Biomedical models and healthcare systems

Editor—Like Wade and Halligan,¹ I think that current medical thinking about illness has serious limitations, which leads to problems for doctors and patients and helps administrators with diagnosis and certification.²,³ The traditional medical model is based on a direct link between lesion and symptom. Medical teaching rightly emphasises the processes linking symptoms with lesions.

Four groups of patients are discernible on the basis of such ideas.

The first comprises those whose symptoms are due to disease. This is home territory for doctors and reasonably well dealt with by current medical knowledge.

The second includes patients who have disease but no symptoms. This is the territory covered by screening, and, although of debatable worth, medicine has developed strategies for making progress in this area such as the Wilson-Junger screening criteria.

The third group consists of people who have no symptoms and no disease. These people are healthy as far as medicine is concerned and will not often attend the doctor.

The fourth group consists of patients who have symptoms but no disease. This group causes most of the problems in medical practice. In some of these people we as doctors can classify the symptoms into syndromes such as schizophrenia, depression, irritable bowel syndrome, and so we feel as if we are “diagnosing” an “illness.” With some symptoms we struggle even to do this. We can feel that we are trying to “knit fog” as we attempt to build a coherent picture out of multiple inexplicable symptoms.

We forget that we are trying to catch the symptoms within a disease matrix, which may not be a valid concept when there is no lesion present. There is a solidity, and validity, to the concept of any disease with a recognisable lesion that is lacking when no lesion has been shown.