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Print ISSN: 0355-3140 Electronic ISSN: 1795-990X Copyright (c)
Scandinavian Journal of Work, Environment & Health
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Clinical report
Scand J Work Environ Health 1997;23 suppl 3:91-96
Clinical concepts and dilemmas between disease and averselife
events
by Getz L
Key terms:disability; general practice; health model;
psychosomatic
medicine
This article in PubMed: www.ncbi.nlm.nih.gov/pubmed/9456074
http://d/www/www.sjweh.fi/show_issue.php?issue_id=25http://d/www/www.sjweh.fi/show_abstract.php?author_id=772http://d/www/www.sjweh.fi/show_abstract.php?keyword_id=778http://d/www/www.sjweh.fi/show_abstract.php?keyword_id=779http://d/www/www.sjweh.fi/show_abstract.php?keyword_id=780http://d/www/www.sjweh.fi/show_abstract.php?keyword_id=781http://d/www/www.sjweh.fi/show_abstract.php?keyword_id=781http://www.ncbi.nlm.nih.gov/pubmed/9456074http://www.ncbi.nlm.nih.gov/pubmed/9456074http://d/www/www.sjweh.fi/show_abstract.php?keyword_id=781http://d/www/www.sjweh.fi/show_abstract.php?keyword_id=781http://d/www/www.sjweh.fi/show_abstract.php?keyword_id=780http://d/www/www.sjweh.fi/show_abstract.php?keyword_id=779http://d/www/www.sjweh.fi/show_abstract.php?keyword_id=778http://d/www/www.sjweh.fi/show_abstract.php?author_id=772http://d/www/www.sjweh.fi/show_issue.php?issue_id=25
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Scand J Work Environ Health 1997;23 suppl3:9 1-96
Clinical concepts and dilemmas between disease and averse life
eventsby Linn Getzi
Getz L. Clinical concepts and dilemmas between disease a nd
averse life events. Scand J Work Envi ronHealth 1997;23
uppl3:91-96.A visual model of general practice as a field of
medicine is presented. Definitions of terminology andconcepts to be
used are discussed. By the application of this terminology a model
of health, includingthe concept of disability, is constructed. This
model is used to define and describe dilemmasoccurring in daily
work. Such dilemmas are frequent and their nature needs to be
explored. Theypresent an area in which psychosomatic medicine could
meet with general practice, and vice versa.Ke y terms disability,
general practice, health models, psychosomatic medicine.
This presentation is about everyday life in medicine.I am a
general practitioner (GP) in Norw ay, currentlyworking at the
University of Trondheim. During thepast 2 years, I have been
conducting two studies ofthe doctor 's role in relation to medicine
in the fieldof social security, in parallel with my work as a GPin
a rural community. This combination of clinicalpractice and
academic work has proved to be highlyinspirin g, experience from
general practice influencesmy scientific work-and the academ ic
challen ge ofthe university enables me to see my work as a GP in
abrighter light.Why listen to the experience of general
prac-titioners? The answer has been formulated by theEnglishman
Peter Toon. He says: "There are moregeneral practitioners than any
other type of doctor,and many more individual contacts with general
prac-titioners than with other clinicians. The cumulativeimpact of
the many decisions made by general prac-titioners is enormous, even
if the difference each ofthem m akes, is small" (1).
I am using this opportunity to highlight s ome verybasic
concepts and dilemmas. They are not new andnot at all advanced.
They may actually be too basic,too evident to be seen as a problem.
I want to show
how this situation repeatedly leads the GP, the prac-ticing
clinician at the front line, into trouble. Theresulting
frustrations cast long shadows on the rest ofthe health care
system.
The concepts and models I use to describe my di-lemmas are made
for practical purposes. The descrip-tion of the true nature and
mysteries of health wouldrequire wider perspectives.One might ask
why we need a practical clarificationof the basics. I can think of
three main reasons: in orderto communicate within the profession of
medicine, inorder to think abo ut our knowledge base and about
medi-cal science, and in order to communicate with
otherprofessions, and with bureaucrats and politicians. Wemight
even need the concepts to improve the dialoguewith our
patients!
The traditional model of general practiceThe "cake" model of gen
eral practice is presented infigure 1. This is one of the
traditional models illus-trating how general practice corresponds
to the clas-sical medical specialities practiced in the
hospital.
1 Department of Community Medicine and General Practice,
University of Trondheim, 5. Etg. Kreftbygget, 7006Regionsykehuset
in Trondheim, N-7005 Norway.
91
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Clinical conceots and d ilemmas between disease and averse life
events
Figure 1. The trad i t iona l "cake" mod e l o f genera l p ract
ice
General practice is thereby seen as the sum of inter-nal
medicine, pediatrics, obstetrics, and so on. When welook at such a
model, it appears that the GP w ould knowless than the
corresponding specialist, no matter whatthe particular problem
might be. However, I am con-vinced this model is wrong.
Figure 2 shows a modified model of the "cake" thatI have made to
express what I think general practice isall about. The sectors from
the other medical disciplinesare the same as in the first model,
but note the emergingzone in the center. This zone is what makes
generalpractice a particular area to specialize in, the very coreof
general practice. It is where biomedical medicine canbest serve the
individual human being, where qualita-tive knowledge about the
individual can be integratedwith knowledge developed in a strictly
biomedical tra-dition. This is my frame of reference as a GP, and I
willcome back to this model at the end of this presentation.
Befinifion of eoncepfs
I would first like to draw attention to a serious
linguisticbarrier involved in my topic. I start by defining
threewords that exist in everyday English, although not inthis
particular meaning. They represent nuances thathave no coun terpart
in the Norwegian language.Disease: a pathological process. Disease
is an objec-tive, naturally occurring entity that exists in the
struc-ture and function of organs. The individual "harbors"the
disease. An example of serious disease is a braintumor.Illness: the
bodily experience of suffering, a unique,subjective, individual
feature. Nausea, headache andanxiety a re examples of illness.
Figure 2. A rev ised mode l o f genera l p ract ice .
Sickness: the objective state of poor health, theperson's
behavior, limitations and reduction in func-tioning. An example is
not going to work or refrainingfrom social activities due to ill
health.Diagnosis: a recognizable entity, which might ormight not
correspond to a particular disease. Diseasesoccur naturally,
whereas diagnoses are man-made.Adverse life event: an unfavorable,
contrary, hostile( adv e rse ) happening, usually something
important(event), according to the Advanced Learrzer's Dictio-nary
o f English.Life change eventsNo w I will try to define an adverse
life event as seen inrelation to the neutral and more scientific
term "lifechange event". Figure 3 shows a model of life
changeevents, based upon my experience from general prac-tice.
Along the horizontal axis is the character of theevent-more or less
objectively characterized. To theright are the challenges, the
entrances, the potentialgains: A new job, a newborn child, moving
to an inter-esting place are examples of gains. To the left are
thelosses. The death of a loved one, serious disease, de-structive
relationships, loss of job, and the like are ex-amples of
losses.
How will a particular event affect the individual?The vertical
axis in figure 3 refers to a person's adapta-tion to the event.
This response may vary from integra-tion by personal growth and
development to destruc-tion. A recent personal report in the
British MedicalJournal pointed to the difference between survivors
andvictims.
The person's personal susceptibility and the socialsupport from
the env ironment are of major importance.In order to und erstand
the effect of a life change event,three factors must be taken into
account, the event itself,
92 Scand J Work Environ H ealth 1997,v o l 2 3 , s u p p l 3
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Life change / - ---.ubject'sevents / Growth1 \ vulnerability/
integration \ and/ t \ social\ support1 1I( Loss Gain I\ I\ \
Destruction1 /\ disintegration ,
\ /'Sum: Event + person + environment
-I-I l lness(subjective)
-&
Disease (object ive)
Figure 3. A mode l of life change events. Along the horizontal
axis is thecharacter of the event-more or less objectively
characterized. To theright are the challenges, the entrances, the
potential gains. The verticalaxis refers to the individual's
adaptation t o the event.
the person undergoing the change, and the person's en-vironment.
Even though experiences can make somepeople grow, my clinical
experience indicates that thesum or sequence of relatively minor
events hitting thewrong person at the wrollg time can lead to
disintegra-tion and ill health.
On the basis of this model, my working definition ofan adv erse
life event is as follows. Caused by a constel-lation of the three
factors-event, person and enviro n-ment-an adve rse life event
leads to some degree of de-struction or disintegration in the
person experiencing it.
I am not focusing on how big the event must be orwhat events are
adverse in themselves. "One m an's m eatis another man's poison".
Rating scales for life changeevents have been constructed. I will
not discuss themhere. They are interesting as such, but add little
to thispicture.
What can be said about the evidence linking adv erselife events
to poor health? In my opinion, the evidenceindicates a clear link.
For example, take unemploym ent,an event that can be described as a
loss to most people.Professor Steinar Westin at the Department of
Comm u-nity Medicine and General Practice in the University
ofTrondheim has summed up the literature, and I brieflyreport what
h e found regarding the health effects knownto be causally related
to unemployment (personal com-munication 1996).
Cardiovascular disease, mortality, psychologicaldistress, and
the "classical" psychosomatic disordersincrease in the unemployed.
Suicide rates rise. Theuse of alcohol and stimulants may or may not
rise.Family confl icts become more frequent . As regardsbehavioral
aspects-we see that the unemployed gomore often to the doctor, they
even end up in thehospital. They are at higher risk for sickness
certifi-cation and disability pension.
Figure 4. lntraindividual model of health. A sort of a
two-by-two tableto be read along two axes: disease-the pathologica
l process-alongthex-axisfro mzero to maximum; llness-the subjective
discomfort-along the y-axis.
Models of normal and poor healthLet us turn to a typical
situation in the doctor's office.Scene 1: I am in my office with a
patient. Here is thestart of our dialogue. D: "What can I do for
you?" P:"You see, doctor, there must be some thing wrong withme, I
want you to find out . "
Without knowing it, I try to fit this patient into amental map
of the world of ill health. He is telling methat he has illness,
his bodily experien ce is negative. Myfirst question as a
professional is-and is expected tobe-does he have a disease?
Cancer, for instance? Thisprocess is illustrated in figure 4,
showing a basic two-dimensional model of poor health. Simplified,
you ei-ther feel ill or you don't, you either have no disease oryou
have disease, and you may hav e ally combination ofthe two.
What goes on in the clinician's head in this situa-tion? I
believe that adverse life events may present them-selves through
illness. Although this possibility wasmentioned in my undergraduate
training, the art of rec-ognizing and diagnosing patients
experiencing bodilyresponses to emotional strain was never taught.
I do notknow enough about the investigation and interpretationof
illness in a psychosocial context to trust my ownsenses fully. Like
most doctors, I therefore start by rul-ing out organic disease.
Relying on intuition or beliefthat illness is not due to disease
can be a risky business,because my actions will not be rooted in or
supported bythe medical tradition to which I belong.
It is not surprising to find that doctors end up withvery
different views and interpreta tions of their patients'bodily
experiences. We are confronted w ith many enig-matic stories that
have never been described in anytextbook or medical journal. The GP
has to learn to livewith this situation. It can certainly be an
i~lterestingchallenge, but it can also lead us to become too
tolerant.Scand J Work Environ Health 1997, "0123, suppl 3 93
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Clinical concepts and dilemmas between disease and averse life
eventsA British guru of general practice, John Howie, statedthis
opinion in the following manner: "The ability ofgeneral
practitioners to tolerate uncertainty as a clinicalskill seems
somehow to have been carried too far" (2 ).
Here comes my first challenge to the experts: Helpus to develop
sound scientific kno wledge about the pa-tient experiencing illness
but presenting little disease,when compared with his or her
suffering. Can diagnos-tic strategies be develop ed? How can we
learn to recog-nize life change events behind symptoms without
ex-hausting our biomedical list of possible diagnoses?
My patient has not left my office yet. Here comesthe ensuing
clinical situation. Fifteen minutes havepassed in this meeting
between two experts-the doctorwith her biomedical knowledge and the
patient withknowledge about his own life and body. The doctor
isrounding off her primary clinical investigation by say-ing:
"We'll do some blood tests today. Com e back in aweek, and we'll
carry on from there ...." Then the pa-tient says: "But anyway, I
need a sickness certificate,and I want to apply for disability
pension. I can't makeit through the day at work anymore."
Situations like this give the doctor a sort of sinkingfeeling.
Why? What has happened now? The patient'srequest has moved the
whole situation out of the two-dimensional clinical model. The
patient's statement isnot about illness or disease alone. It is
about a thirddimension, that of sickness (figure 5).
The emerging model of ill health has three axes.Two dimensions
are common to the previous model(figure 4) with disease, ischemic
heart disease, as on eexample, and illness, "something feels
wrong", be itchest pain or fatigue. These two axes define
differentbut intraindividual entities, and they relate to the
clini-cal situation.
A sickness certificate, however, is not a clinical is-sue. It is
the result of politics, and it is governed bysocial security
legislation. It regulates the person's rightto refrain from job
tasks given to him by society. There-fore, the third axis is not an
individual dim ension. It isrelational, describing the interface
between the patientand his surroundings.
Illness Intra-individualr dimensions
Social1 Sicknessrelationaldimension I /ILx-1 DiseaseJ.Fitness?
Wellness?
Figure 5 . Dimensions of poor health-three-dimensional model.94
Scand J Work Environ Health 1997, vo l23 , supp l3
SociallrelationalLimitation dimension
s/Ability?Figure 6. Dimensions of disab ility.
In this situation, the doctor is not a clinician, butrather a
gate-keeper: "If you're healthy, you should goto work. If your
health is sufficiently poor, you mayenter the sick role, with its
privileges and obligations".When we look at health in this
three-dimensionalmodel, the gate-keeper's role seems clear, even
thoughdifficult to practice. The patient not only asked for
asickness certificate, he wanted a disability pension. Letus
therefore look at a model describing disability (fig-ure 6). Th e
terminology is to be found in an A mericanpaper in Social Science
and Medicine from 1994 ( 3 ) .Along the x-axis is the pathological
process, corre-sponding to disease in figure 5. Along the second
axisis the limitation experienced by the person, what he canor
cannot do. Finally we come to disability that again isthe
relational feature, disability being defined as thegap between
personal capability and environmental de-mand. Th e rationale
behind the two theoretical m odelspresented here is completely
parallel.
Dimensions and models of disabilityNow it is time to adjust to
reality. I adjust to mine. Youadjust to yours. In Norway one does
not look upon ortalk about health and disability in this way. This
is
Level of healthPerson's health Disease(Disease, illness, 1
leaves~ckness) Disability pension
TimeFigure 7. Medical model of d isability (reference4 ). The
level of healthrequired o perform the patient's job is represented
by the thin straightunbroken ine, disease by the broken line,
illness by thedotted line, andsickness by the curved unbroken
line.
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where linguistics coines onto the scene: If someone isnot well,
we have one word to describe the situation:"Syltdom". We have no
words to help us differentiateour thoughts in terms of disease,
illness and sickness.Sykdom is still treated by many doctors and
most bu-reaucrats as if it were an uncomplicated entity that canbe
quantified along one axis. In other words, the patho-logical
process, the patient's experience and his func-tional disability
are expected to vary together in a paral-lel manner as in the
Norwegian model of disability pre-sented in figure 7. Let us
imagine a level of healthsufficient for the patient to cope in
daily life. As long asthe three dimensions vary in harmony, the
simple word"sykdom" will tell the tale. A man develops, for
in-stance, severe rheumatoid arthritis. He experiencesmuch pain,
and after a while he is no longer able towork. He applies for
disability pension. The three di-mensions of health are affected in
a parallel manner.The gate-keeper can relatively easily fit the
occurrenceinto the medical mod el: "Sykdom n-objective
pathol-ogy-is clearly the cause of disability.But what actually
happens in reality? Let us imaginethe patient sitting in my office
talking about disabilitypension. He is 60 years old, his back
aches, he hasconstant headache, he feels worn out. But only
minordefects can be foun d in him according to the biomedicalmodel.
However, he says he cannot work. The threedimensions of health are
in disharmony (figure 8) . Ill-ness and sickness are major, but
disease is minor. Thedoctor does not know how to handle the
situation: thesocial security office demands pathology to be
docu-mented; the patient is sent from one clinical specialist
toanother. The GP has little choice but to listen to thepatient and
is left in the middle of the conflict.This brings me to my second
request, this time it isthe gate-keeper's, not the clinician's. We
need furthertheory and knowledge about the "disability gap". As
aGP, both clinician and gate-keeper, I am confrontedwith this
question so often that it has become of greatinterest to me. The
welfare state that I live in adheres to
a model of health that does not want to see the depth anddanger
of this dilemma. This twilight zone betweenmedicine and politics is
loaded with preconceptions, butit seems to be a no-m an's land from
a scientific point ofview. How can we explore and explain the
disabilitygap? There is much evidence that the
environmentalsyndrome is often associated with one or more
psychiat-ric disorders, defined by criteria the Diagnostic
nrzdStatistical Maiztual of Meizttnl Disorders (DSM). Myquestion as
a GP is then: Does this situation mean thatthe patient can be
considered disabled?
In my presentation I have pointed out two commondilemmas
occurring in the average GP's office. I havenoted that our tools
are inadequate and that there aresevere limitations in our way of
thinking and communi-cating about health and disability. I believe
that thissituation undermines the quality and fairness of care,and
also the well-being of both the professional and thepatient.
The GP is, as a result of patient turnover and his orher contact
with people in the early phases of ill health,an important target
if our wish is to implement changein the health care system. I
therefore consider generalpractice to be among the most important
targets when itcomes to research in psychosomatic medicine. If
thethinking and behavior of the GP can be changed, thenhealth care
as a w hole can be changed.
An new model for general practiceI want to finish this
presentation where I started, withmy model of general practice
(figure 9) . In the centerzone, the very core, lies the challenge
for general prac-tice, ie, to observe and understand the individual
in his
Level of healthPerson's health Disease(Disease,
illness,s~ckness) 1 Disabilitv oension?
7TimeFigure 8. "Incongruent" model of disability (reference4).
The level ofhealth required to perform the patient's job is
represented by the thinstraight unbroken line, disease by the
broken line, illness by the dottedline, and sickness by the curved
unbroken line.
Psycho- Psycho-somatlcs somatlcs
Psycho-somatlcs
Figure 9. Model of general practice with the patient in the
center.Scand J Work Environ Health 1997, "0123, suppl3 95
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Clinical concepts and dilemmas between disease and averse life
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