Monthly Archives: February 2017

Contemporary Medical Training And Societal Medical Requirements – How Does One Balance The Manifest Need for General Practitioners With Modern Super-Specialist Trends

For all of my career, since starting as a medical student at the University of Cape Town as an 18 year old fresh out of school many years ago, I have been involved in the medical and health provision and training world, and have had a wonderful career first as a clinician, then as a research scientist, then in the last number of years managing and leading health science and medical school research and training. Because of this background and career, I have always pondered long and hard about what makes a good clinician, what is the best training to make a good clinician, how we define what a ‘good’ clinician is, and how we best align the skills of the clinicians we train with the needs and requirements of the country’s social and health environments in which they trained. A few weeks ago I had a health scare which was treated rapidly and successfully by a super-specialist cardiologist, and I was home the next day after the intervention, and ‘hale and hearty’ a few days after the procedure. If I had lived 50 years ago, and it had happened then, in the absence of modern high-tech equipment and the super-specialists skills, I would probably have died a slow and uncomfortable death treated with drugs of doubtful efficacy that would not have much benefited me much, let alone treat the condition I was suffering from. Conversely, despite my great respect for these super-specialist skills which helped me so successfully a few weeks ago, it has become increasingly obvious that this great success in clinical specialist training has come at the cost of reduced emphasis on general practitioner-focused training, and a reduction in the number of medical students choosing general practitioner work as a career after they qualify, which has caused problems both to clinical service delivery in a number of countries, particularly in rural areas of countries, and paradoxically put greater strain on specialist services despite their pre-eminence in contemporary clinical practice in most countries around the world. My own experience with grappling with this problem of how to increase general practitioners as an outcome of our training programs, as a Head of School of Medicine previously, and this recent health scare which was treated so successfully by super-specialist intervention, got me thinking of how best we can manage the contradictory requirements of the need for both general practitioners and specialists in contemporary society, and whether this conundrum should be best managed by medical schools, health and hospital management boards, or government-led strategic development planning initiatives.

It is perhaps not surprising, given the exponential development of technological innovations that originated in the industrial revolution and which changed how we live, that medical work also changed and became more technologically focused, which in turn required both increased time and increased specialization of clinical training to utilize these developing technologies, such as surgical, radiology investigative and laboratory-based diagnostic techniques. The hospital (Groote Schuur) and medical school (University of Cape Town) where I was trained was famous for the achievements of Professor Chris Barnard and his team’s work performing the first heart transplant there, using a host of advanced surgical techniques, heart-lung machines to keep the patients alive without a heart for a brief period of time, and state-of-the-art immunotherapy techniques to resist heart rejection, all specialist techniques he and his team took many years to master in some great medical schools and hospitals in the USA. Perhaps in part because of this, our training was very ‘high-tech’, consisting of early years spent learning basic anatomy, physiology and pathology-based science, and then later years spent in surgical, medical, and other clinical specialty wards, mostly watching and learning from observation of clinical specialists going about their business treating patients. If I remember it correctly, there were only a few weeks of community-based clinical educational learning, very little integrative ‘holistic’ patient-based learning, and almost no ‘soft-skill’ training, such as optimal communication with patients, working as part of a team with other health care workers such as nurses and physiotherapists, or learning to help patients in their daily home environment and social infrastructure. There was also almost no training whatsoever in the benefits of ‘exercise as medicine’, or of the concept of wellness (where one focuses on keeping folk healthy before they get ill, rather than dealing with the consequences of illness). This type of ‘specialist-focused’ training was common, particularly in Western countries, for most of the last fifty or so years, and as a typical product of this specialist training system, for example, I chose first clinical research and then basic research rather than more patient-focused work as my career choice, and a number of my colleagues from my University of Cape Town medical training class of 1990 have had superb careers as super-specialists in top clinical institutions and hospitals all around the world.

This increasing specialization of clinical training and practice, such as the example of my own medical training described above, has unfortunately had a negative impact both on general practitioner numbers and primary care capacity. A general practitioner (GP) is defined as a medical doctor who treats acute and chronic illnesses and provides preventative care and health education to patients, and who has a holistic approach to clinical practice that takes all of biological, social and psychological factors into consideration when treating patients. Primary care is defined as the day-to-day healthcare of patients and communities, with the primary care providers (GP’s, nurses, health associates or social workers, amongst others) usually being the first contact point for patients, referring patients on to specialist care (in secondary or tertiary care hospitals), and coordinating and managing the long term treatment of patient health after discharge from either secondary or tertiary care if it is needed. In the ‘old days’, GP’s used to work in their community often where they were born and raised, worked 24 hours a day as needed, and maintained their relationship with their patients through most or all of their lives. Unfortunately, for a variety of reasons, GP work has changed, and they now often work set hours, patients are rotated through different GP’s in a practice, and the number of graduating doctors choosing to be GP’s is diminishing, and there is an increasing shortage of GP’s in communities and particularly rural areas of most countries as a result. Sadly, GP work is often regarded as being of lower prestige than specialist work, the pay for GP’s has often been lower than that of specialists, and with the decreased absolute number of GPs, the work burden on many GP’s has increased (and paradoxically with computers and electronic facilities the note and recording taking requirements of GP’s appears to have increased rather than decreased) leading to increased level of burnout and GP’s choosing to turn to other clinical roles or to leave the medical profession completely, which exacerbates the GP shortage problem in a circular manner. Training of GP’s has also evolved into specialty-type training, with doctors having to spend 3-5 years ‘specializing’ as a GP (often today called Family Practitioners or Community Health Doctors), and this also has paradoxically potentially put folk off a GP career, and lengthens the time required before folk intent on becoming GP’s can do so and become board certified / capable of entering or starting a clinical GP practice. As the number of GP’s decrease, it means more folk go directly to hospital casualties as their first ‘port of call’ when ill, and this puts a greater burden on hospitals, which somewhat ironically also creates an increased burden on specialists, who mostly work in such hospitals, and who end up seeing more of these folk who could often be treated very capably by GP’s. This paradoxically allows specialists less time to do the specialist and super-specialist roles they spent so many years training for, with the result that waiting list and times for ‘cold’ (non-emergency) cases increases, and hospital patient care suffers due to patient volume overload.

At a number of levels of strategic management of medical training and physician supply planning, there have been moves to counter this super-specialist focus of training and to encourage folk to consider GP training as an appealing career option. The Royal College of Physicians and Surgeons of Canada produced a strategic clinical training document (known as the ‘CanMeds’ training charter) which emphasizes that rather than just training pure clinical skills, contemporary training of clinical doctors should aim to create graduates who are all of medical experts, communicators, collaborators, managers, health advocates, scholars and professionals – in other words a far more ‘gestalt’ and ‘holistically’ trained medical graduate. This CanMeds document has created ‘waves’ in the medical training community, and is now used by many medical schools around the world now as their training ‘template’. Timothy Smith, senior staff writer for the American Medical Association, published an interesting article recently where he suggested that similar changes were occurring in the top medical schools in the USA, with clinical training including earlier exposure to patient care, more focus on health systems and sciences (including wellness and ‘exercise is medicine’ programs), shorter time to training completion and increased emphasis on using new communication technologies more effectively as part of training. In my last role as Head of the School of Medicine at the University of the Free State, working with Faculty Dean Professor Gert Van Zyl, Medical Program Director Dr Lynette Van Der Merwe, Head of Family Medicine Professor Nathanial Mofolo, Professor Hanneke Brits, Dr Dirk Hagemeister, and a host of other great clinicians and administrators working at the University or the Free State Department of Health, the focus on the training program was shifted to try to include a greater degree of community based education as a ‘spine’ of training rather than as a two week block in isolation, along with a greater degree of inter-professional education (working with nurses, physiotherapists, and other allied health workers in teams as part of training to learn to treat a patient in their ‘entirety’ rather than as just a single clinical ‘problem’), and an increased training of ‘soft skills’ that would assist medical graduates not only with optimal long term patient care, but also with skills such as financial and business management capacity so that they would be able to run practices optimally, or at least know when to call in experts to assist them with non-clinical work requirements, amongst a host of other innovative changes. We, like many other Universities, also realized that it was important to try and recruit medical students from the local communities around the medical school in which they grew up, and to encourage as many of these locally based students as possible to apply for medical training, though of course selection of medical students is always a ‘hornets nest’, and it is very challenging to get it right balancing marks, essential skills and community needs of the many thousands of aspirant clinicians who wish to do medicine when so few places are available to offer them.

All of these medical training initiatives to try and initiate changes of what has become a potentially ‘skewed’ training system, as described above, are of course ‘straw in the wind’ without government backing and good strategic planning and communication by country-wide health boards, medical professional councils, and hospital administrators who manage staffing appointments and recruitment. As much as one needs to change the ‘focus’ and skills of medical graduates, the health structures of a country need to be similarly changed to be ‘focused’ on community needs and requirements, and aligned with the medical training program initiatives, for the changes to be beneficial and to succeed. Such training program changes and community based intervention initiatives have substantial associated costs which need to be funded, and therefore there is a large political component to both clinical training and health provision. In order to strategically improve the status quo, governments can choose to either encourage existing medical schools to increase student numbers and encourage statutory clinical training bodies to enact changes to the required medical curriculum to make it more GP focused, or build more medical schools to generate a greater number of potential GP’s. They can also pay GP’s higher salaries, particularly if they work in rural communities, or ensure better conditions of service and increased numbers of allied health practitioners and health assistants to lighten the stress placed on GP’s, in order to ensure that optimal community clinical facilities and health care provision is provided for. But, how this is enacted is always challenging, given that different political parties usually have different visions and strategies for health, and changes occur each time a new political party is elected, which often ‘hinders’ rather than ‘enacts’ required health-related legislation, or as in the case of contemporary USA politics, attempts to rescind previous change related healthcare acts if they were enacted by an opposition political party. There is also competition between Universities which have medical schools for increases in medical places in their programs (which result in more funding flowing in to the Universities if they take more students) and of course any University that wishes to open a new medical school (as my current employers, the University of Waikato wish too, and who have developed an exciting new community focused medical school strategic plan that fulfills all the criteria of what a contemporary focused GP training program should be, that will surely become an exemplary new medical school if their plan is approved by the government) is regarded as a competition for resources by those Universities who already run medical training programs and medical schools. Because of these competition-related and political issues, many major health-related change initiatives for both medical training programs and the related community and state structural training requirements are extremely challenging to enact, and are why so many planned changes become ‘bogged down’ by factional lobbying either before they start or when they are being enacted. This is often disastrous for health provision and training, as chaos ensues when a ‘half-changed’ system becomes ‘stuck’ or a new political regime or health authority attempts to impose further, often ‘half-baked’ changes on the already ‘half-changed’ system, which results in an almost unmanageable ‘mess’ which is sadly often the state of many countries medical training, physician supply, and health facilities, to the detriment both of patients and communities which they are meant to serve and support.

The way forward for clinical medical training and physician supply is therefore complex and fraught with challenges. But, having said this, it is clear that changes are needed, and brave folk with visionary thinking and strategic planning capacity are required to both create sound plans that integrate all the required changes across multiple sectors that are needed for the medical training changes to be able to occur, and to enact them in the presence of opposition and resistance, which is always the case in the highly politicized world of health and medical training. Two good examples of success stories in this field were the changes to the USA health and medical training system which occurred as a result of the Flexner report of 1910, which set out guidelines for medical training throughout the USA, which were actually enacted and came to fruition, and the development of the NHS system in the UK in the late 1940’s, which occurred as a result of the Beveridge report of 1942, which laid out how and why comprehensive, universal and free medical services were required in the UK, and how these were to be created and managed, and these recommendations were enacted by Clement Attlee, Aneurin Bevin and other members of the Labour government of that time. Both systems worked for a time, but sadly both in the USA and UK, due to multiple reasons and perhaps natural system entropy, both of these countries health services are currently in a state of relative ‘disrepair’, and it is obvious that major changes to them are again needed, and perhaps an entire fresh approach to healthcare provision and training similar to that initiated by the Flexner and Beveridge reports are required. However, it is challenging to see this happening in contemporary times with the polarized political status currently occurring in both countries, and strong and brave health leadership is surely required at this point in time in these countries, as always, in order to initiate the substantial strategic requirements which are required to either ‘fix’ each system or create an entirely new model of health provision and training. Each country in the world has different health provision models and medical training systems, which work with varying degrees of success. Cuba is an example of one country that has enacted wholesale GP training and community medicine as the centerpiece of both their training and health provision, though some folk would argue that they have gone too far in this regard in their training, as specialist provision and access is almost non-existent there. Therein lies an important ‘rub’ – clearly there is a need for more GP and community focused medical training. But equally, it is surely important that there is still a strong ‘flow’ of specialists and super-specialists to both train the GP’s in the specific skills of each different discipline of medicine, and to treat those diseases and disorders which require specialist-level technical skills. My own recent health scare exemplifies the ‘yin and yang’ of these conflicting but mutually beneficial / synergistic requirements. If it were not for the presence of a super-specialist with exceptional technical skills, I might not be alive today. Equally the first person I phoned when I noted concerning symptoms was not a super-specialist, but rather was my old friend and highly skilled GP colleague from my medical training days, Dr Chris Douie, who lives close by to us and who responded to my request for assistance immediately. Chris got the diagnosis spot on, recommended the exact appropriate intervention, and sent me on to the required super-specialist, and was there for me not just to give me a clinical diagnosis but also to provide pastoral care – in other words ‘hold my hand’ and show me the empathy that is so needed by any person when they have an unexpected medical crisis. In short, Chris was brilliant in everything he did as first ‘port of call’, and while I eventually required super-specialist treatment of the actual condition, in his role as GP (and friend) he provided that vital first phase support and diagnosis, and non-clinical empathic support, which is so needed by folk when they are ill (indeed historically the local GP was not just everyone’s doctor but also often their friend). My own example therefore emphasizes this dual requirement for both GP and specialist health provision and capacity.

Like most things, medical training and health care provision has like a pendulum ‘swung’ between specialist and generalist requirements and pressures in the last century. The contemporary perception, in an almost ‘back to the future’ way, is that we have perhaps become too focused on high technology clinical skills and training (though as above there will always be a place and need for these), and we need more of our doctors to be trained to be like their predecessors of many years ago, working out in the community, caring for their patients and creating an enduring life-long relationship with them, and dealing with their problems early and effectively before they become life-threatening and costly to treat and requiring the intervention of expensive specialist care. It’s an exciting period of potential world-wide changes in medical training and the clinical health provision to communities, and a great time to be involved in either developing the strategy for medical training and health provision and / or enacting it – if the folk involved in doing so are left in peace by the lobby groups, politicians and folk who want to maintain the current unbalanced status quo due to their own self-serving interests. Who knows, maybe even clinicians, like in the old days, will be paid again by their patients with a chicken, or a loaf of freshly baked bread, and goodwill will again be the bond between the community, the folk who live in them, and the doctors and healthcare workers that treat them. And for my old GP friend Chris Douie, who is surely the absolute positive example and role model of the type of doctor we need to be training, a chicken will heading his way soon from me, in lieu of payment for potentially saving my life, and for doing so in such a kind and empathetic way, as surely any GP worth his or her ‘salt’ would and should do!

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Muscle Dysmorphia And The Adonis Complex – Mirror, Mirror On The Wall, Why Am I Not The Biggest Of Them All

I have noticed recently that my wonderful son Luke, who is in the pre-teenage years, has become more ‘aware’ of his body and discusses things like ‘six-pack abs’ and the need to be strong and have big muscles, probably like most boys of his age. I remember an old colleague at the University of Free State mention to me that her son, who was starting his last year at school, and who was a naturally good sports-person, had started supplementing his sport with gym work as he perceived that ‘all boys his age were interested in having big muscles’, as my colleague described it. A few decades ago, my old colleague and friend Mike Lambert, exercise physiologist and scientist without peer, and I did some work researching the effect of anabolic steroid use on bodybuilders, and noted that there were not just physical but also psychological changes in some of the trial participants. I did a fair amount of time in the gym in my University days, and always wondered why some of the biggest folk in the gym seemed to do their workouts with long pants and tracksuit tops, sometimes with hoods up, even on hot days, and how in conversation with them I was often told that despite them being enormous (muscular rather than obese-wise), they felt that they were small compared to their fellow bodybuilders and weightlifters, and that they needed to work harder and longer in the gym than they were currently doing to get results. All of these got me thinking of the fascinating syndrome known as muscle dysmorphia, also known as the Adonis complex, ‘bigorexia’, or ‘reverse anorexia’ and what causes the syndrome / disorder in the folk that develop it.

Muscle dysmorphia is a disorder mostly affecting males (though females can also be affected) where there is a belief or delusion that one’s body is too small, thin, insufficiently muscular or lean, despite it often being normal or exceptionally large and muscular, and related to obsessional efforts to increase muscularity and muscle mass by weightlifting exercise routines, dietary regimens and supplements, and often anabolic steroid use. This perception of being not muscular enough becomes severely distressing for the folk suffering from the syndrome, and the desire to enhance their muscularity eventually impacts negatively on the sufferer’s daily life, work and social interactions. The symptoms usually begin in early adulthood, and are most prevalent in body-builders, weight-lifters, and strength-based sports participants (up to 50 percent in some bodybuilder population studies, for example). Worryingly, muscle dysmorphia is increasingly being diagnosed in younger / adolescent folks, and across the spectrum of sports participants, and even in young folk who begin lifting weights for aesthetic rather than sport-specific purposes, and who from the start perceive they need to go to gym to improve their ‘body beautiful’. Two old academic friends of mine, Dave Tod and David Lavallee, published an excellent article on muscle dysmorphia a few years ago, where they suggested that the diagnostic criteria for the disorder are that the sufferer needs to be pre-occupied with the notion that their bodies are insufficiently lean and muscular, and that the preoccupation needs to cause distress or impairment in social or occupational function, including at least two of the four following criteria: 1) they give up / excuse themselves from social, occupational or recreational activities because of the need to maintain workout and diet schedules; 2) they avoid situations where their bodies may be exposed to others, or ‘endure’ such situations with distress or anxiety; 3) their concerns about their body cause distress or impairment in social, occupational or other areas of their daily functioning; and 4) they continue to exercise and monitor their diet excessively, or use physique-enhancing supplements or drugs such as anabolic steroids, despite knowledge of potential adverse physical or psychological consequences of these activities. Folk with muscle dysmorphia spend a lot of their time agonizing over their ‘situation’, even if it is in their mind rather than reality, look at their physiques in the mirror often, and are always of the feeling that they are smaller or weaker than what they really are, so there is clearly some cognitive dissonance / body image problem occurring in them.

What causes muscle dysmorphia is still not completely known, but what is telling is that it was first observed as a disorder in the late 1980’s and early 1990’s, and was first defined as such by Harrison Pope, Katharine Phillips, Roberto Olivardia and colleagues in a seminal publication of their work on it in 1997. There are no known reports of this disorder from earlier times, and as suggested by these academics, it’s increasing development appears to be related a growing social obsession with ‘maleness’ and muscularity, that is evident in the media and marketing adverts of and for the ‘ideal’ male in the last few decades. While women have had relentless pressure on them from the concept of increasing ‘thinness’ as the ‘ideal body’ perspective for perhaps a century or longer from a social media perspective, with for example the body size of female models and advertised clothes sizes decreasing over the years (and it has been suggested that in part this is responsible for the increase in the prevalence in anorexia nervosa in females), it appears that males are now under the same marketing / media ‘spotlight’, but more from a muscularity rather than a ‘thinness’ perspective, with magazines, newspapers and social media often ‘punting’ this muscular ‘body ideal’ for males when selling male-targeted health and beauty products. Some interesting changes have occurred which appear to support this concept, for example the physique of GI-Joe toys for young boys changing completely in the last few decades, apparently being much more muscular in the last decade or two compared to their 1970 prototypes. Matching this change, in 1972 only 15-20 percent of young men disliked their body image, while in 2000 approximately 50% percent of young men disliked their body image. Contemporary young men (though older men may also be becoming increasingly ‘caught up’ in similar desire for muscularity as contemporary culture puts a price on the ‘body beautiful’ right through the life cycle) perceive that they would like to have 13 kg more muscle mass on average, and believe that women would prefer them to have 14 kg more muscle mass to be most desirable, though interestingly when women were asked about this, women were happy with the current mass of their partners, and many were indeed not attracted to heavily-muscled males. Therefore, it appears that social pressure may play a large part in creating an environment where men perceive their bodies in a negative light, and this may in turn lead to the development of a ‘full blown’ muscle dysmorphia syndrome in some folk.

While the concept that social pressure plays a big role in the development of muscle dysmorphia, other factors have also been suggested to play a part. Muscle dysmorphia is suggested to be associated with, or indeed a sub-type of, the more general body dysmorphic disorder (and anorexia nervosa, though of course anorexia nervosa is about weight loss, rather than weight gain), where folk develop a pathological dislike of one or several body parts or components of their appearance, and develop a preoccupation with hiding or attempting to fix their perceived body flaw, often with cosmetic surgery (and this apparently affects up to 3 percent of the population). It has been suggested that both muscle dysmorphia and body dysmorphic disorder may be caused by a problem of ‘somatoperception’ (knowing one’s own body), which may be related to organic lesions or processing issues in the right parietal lobe of the brain, which is suggested to be the important area of the brain for own-body perception and the sense of self. In folk that have lesions of the right parietal cortex, they perceive themselves to be ‘outside’ of their body (autoscopy), or that body parts are missing / there is a lack of awareness of the existence of parts of the body (asomatognosia). Non-organic / psychological factors have also been associated with muscle dysmorphia, apart from media and socio-cultural influences, including being a victim of childhood bullying, being teased about levels of muscularity when young, or being exposed to violence in their family environment. It has also been suggested that it is associated with appearance-based rejection sensitivity, which is defined as anxiety-causing expectations of social rejection based on physical appearance – in other words, for some reason, folk with muscle dysmorphia are anxious that they will be socially rejected due to their perceived lack of muscularity and associated appearance deficits. Whether this rejection sensitivity is due to prior negative social interactions, or episodes of childhood teasing or body shaming, has not been well elicited. Interestingly, while studies have reported inconclusive correlations with body mass index, body fat, height, weight, and pubertal development age, there have been strong correlations reported with mood disorders, anxiety disorders, perfectionism, substance abuse, and eating and exercise-dependence / addiction disorders, as well as with the clinical depression, anxiety, and obsessive-compulsive disorders. There does not appear to be a strong relationship to narcissism, which perhaps is surprising. Whether these are co-morbidities or they have a common pathophysiology at either a psychological or organic level is yet to be determined. It has been suggested that a combination of cognitive behavioural therapy and selective serotonin reuptake inhibitor prescription (a type of antidepressant) may improve the symptoms of muscle dysmorphia. While these treatment modalities would support a link between muscle dysmorphia and the psychological disorders described above, the efficacy of these treatment choices is still controversial, and there is unfortunately a high relapse rate. It is unfortunately a difficult disorder to ‘cure’, given that all folk need to eat regularly in order to live, and most folk incorporate exercise into their daily routines, which make managing ‘enough’ but not ‘excessive’ amounts of weightlifting and dietary regulation difficult to regulate in folk who have a disordered body image.

Muscle dysmorphia appears therefore to be a growing issue in contemporary society, which is increasing in tandem with the increased media-related marketing drive for the male ‘body beautiful’, which now appears to be operating at a similar level to the ‘drive for thinness’ media marketing which has blighted the female perception of body image for a long time, and has potentially led to an increased incidence of body image disorders such as anorexia nervosa and body dysmorphic syndrome. However none of these are gender specific, and it is not clear how much of a relationship these body image disorders have with either organic brain or clinical psychological disorders, as described above. It appears to be a problem mostly in young folk, with older folk being more accepting of their body abnormalities and imperfections, whether these are perceived or real, though sadly it appears that there is a growing incidence of muscle dysmorphia and other body image disorder in older age, as societies relationship and expectations of ‘old age’ changes. As I see my son become more ‘interested’ in his own physique and physical development, which must have obviously been caused by either discussions with his friends, or due to what he reads, or what the ‘actors’ in his computer games look like which he so enjoys playing, like all his friends, I hope he (and likewise my daughter) will always enjoy his sport but have a healthy self-image through the testing teenage and early adult period of time. I remember those bodybuilders my colleague Mike and I worked with all those years ago, and how some of them were comfortable with their large physiques, while with some it was clearly an ordeal to take off their shirts in order to be tested in the lab as part of the trials we did back then. The mind is very sensitive to suggestion, and it is fascinating to see that males now are being ‘barraged’ with advertising suggesting they are not good enough, and if they buy a certain product it will make them stronger, fitter, better, and thus more attractive, to perhaps the same level females have been subjected to for a long period of time. The mind is also sensitive to bullying, teasing and body shaming, as well as a host of other social issues which impinge on it particularly in its childhood and early adolescent development phases. It’s difficult to know where this issue will ‘end’, and whether governmental organizations will ‘crack down’ on such marketing and media hype which surely ‘target’ folks (usually perceived) physical inadequacies or desires, or if it is too late to do so and such media activity has become innate and part of the intrinsic fabric of our daily life and social experience. Perhaps education programs are the way to go at school level, though these are unfortunately often not successful.

There are so many daily challenges one has to deal with, it may seem almost bizarre that folk can spend time worrying about issues that are not even potentially ‘real’, but for the folk staring obsessively at themselves in the mirror, or struggling to stop the intrusive thoughts about their perceived physical shortcomings, these challenges are surely very real, and surely all-consuming and often overwhelming. In Greek mythology Adonis was a well-muscled half man, half god, whose was considered to be the ultimate in masculine beauty, and according to mythology his masculine beauty was so great that he won the love of Aphrodite, the queen of all the gods, because of it. Sadly for the folk with muscle dysmorphia, while they may be chasing this ideal, they are likely to be too busy working on creating their own perfect physique to have time to ‘woo’ their own Aphrodite, and indeed, contemporary Aphrodite’s don’t appear to even appreciate the level of muscularity they eventually obtain. The mirror on the wall, as it usually is, is a false siren, beckoning those weak enough to fall into its thrall – no matter how big, never to appear as the biggest or most beautiful of all.


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