The demise of disease? I don't think so

One may answer in a nondisputatious way by saying that the authors identify valid problems that are widely recognized. There is no doubt that some patients are undertreated, some overtreated, and some mistreated. What seems peculiar is the claim that these are due to a “primary focus on disease.” No one doubts that polypharmacy is a problem. Even when outcomes research in heart failure demonstrates that treatment with multiple drugs decreases mortality, one may choose not to use all drugs in a patient because of cost or side effects. There are probably very few physicians who do not treat chronic dizziness in the elderly even if the only disease is cerebral small vessel defects perceived by magnetic resonance imaging. On the other hand, if the problem is not chronic dizziness but acute dizziness, one would likely look for disease. In fact, on the day that I wrote this paper, I was presented with a case of a 75-year-old woman with the chief complaint of dizziness who proved to have an operable meningioma. Some of the statements in their Table 1 seem extreme. For example, in the proposed integrated, individuallytailored model, we read that “clinical decision making is focused primarily on the priorities and preferences of individual patients” (1). This assumes that the patient is capable of deciding what is the best therapy, which may not be possible either because of major or minor dementia or because the issues themselves are too complicated. The late Franz Ingelfinger, the editor of the The New England Journal of Medicine who was himself a gastroenterologist, wrote of the difficulty he had in deciding on the therapy for his carcinoma of the esophagus (2). In the end, he could not decide and concluded that he should find a doctor whom he could trust and follow his advice. Similarly, it seems strange for Tinetti and Fried to state that “relevant clinical outcomes are determined by individual patient preference” (1). Indeed, Ingelfinger had a strong opinion about this point: “A physician who merely spreads an array of vendibles in front of the patient and then says ‘Go ahead and choose, it’s your life’ is guilty of shirking his duty, if not malpractice.” In the disease-oriented model, we read that “discrete pathology is believed to cause disease; psychological, social, cultural, environmental, and other factors are secondary factors, not primary determinants” (1). One has to ask, is disease not caused by discrete pathology? Would any physician not recognize that environmental and cultural factors are sometimes primary factors (e.g., druginduced endocarditis, alcohol-induced cirrhosis, obesity), or that secondary factors such as poverty, age, or depression need to be dealt with? Fortunately, under the section entitled “A Solution,” the authors revert to a more balanced and prudent, less polemic stance. It is admitted that “the concept of individual disease should not be abandoned, but should be better integrated with individually tailored care” (1). Prudence is fundamentally a type of wisdom that guides decision making. It is characterized by a keen understanding of the present that is informed by a memory of the past and modulated by current counsel (3). Michael Novak defines the prudential habit as “the acquired skill of recognizing and doing the right thing at the right time and in the right way so as to be judged by history as having acted wisely rather than foolishly” (4). It would seem imprudent to pronounce that the disease era is over. As science progresses, many of the issues defined as “health conditions” by the authors will be explained scientifically and thereby open to therapy or prevention. To cite one example, the first of the “stroke genes” has just been discovered (5). Even in polygenic diseases, one can deal with a single gene product and still treat the condition. For instance, although several inflammatory cytokines are found in the synovial fluid of patients with rheumatoid arthritis, blockade of one—tumor necrosis factor — has powerful therapeutic effects, an observation that earned Ravinder Maini and Mark Feldmann the 2003 Lasker Award (6). I am very sympathetic to the authors’ desire to treat the whole patient and not the disease alone. Most good physicians do that. But it is increasingly harder to do so in an economic environment where there is not much time to talk to patients or their families. Furthermore, there are additional barriers. For example, Medicare proposes not From the Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas. Requests for reprints should be addressed to Daniel W. Foster, MD, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, Texas 753909030, or daniel.foster@utsouthwestern.edu.