The Whole Patient
By 2012, I had been practicing medicine long enough to know that the diagnosis on the chart was often the least complicated part of the visit. That became especially clear as I moved more deeply into pain management and addiction treatment.
Pain has a way of spreading well beyond the place that hurts.
A patient may come in because of a bad back. The MRI shows degenerative changes, the examination shows limited motion, and there may be numbness, weakness, or years of treatment behind them. But that is only the beginning of the story.
The back pain may also mean they haven't slept through the night in six months. They stopped walking with their spouse. They gave up fishing because sitting in the boat became miserable. They are missing work, irritable because they are exhausted, and frightened because somebody has told them the MRI looks terrible. Somewhere along the way, depression or anxiety may have entered the picture.
Which part of that is the "real" problem?
All of it.
That was one of the things pain medicine taught me very clearly. The human body does not care very much about the lines we draw between specialties. The spine is not separate from sleep. Sleep is not separate from mood. Mood is not separate from pain. Pain is not separate from function. And function is not separate from whether somebody can work, take care of a home, or still recognize the person they were before they became sick.
Physicians sometimes have the luxury of dividing those things into boxes. Orthopedics looks at the spine, psychiatry looks at the depression, a sleep specialist looks at the insomnia, physical therapy looks at function, and somebody else manages the medications. Every one of those people may be doing their job correctly, but somebody still has to ask how the pieces fit together.
That is one reason I always liked internal medicine. You are allowed to step back. You can look at the laboratory work, imaging, medications, symptoms, functional changes, and what was happening in the patient's life at the same time. You can ask whether one condition caused another, whether two things simply happened together, or whether a treatment that helped one problem quietly made another one worse.
Addiction treatment made that even more important. By then, the conversation around opioids had become increasingly polarized. There were people who had clearly been harmed by medications. There were also people with very real pain who were terrified that nobody believed them anymore. Occasionally, both realities existed in the same patient.
That is an uncomfortable place for easy answers. It forced me to separate questions people naturally want to combine. Is the pain real? What is causing it? How much is it affecting function? Is the treatment helping? Is the treatment creating another problem? Those questions may be related, but they are not the same question.
I became cautious about turning complicated people into simple labels: "chronic pain patient," "drug seeker," "depressed," "addict." Labels can be useful shorthand. They can also become a way of stopping the thinking.
Once a label explains everything, we stop asking what actually happened.
That can be dangerous.
The same lesson applies when trying to understand cause. Someone who develops depression after years of worsening pain, loss of mobility, poor sleep, repeated procedures, and the loss of a career has a different medical story from someone whose depression began years before the physical illness. The eventual diagnosis may be the same; the path to it may not be.
Today, when I review a complicated medical file, I still look for those relationships. When did the pain begin? When did sleep change? When did mood symptoms appear? What happened to function? What treatment was being used at the time?
The answers are often scattered across different specialties and different years. An orthopedic note mentions sleep. A psychiatry note mentions pain. A primary-care note says the patient stopped working. A spouse says the person has not been the same since the injury.
None of those observations tells the whole story by itself. Put them together, though, and something may become visible that was difficult to see when every specialty was viewed separately.
That is probably the biggest lesson I carried from internal medicine, pain management, and addiction treatment into the work I do now. The diagnosis matters, but the patient matters more.
Disease doesn't happen to a chart.
It happens to somebody.
And if you want to understand what really happened, sooner or later you have to put the whole patient back together.