“So what do you think it is” he asked.
Bear in mind that we were a full 5 minutes into the consultation. This seems a good a place as any to introduce medical taxonomy. Taxonomy is a description, identification, nomenclature (words) and classification of disease states. Essentially drawing lines. It’s Latin origins translate as method of arrangement. What makes Susan’s disease different to Brian’s? And what makes Brian’s the same disease as Bahadur’s? A category has not only to distinguish what it is not but also to do distinguish what it is which is a lot harder.
Disease can be identified by its object (cancer, pulmonary embolism, nerve compression). The problem with this is that there are a multitude of ways to either differentiate or associate objects. A tumour may look similar in size but be benign or malignant. There are over 200 types of cancer. Whilst cancer can be non-tumourous (e.g. leukaemia).
Disease can also be identified by its subject or symptoms (breathlessness, dizziness, fatigue). Diagnosis is often seen as discrete atemporal rationale. Like mental arithmetic it’s just a case of working it out. But often pathology is described by the person as a story. It has a start and an end. It fluctuates. Moves. It is expressed in different words, symptoms and experience. They are common enough for us to be able to share experiences but diverse enough to be a unique story. The story isn’t the pathology. It may resemble features. It may not. They are non-essential.
Story is about dispositions. Dispositions make good stories. It might be the protagonist who is predisposed bad jokes, kind acts, losing their temper. A pain may be predisposed with certain movements, times or seasons, feelings. A disease may be prone to progression, resolution, a cluster of symptoms.
The story attempts not only the what question it but the why. Hume would say we can only observe the what, that the story is a cognition, distraction, non-truth. Of course in some cases this may be true…..
Essentialism is the view that any specific entity requires necessary set of attributes for identity and function. Even subjective ideals such as beauty, love or pain have, in essence, an objective strand which defines it and appears in every case.
Essentialism has provided the basis for taxonomy. It requires making discrete. Separate. Putting in boxes. Here not there. Surely there is value in this. This is how we see detail. However seeing only in detail, distinction, isolation may come at a cost if not built back into the world which is connected. Non-essentialism however states that there are no specific traits which entities must possess. For example a 3 legged albino tiger is still a tiger without characteristic appearance.
Essentialism attributes fixed essence of gender, race, disability amongst other things. It assigns normals. Family resemblance is a concept suggested by Wittgenstein (see previous blog). Instead of a box to fit in family resemblance looks for potential connections or similarities between related things.
Why is this important in healthcare? Well we see people without a classical presentations. That don’t always fit in boxes. We are (unlike Hume) concerned with the why (see previous blog). ‘Why is this happening’ gives us more than just the what is happening. The story can hint at the why without deterministic certainty. The drivers of diabetes, cancer or pain vary between individuals. The what only tells us the pathology, the diagnosis with no indication of why this is happening. So everyone gets the same robotic intervention.
We also tend to diagnose by pain in MSK health not by deficits. Lateral hip pain, anterior knee/patellofemoral pain, low back pain. This is in response to the unease at previous taxonomies bursitis, tendinitis, disc bulge which look to ascribe single cause. Pain is tricky to put into taxonomy due to its difficulty to describe, measure and understand. These new diagnoses only tell us the what and again do not guide intervention. Only tell us where pain is felt.
Finally it is worth remembering the patient has to resemble themselves. Not you. Not an ideal. Don’t hope for a new prototype. The story resembles them. Body, mind and environment. Never in isolation. We may resemble ourselves from moment to moment but we are never truly the same. We also are active in creating our communities not just a passive recipient. This gives us hope for change. But we must let the person be themselves in it all which means giving them control of the future. Not us.
So what does the persons story resemble? Can we give them more than a what? How can we look for changes but allow them to resemble themselves?
Be more human. Be less robot.
Thanks for reading this far. As always a short song and/or poem can be found below to adjunct the piece. Enjoy!
It looks like you but girl you’ve changed, girl you’ve changed, girl you’ve changed.
It sounds like you but your voice is new. I can’t see but I hear you.
It tastes like you with a different twist. Umami, sour and sweet.
It feels like you, I sink right in, to your skin, warm soft skin.
You still mean that munch to me, over time, all this time.
Something holds in all of this. Through the changes, you remain.
The past is gone, it always does. I still see you but your strength has come.