Heroes Not Zombies

Eric Cassell has a new book out. The Nature of Clinical Medicine. Maybe not a title which grabs your imagination but I was very influenced by two of his earlier works – The Healer’s Art, and The Nature of Suffering. In particular, I appreciated the way he articulated the difference between “disease” and “illness”. It seemed to me that the patient’s illness could only be understood by including their story, their reports of the invisible, subjective experiences we call symptoms. 

When I studied Medicine in Edinburgh, the first three years of the six year degree course had a curriculum of “medical sciences” and so my first degree was a BSc in Medical Sciences. It was only when we entered into Year 4 that we were introduced to patients and to a curriculum of “clinical medicine”. So, the first time I saw “cirrhosis of the liver” it was in a perspex box marked “cirrhosis of the liver”. It was a full two years later before I encountered a person who had “cirrhosis of the liver”. 

I know Medical degree curriculae and teaching methods have changed a lot over the years, but what Eric Cassell does, so eloquently, in this book, is make the case for the practice of “Clinical Medicine” which does NOT focus on the disease. Instead, he argues, it needs to focus on the patient. 

The major problem is, simply stated, that when persons are sick, the sickness has an effect on every part of them, and if attention is paid only or even primarily to the pathophysiology, the disease, or the body, then the other aspects and particulars of sickness will get inadequate attention and the impact of the sickness may go on and on. That probably did not matter so much in the era of acute diseases because the patient was either soon well again or died. Now that the overwhelming majority of medical problems come from chronic diseases, from persons with enduring disability secondary to diseases, birth defects, or trauma, and from an aging population, the inadequacies of disease-centered medicine cause problems for individuals and for populations.

Even if this way of focusing on disease paid off in terms of managing acute illness, he makes the point that the world has changed, and now doctors primarily have to help patients who have chronic illnesses. A continued focus on pathophysiology, is a focus on disease, and it runs the significant risk of failing to understand or help the person who actually has that disease.

If no disease is believed to be present or cannot be found, generally the patients’ problems are shunted aside, symptoms are treated simply because there are treatments, or the patients are essentially dismissed or placed in a category of lesser interest.

This is one of the worst effects of a focus on disease. When the test results return normal readings, the patient is declared to be disease-free, and either dismissed, categorised as having a mental illness, or is prescribed medication to attempt to dull the symptoms they are experiencing even though the doctor can’t explain the presence of those symptoms. Sadly, this often results in loss of trust, breakdown of the doctor patient relationship, and ultimately a failure of care.

It is this almost single-minded focus on disease entities, especially hunting for their ultimately molecular origin, that marks Western scientific medicine and creates difficulties for physicians in the multiple other things they do, from counseling to treating suffering.