What is the focus of medicine? Is it the disease or the sick human being? Health and illness encompass a number of definitions: What is normal, what is pathologic? How do medical practitioners, the healthcare system, and the patients themselves define and at a personal level experience health and illness? Social science and psychological fundamentals are no „Troubles-on-top-of-everything-else“ at the preclinical stage of education, but rather an important pillar for subsequent work in the medical field. The following summarizes everything important with regard to systems of reference in health and disease:  This is the perfect article to learn for your USMLE!
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Definition of health and illness

Several nuances and variations do exist between the two extremes of health and disease. Medicine primarily takes cues from the World Health Organisation (WHO) of health:

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

But not every deviation from the normal, the optimum, can be classified as ill/pathologic. The doctor in charge is aware of the several gradients and nuances of the well-being of a person, but due to outer structures (health insurance, employer, …) often has to categorize patients into one of both categories, health or illness.

Health and illness: What is the norm?

  • Biological and physiological: Diagnostic standards define certain limit and variations thereof are classified as pathology.  Think of lab results with precise limitations of the values!
  • Social: Codes of behavior are learned and differ a lot between different cultures.
  • Statistical: The statistical average is considered as normal.
  • Ideal: Wants and ideals fabricate a target status, which is aimed at.
  • Functional standard: The functional ability within the own limit of performance.
  • Reference standard: Normal within a reference group.
  • Role standard: Behavior in a defined role

Basic concepts in health and disease

You will encounter some important technical terms regarding health and illness throughout your studies. So it is worthwhile to memorize the following:

As a doctor, you search for the cause of a patient’s illness that in its entirety is termed aetiology.

outfit of a doctorThe empiric origin and development of an illness is called parthenogenesis.

Some people carry risk factors that are genetic or due to lifestyle choices which can precipitate the outbreak of an illness.

On the other hand, protective factors can prevent the outbreak of an illness.

People with many risk factors can be exceptionally resistant and resilient: The technical term therefore is resilience.

In the case that an illness is temporarily out of character, we speak of  chronification.

If there is a flare-up of the illness after healing, then the patient suffers a relapse.

Ideally, the healing process of a disease or a procedure is followed by the regaining of abilities, called rehabilitation.

The affected person: Subjective feelings and experiences

advice, assistance, healthcare, healthy, help

Image “advice, assistance, healthcare, healthy, help” von www.audio-luci-store.it.. License: CC BY 2.0

When it comes to sharing findings and diagnosis with the patient, the doctor should naturally possess empathy. In the daily routine of the medical environment, time is often a limiting factor. Nevertheless, you should always try to evaluate the subjective condition of the patient and to adjust the doctor-patient-talk individually.

Terminology for subjective experience of health and illness

Next to common terms like well-being, discomfort, and symptoms you should get acquainted with a number of terms that are associated with the subjective experience of illness and health.

1. Symptom awareness

Each individual perceives symptoms differently in strength.

Insufficient symptom awareness Enhanced symptom awareness
Very high symptom tolerance Even minimal changes are recognized and observed with low symptom tolerance
i.e. depressive patient, people dealing with alcohol abuse  etc. Very pronounced with hypochondria

You, as a doctor, cannot naturally assume self-reflection!

2. Interoception / Exteroception:

To be able to experience discomfort, a physical awareness is required. Proprioception, visceroception, and nociception fall under interoception, the awareness of one’s body.

  • Proprioception: we are aware of our locomotor system
  • Visceroception: describes the perception of the organs
  • Nociception: describes the perception of pain
  • Exteroception: describes the own body. e.g. by seeing, smelling, tasting (outer awareness)

Sneak peak into a medical center:

Two examples of divergent experiences are hypochondria and the somatisation disorder.

When it comes to hypochondria, an excessive self-perception leads to overvaluation of the smallest symptoms or non-symptoms. The patient feels a constant state of anxiety and fear and worries about being ill or falling ill.

In the case of a somatisation disorder, psychic or mental distress cannot be expressed, this neither in front of oneself or in front of others. The body finds a way out of this stressful situation by „talking via the organs“, i.e. physical symptoms.

The subjective perception includes interoception, exteroception, and the ability to act.

The quality of life with reference to health is never dependent on a single factor. Remember WHO‘s definition of health: Physical, psychological and social wellbeing constitute, together with the patient’s ability to act, the quality of life for an individual.

Implicit theories of illness

The implicit theories of illness have a large impact on the healing process. A patient who considers an illness as „just punishment“ will have a different healing process than someone who sees it as a „temporary obstacle“ that has to be surmounted. If you, as a doctor, can appreciate these highly subjective theories of illness, this „key“ will facilitate the understanding for the patient’s perception of the illness.

Disease-sustaining cognition: primary and secondary gain

Your first impulse might be: illness and gain – a paradox? In the psychodynamic model, illness can be interpreted as a follow-up to a conflict: It does contribute to the resolution of the conflict while the patient draws a hidden, intra-psychological advantage from the illness. The secondary gain is easier to understand and has to do with the objective unloading and gratification.

Primary gain Secondary gain
Reduction of the intra-psychological tension The afflicted person gets to rest and is looked after.
The afflicted person is freed from school attendance /obligation to work and possibly draws sickness benefits.
Relatives and friends react with hightened thoughtfulness and sympathy.
People who possibly feel neglected, receive increased attention from others and the medical staff

Excursion to medical practice: Perhaps you have already made the experience during your nursing internship, namely that often older patients living alone „enjoy“ finally being looked after extensively and being at the center of attention.

Medicine as knowledge- and action-system

Medical findings and diagnosis

Before imaging procedures were invented, the doctor was dependent on the visual appearance in order to „visualize“ the patient. Nowadays x-ray, sonography, CT and MRT considerably facilitate the diagnostic work. They are, however, just a part in the pool of methods, which you as a doctor should use to arrive at findings. Part of complete medical findings and diagnosis are:

  • Anamnesis: With the anamnesis you record the history of the illness. Often you have to work other-anamnestic, e.g. with children, traumatized or confused-conscious patients
  • Exploration: Why does the patient come to you?
  • Behaviour monitoring: By monitoring the patient’s behavior, you evaluate important information about the symptoms of the illness
  • Physical examination: Important elements of the physical examination are: inspection (seeing), percussion (tapping), palpation (touching)
  • Medical-diagnostic procedures: The previous first steps, involving listening and looking, allow the physician to formulate a working hypothesis. For further adjustments, laboratory and imaging procedures are employed accordingly.
Notice: The state of health describes a subjective experience-based value, the report describes objective data.

Classification systems for health and illness

The classification systems for psychological and somatic illnesses are instruments of categorical diagnosis.

International Classification of Diseases ICD-10

Attempts have been made since the 19th century to compile some kind of catalogue for the purpose of organizing physicians’ diagnostic experience in one classification. What was in the beginning the international nomenclature of causes of death from 1893 has to this day been developed further to the International Classification of Diseases (ICD): More than 2500 diseases out of the somatic and psychic area are classified in 21 categories. Since 1958, the WHO is responsible for the work on the  ICD-10-catalogue. ICD-11 is not planned, but there are annual actualizations by the WHO.

Diagnostic and Statistical Manual of Mental Disorders DSM

Initially introduced in the USA in the 19th century as the first classification for idiocy/insanity, the DSM is adapted and updated by the American Psychiatric Association since 1952. The latest version is called DSM-IV-TR and contains a diagnostic system with five axes. The DSM has a bigger impact on the psychological research than the ICD-10-catalogue.

5 axes of the DSM

I Clinical disorders and other clinically relevant problems

II Personality disorders

III Medical factors

IV Psychosocial and environmental problems

V Global Assessment of Functioning based on the GAF-Scale.

Society: Societal viewpoint on the aspects of health and illness

Fulfillment of/Deviation from social norms and roles

Our behavior is measured against different norms and roles (see above). The role differentiation is the result of task-specification within our society. With being new in a group comes the conception of roles: roles are redistributed and/or assumed. There are certain expectations attached to a role: The physician fulfills a precisely defined, formal role, whereas the expectations for a student in his informal role are rather variable.

By virtue of the Abitur, the state examination, or the like, or even as goalkeeper, or as the spokesperson of a chorus we assume acquired roles. Attributed roles, like gender are less modifiable. In order to cut ties with an attributed role or to change it, distance from the role is required (e.g. women’s emancipation). The opposite of distance from the role is role-identification. The person accepts and affirms the role.

As early as in the course of your education you probably have a conflict between roles: The expectations of the different roles that you fulfill diverge and lead to a conflict. The role of the medical student, the role of the teaching assistant, the role of the flat occupant… conflicts within a role are called intra-role-conflicts, like e.g. the expectations of a doctor on the part of the nursing staff and the completely different expectations on the part of the patient.

The environment sanctions role-compliance or non-compliance with positive sanctions (praise, gratitude, approval) and negative sanctions (penalties, disbelief, disapproval), respectively.

Legal regulations of the health- and social-system

During your studies you will be briefly confronted with the health- and social-system in the clinical section in the field of occupational medicine/social medicine. Sick certificates, rehab applications and level of care categorisations are a bureaucratic jungle, which is hard to grasp as a freshman intern. In the meantime, try to memorize the following basic terms that legally define different stages of disease:

  • Sick certificate: By means of the medical certificate you legally release someone from work, exams, or court appearances.
  • Occupational disability and disability: The patient is not able to practice the originally learned profession because of health reasons. In contrast to occupational disability, a patient with total disability is not able to pursue any other career options either.
  • Invalidity: The patient is permanently affected by an accident at the mental and/or physiological level.
  • Pension: Pension is a complex topic with many subcategories: There are retirement pension, early retirement pension, pension because of partial disability, pension because of full disability, widow’s and orphan’s pensions.

Assessment of health and disease under socialcultural aspects

the physican

Image “The physician” by Adrian Clark. License: CC BY 2.0

In society, illness is a state that deviates from the normal situation. This divergent state is to be changed or restored as much as possible: To this end, specific rules exist, the meeting of which or non-compliance with are sanctioned positively or negatively, respectively.  The illness of the individual is no personal matter, but it also has repercussions for society (e.g. high cost factor for chronic diseases or the additional work, which has to be covered by colleagues when absent).

Great emphasis is to be put on the fact that society views disease of organic or psychologic origin differently. Patients with psychologic diseases are often exposed to serious stigmatisations. The common chronification of mental illness emphasizes the negative societal valuation of these patients.

Popular exam questions regarding systems of reference of disease and health

1. “Normal“ is something that is defined by specific standard terms. Thereby it is important which criteria this standard is based on. Which criterium is primarily crucial for developing the therapeutic norm of arterial blood pressure?

  1. The patient’s psychological wellbeing.
  2. WHO’s definition of health
  3. Risk-reduction for secondary illness.
  4. Statistical deviation from the population mean
  5. The patient’s impairment in daily life

2. Two systems are used to classify mental illness: The ICD-10 and the DSM. Which features characterize the (newest) DSM version?

  1. There are only diseases stated that are exclusively treated in-patient, not out-patient.
  2. The procedure for mental illness is precisely described including the therapeutic guidelines.
  3. All mental illnesses are listed in alphabetic order.
  4. It is a multi-axial diagnosistic system with 5 axeis.
  5. Indications for therapies are stated.
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