Treating a symptom is not the same as treating a disease

Physicians and patients collaborate to treat symptoms. This is not newsworthy and even sounds appropriate. Isn’t that what doctors are trained to do? It is but I’m not sure this should be a central focus of our healing mission. Treating a symptom is not the same as treating a disease.

For example, if an individual is having abdominal discomfort, pain medicine should not be the first responder, even if this would bring the patient relief. Physicians try to understand the cause of the pain which would then guide our therapeutic response. The treatment would differ substantially if the cause of the pain were appendicitis or an ulcer or a kidney stone.

Often symptoms are regarded as diseases themselves that need to be treated. Over the years, I have been called by nurses hundreds of times to prescribe medicine for patients who were nauseated. Nurses are exceptional professionals, but they are not physicians. They are preoccupied with the patients’ comfort and welfare and are vigilant about symptomatic treatment of nausea, diarrhea, headaches, constipation and insomnia.

This is one reason, but not the only reason, that hospitalized patients routinely receive sleeping pills, Imodium, laxatives and acetaminophen. Most of us at home do not reach for antacids or other symptomatic remedies as often as these elixirs are dispensed in the hospital, where the culture of medicating is more pervasive. In fact, medical interns and residents often include several “standing orders” for patients they admit to the hospital so that nurses will not have to contact them for advice if these common symptoms develop.

Standing orders

If patient develops constipation, then give laxative A.
If patient develops diarrhea from laxative A, then give Metamucil.
If patient develops gas and bloating from Metamucil, then give simethicone.
If simethicone does not relieve gas, then double the dose.
If patient complains that high dose simethicone is causing sleeplessness, then give sleeping pill Y.
If patient complains of lethargy after receiving sleeping pill Y…

Interns who didn’t use standing orders would be guaranteed to receive nurses’ pages around the clock alerting young, tired physicians with scores of symptoms to respond to. Standing orders were an intern’s insurance policy against paging assault. This collaboration between interns/residents and nurses is where we physicians first learned to pull the symptomatic trigger so reflexively. I think even seasoned physicians often casually prescribe anti-nausea medicine rather than aim to understand the cause of the symptom. It’s a tidy response to nurse’s concern about a patient, which is often relayed to the doctor after hours on the phone.

In addition, not every symptom should demand an immediate pharmacologic response. Yet, in the hospital, and often in our offices, this may be our modus operandi.

And finally, are we so sure that symptoms should be squashed? Why do we treat every fever, for example? Could it be that fever, diarrhea or vomiting are actually bodily defense mechanisms that are combating disease and illness? Could it be that an infected person develops a fever in order to make his body less hospitable to germs or to sharpen his immune system? Are today’s medical professionals really much smarter that millions of years of natural selection? Let’s dose ourselves with a tincture of humility. We’re not all that smart.

Even writing about this stuff gets me worked up. I feel some heartburn developing. Where are my Tums?

Michael Kirsch is a gastroenterologist who blogs at MD Whistleblower

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  • DoubtfulGuest

    Excellent post, Dr. Kirsch. After my first laparoscopic surgery, I was stuck in the recovery room for several hours because I kept throwing up, falling asleep, throwing up, falling asleep. Finally, I groggily asked the nurse what was going on. She said “I’m sorry, Hon. The pain meds make you nauseous and the nausea meds make you sleepy. It’s a vicious cycle.” I thought about that for a minute…”Well, could we just stop all that stuff, please, and see how I do? I’d like to try to go home today.” But she couldn’t do anything, of course, except ask the doctor when she came by two hours later, after yet another round of drugs. If I had known all that, I’d have been more conservative about asking for pain treatment. I was fine afterward, and have no complaints about the care. It’s a system problem, I agree.

    • rbthe4th2

      I don’t know. I had a couple of docs who didn’t do this and I got worse. I think there is a fine line, knowing the patient helps.

      • DoubtfulGuest

        Agreed. It depends on the situation. I’ve been to other doctors who thought “care” just means telling you you don’t need any care. Weeeeeeeeelllll, actually…

        They say it with a big grin and a hearty handshake, too. It’s irritating.

  • Wendy Felsenthal

    Okay—-quick obvious question here….

    Why are doctors not trained to treat the disease that is causing the symptoms or to be looking deeper than the symptoms themselves to get to the root of the matter. To me this IS one of the biggest problems I see in the medical field(s) other than in a Naturopathic practice .

    I find myself going into doctors’ offices after waiting weeks/months to get in and I have all kinds of info about the disease I have and the doctor(s) just want to hand me a pill for pain or some other ailment when I really want to find out what is causing the issue in the first place and fix it w/ o having to mask all the symptoms w/ pharmaceuticals.

    Example- leg hurts. Instead of getting an MRI or imaging of some sort where leg hurts and at spinal levels a doc wants to just shoot you in the back w/ a nerve block or prescribe gabapentin …How about we find out why the nerve you are blocking is affected and try to alleviate that while we do some pain relief?

    My advice to all I know is to get a concierge doc who has the time to spend w/ you and can dig a little deeper into therapies . Its sad that what we now have to pay extra for used to be the norm…

    I agree w/ your statements doc, its just that I am surprised that the first sentence reads in the order that it does. To me , it should be obvious that the doctors are trained to treat the disease w/ the symptoms and not just the symptoms.

  • Dave Mittman, PA, DFAAPA

    As a PA I have always treated the disease and tried to watch the symptoms. Sometimes you have to treat the symptoms also as in vomiting or severe pain and watch and see what happens

  • Tom Clayton

    Dr. Kirsch’s editorial overlooks some main issues. His complaints seem to be the overuse of these substances and using them to treat symptoms but not the disease. But symptoms and signs DO represent the clinical manifestations of disease. If a patient is IN the hospital, then their disease process(es) have already been diagnosed OR they are in the process of being worked up and at least a preliminary diagnosis has been made.

    Recall that symptoms are what patients develop that make them go to the doctor in the first place; signs are what the doctor sees on examination. Absent more sophisticated and accurate diagnostic tests, here are some of the medical and surgical problems that would have killed patients in the past:

    “Adrian’s lung spontaneously collapsed when he was 18.
    Becky had an ectopic pregnancy that caused massive internal bleeding. Carl had St. Anthony’s fire, a strep infection of the skin that killed John Stuart Mill. Dahlia would have died delivering a child (twice) or later of a ruptured gall bladder. David had an aortic valve replaced. Hanna acquired Type 1 diabetes during a pregnancy and would die without insulin. Julia had a burst appendix at age 14.”

    There is a huge OTC market for people outside the hospital
    where they treat themselves, often successfully and often for disease processes that are self-limited and do not require a doctor. The doctor-is-the-only-one-really-qualified to make disease diagnoses paradigm is fading as radiological and laboratory
    test diagnoses have assumed center stage. This was not the case in the old days, where a careful clinical exam and history could only sometimes result in an accurate disease diagnosis. The H and P is still absolutely necessary, in my opinion, with the history perhaps the most important element. Diagnostic tests to confirm or deny clinical suspicions then take center stage.

    Most of the time there is no harm in using substances to
    make the patient feel better, which is a primary function of medical care. It does not require a physician to make most of these decisions. As for the times that it does, the primary usefulness of the physician is to alert the nurse when something should NOT be given for a particular disease diagnosis. Isn’t that the main distinction here?

    Absent a contraindication, nurses are perfectly qualified to
    make these types of decisions and should be doing so without having to call a doctor at all hours. The nurse is there with the patient, not the doctor, so exactly how is this anything other than a relic of earlier times? Everything is now documented in the patient chart, not in the doctor’s head (as it often used to be in the old days) and there should be specific orders for individual
    patients.

    The reason for the exceptions to using these substances,
    which should be determined by the doctor a priori in writing, is because symptom relief actions should not interfere with the disease process. Take for example a patient who has a ureteral stone that is small enough to be passed. Besides questioning why they are in the hospital in the first place, there is no harm in giving them some pain medication to help them feel better, as long as it
    does not interfere with ureteral peristalsis. Take another example where a patient is throwing up. Unless they are evacuating their stomach contents from food poisoning, giving them a suppository to help make them feel better is the thing to do and that decision can be made by a nurse.

    Using the example of a patient’s situation where they were in a vicious cycle of symptoms caused by pain and nausea medications, the physician was responsible for doing this BUT the patient has some degree of responsibility for not asking to be taken off the medication or telling the doctor the problem or both. Almost all other situations described by Dr. Kirsch are where the patient is ASKING for relief.

    But the reality today is that the clinical exam is and has always been extremely limited until many disease processes became quite advanced. Many, many mistakes were made in the old days, but absent technology, this was all that could be done. Prior to the technological explosion, many older patients would have laparotomy scars where the surgeon was forced to take a look. As an older radiologist who has engaged in active patient care in the
    hospital setting, including interventional procedures, I assure you that this paradigm change is the case. And it would be best to embrace it, not continuing to do things that make no sense.

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