Heroes Not Zombies

Most people don’t go to see a doctor unless they feel that something’s not right – in other words, they have a symptom. However, you might go and see a doctor just for a check up or for some screening, even if you’re feeling well. Maybe the following graphs will provoke some thoughts about this.

If you’re healthy, let’s assume you can place yourself in the bottom left hand quadrant. However, if you’re feeling OK but you go to your doctor and he or she finds something not right, say raised blood pressure, or raised cholesterol level or something then you’re in the bottom right quadrant (where the red star is)

If you’re not feeling well, say you’ve got some pain, or maybe nausea, or you’re feeling unusually exhausted or something, and either there’s something you can see wrong – a lump, or swelling, or a rash, for example – or your doctor examines you or does a few tests and finds some abnormalities, then you’re up there with the
blue star in the top right corner.

But if the doctor examines you and does tests and finds NO abnormalities then you’re in the top left with the green star

Doctors are most comfortable dealing with patients who fall into the right hand side of this chart. When we can make objective findings we can diagnose a particular disease.

This is the main goal of undergraduate medical training – to be able to make diagnoses (in the sense of being able to identify or exclude the presence of a particular disease).
Two things follow this clinically. First of all, treatments are specifically targeted towards the disease. Secondly, symptoms are assumed to be in direct, linear relationship with the disease, so if the disease is reduced, there is an expectation that the symptoms will be reduced accordingly, and, on the other hand, if symptoms are reduced then that can be taken as a sign that the disease is on the wane.
But, actually, human beings are more complex than that. Symptoms and disease are not in direct linear relationships. In fact, in all complex systems, we find that non-linearity is a key characteristic.
Let me give you an example. A woman may complain of severe recurrent or chronic pelvic pain. Tests show that she has some of the tissue which normally lines the uterus lying outside the uterus – a condition known as endometriosis. The surgeon removes the offending wayward tissue but after recovery she finds she still has the pain. I’ve seen patients who have had large portions of their bowel removed for bowel pain who continue to have bowel pain and patients whose spinal abnormalities are treated surgically but whose back pain remains as severe as ever. That’s the downside. On the upside, if a patient has, say diabetes, then getting the dose of insulin right is highly likely to improve ALL of their symptoms. Or if a patient has a broken leg then repairing the fracture is highly likely to remove the disability and the pain. There are relationships between symptoms and diseases, they’re just not simple, linear ones!

But what about the patients who present with symptoms but where the doctors can’t find any objective abnormalities? Well, they are part of a group of patients who can be understood from a different perspective from the disease one – illness.

Eric Cassell puts it very nicely in his “Healer’s Art” where he says that illness is what a man has, and disease is what an organ has; illness is what you go to the doctor with, and disease is what you come home with! In other words, illness is the whole picture of the patient’s symptoms and their disease.

Sure, if their illness does at least include an indentifiable disease process, the treatments can still be targeted against that disease (in the hope that such an approach will solve the whole problem), but what about the patients who have symptoms but no identifiable disease?

In Glaswegian there’s an expression for this “It’s in yer heid!” But this is more than a little unfair! It implies that if you’ve got a symptom which remains “medically unexplained” then it’s either imaginary, or due to a psychological problem. This is overly simplistic. First of all because there may indeed be a physical disease process going on that’s just not been uncovered yet. Secondly, because as complex organisms, disturbances of the inner healthy functions are often vague and hard to pin down, but become clearer as they become more severe. And thirdly, because we are all embedded creatures, you can’t consider us in isolation. If you want to understand someone’s symptoms, you need to understand something about their life, especially their changes, challenges and stresses. Changes, challenges and stresses can impact on the mind and the body in diverse ways.

How often does this latter case appear in the working life of a doctor? Well, an American physician by the name of Kroenke, has done a lot of research into this and here’s a slide which summarises one of his key findings –

Kroenke has found that of the top ten commonest symptoms presented to doctors by their patients, almost 9 out of 10 of them will fall into this category. As I heard him say once – medical school teaches you how to treat the 1 in 10 with a medical diagnosis, but how are you going to treat the other 9 in 10?

This illness perspective presents a completely different set of challenges from the disease one. I’ll say more about them in another post cos this one’s gone on long enough I think.

But, tell me, what do you think about this?

Oh, and just in case you were wondering, the bottom left segment does represent health, but that feels strangely unsatisfying. Health is just the absence of the bad stuff? It was this diagram which led me to explore what health actually is.