While in chiropractic school, some of my colleagues and I used to tell the following joke:
Q: What is the definition of health?
A: An incomplete work-up.
Immersed in studies of endocrinology, obstetrics, orthopedics, etc., we were captivated by the detective’s game of diagnosis, the collection of data and its sorting and re-sorting into logical chains of decision making to arrive at a named condition: diabetes, carpal tunnel syndrome, migraine, etc. Everyone had something–at least everyone who came through our clinic doors did. That was the reason they were there. Our job, we were taught, was to find the problem and put a name on it so that we could treat it. If we could not find the diagnosis, we had no business offering treatment. So when the diagnosis was elusive, we had to look harder, be more clever detectives. If we interns were not clever enough we would look to our attending physicians for help, who in turn could consult with their department heads if they got stuck. If the head of a department could not make a reasonable diagnosis that meant there was nothing physically wrong, and the case was classified as ‘supratentorial’ (psychological or psychiatric in nature). During my internship I attended several patients with complaints such as fatigue, generalized body aches, insomnia, constipation, indigestion, etc., who never received a diagnosis and as such, never received treatment at our clinics or hospital. Their blood work, imaging studies, and urinalysis was normal. There was nothing really wrong with them, and such patients were dismissed or referred out for psychological or psychiatric evaluation.
Our model, never explicitly stated but certainly transmitted to us through example, was that health was the absence of identifiable disease. A patient with symptoms but no disease was either a complainer, someone looking for attention, a person working the system for benefits of one kind or another, or a psychiatric patient, not a chiropractic one, healthy of body if not of mind. But what about patients with chronic pain who’d never had an injury, had no real findings on their exam other than tenderness, but who did not seem to be seeking attention, never stayed home from work, were not involved in litigation of any kind, did not have a Worker’s Compensation or Personal Injury claim, and who were paying hard-earned cash out of meager budgets to seek help from us? Fatigue, sleeplessness, body aches–these were common complaints, but they were symptoms not diagnoses. And what about the patients who came in for a yearly physical with no specific complaints, but were clearly obese and became winded just climbing up and down from the exam table? ‘Out-of-shape’ may not be a medical diagnosis but clearly such a person is not healthy.
At the earliest stages of my clinical training I had a sense that health went beyond the mere absence of identifiable disease. Over time it became clear to me that, like any complex human descriptor, ‘health’ is not best described in dualistic terms of black or white. People were not simply either intelligent or stupid, tall or short, good or bad; and patients were not simply either healthy or sick. Health, it seemed to me, was a term that lent itself to infinite degrees of qualification depending upon factors objective (blood tests, physical examination, imaging studies) but also subjective (one’s sense of happiness and well-being).