Tuesday, 14 December 2010

Wise Old Dog

To say that people go to their doctor when they are ill is to make simplistic a vastly complex phenomenon. People go to their doctors for all sorts of reasons, but primarily they go with a concern that may or may not fit the doctor’s view of a thing that is “medical”.  A difficulty – even a danger – can arise when the doctor construes a presentation that has no origins in clinical disease as an illness. Sometimes indeed doctor and patient collude together in attributing “symptoms” to disease and then defining an illness that is not present. However it may suit both patient and doctor that they do so. The doctor may be anxious to press on and finish his surgery. The patient may actually want or need an illness for one reason or another. So the truth, perverse though it may seem, is that people may go to their doctor not only to have an illness diagnosed and treated, but conversely to be “given” a disease. But the patient may be exposed to risk in such an outcome, in terms of potentially hazardous investigations or medications that may cause side effects.

            One may sympathise with a person who sees “illness” as the only way of opting out of intolerable life or work situations. Perhaps less so with those who are out to gain clear advantage over their fellows through being afforded the special status that accrues from being ill. This reality has been recognised throughout history. Robert Burns illustrated it famously in his poem The Twa Dugs, an imagined conversation between two mutts from very different backgrounds:

The first I'll name, they ca'd him Caesar,
Was keepit for His Honor's pleasure:
His hair, his size, his mouth, his lugs,
Shew'd he was nane o' Scotland's dogs;
But whalpit some place far abroad,
Whare sailors gang to fish for cod.

And …

The tither was a ploughman's collie-
A rhyming, ranting, raving billie,
Wha for his friend an' comrade had him,
And in freak had Luath ca'd him,
After some dog in Highland Sang,
Was made lang syne,-Lord knows how lang.

            Anyway – this is what well bred Caesar had to say to rough and ready Luath about the monied, idle classes:

It's true, they need na starve or sweat,
Thro' winter's cauld, or simmer's heat:
They've nae sair wark to craze their banes,
An' fill auld age wi' grips an' granes:
But human bodies are sic fools,
For a' their colleges an' schools,
That when nae real ills perplex them,
They make enow themsel's to vex them;
An' aye the less they hae to sturt them,
In like proportion, less will hurt them.

            Do you see what it is that the sagacious Caesar is conveyingto his bemused companion? Essentially that hypochondriasis is a middle class phenomenon. In Burns’s time the poor had to contend with ill health and early death as a matter of course, while the wealthy might “need” illness as a way out of the boredom that afflicted them. In a more affluent society it might be assumed that the phenomenon has become prevalent, and indeed it is the experience of many doctors in primary care that this is the case.

            Such symptom complexes so constructed are sometimes referred to as “syndromes”. And indeed one definition of a syndrome is essentially that of a collection of symptoms. Strictly speaking, in a scientific or medical sense, the symptoms are often, but not always, a combination of symptoms and clinical signs, as is the case, for example, in Cushing’s Syndrome or Down Syndrome. These are indisputable physical entities. But there are others where symptoms are less specific (but often dramatic), not generally supported by hard physical signs and where there are no investigations that can support the existence of a physiological or pathological process.

            Curiously, too, these “syndromes” are the cause of much debate, not to say acrimony, within the medical profession, and huge drives to promote them without it. They are the subject of campaigns whose supporters are possessed of an almost religious zeal and energy. “Non-believers”, particularly in the medical profession, may find themselves vilified, even the recipients of threats. It is a brave doctor who will publicly state a view that holds that these things have no existence other than in the mind. And probably unwise too – for doctors above all else should be open minded (this is not the same as being credulous). For it is always unkind for a doctor to be dismissive of what his or her patient puts to them.

            Nevertheless, no doctor can afford to be dismissive of her or his scientific training either. As scientists, doctors ought to deal with facts and their practice should be based on facts. Not theories. Not unfounded beliefs. And not, of course, on lies or distortions put about for the purpose of dishonest advantage of one sort or another – either for the “sufferer” or for those unscrupulous pedlars and practioners of fringe medicine and quack remedies who do so well out of the vulnerable, the frightened or the foolish.

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