Responding to comments on “great physicians treat patients”

Focusing on a ‘disease’ means focusing on an abstraction, a grouping of similar signs and symptoms which may or may not be related. While this may be useful in research, and lead to new insights, it is essentially useless in treating real patients.

Disease does not occur outside of a patient. Even when there is a pathogenic organism, such a a virus, disease only occurs when there is an interaction between the patient and the organism. Since patients vary, identical pathogenic organisms can cause significantly different responses/disease in different patients.

Disease is even more patient specific when it occurs as an interaction between the patient and environment (e.g., allergies) and/or as an internal process (e.g., heart disease).

So ‘focusing on disease’ is a set up for treatment failure (recognized or unrecognized). First, a given set of signs and symptoms in a particular patient may or may not fit in the ‘correct’ diagnostic box. Given enough time in practice, every clinician will see a ‘classic case’ that turns out to NOT be the presumed problem. This is why it is so important to avoid premature closure of diagnostic evaluation.

On top of the uncertainty in diagnosis, every patient responds to treatment in different ways. Sometimes you get the diagnosis right, prescribe the ‘right’ treatment, and the patient still doesn’t get better. On the flip side, sometimes you get the diagnosis wrong, and the recommended ‘wrong’ treatment appears to help the patient anyway.

To make this more concrete, look at the abysmal treatment of low back pain in the U.S. Billions of dollars have been spent on surgical interventions which usually make the problem worse. The most commonly prescribed drug is hydrocodone, very often for back pain, yet it only covers up the pain, doing nothing to solve the problem(s). A major reason is that multiple specialists are focusing on diseases, whether they be radiculopathy, spinal instability, etc., and very few are treating the many environmental and patient-specific things that can affect low back pain, such as job/hobby activities, abdominal strength, hip range of motion, life stress, diet, etc., etc., etc.

Actually, patients have changed as well because the world they live in has changed.

You can not assume that a man lives at home with a wife who will cook to meet his new diet.

You can not assume that a child has a mother who will always be available to administer medication at short intervals.

You can not assume an older person has children to keep after them about their lifestyle or medications.

The diseases may or may not be the same, but the social environment the patient exists in has changed.