THINKING DIFFERENTLY ABOUT HEALTH - BUT WHAT IS HEALTH?

Each patient is unique, and every journey is different – “until you walk in my shoes, it is hard for you to truly understand.” As seen through the patient lens, Albert Einstein stated, “learn from yesterday, live for today, hope for tomorrow. The important thing is not to stop questioning.”

Patients stand on the shoulders of those before us, be it other patients who have participated in clinical trials to discover and provide a new era of treatment, or researchers in constant pursuit of innovation. When we marry up the technological revolution with scientific and patient insight, it creates a new wave of possibilities. There are lessons that can be learned from “Hamilton” the musical that frame the evolution of the patient.

The fundamental nature of health care involves people taking care of other people in unique times of distress. Thus, the human experience is. But what is health? For some people and most doctors that’s an uninteresting question.

Lets not generalise , not all doctors are equals. Some doctors are interested in your health and most are interested in disease only, not health.

Medical textbooks are a massive catalogue of diseases. There are thousands of ways for the body and mind to go wrong, which is why disease is so interesting. We’ve put huge energy into classifying disease, and even psychiatrists have identified over 4000 ways in which our minds may malfunction.

Health for some doctors may be a negative state—the absence of disease.

In fact, health is an illusion. If you let doctors get to work with their genetic analysis, blood tests, and advanced imaging techniques then everybody will be found to be defective—”dis-eased.” Could we, however, have reached a stage when the concept of disease has ceased to be helpful?

Let me tell you, I’m happy and also coming close to flippancy, but in a world where most of medicine is concerned with people with multiple chronic conditions combined with social and family problems health care must be person not disease centred.

“The time has come,” they write, “to abandon disease as the focus of medical care. The changed spectrum of health, the complex interplay of biological and non-biological factors, the aging population, and the inter-individual variability in health priorities render medical care that is centred on the diagnosis and treatment of individual diseases at best out of date and at worst harmful. A primary focus on disease may inadvertently lead to undertreatment, overtreatment, or mistreatment.”

The numerous strategies that have evolved to address the limitations of the disease model, although laudable, are offered only to a select subset of persons and often further fragment care. Clinical decision making for all patients should be predicated on the attainment of individual goals and the identification and treatment of all modifiable biological and nonbiological factors, rather than solely on the diagnosis, treatment, or prevention of individual diseases. Anticipated arguments against a more integrated and individualized approach range from concerns about medicalization of life problems to "this is nothing new" and "resources would be better spent determining the underlying biological mechanisms." The perception that the disease model is "truth" rather than a previously useful model will be a barrier as well. Notwithstanding these barriers, medical care must evolve to meet the health care needs of patients in the 21st century.

1) Patient inclusion
The scientific community does not only consist of physicians: medical researchers, nurses, nutritional therapist etc...and patients must be included – also symbolically. Doctors are not the sole repositories of medical knowledge, and the ivory tower of medicine is crumbling under the weight of the digital sphere, social media, empowered patients or the DIY movement.

The Hippocratic Oath should reflect that.

“I will respect the hard-won scientific gains of those physicians, patients and researchers in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.”

2) The inclusion of equal-level partnership

Access to information and technologies is not a privilege of physicians sitting in the ivory tower anymore. Patients also have access to information about drugs, cures, methods online, and with a pinch of digital literacy, anyone can find curated and credible medical data online. This started to shift the hierarchical patient-doctor relationship into a collaborative partnership in the future. The oath has to address the changing social relations within the structure of the medical system, and therefore The Medical Futurist suggests the inclusion of the following:
“I will treat my patients in an equal-level partnership, and I will not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.”

A legitimate disease had both a characteristic clinical course and a mechanism, in other words, a natural history that—from both the physician's and the patient's perspective—formed a narrative. The act of diagnosis inevitably placed the patient at a point on the trajectory of that ineluctable narrative. Ubiquitous modifying terms such as atypical or complications only underscored the unspoken centrality of such ideal-typical disease models—and the need for secondary elaborations that would make these concepts more flexible and thus viable clinically.What is your health history?

A quick recapitulation, by the end of the 19th century, a vocabulary of named disease pictures had already become a widespread and largely unquestioned component of Western medicine.

And diagnosis of such ills was becoming inexorably and increasingly dependent on tools and techniques derived from the laboratory. This linkage among procedures, machines, and diagnosis seemed to the majority of physicians both desirable and inevitable, for disease could now be defined in increasingly objective terms. It is hardly surprising that as early as the first decade of the 20th century, critics were beginning to express a kind of oppositional disquietude, the fear that a brash and burgeoning scientific medicine meant treating diseases and not people, that it meant excessive dependence on the laboratory's tools and findings, that it meant a glorification of the specialist at the expense of the generalist, and that it denigrated the physician's holistic and intuitive clinical skills.

I have not even mentioned the much-discussed moral and policy implications of an acute-care and mechanism-oriented clinical medicine that assigns a comparatively low priority to the multicausal, to the social, ecological, public policy, and quality of life perspectives. Western medicine's historical focus on specific disease entities and the management of acute illness is obviously an integral aspect and product of this fundamental worldview—and thus policy—reality???. This is another area of maladjustment or difficulty of fit, not, from this perspective, the fit between the individual patient and the generalized disease picture, but between a reductionist, mechanism-centered understanding of disease and a collective strategy for defining and "maximizing health" in term of what?

Specific disease entities can be understood as holistic and integrative in a social system sense, just as they can be fragmenting and alienating in terms of an individual's relationship to that larger society. We are never illness or disease but, rather, always their sum in the world of day-to-day experience. Illness and disease are not closed systems but mutually constitutive and continuously interacting worlds. In the patient's case, it is always experience as well; we are always in contact with our own worlds of physical and emotional pain and experience—and thus identity—that cannot be reduced to the external zone of intersection between society and the men and women who constitute it.

When politician and medical spokespersons boast of enjoying the world's best health care, they are implicitly referring to the capacity to intervene in the trajectory of disease, to alter a worst-case scenario. Emergency care is not the same!

1. The end of the disease era: https://pubmed.ncbi.nlm.nih.gov/14749162/

2. Richard Smith: The end of disease and the beginning of health: https://blogs.bmj.com/bmj/2008/07/08/richard-smith-the-end-of-disease-and-the-beginning-of-health/?fbclid=IwAR2udojKdv62CaVSZU8RTnLAnaZd3sAQMKlPfCjtZcWEm5dn1jXY6zUTAhw