Modern medicine is very good at naming things.
We have codes for everything. Codes for high blood pressure. Codes for low thyroid. Codes for high cholesterol, low testosterone, bad sleep, sad moods, angry bowels, rebellious immune systems, and knees that have finally filed for divorce.
Give us a symptom and, by God, we will give it a billing code.
This is one of the great triumphs of modern medicine. It is also one of its great weaknesses.
We have become extraordinarily good at diagnosis, but somewhere along the way we began confusing the name of a problem with an explanation for why the problem exists.
Your blood pressure is high. Hypertension. Why? Because you have hypertension. Ah. Glad we cleared that up. Here is your prescription.
Diagnose and adios.
The Magnificent Machine
Conventional medicine inherited much of its worldview from reductionism – the wonderfully productive idea that complicated things can be understood by taking them apart. The human body became a magnificent machine.
The cardiologist got the pump. The pulmonologist got the bellows. The gastroenterologist got the plumbing. The neurologist got the wiring. The endocrinologist got the hormones. The psychiatrist got whatever was left over after everybody else had gone home.
And this worked spectacularly well. If your appendix ruptures, please do not rebalance your microbiome. If your coronary artery closes, this is not the moment for a seminar on turmeric. If you have bacterial meningitis, antibiotics are not an affront to holistic medicine. They are a miracle.
Reductionism has given us anesthesia, antibiotics, insulin, joint replacements, cardiac stents, organ transplantation, cancer chemotherapy and the astonishing ability to keep premature babies alive who once had almost no chance at all.
The problem isn’t reductionism. The problem is believing that the pieces are the whole.
One Disease, One Drug
The pharmaceutical era gave reductionism a particularly attractive business model.
Identify the disease. Identify the molecular target. Find a molecule that changes the target. Patent molecule. Advertise during the evening news. Repeat.
Hypertension? Lower the pressure. Reflux? Suppress the acid. Insomnia? Induce sleep. Depression? Alter neurotransmission. Type 2 diabetes? Lower the glucose. High LDL? Lower the LDL.
There is nothing inherently wrong with any of this. Sometimes the molecule is exactly what the patient needs. But notice what happened. The surrogate became the disease.
Blood pressure is not hypertension’s life story. Glucose is not diabetes. LDL is not atherosclerosis. TSH is not the thyroid. CRP is not inflammation. And insomnia is not an Ambien deficiency.
These are measurements, sometimes extraordinarily useful measurements, taken from biological systems of almost ridiculous complexity. Yet our medical system rewards us for converting complexity into codes. And codes into prescriptions.
The Tyranny of the Fifteen-Minute Visit
There is another culprit here, and it isn’t the doctor. It’s the clock.
Imagine trying to understand why a 57-year-old woman is exhausted, gaining weight, waking at 3:00 every morning, hypertensive, insulin resistant, achy, constipated and depressed.
Now do it in fourteen minutes. Also reconcile seven medications. Review her mammogram. Order her colonoscopy. Answer three portal messages. Document smoking status. Click the quality-measure box. And don’t forget to ask whether there are guns in the house.
The physician isn’t stupid. The system is.
Complexity requires time, and modern medical economics has somehow concluded that the one thing a physician should have as little of as possible is time with the patient.
So the complicated human being sitting across from us gets compressed into something the system can process. Hypertension. Code I10. Wonderful. Now we know what she has. We still haven’t the faintest idea why she has it.
The Body Has Not Read the Textbook
Biology is inconveniently interconnected.
Insulin affects the brain. Sleep affects insulin. Cortisol affects sleep. Exercise affects cortisol. Muscle affects glucose. The gut talks to the immune system. The immune system talks to the brain. The liver negotiates with everybody. Even the bacteria in your mouth have entered the conversation.
The body is less like a collection of departments and more like an Italian family arguing over Sunday dinner. Everybody is related. Everybody is talking. And whatever happened twenty years ago is apparently still relevant.
That is why chronic disease so often refuses to fit comfortably inside our little diagnostic boxes. The patient doesn’t arrive with six unrelated diseases. She arrives with one body.
The Pill Is Not the Villain
It is fashionable in some corners of alternative medicine to make pharmaceuticals the villain. That is equally foolish. A pill can be magnificent.
Levothyroxine can restore a life. Insulin can save one. Antihypertensives prevent strokes. Statins prevent cardiovascular events in appropriately selected patients. Antibiotics have rescued humanity from infections that once routinely killed us.
The problem begins when medication becomes the end of curiosity.
The blood pressure fell. Case closed. But why was it high? Visceral fat? Sleep apnea? Alcohol? Insulin resistance? Kidney disease? Hyperaldosteronism? Chronic stress? Medication effects? Sedentary living? Genetics? Some unholy combination of all of them?
Treat the blood pressure, certainly. But keep asking questions. A prescription should sometimes be the beginning of the investigation rather than its conclusion.
From What to Why
The most useful question in medicine is often not “What disease does this patient have”?
It’s “Why is this happening to this particular person at this particular time”? That question changes everything.
Type 2 diabetes stops being merely an elevated A1c and becomes a story about muscle, liver, visceral fat, sleep, food, movement, genetics and insulin signaling.
Osteoporosis stops being merely a T-score and becomes a story about hormones, protein, minerals, resistance training, medications, absorption and decades of skeletal history.
Cognitive decline stops being merely a failing memory and becomes a reason to investigate vascular health, metabolic health, hearing, sleep, medications, nutrition, exercise and neurodegenerative pathology.
The diagnosis still matters. But it should become the beginning of the sentence rather than the period at the end of it.
Diagnose and Don’t Adios
Medicine desperately needs both worlds.
We need the reductionist brilliance that can identify a single mutated gene, replace a stenotic valve or design an antibody against a specific molecular target.
And we need the humility to remember that the human being carrying that gene, valve or molecule is an integrated biological creature who eats, sleeps, moves, loves, worries, works, ages and occasionally drinks too much Chardonnay.
Good medicine asks “what”. Better medicine also asks “why”.
The ICD code can tell us what drawer to put the patient in. It cannot tell us the patient’s story.
Somewhere beneath the diagnoses, laboratory values, medications and billing codes, there remains an actual human being whose biology stubbornly refuses to fit inside a drop-down menu.
So make the diagnosis. Use the code. Prescribe the pill when the pill is needed. But don’t stop there.
Diagnose and adios is efficient medicine. It just isn’t always good medicine.
Author
Scott Rollins, MD, is Board Certified with the American Board of Family Practice and the American Board of Anti-Aging and Regenerative Medicine. He specializes in bioidentical hormone replacement for men and women, thyroid and adrenal disorders, fibromyalgia and other complex medical conditions. He is founder and medical director of the Integrative Medicine Center of Western Colorado (www.imcwc.com) and Bellezza Laser Aesthetics (www.bellezzalaser.com). Call (970) 245-6911 for an appointment or more information.
