That most nagging question in health care

A challenge to medical school deans

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As I mentioned a couple of days ago, Jeffrey Flier, Dean of Harvard Medical School, wrote an Op Ed in the WSJ in which he makes some cogent proposals to medical journal editors about how to minimize the irreproducibility of clinical science.  He even proposed to hold a symposium to discuss the topic.

Now, that is all well and good, as far as the problems of science are concerned, but I wish that deans of medical schools thought about another problem that’s closer to home, and more directly relevant to the medical profession. Isn’t it time the medical community confronted the fact that we don’t have a cogent definition of health?

After all, our legal privilege to practice medicine is imparted by strict licensing laws which are contingent on graduating from accredited medical schools.  And the idea implicit behind that arrangement is that the “self-regulated” professional must become adept at distinguishing what health is from what it is not.

But from what I recall of my medical school experience, learning what constitutes health isn’t really part of the curriculum.  Following Flexner’s advice, we start with anatomy, biochemistry, and microbiology, and off we go…Students may, during a public health elective, be told in passing of the WHO’s idea of health.   But no one seriously believes that definition.

WHO definition of health

In fact, even public health folks don’t believe in the WHO’s definition.  I recently checked out a population health textbook from the library.  There was a chapter dedicated to addressing the question “What is health?”  Seventeen possible answers were offered, and the authors duly noted that the concept of health is “complex,” “nuanced,” and ultimately unresolved.  That didn’t keep them from proceeding with 900 pages of analysis and recommendations on how to improve the health of the population.

[related post: How to safeguard your career in a treacherous healthcare environment]

Closer to home, practicing physicians with less ambitious plans may simply use the medical dictionary’s definition: “health is the absence of disease.”  But that only pushes the can down the road a bit.  For what is “disease”?  We might invoke “abnormal function,” “ill-ness” and other related concepts, but these can be arbitrary and fail to capture all the things we label as diseases.

We also change our mind: homosexuality, alcoholism, obesity, fertility, ennui…At one point or another in the last decades, all of these were, and then were not (or vice versa), considered diseases.  Talk about medical reversals!  And that’s not mentioning the diseases we seem to manufacture

Many today worry about over-diagnosis and over-treatment.  They may be right.  But how do we know that we are not throwing the baby with the bath water when we can’t articulate the criteria by which a condition can properly be called a disease?

Now, I realize that the problem is not being completely ignored, but it’s been relegated to a conversation among philosophers and ethicists in their specialized journals.  And it’s a conversation few, if any, medical students or practicing physicians participate in or are even aware of.

For example, a commentary in the Journal of Medicine and Philosophy identified Christopher Boorse’s “biostatistical theory of disease” as “the main contender” in the naturalist camp in the debate on the theory of disease, a status that must compel others to either declare allegiance to his theory or explain why they reject it.  In recent years, international symposia have been dedicated to Boorse’s theory.  But how many doctors have heard of him and of his concept of health?  How many know what the “naturalist camp” refers to and what other camps there are?

I don’t mean to endorse Boorse’s idea in particular,¹ but I only wish to point out the remarkable gap between what ought to be a central problem doctors should be attentive to and the actual attention given to it in medical schools.  From what I can see, the last time a mainstream medical journal devoted some articles on this topic was in the mid 1980’s.  Later this month I will be presenting a paper on the concept of health, but it will be to an audience of economists, of all people!

We need more than just articles fleeting by, here and there, across the visual fields of overly busy physicians.  We need academic leaders to  recognize and grapple with the fact that a lack of definition of health and disease, and a lack of agreement on what the proper role of the physician ought to be, could very well lie at the root of the unending healthcare crisis we’ve been experiencing for the last century.

So, come on, Dr. Flier, leave to the scientists the problem of science’s reproducibility, however important it may seem to be (and it’s not…).

Yes, we need a symposium.  But the symposium should discuss what exactly is the nature of our business as “health professionals,” or else we may continue to be steam-rolled by that ever-growing portion of GDP for failing to understand our mission.  That’s a question you and your academic dean colleagues across the country must bring back into your schools and insert at the very basis of medical education, however difficult answering it may seem to be.

If we hope to continue to play an independent role in health care, we’d better have clarity about this health we claim to be caring for.

[related post: How Western medicine lost its soul]


Note:

1.  In fact, I generally reject his theory, although I agree that he has articulated concepts that are very worthwhile for discussion.  I have a manuscript in preparation about Boorse’s theory, which I invite anyone interested to read and give me feedback about.

6 thoughts on “That most nagging question in health care

  1. Good questions, Michel!
    I haven’t heard of Boorse either and I’m curious about your paper on the concept of health. Time to challenge the establishment..

    Having practiced psychosomatic medicine and the “biopsychosocial model” for years, it seems to have lead to better understanding ill-health, but also an extension of services with no clear definition of boundaries regarding responsibility and financing.

    Guessing forward: Apart from the obvious dysfunctions of the mind-body continuum, isn’t health a dynamic process and an subjective judgment? What’s ill-health to the hypochonder isn’t the same as for others. Is a top-down definition even possible?

    • Thank you, Marc. You raise good questions as well. I don’t underestimate the difficulty of a general definition for health, and I suspect there won’t be one to satisfy everyone for a long time, if ever. But, then, maybe there should be different “schools” of medicine, each forthright about what it defines health to be, rather than avoiding the topic as we do now, which opens the door for all kinds of opportunism. If you don’t mind, in a few weeks I’ll have had a chance to get feedback from the AERC audience, and if encouraging, I’ll share my thoughts on this then.

  2. “We need more than just articles fleeting by, here and there, across the visual fields of overly busy physicians. We need academic leaders to recognize and grapple with the fact that a lack of definition of health and disease, and a lack of agreement on what the proper role of the physician ought to be, could very well lie at the root of the unending healthcare crisis we’ve been experiencing for the last century.”

    –The proper role of the physician is to distinguish between the therapy and the disease. To misidentify this function of the physician has lead to all manner of bad medicine. If a patient has a sliver in their finger and the next day it produces pus; Is the pus the disease or the therapy?

    • Excellent question, but I still think the the one about health comes first. Otherwise, distinguishing between therapy and disease wouldn’t matter much.

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