Did I Discover the Concept of Social Determinants of Health?

I know what you are thinking but hear me out. And, by the way, those who are easily offended should not continue reading. Anyway, I was contacted by a writer who wrote a piece for this magazine. Here is how this went:

Hi Doug, I am drafting a short article on SLS for a magazine which goes out to all docs in Western Australia and want to credit the originator of the “condition”. From my research it appears that a UK GP in 2010 used it (but with out ‘ty’ added to shit) but you alluded to it earlier as far as I can tell in your MAD mag for docs. Also it is mentioned in Case 11-2002 in the Placebo Chronicles.   But it’s being taken seriously (eg the Financial Times Article) being blamed for the stop in improvement in life expectancy in the UK for the first time since 1982 and likewise in your country. The same is starting here so its a good time to say for the first time that SLS has arrived in Australia.  I note on your website a similar request below and wonder if you can provide further information. Regards, Bret

So, yes, SLS or Shitty Life Syndrome truly did originate from the Placebo Journal. I believe it was in our inaugural issue in 2001. Here is the “fake” study in its entirety. Enjoy.

A Landmark Case Study of SLS

Cornelius Parody MD and Aristotle Jones PhD

Below is a case study which reveals a new but common syndrome plaguing many medical offices around the country.  SLS is endemic and Drs. Parody and Jones use their unique style to address this disorder and give some recommendations for treatment.

HPI:  A 38 year old WF presents to the office as a new patient with multiple complaints.  She has had an eighteen-month history of fatigue as well migrating myalgias and fleeting arthralgias.  She is currently on workers compensation and looking for disability for worsening back pain that occurred while lifting a patient on the job as a certified nurse assistant.  She has been seen by multiple specialists for her ills including a neurosurgeon, rheumatologist, physiatrist, psychiatrist, gastroenterologist, gynecologist, internist, two chiropractors and a shaman.  Their diagnoses consisted of reflex sympathetic dystrophy, fibromyalgia, myofascial pain syndrome, major depression, irritable bowel syndrome, premenstrual dysphoric disorder, chronic fatigue syndrome, atlanto-axial misalignment and “animal spirit disunity” respectively.

ROS: all positive including 21 normal TSH tests; also has multiple  normal sleep studies, CT scans and MRIs

PMH: As per HPI as well migraines, PTSD, overweight, fibroids, insomnia, fibrocystic breast disease and chronic abdominal pain

SH: Single mother with three children at home, ages 4, 5, 6.  She has another child, age 9, who is currently incarcerated but she states “I am not sure he’s mine”.  The six year old has been diagnosed with ADD and had been suspended from the school and its buses for behavioral outbursts such as lighting them all on fire.  The youngest two children are being seen by a child psychiatrist for depression and probable oppositional defiant disorder. The patient smokes three packs per day, in the house, and has failed cessation treatment on multiple occasions because “no medicine will work on me!”  The patient drinks over 14 cups of coffee before noon and states she only eats eleven or twelve calories a day yet “keeps gaining weight!”  Her alcohol use is defined as minimal.  Patient does not exercise but gets offended when questioned and responds by stating “I get enough exercise watching these crazy kids”. Education includes GED and local night college for her certified nurse assistant certificate.

MEDS:  Valium 5 mg prn, Zoloft 100 mg a day, and trazedone 100 mg qhs, Imitrex 50 mg prn migraine (average 15 per month).  OTC meds include Metabolife 356 for energy and weight loss.

ALL: PCN, all macrolides, sulfa and quinolones.  

FH: Depression and alcoholism throughout her family including siblings and parents.  Mother also has chronic fatigue and fibromyalgia. Father has PTSD from being married to her mother.

SxHx:  T&A as a child for chronic sore throats. Tympanostomy tubes as a child for chronic ear infections (parents smoked in the house as now does she).  TAH-BSO for fibroids and dysfunctional uterine bleeding.  Multiple benign breast biopsies for fibrocystic breast disease.

PE: 

VSS; wt 243, ht 5 “1

Gen – Patient switches from crying jags to out and out aggressive or defensive demeanor.

Neck – no thyromegaly

CV- RRR no murmer

Lungs – clear

Abdomen – obese; diffuse pain throughout with no rebound or Murphy sign

Skin – multiple tattoos; no rash or dysplastic lesions

Back- no spasms but exquisite pain with palpation, percussion or even observation

Musculoskeletal – pain with palpation of every muscle

Neuro – grossly intact, negative straight leg raises, normal reflexes 

Workup: Full review of patients old records (over 640 pages) show that all possible testing has been done including Pet-Scans, dexamethasone suppression tests, Schilling tests, tilt table testing, EEG, allergy RAST testing, pan-endoscopies and even a PSA for some reason.  All studies normal.

Diagnosis: SLS (classical type)

Discussion:  Just as described by Edward B. Foote MD in 1896 in his infamous book Plain Home Talk: Medical Common Sense, the above patient symbolizes a syndrome that is very real to physicians yet surreal in its etiology, work-up and treatment.  Similar to Foote’s “neurasthenia with a notion of chronic withering” it becomes more obvious that with this patient there really is less here than meets the eye.

Like an onion, the layers of fibromyalgia, chronic fatigue, IBS, etc. continue to be peeled off until the final syndrome is truly defined.  SLS or “Shitty Life Syndrome” is a constellation of ailments not unlike an enigma wrapped in a riddle whose only common thread to reality is social dysfunction.  These patients, like our lady described above, present to the medical community and are subsequently medicalized, surgerized, and psychoanalyzed only to have the true cause escape all.  The reason these patients have these symptoms is quite simple.  To them their life totally sucks and for this there is no medical cure.

Although there is no hard data to support our conclusions or anything else we say for that matter, the authors justify the existence of SLS in order to maintain their own sanity.   Because SLS is contagious, it is the physician who may come away from the visit with medical problems such as GERD, abdominal pain and depression.  Therefore treatment for this syndrome is not so much for the patient but for the poor doctor who must endure the torture of frustration.

SLS is very common and the differential is very large.  Such syndromes as irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, gastroparesis, migraines, myofascial pain syndrome, stress, depression, anxiety, cystitis, RSD, chronic pain and PTSD only reveal the tip of the iceberg whose base is comprised of one big piece of SLS.  

Treatment is usually unsuccessful as the medical dollars are burned yet the patient’s symptoms worsen or change.  Anti-depressants help briefly but the doctor soon has to realize he or she can’t rely on taking these medications forever.  He or she must go back to work and stare the patient in the face with an SLS eating grin and let the SLS hit the fan. Since it is the patient who believes that their life sucks then it is only the patient who can wipe themselves clean of SLS. 

In conclusion, the authors believe in their heart that SLS or “Shitty Life Syndrome” not only exists but is actually pervasive.  Like kryptonite, physicians are powerless against this disorder.   If one is not careful, one may step into a big pile of SLS without ever knowing it.

So, there you have it, the first landmark case of Shitty Life Syndrome or SLS or Social Determinants of Health. You’re welcome. Someone needs to amend Wikipedia here and here. You can read this writer’s article here.

Now where is my prize?

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  8 comments for “Did I Discover the Concept of Social Determinants of Health?

  1. john
    August 29, 2019 at 9:12 am

    I may have discovered this same ailment in a peripheral way, years ago => https://docsontheweb.blogspot.com/2008/04/at-devorrahs-request-911docs-cam-garb.html

  2. Heidi McKellar
    August 28, 2019 at 6:03 pm

    SLS is on the rise. The conspiracy theorist in me, believes it is the government’s fault, as it is easier to control those who suffer from it. It is often followed by an irrational and unrealistic expectation of immortality when they indeed suffer from a true terminal event or disease.

  3. Bridget Reidy
    August 24, 2019 at 1:23 pm

    There is so much truth in satire!

  4. Theresa Peet
    August 24, 2019 at 11:47 am

    Funny, but also sad. I see people all the time who need a “life do over,” and by that I mean that they need to be reborn to different parents and relive their entire childhoods and young adult hoods to be cured. Sigh. Having said that, with conscious efforts, I have seen some people heal with lots of very good therapy, not the kind that most people have coverage for through their insurance. I’m talking insight-oriented therapy that take LOTS of time and patience. So there again, lack of resources to get the therapy needed is a killer.

  5. R Stuart
    August 24, 2019 at 10:15 am

    Bravo!

    She just needs a good DPC doc who’ll meet with her four or five times/week, right?

  6. John
    August 24, 2019 at 9:46 am

    Doug, all too common a scenario most docs I believe, see daily. The hardest question though is can we provide the most meaningful and effective care for these people as their PCPs? I believe the answer is yes. I’m not aware of any hard studies that support my contention though…thanks for sharing!

  7. Pat
    August 24, 2019 at 9:23 am

    I remember SLS from waaay back in 2001. It was the single funniest thing ever written in the hilarious Placebo Journal, and it was dead-on, 100% true. Never has one case history so brilliantly encompassed the true state of US health care and medicine’s losing battle. Long live the King.

    • arthur gindin MD
      August 24, 2019 at 2:41 pm

      I can only sympathize with those meeting SLS for the first (and hopefully ONLY) visit. As a neurosurgeon I could simply “pass” and send her back.

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