Some patients don’t expect doctors to be miracle workers

In an article entitled Culture, Illness, and Care, medical anthropologist Arthur Kleinman writes about the important distinction between illness and disease.  He defines diseases as “abnormalities in the structure and function of body organs and systems.”  In other words, disease is what is actually physically wrong with the body.  In contrast, illness is what patients experience when they are sick.  This is profoundly influenced by multiple factors such as a person’s culture, social situation, and the meaning attributed to symptoms.

Kleinman writes that the focus of modern medicine tends to be disease. Doctors are trained to find a distinct abnormality in the structure and function of the body and provide an effective remedy.  This approach works for straightforward problems such as appendicitis and pneumonia that have a clear biological cause.  It is much less useful for conditions that do not have a discernible physical etiology.  This is a significant limitation since about 50% of visits to the doctor are for complaints without an ascertainable biologic basis.

In some cultures, physical symptoms are the most acceptable way of expressing psychological problems such as anxiety and depression.  When I volunteer at a local clinic that provides care for immigrants and refugees, I try to always ask about the stories of the people I see.  In learning about their life journeys and hardships, the causes of otherwise inexplicable physical symptoms, such as headaches, chest pain, and shortness of breath, often reveal themselves.

I have asked patients suffering from illnesses without a straightforward diagnosis and treatment how physicians can be most helpful.  They tell me that sometimes doctors become frustrated when they cannot find a diagnosis and cure for what is wrong.  I must admit that I have at times felt nervous seeing somebody whose symptoms I cannot understand and effectively treat.  But many of these patients tell me they understand that doctors cannot always figure out what is wrong.  They don’t expect us to be miracle-workers.  What these patients tell me they most appreciate is a physician who will not stop caring and trying to be helpful.

James Marroquin is an internal medicine physician who blogs at his self-titled site, James Marroquin.

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  • DoubtfulGuest

    Dr. Marroquin, for “complaints without an ascertainable biologic basis”, what time frame are we looking at? The first visit, any workup ordered at the first visit (i.e. one round of testing), or what? So many patients on thin ice with this issue. Everything you say is true, but depending on how this is interpreted, effects on the patient can be devastating. There are quite a few angry, cynical doctors out there who take these kinds of statements and twist them to accuse patients of faking, even with no objective evidence. I’ve been on the receiving end of that… I turned out to have a disease for which a specific biochemical basis was identified. But I like your approach with patients, asking how they want to be helped. You are right, often at least in the short term, a caring physician who makes some effort is good enough. Many people do understand that diagnosis can be a long process. Many of us also have insight into the mind-body connection and how it affects us as individuals. I knew not to medicalize my shaking hands or stomach pain that started as I waited to see doctors who I knew were angry with me. But my emotional stress didn’t change the fact that the longstanding symptoms for which I was seeking care, had a definite biological basis. All I can ask of doctors in general is to please be careful, and whatever you do, don’t get mad at the patient or accuse them of doing something wrong unless you have objective evidence.

    • jimmyquin

      You make a good point. Doctors shouldn’t prematurely stop testing and sending a pt for consultation when a diagnosis is elusive. On the other hand, when it is very likely that a symptom is psychosomatic, it makes sense to get at the root of the problem rather than doing more and more expensive testing that is unlikely to offer much in the way of healing.

      • DoubtfulGuest

        Well, it seems that often multiple iterations of testing + consideration of psychosomatic causes would make sense? In my experience, psychologists and psychiatrists can be incredibly helpful. There’s a social stigma with that kind of assessment that shouldn’t exist. I can understand why many patients are reluctant to go that route. I actually sought mental health counseling on my own initiative before I ever asked for any expensive medical tests. After some time they said: “You’re clearly doing better emotionally. But you look unwell! And you are still just as tired and sick-feeling as before. Are they sure there’s nothing else going on?”. Later, when doctors accused me of faking my symptoms, they did not offer me any psychiatric assessment, which could have provided some evidence one way or the other. I would respectfully suggest that many doctors are out of their element trying to “get to the root” of patients’ emotional problems. I think it is really hard for physicians to avoid projecting their own life experiences and insecurities onto patients’ emotional issues, unless they are specifically trained to do so like mental health professionals are. Compassion does go a long way, I would just like to see more self-awareness on doctors’ parts in handling these cases.

        • rbthe4th2

          Agreed DG. However, let me add that as someone who has gotten (as of today) now 2 issues for which a doctor said ‘its all in your head’, and another 2 who have said ‘here is the root cause, physical not mental’, doctors really need to be careful when they give someone a “mental” diagnosis. It only makes the profession and a particular group, specialty, look bad when a same type specialist does different testing and finds answers.

  • rbthe4th2

    Amen!! The other is that sometimes its necessary to look at the patient, not the labs. Had too many where I was high or low or changes over time showed what the true picture was. So while we’re not expecting everything, I would expect a doc to make allowances for the patient who doesn’t fit neatly into the “computer labs say you are fine” type.

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