For my first post directly related to the scientific process, I decided to start with the most official scholarly search engine, Google. Yes, I know I’m being sarcastic, however, you’d be surprised how despite many lectures on the technical tools available for academic inquiry through the internet, many still rely on the most basic. Anyway, I decided to enter the phrase “it’s healthy to question” in the Google window. This yielded a numerous results, but one of the first that jumped out at me was an article published in the British Medical Journal entitled, “What is disease? And why it’s a healthy question”. This publication comments on findings of a recent study that came out of Finland and surveyed 3000 laypeople, 1500 doctors, 1500 nurses and 200 government officials on different “states of being”. These conditions were of a wide variety ranging from breast cancer to homosexuality and including others such as wrinkles, menopause and lactose intolerance. The survey was designed to capture if subjects identified each state as a “disease”. It may not be so surprising that physicians were particularly inclined to label conditions as diseases, but what’s interesting is that there was a large discrepancy among all participants’ responses for the various conditions. This is demonstrated by their rainbow of a figure (see manuscript, figure 2, reference: Tikkinen et al 2012).
Moynihan uses the works of Charles Rosenberg, a Harvard historian, to reflect upon the findings of Tikkinen. Rosenberg describes how there is a tendency in today’s era for disease to be depicted as, “existing outside of the human body”. He goes as far as to indicate that the disease not only exists in protocol format of the diagnosing physician, but also in the eyes of the media. Come on, have you not seen a pharmaceutical drug ad on television? If so, you’d have a perfect example of what I believe Moynihan is attempting to describe. As much such examples project a reductionist approach to disease, is it not fact that disease does not exist without the patient? Could this externalization of disease be at the root of why modern medicine aims at treating it often seemingly without consideration for the patient? While barking up the historic tree I might as well identify the roots of the word disease. Now, this shouldn’t be much of a shocker, but I wonder how many of you have actually taken the time to study the word enough to have become aware that it simply embraces a “lack of ease” (originally an Old French word from the 14th century). At its core the word is rooted in the patient, specifically, in the lack of ease of the patient’s state. A state just like all of those listed in figure 2. Ease is not something that an illness carries; it’s something a person possesses. Note that I say possesses to imply that ease can be attained. However, a person can lose balance and harmony in their physiological systems (or spirituality as physicians of 14th century would have identified). This is also known as a loss of homeostasis. To maintain homeostasis is to maintain ease and it happens inside of the human body, not outside of it. To maintain homeostasis is to maintain health. To lose homeostasis is to attain dis-ease.
Semantics aside, we have become a medical system that identifies lists of diseases in a patient with a, “chief complaint” that must be ranked above the others. This system is instead of one that identifies with a person who possesses a “perspective of illness” that, if we listen close enough, just might give away the origin of the dis-ease. As an aside, this “patient perspective of illness” is a piece of information I was taught is the most important of that gathered in the medical interview. That is likely because my training institution, “also treats the human spirit”, not forgetting the roots of the physicians of the 14th century. I was also taught that 80% of a diagnosis is in the patient’s history or story, or perspective, behind the “chief complaint”.
So, what is a “chief complaint”, really? It is a person expressing something that is preventing them from feeling the way they would like, feeling “normal”, or experiencing homeostatic balance. Well, doesn’t that just sound like sharing what is preventing his or her ease? It is noteworthy to mention that not all patients come in with an overt and verbal complaint, but this term can loosely describe any imbalance from “normal”. Let’s take the example of an abnormal laboratory test such as a high LDL cholesterol level when the patient reports, “I feel fine”. If a thorough history is taken, the patient still may reveal lifestyle habits or family history or some circumstance that may indicate that this person is indeed impacting their homeostasis yielding this “chief complaint”. Another example? Sure. Take alcoholism (one of those on figure 2 referenced above). A thorough history may reveal, for example, the patient has thrown back a 12-pack of beer every night since adolescence when they ran away from home to avoid an abusive parent or a history of hospitalizations with severe tremors. Though the art of medicine lies in the ability to elicit such information when working with a patient and their story, in some way, a “chief complaint” will emerge. Further, before, after or during this process, so too will emerge a “patient perspective of illness” and a picture painted of what, specifically, strays their being (biologically/physically, psychologically or socially) from an optimal state of function, or homeostasis. Do these examples not, therefore, imply that each patient defines his or her health by some state of ease and any disturbance to it is a dis-ease, whether it qualifies as a state of being or a disease meeting clinical diagnostic criteria?
Interestingly, Tikkinen et al notes that conditions identified as disease where was attributed to responders linking the state to biological underpinnings. Whereas those not indicated as “disease” could possibly be explained by a state that is “socially mediated”, a “lifestyle choice”, a “collection of symptoms, signs, behaviors” or indicative of “moral failing”. I may argue that these in-and-of themselves could serve as “chief complaints” and either way are certainly part of the “patient perspective of illness”. Perhaps the medical system of today in general, at no fault to those practicing it, struggles to define disease because it has been removed so far from any definition of health. So, I pose to you… does the definition of disease depend on the definition of health?
References: 1) Moynihan, R. What is disease? And why it’s a healthy question. BMJ 2013;346:f107. 2) Tikkinen KA, Leinonen JS, Guyatt GH, Ebrahim S, Jarvinen TL. What is disease? Perspectives of the public, health profressionals and legislators. BMJ Open 2012;2:e001632. Retrieved on January 12, 2014 from: PubMed
* Disclosure: Please note that all reference to publications above reflect only the opinion of the author of this blog and in no way are endorsed by the authors of the cited publications. Further, the author of this blog is obtaining no commercial benefit from the reuse of these materials. This statement is in accordance with the open access and creative commons policy of BMJ.