Ben Hoban is a GP in Exeter.
Life is full of periodicity: daily, weekly, monthly and annual patterns whose regularity generates a familiar rhythm. A certain amount of progression, perhaps, but mainly back and forth: wake and sleep, work and play, well and sick. In this sense, illness is something normal, to be borne while the pendulum swings that way in expectation that it will soon swing back again. Most of the time, it does, and it is easy for us to claim credit as doctors, even though we know that many problems get better by themselves. It’s worth considering for a moment how this works, and what happens when it doesn’t.
Acute infections, injuries and psychological traumas are not intrinsically self-limiting, but often seem to be because our natural response to them is so automatic and effective. Fever, pain, autonomic arousal, and distress are all components of this response, although it is easy to conflate them with the problem that triggered them. We do not experience disease directly, but only through the lens of illness, whose symptoms may indicate not that help is needed, but that it is already on the way.1
Labelling something as a symptom necessarily implies an underlying problem. Many “symptoms” in fact represent noise within the system, physiological processes that for some reason cross the threshold of our awareness, registering as a mismatch between how we feel and how we expect to feel.2 This naturally gives rise to certain concerns, by addressing which we can resolve the mismatch, normalising it rather than looking for a cure. Even symptoms clearly related to long-term conditions naturally oscillate about a mean and will at times peak for no reason. These are the times when patients tend to seek help, but also when their symptoms are most likely to improve spontaneously, by a simple reversion to the mean.
Patients ride the oscillations of their health like a swing, waiting for things to get better one way or another, and holding on in confidence that this will indeed happen. The placebo effect describes the impact of this confidence on the degree and speed of their recovery, whether mediated by a pill, a person, or some other element of their care.3 Even simple observation is known to affect outcome measures: watching and waiting is not the same as just waiting.4
A quiet desperation starts to pervade the consultations, whose focus narrows in search of the elusive treatment, test or referral that will at last provide an answer.
There are many whose recovery from illness is more complicated and at best partial, despite appropriate treatment and a lack of ongoing disease. It is as if the normal processes by which an illness resolves have shut down and the pendulum has become stuck at one extreme of its arc: adaptive responses become maladaptive, the statistical outlier pulls down the mean rather than reverting to it, symptoms multiply and expectations become increasingly bleak. A quiet desperation starts to pervade the consultations, whose focus narrows in search of the elusive treatment, test or referral that will at last provide an answer.
Although doctor and patient both worry about missing a significant underlying cause, there is by this time often no simple diagnosis that can make sense of it all. Whatever the original trigger, ongoing symptoms are more likely to be due to secondary factors such as deconditioning, autonomic dysfunction, altered processing of sensory signals, and loss of routine, purpose, and social interaction.5 Patients who have fallen off the swing of their daily lives find themselves unexpectedly on the floor, having lost momentum, sore, and unsure of themselves. If they are to recover, they first need help to get off the ground, remount, and restart those small regular movements that over time progress to a more graceful and effortless motion. Above all, they must have a reasonable expectation that these things are possible.
It is easy to feel as if we have nothing to offer patients suffering from chronic ill health, or even to resent them as a reminder of our failure to make things better. We cannot turn back the clock to a time before it all went wrong, but we can still entertain more modest aspirations. Healthy eating, a good night’s sleep and a bit of fresh air will not fix anything, but small changes can still create conditions more favourable to some degree of meaningful recovery, and our role as doctors is to enable and support this rather than to bring it about ourselves. Health too is dynamic, a daily succession of breaths in and out, systole and diastole, back and forth. We can draw our patients’ attention to the small daily fluctuations in their symptoms that demonstrate this, help them to understand the physiological processes at work, and encourage a positive response that over time builds momentum. Most of all, though, we can just be there, a hand on the swing that gives someone the confidence to start moving again.
References
1. Cecil Helman, Disease versus Illness in general practice, Journal of the Royal College of General Practitioners, 1981, 31, 548-552
2. Van den Bergh O, Witthӧft M, Petersen S, Brown RJ. Symptoms and the body: taking the inferential leap. Neurosci Biobehav Rev 2017;74:185-203
3. Enck, Bingel, Schedlowski & Rief, The placebo response in medicine: minimize, maximize or personalize? Nature reviews: drug discovery 2013; 12: 191-204
4. McCarney, R., Warner, J., Iliffe, S. et al. The Hawthorne Effect: a randomised, controlled trial. BMC Med Res Methodol 7, 30 (2007). https://doi.org/10.1186/1471-2288-7-30
5. Functional Disorders and Medically Unexplained Symptoms: Assessment and treatment, Edited by Per Fink and Marianne Rosendal, Aarhus University Press, 2015
Featured Photo by Nick Monica on Unsplash
