by Stephen Tyreman, Better Evidence for a Better Healthcare Manifesto
Most healthcare professions claim to seek and treat the causes rather than the symptoms of disease. This started as a reaction to the medicine of the nineteenth century, which was still influenced by Humoral Theory and Paracelsus. Treatments were given to counter the symptoms patients were experiencing. Unfortunately, many of the heroic purgative and cathartic potions given, such as calomel, arsenic, mercury and opium, were more harmful than the diseases they were treating. It led Hahnemann, for example, to develop homoeopathy on the opposite principle that substances that caused similar symptoms to the condition and given in small doses were more effective – but that’s another debate. The focus today, apart, perhaps, from in palliative care, is on treating the cause, bypassing symptoms per se, or using them as monitors of healing.
The bigger question in the context of thinking about causation is: how should we understand symptoms? Are they, as modern healthcare assumes, the equivalent of packaging that tells you what’s in the box, to be discarded after uncovering the contents, or do symptoms have a different and perhaps more significant rôle to play in our understanding of health and illness? Might a different approach lead to a clearer understanding of the experience of illness and more effective management strategies?
Symptoms are what matters to patients; pain, lethargy, nausea, diarrhoea, anxiety, depression and so on are what disrupt our lives and cause suffering. The ultimate symptom is death itself. Body anomalies are only classified as diseases if they cause the person distress or death.
Illness (in English, suffering in some other languages) is not a property of the disease, but of the person. Part of the issue around medically unexplained symptoms (MUS) may be that symptoms have been conceptualised as properties of disease, even though people experience the same disease in different ways and at different times. What do symptoms tell us about the person rather than their disease? Symptoms are key elements in a person’s narrative about illness in general and their illness in particular. We want to know what symptoms mean, what they tell us (in a narrative sense) about what has happened and what the future will be like. As much as indicating a particular biological problem, symptoms reflect how we live—the smoker’s cough, the athlete’s muscle ache, the workaholic’s tiredness, the sedentary person’s breathlessness, and so on. Are these indicators of actual or potential disease or is disease a possible emergent outcome of such behaviour? Many symptoms we accept as normal and healthy—the discomfort of pregnancy and childbirth or the stiffness after a day’s physical activity, for example. In other words, do symptoms tell us more about a person’s living before they tell us about disease?
I am not suggesting that we return to an age where the medical focus is merely on alleviating symptoms, but the meaning of symptoms for the person rather than the doctor and the rôle symptoms play in a patient’s narrative might open novel therapeutic avenues. This is already being done in more psychologically focused areas of healthcare and in narrative medicine, but the ongoing debate around MUS suggests that this is far from widespread. In backpain we distinguish between the appropriate acute pain from tissue damage following trauma that minimises further damage and the inappropriate chronic pain that can result from over-protection or changed behaviour. The symptoms may be identical but the context of the person in each situation, is different. Symptoms only exist as an experience of the person, they are not properties of anything else. Is this something else we need to consider in the EBM debate where effectiveness is frequently measured against changes in symptoms as though it is a property?