentary on this article (2) also review the meaning of these rituals.

The editorial first and the commentary by Louise Humphrey (2) from the Center for Human Evolution Research. Dr. Humphrey sets the stage in the Middle capstone Age (320,002 30,000 years ago). The research question is the first evidence of modern human behavior during that era. Various human innovations were discovered during this timeframe in Africa. The earliest human fossils were also discovered in Africa during this timeframe. One of the key indicators of complex behavior is how the dead were prepared and handled. Anthropologists considered this to be a marker of increased symbolic capacity and thought. Dr. Humphrey reviews existing fossil records of mortuary treatments done by humans and provides a map in her paper (2) where the archaeological sites are mapped ranging from 50 to 780 thousand years ago. Given the time range the hominid species identified included Homo sapiens, Homo neanderthalis, and other species of the genus Homo.  The critical work of the scientist involved is to “reconstruct a series of human actions associated with the deposition of the body”. What does the planning suggest? What meaning can be inferred from the site? Time and effort involved in the ritual suggest that the treatment is more meaningful. In the literature reviewed that included a dedicated site, wrapping the body, and positioning the body. Her conclusion was that the paper suggested the burial in the main paper was “symbolically significant”.

The research article (1) is a detailed description of the excavation and analysis of gravesite of a 2.5 to 3.0-year-old child. The researchers named the child Mtoto – a Kiswahili word for small child.  Estimated age of the gravesite was about 78,000 years ago. There is a detailed drawing of the preserved skeleton that includes a large portion of the cranium, spine, ribs, right clavicle, left scapula, left humerus, and proximal femurs.  There were 5 teeth present and they were felt to be consistent with H. sapiens, although some other features were present suggesting that there may have been regionally distinct populations. The evidence for placement of the body in a specific location was reviewed. The skeletal remnants were minimally displaced. The body was in a flexed position. The body present position was consistent with wrapping. This was interpreted as “more elaborated involvement of the community in the funerary rite…”. The evidence for intentional burial included an excavated trench and settlement patterns consistent with burial.

The authors review the scant evidence for mortuary practices during this era. They conclude that H. sapiens was probably preserving corpses of the young members of their groups between 69 and 78 thousand years ago.  That is contrasted with burial practices in Eurasia by Neanderthals and other modern humans dating back 120,000 years.  Infant and child burials in the sites were described as “ubiquitous”. The authors see the lack of mortuary practices during the middle Stone Age in Africa in general as being inconsistent with “modern-like conceptions of the afterlife and/or treatment of the dead”. They do point out that the absence of the behavior is not the same as the lack of capacity.

This paper was important from a number of perspectives. Overall, it is apparent that archaeological/paleobiological evidence of burial practices during the Stone Age is limited. East Africa is commonly viewed as the cradle of civilization. In 2 of the DNA analyses I have had done on myself, all my ancestors retraced back to East Africa. The data about Neanderthals mortuary practices is interesting because in the past decade, archaeological evidence supports the idea that they were conceptually more sophisticated than they had previously been given credit for.  One of the questions I came away with from this paper is why so few burial sites or other evidence of mortuary practices exist in Africa.

The inferences about human cognition based on mortuary practices are interesting to consider even in modern times. Over the course of my lifetime, funerals have changed significantly. Embalming and displaying the body, was fairly typical in the families I have been affiliated with until the turn-of-the-century. That mortuary practice was primarily grief focused. There was a religious service that was often a divine explanation of what had occurred and what was to be expected. Over the years I grew to become very interested in what the clergy from different faiths would say during the funeral. Other people would frequently speak with varying degrees of effectiveness. A common meal or reception would frequently follow the religious service there is often a separate burial with the graveside religious service the next day.

In about the year 2000, things seem to change significantly. I remember attending a funeral and being shocked that the body had been replaced by a small box of ashes. Cremation suddenly became the rule rather than the exception. The funeral service was focused on being a celebration of the deceased’s life rather than strictly grief focused. There were often photographs and video displays relevant to the deceased person’s life. The eulogies were also more lighthearted. Jokes or humorous vignettes about the deceased were more common. I don’t know what lead to these changes and have not been able to find a good analysis of why it occurred. The archeological elements of ritual, respect for the dead, the existential balance of the meaningfulness of their life in contrast to death, and the promise of a spiritual afterlife is all there. With cremation there is an added element of remembering the deceased as they were in real life and that theme is more consistent with a celebration of their life.  All of these elements are fairly implicit and embedded in ritual. An obituary is written and proofed several times. In the Internet era, it is posted on several sites and is eventually routed to sites when ancestry analysis occurs.  I have seen direct evidence that Internet obituaries exist in cyberspace much longer than they could be viewed in a newspaper. There is no doubt that multiple people have carefully planned the event.

The most important aspect of the death of an individual is their impact on the conscious states of others.  That is often simplified as a “memory” but it is more complex than that. For decades the grief process was considered to be a closed process. The person grieving goes through a number of cognitive-emotional stages and at some point they reach a stage where there baseline emotions return and they are left with memories of the individual. In the common vernacular that was described as closure.  In reality, the process is typically more open ended and the relationship with the deceased lives on. Any one of us who has lived long enough can recall at will or by association what those relationships and that person was like, why they are missed, and how they are still affecting us.  The increasing lifespan of modern humans leaves us all with a lot more time for those thoughts.

An additional consideration is the pattern of mortality and how it differs from the Stone Age to modern times. The average age of a person in the Stone age is estimated to be in the 25-35 range but that is skewed by considerable (45%) infant mortality. Did that have an impact on mortuary practices and the grief process?  Some experts suggest that more care was taken in attending to deceased infants and children implying that our ancestors had a selective thought process about those deaths. Given the time and scant evidence we may never know what our ancestors were thinking with a high degree of certainty. We do know that in the Middle Stone Age – our ancestors engaged in rituals that reflected their thoughts on death in general and that specific person.

 

George Dawson, MD, DFAPA

 

 

References:

1:  Martinón-Torres M, d'Errico F, Santos E, Álvaro Gallo A, Amano N, Archer W, Armitage SJ, Arsuaga JL, Bermúdez de Castro JM, Blinkhorn J, Crowther A, Douka K, Dubernet S, Faulkner P, Fernández-Colón P, Kourampas N, González García J, Larreina D, Le Bourdonnec FX, MacLeod G, Martín-Francés L, Massilani D, Mercader J, Miller JM, Ndiema E, Notario B, Pitarch Martí A, Prendergast ME, Queffelec A, Rigaud S, Roberts P, Shoaee MJ, Shipton C, Simpson I, Boivin N, Petraglia MD. Earliest known human burial in Africa. Nature. 2021 May;593(7857):95-100. doi: 10.1038/s41586-021-03457-8. Epub 2021 May 5. PMID: 33953416.

2:  Humphrey L.  Burial of a child during the Middle Stone Age in Africa.  Nature. 2021 May; 593(7857): 39-40.

3:  Ponce de León MS, Bienvenu T, Marom A, Engel S, Tafforeau P, Alatorre Warren JL, Lordkipanidze D, Kurniawan I, Murti DB, Suriyanto RA, Koesbardiati T, Zollikofer CPE. The primitive brain of early Homo. Science. 2021 Apr 9;372(6538):165-171. doi: 10.1126/science.aaz0032. PMID: 33833119.

4:  Beaudet A. The enigmatic origins of the human brain. Science. 2021 Apr 9;372(6538):124-125. doi: 10.1126/science.abi4661. PMID: 33833107.

5:  Olden K, White SL. Health-related disparities: influence of environmental factors. Med Clin North Am. 2005 Jul;89(4):721-38. doi: 10.1016/j.mcna.2005.02.001. PMID: 15925646.

6:  Brotherton P, Haak W, Templeton J, Brandt G, Soubrier J, Jane Adler C, Richards SM, Der Sarkissian C, Ganslmeier R, Friederich S, Dresely V, van Oven M, Kenyon R, Van der Hoek MB, Korlach J, Luong K, Ho SYW, Quintana-Murci L, Behar DM, Meller H, Alt KW, Cooper A; Genographic Consortium. Neolithic mitochondrial haplogroup H genomes and the genetic origins of Europeans. Nat Commun. 2013;4:1764. doi: 10.1038/ncomms2656. PMID: 23612305; PMCID: PMC3978205.

7:  Fu Q, Rudan P, Pääbo S, Krause J. Complete mitochondrial genomes reveal neolithic expansion into Europe. PLoS One. 2012;7(3):e32473. doi: 10.1371/journal.pone.0032473. Epub 2012 Mar 13. PMID: 22427842; PMCID: PMC3302788.

 

Supplementary:

Additional references above are for a more expansive essay on paleobiology, genetics and the importance recognizing a common ancestry.