Here’s an example of how I think something through. I often write out my thoughts in a notebook and frequently I do so by constructing a kind of mind map – not the Tony Buzan kind of mind map with all its bells and whistles but spreading the main ideas and concepts out over a blank canvas then seeing the connections between them and using boxes and arrows to tie it altogether. When I was wondering about what exactly is a doctor’s job recently I drew this map –
Let me explain it because some of it might be self-explanatory but it’s drawn as a thinking tool, not a communication one.
On the left hand page I’m thinking about diagnosis and the difference between the concepts of “disease” and “illness”.
People present to their doctors with symptoms (what they experience) and signs (what the doctor can feel, hear, measure and so on). Together they are used to make a “diagnosis” – a diagnosis, is, essentially, simply and understanding. It’s where the doctor recognises what these symptoms and signs are evidence of. Actually, diagnosis in the biomedical approach (that’s what we European and American doctors sometimes call “Western medicine”), is usually about discovering and naming pathology ie diseased tissue. Historically, that was known as the “lesion”. It’s a very materialistic and, frankly, usually reductionist approach to medicine. That circle means that it’s the symptoms and the signs together which constitute the diagnosis. What Kroenke and others have shown us is that there is a relationship between the symptoms and signs but whilst a sign may be highly likely to be indicative of a certain pathology, symptoms most definitely are not. Kroenke shows that over 80% of the symptoms patients experience are NOT caused by any “lesions” or pathology. This is best understood by thinking about “disease” and “illness” differently. Eric Cassell is great about this. He says “disease” is what the organ has and “illness” is what the man has. Disease is about pathology and illness is about suffering. It’s illness that encompasses the subjective experience and disease remains an objective, measurable concept.
So, as doctors, we can engage with the patient at the level of their disease, but if we want to help relieve suffering we have to think more broadly than that, and expand into the unmeasurable. This is where stories come in. People convey their illnesses by telling the stories of their experience. Two things about this are highlighted in the above mind map. Firstly, that experience is interpreted by patients themselves as well as by their doctors. It’s through narrative (story-telling) that we make sense of our experience. It’s through narrative and talking that we can understand the meaning of our illnesses. People like Darian Leader and David Corfield, and Brian Broom have made that very clear in their work on psychosomatic medicine.
Once we start to consider more than the material, the physical and the measurable, we can start to try and understand an illness in the contexts of a person’s life. The triangle of body, mind and spirit highlights how context might refer to what’s important in an individual person’s life. Some people talk about physical and material needs and security, others primarily of feelings and relationships and yet others of a world greater than themselves ie of purpose, meaning and belief. A patient’s suffering needs to be understood in the context which matters most to that person. Some people for example have chest pain because they believe they’ve offended God, others because they’ve been humiliated or abandoned and yet others because they’ve lost their jobs and income.
The final part of that left hand page is the contexts of the individual, their relationships and their environments (cultural and physical). Cassell again is great on this, asking the question of where a patient’s suffering actually lies – is it in them, their relationships or family, or their society or culture?
Many doctors don’t consider these questions but I think if we want to understand people we have to go further than the materialistic, disease model.
OK, that’s enough for this post! I’ll cover the right hand page, which is about thinking through appropriate interventions and treatments, in another post.
One time I was was asked in a deposition what specialty of medicine I was an expert in. (I am a Family Doc.) I said no one would could consider me any kind of expert except I was an expert in my people, and I’d take my odds on helping them over any doc in the world if he/she did know know them well. The depostion went to suit me.
Dr. Bob, you have an uncanny sense of timing. The post I plan for Saturday addresses this very issue.
Dr. B
[…] this remedy a few times since in similar circumstances. It’s one of the remedies which really makes me think about our basic concepts of health and healing. It does not cure cancers, but in the right circumstances, in my very small experience with this, […]
[…] humanly relevant medicine. Eric Cassell nicely explores this conceptually by unpicking the words “disease” and “illness”, and clinically by asking doctors to encourage patients to talk about their […]
[…] what is the job of a doctor? Or what makes for a good doctor? I’m pretty sure it involves trying to understand people better. I’m also pretty sure it involves helping people. It involves never thinking […]
[…] to describe what I observe. I’m also very keen on finding explanations for things (I think one of the definitions of a doctor’s job is “a person who tries to understand” – but that’s another story!). I also […]