Disease
What?
- Disease is a disturbance of a living process that impairs the body’s functioning. In the classical account, it is a loss or privation of health. To understand what is wrong, we need an account of how the organism works well.
- Symptoms, bodily measurements and lived experience do not always align. Defining disease raises questions about structure, function, normal limits and the purposes served by the body’s activities. These questions shape the good that medicine aims to restore.
So What?
- Medicine’s knowledge can produce help or harm. Its orientation toward health gives clinical action a purpose beyond changing numbers or satisfying a request. Understanding bodily functions and their purposes helps clarify a clinician’s obligations and the limits of an intervention.
- A person may feel well despite significant risk, or feel unwell without a clear laboratory abnormality. These situations require prudence, attention to context and careful inquiry into what is impairing the patient’s life; neither symptoms nor test results alone settle every question.
Now What?
- Make the intended good of care explicit. Look beneath the presenting complaint: what process or function is disturbed, what may explain it, and how has it affected this patient? Seek the root of the problem without dismissing distress when a test is normal.
- Consider the whole person without assuming that every difficulty has the same cause or remedy. Examine how your understanding of health directs prevention, treatment and accompaniment, and how biological, psychological, social or spiritual concerns bear on the encounter.
Clinical Case
You are an internist with several phone appointments to discuss test results. The first patient is Sam who is 45 years-old and presented with classic hypothyroidism (fatigue, weight gain, cold sensitivity and dry skin) confirmed with very abnormal thyroid function tests. You placed Sam on Synthroid one month ago and decided to repeat the thyroid function tests which are all within normal limits now. You ask Sam how things are going, and he responds that he feels “brand new” which along with the report of normal thyroid tests gives everyone a great sense of satisfaction.
Your second patient is a 52-year-old named Ed who you have seen annually for several years. Ed consistently runs high lipid panels, which, along with his smoking and early family history of myocardial infarction, make him high-risk for early heart disease. Your annual entreaties to stop smoking and eat right seem to have fallen on deaf ears. This year you managed to get Ed to acquiesce to a coronary calcium score CT. His results are worse than you expected at 534 putting him at the 99th percentile. You gently break the news and strongly recommend a statin and aspirin daily, but he resists insisting that he feels great and he has heard that lots of people have problems with statins. Your further exhortations go nowhere, and you fall back to telling him to stop smoking and eat right.
Jane is your third patient. She is a 35-year-old lawyer working in a high-profile law firm who has two small children. She came to you complaining of being tired and was sure that her thyroid was underactive. She stated that several years ago another doctor put her on Synthroid and that seemed to help. You ordered the usual laboratory tests including a thyroid panel, but everything came back completely normal. You suspect that maybe she is just working too hard and not getting enough rest. You break the news that there does not seem to be anything wrong and that maybe we should explore other possibilities, but she is confident that her thyroid is to blame and asks again for Synthroid. You don’t think it would harm her, but you don’t want to give her anything she doesn’t need either.
Discussion Questions
- What contributes to each patient’s lack of health? How do symptoms, findings and life circumstances differ?
- How does prevention in an asymptomatic person fit a definition based on impaired function?
- What limits prudent judgment in these encounters? How would results near the limits of “normal” change your judgment?
- How should we assess requests for a therapeutic trial without a demonstrated abnormality, including questions about placebo effects?
- Can a biological treatment help or harm when a problem may be psychological, social or spiritual?
- How do structure and function relate? What do illness, death and the limits of prevention tell us about medicine’s aims?
Sources
Sources: LearnWorlds lessons and the earlier Canva one-pager.