Two Main Perspectives on Drug Therapy Illness and Disease

A fundamental distinction is made in the sociology of medicine between how a patient experiences illness and how a professional thinks about it. The terms illness and wellness refer to a person's subjective feelings and perceived ability to function. For example, Mr. Green knew that he felt tired and occasionally dizzy. Furthermore, a person may act sick, i.e., change his normal activities as a result of illness. Illness experience is the primary reality of health care. That is, people experience illness directly. Illness often comprises the motivation for, and basis of, health care and may powerfully influence a person's other life experiences.

The term disease is reserved for a professional interpretation of the person's (patient's) account of illness experience and any additional objective or subjective information the professional obtains, e.g., from physical examination or laboratory tests. A disease is an abnormality or derangement of structure or physiology. Although the derangement must be objectively verifiable, the diagnosis of disease is often an inference about reality rather than reality itself, a theoretical construct based on data. Disease can be thought of as a professional's secondary perception of the primary illness experience.

Mrs. Loring, a 60-year-old white female in apparently good health, went to Dr. George with complaints of vague chest pain. Her cholesterol was slightly elevated, so Dr. George ordered a treadmill stress test with the injection of a radioactive dye that would allow the cardiologist to visualize the overall coronary blood flow. Mrs. Loring showed good coronary blood flow before exercise, some EKG abnormalities before and during exercise, and a "cold spot" after exercise, suggesting that blood flow to part of her heart muscle was less than it should be in response to exercise. The cardiologist recommended a cardiac catheterization, in which dye was injected directly into her coronary blood vessels so that they could be visualized. The result showed 25% blockage in one artery, not enough to explain her chest pain. The cardiologist did, however, diagnose a minor problem with Mrs. Loring's mitral valve, which he said was consistent with her symptoms.

Naming and classifying disease is fundamental to medical practice because once a doctor recognizes a disease or syndrome, he gains access to a wealth of scientific knowledge that may be essential in managing the patient — some as part of the doctor's educational background and even more through clinical experience and current literature. In this example, although the cardiologist may not know a great deal about Mrs. Loring's mitral valve prolapse (MVP), he may know a lot about MVP from scientific studies and clinical experience. He can, with the exercise of clinical judgment, apply his general knowledge to Mrs. Loring's case.

However, MVP is arguably not what is really wrong with Mrs. Loring. The symptoms are real, but the diagnosis is little more than a proposition to explain the symptoms. Despite its great value, general scientific and experiential knowledge of disease is abstract knowledge about people other than the patient. It complements, but does not substitute for, the patient's primary experience.

During a routine visit, Mr. Green asked his doctor if ibuprofen can make you feel tired and sometimes make you dizzy. Dr. Smith replied that although dizziness and drowsiness are occasionally reported side effects of ibuprofen, they may go away during treatment and usually do not require medical attention. She reviewed his record and noted that he was not taking any other medications. Just to be sure, however, she asked Mr. Green about other medicines that he might have been using and verified that he was not taking any others. His diet and sleep habits were normal. She recommended that he get plenty of sleep and keep well hydrated in hot weather. They chatted briefly, and then Mr. Green left. A week later, Mr. Green's daughter called 911 because his weakness and gray pallor frightened her. In the emergency room, his hematocrit and red blood cell count showed that he was extremely anemic. He required transfusions of whole blood. Tests for occult blood in his stool were positive. Endoscopy showed that Mr. Green had bled from a gastric lesion.

Mr. Green's question unintentionally diverted Dr. Smith's attention to the ibuprofen. Had he asked Dr. Smith about gastrointestinal bleeding from ibuprofen, she surely would have replied that it is quite common and recommended a course of action that might have avoided his collapse. Perhaps Dr. Smith dismissed weakness and dizziness because they are not recognizably symptoms of an adverse reaction to ibuprofen. She answered correctly in the narrow context of direct side effects of ibuprofen, but incorrectly in the broad context of Mr. Green's health.

Despite Mr. Green's question, Dr. Smith should have asked herself, "Why does Mr. Green feel dizzy?" Scientific thinking about drug products instead of patients can mislead a health professional if the patient appears not to have a disease known to have a particular symptom or is not taking a drug known to have a particular side effect. While it is rare for a pharmacist or physician openly to deny a patient's illness experience, it may not be unusual for them to ignore it (in effect) or to decide that nothing can be done. Subjective symptoms (pain, weakness, fatigue) of unknown cause are common examples.

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