Infinite possible causes

CMAJ 1999;160:1349

© 1999 Canadian Medical Association

Midway this way of life we're bound upon, I woke to find myself in a dark wood, Where the right road was wholly lost and gone.

In the opening scene of Patch Adams the title character, played by Robin Williams, recites these lines from Dante's Inferno as he looks at himself in the mirror and contemplates his life. Suicidal, he has just committed himself to a mental hospital and is about to experience the hell of institutionalization. He is also about to find his genius and a new road that will lead to medical school and to the dream of being a new kind of doctor.

Patch's epiphany comes when he and his roommate Rudy (played by Michael Jeter) become engaged in a pitched battle with squirrels that are invading their room. The squirrels are all in Rudy's head, but Patch finally has to use a bazooka (in fantasy, of course) to exert sufficient firepower to overwhelm the squirrels and allow Rudy to get to the bathroom. The success of this manoeuvre is also an overwhelming experience for Patch, one that leads him to discharge himself from the hospital and, eventually, to enter medical school.

What happens there is by turns touching, sad and hilarious. His mission is to break down the barriers that separate people, particularly doctors and patients. He wants to make contact, to find out what a patient's dreams are and to use this information creatively to help healing and recovery. For instance, an old woman who refuses to eat remembers her mother allowing her to handle the noodles she was cooking; she confides that she has always dreamed of swimming in a pool full of noodles. Patch's solution to her anorexia is not a Dobhoff tube or intravenous hyperalimentation, but to give the patient her wish: he swims with her in a pool full of spaghetti set up on the hospital lawn. Naturally, this kind of thing does not go down well with the dean of the medical school.

This film could be seen as an argument for more humour in medicine, which might certainly be a good thing. It could also be seen as a wake-up call for doctors to make deeper contact with their patients' ineradicable humanity. I see it also as a call for greater humility and openness to creativity in clinical practice. Even our best medical solutions to problems are just a limited set of approaches that appear, on average, to work. There may be many other approaches for any given problem that would work equally well, or better, in individual cases, such as swimming in a pool of spaghetti as a cure for anorexia. This idea is supported by epidemiological thinking. Rothman and Greenland¹ discuss causation as a construct that we have designed in order to know how to intervene effectively in the world. A cause is something without which the event of interest would not have occurred as and when it did. Removing a cause can prevent an event or reverse an undesirable state (such as anorexia). We can attribute a proportion of any disease in a population to a specific cause; for example, more than 90% of cases of lung cancer are caused by smoking. But here is the interesting part: if we add up the proportions for all the different causes of the same disease, the result is not 1 (or 100%), as most of us assume, but infinity. Why? Because causes overlap ad infinitum. In other words, if we want to reverse someone's anorexia there is a potentially infinite number of ways that might work equally well. Shouldn't we open clinical practice to the invitation to creativity that this represents? Why should our creativity be limited to the laboratory or the research paper? Should the modern trend for practice guidelines and standardized practice be balanced by a new motto: "There's more than one way to skin a cat"?

Tom A. Hutchinson, MB
Professor, Departments of Medicine
  and of Epidemiology and Biostatistics
McGill University

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1. Rothman KJ, Greenland S. Modern epidemiology. 2nd ed. Philadelphia: Lippincott-Raven; 1998.