Read time: 10 minutes
It’s the essence of every medical encounter and the basis for doctoring itself – the chief complaint. Patients tell us their primary symptoms and we then proceed to the HPI or History of Present Illness. This dialogue between the sick and the healer is at the core of what we do as doctors. We listen, we try to understand, and then we offer treatments when we can and empathy when we can’t.
Not so much.
Think of it this way. Imagine a bell curve
On the extremes, we have outliers. On the left (the left censor in statistical terms), would be those who are healthy. On the right are those that are unfortunately ill, either acutely or chronically. They have objectively confirmed disease with pathological changes of their genetic, cellular, and or organ system functions. Sometimes people shuttle back and forth between these extremes. However, increasingly, chronic comorbidities are keeping people on the right side of the curve.
Medicine has typically been preoccupied with these people. These are the people we seek to lay hands on. They, of course, are the sickest and deserve our help.
These people are fine enough, but they don’t feel great. They lack mojo. They are occasionally worried well, but often feel okay but are tired of just being “okay.”
Increasing portions of patients don’t see themselves as sick (regardless of whether they actually are). They are not interested in occupying the role of “patient,” and seeing a medical doctor is not only irrelevant but also perhaps distasteful. They want to feel vital, live optimally, be vibrant. They want flow states, mojo, taut skin, and the vigor (and) sex of youth, supple bodies and a proverbial state of energy and grace. They hope to prevent disease and stave off age as long as possible.
It is in the middle where conditions such as brain fog, IBS, fibromyalgia and chronic fatigue syndrome among others exist (especially as you move from left to right on the graph). These are problems that typically cannot be fully understand by a bio-medical model of care alone (at least not yet), and have strong overlays with mental health risk factors. There is not structural dysfunction that we can easily quantify, and most objective tests are typically normal in these patients. Hence, physicians can be apt to write these people off. These types of illnesses subsequently get short drift in a time pressured by well-meaning but overworked and often burned out doctors, who well, real diseases to treat after all.
“There’s nothing wrong with you.”
“It’s in your head.”
“Just relax more.”
It is here that integrative, functional, holistic, and complementary medicine has focused their efforts. They have pioneered Internet based information, with friendly faces and have emphasized appealing recipes, herbs, tonics, and vitamins. They explicitly have contrasting marketing to traditional Western medicine.
The people in the middle want to feel well. They want to feel alive.
This desire, itself, has become only so prevalent in part because of western medicine and public health. When human life expectancy was half of what it is now, infectious disease was rampant, and childhood and maternal mortality was tragically high (and I may remind you that, unfortunately, these conditions still exist both within and outside of the United States) these notions were too tenuous and distant to have any real weight.
So can medicine offer these patients anything meaningful?
I do, but I think some simple but profound changes will need to occur.
First, I think we need to remove ourselves of the notion that only a chief complaint or the presence of symptoms merits an interaction with a healthcare provider. This is not so radical. I the fields of pediatrics and family medicine and ob/gyn, preventative check ups and well child visits are routine. While the notion of annual physical has been controversial in adult medicine for the lack of evidence basis, the paradigm of measurement is typically disease control. Again, for those who are healthy and asymptomatic, this is using the wrong lens.
Second, we need to have more time with providers explicitly focused on behavioral and lifestyle counseling. It is here where Western medicine is penny wise and pound-foolish. Back pain is the one of the leading causes of disability because people “all of the sudden” throw their back out. Rather, people execute thousands of poor body weight repetitions in poor biomechanical movement patterns over years until their tissues give out and they have “acute” back pain. Yet, have you ever had a functional movement screen (FMS) let alone a discussion with your primary care doctor on how to move? Sit? Stand? Squat? Pick something off the ground? These are foundational movements that all mammals do (in some form or another), and humans use to know how to perform. Yet, when was the last time you had a doctor go over these skillsets with you when you did not have back pain?
In a similar vein, patients don’t need diabetes or hypertension to learn how to improve their eating habits. Heck, I need to improve my eating habits and I’m an expert on these things.
Third, medical education needs to emphasize a new set of skillsets on doctor-patient rapport building that is not centered on illness but on explicit concepts of wellness. One example in this area is motivational interviewing, which is a powerful clinical tool to allow providers to express empathy and form deeper relationships with their patients to assist in behavioral changes.
Fourth, we need to better utilize other excellent healthcare providers that have expertise in addressing those in the middle of the health continuum. Occupational therapists, dietitians, pharmacists and community health workers all have powerful, if not underappreciated, roles to play in lifestyle redesign, nutrition training, and counseling. Doctors need to learn to play nice with others.
Fifth, we as medical doctors have to go out and reach people. It is ludicrous the only reimbursable interaction patients can have with providers is a hectic interaction with a doctor who spends half their time on a computer screen. Tele-health, online chatrooms and AMA’s, Twitter clinics, IRL community lectures, and more – all of these are opportunities for us to reach out to people so we can help, empower and if need be, heal.
Sixth, let’s change our words. Language shapes thought. Some people are not patients. And they may not have a chief complaint. For the providers who read this, next time don’t ask “what’s wrong with you?” or “what problem you are having?” Try asking, “how can I help?” or “what area would you like to improve even more?”
It may make all the difference.