Sunday, 17 May 2015

My right foot: predicament versus illness

My right foot hurts. It hurts in the middle, underneath, but not all the time, and only when I walk or take any weight on it, especially when I get up in the morning, when it becomes difficult to walk. It has been hurting on and off since I did an 80km trek three months ago. It could be a stress fracture, or some kind of fasciitis, soft tissue tear, fatigue, injury or degeneration, but I don't really care, because I am not going to have any tests or see any health care practitioners to get their version of a diagnosis. I'm just going to leave it alone. I am going to be a person with a predicament that I can cope with, and not a patient with an illness.

Predicament versus illness
Nortin Hadler makes a clear distinction between a person with a predicament - a condition of which they are aware and which may be causing some interference with their daily life but importantly, a predicament with which they can live. The physical disruption in this case is not causing undue psychological distress. As soon as that person enters a doctor's office to seek treatment, they will become a patient with an illness. Even if the doctor isn't sure of the diagnosis, he or she will label the patient with at least a working diagnosis of a disease, and the person will remain under investigation or treatment until they get better or leave that paradigm. If they get better anyway, which is surprisingly common, then the medical treatment will be given credit for the improvement. If the patient does not get better, they will be frustrated with medicine's failure to treat what appears to be a clear case of an identifiable disease. Their psychological status may deteriorate. Their personal responsibility will have been reduced by abrogating responsibility to the medical profession, and this is reinforced by the medical profession's attitude that it is not the patient's fault, and that it should be left to the doctors to manage and cure the condition.

What will happen to me
It is almost certain that my foot will get better with time without any tests, injections, physical therapy arthroscopies or even rest. In the meantime, however, I don't care about it. I am continuing to run, socialise, walk and work without interruption, and I am saving money, time and stress in the process.

What can happen to others
Unfortunately, most people turn to medicine for help whenever symptoms are felt that are unexplained, on the assumption that this is what should be done and that there is a net benefit in doing so. They turn for help even when they are coping, and in seeking help, they may be reducing their own capacity to cope.

Why am I different
The main reason is that my estimation of the ability of modern medicine to diagnose and improve my condition, and avoiding harm in the process is likely to be very different from the estimation of the public. I have an advantage as a medical practitioner, particularly one in the musculoskeletal field – why see a doctor when I have already diagnosed myself? True, but even my colleagues are amongst the first to order MRI scans and X-rays on themselves and seek out the advice of colleagues for any little niggle, because these are so readily available. Again, it is my estimate of the effectiveness and harms of medicine, even compared to my colleagues, that makes me different. Others can have a similar estimation, if they become more critical and less accepting of medicine’s claims, which is what this blog is all about.

The bottom line

I am reminded a few times each day about my right foot pain, but I am quick to remind myself that it is not currently interfering very much with my life, and that I do not wish it to interfere any more than it is currently, and that I have better things to think about. Sometimes we can be better off coping with our predicaments instead of rushing to hand ourselves over to the medical system and becoming a patient with an illness.

14 comments:

  1. I think we often find ourselves over treating patients. This seems like an interesting article due to be published on the topic.
    http://www.ncbi.nlm.nih.gov/pubmed/25957212

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    1. Hey, don't give too much away, I was part of that study and I am preparing an upcoming blog post on it.

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  2. Thank you Dr. Skeptic. As a rehab skeptic I see many people with predicaments only to be treated as an illness. I wish someone would tell them these predicaments are normal and natural aches and pains all humans experience. Unfortunately I'm the first to inform them of the normalcy of their condition. There is no fix or cure for normal natural human predicaments. Of course I'm the schmuck because some tooth-fairy/ pseudoscience looney toon is happy to diagnose them with something ridiculous and provide a 'treatment' to fix their so-called 'diagnosis.'

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    1. Thanks. Yep, I feel your pain (or your predicament). I often tell people that all the diagnoses they received were just non-validated labels and were probably counter productive. I think that some patients suspect that this is the case.

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  3. A 50+ year old male is referred to you with a three month history of midfoot pain following an 80km walk with pack. He is normally somewhat laconic and sedentary. It hurts it the morning and he finds it difficult to walk when he first gets up. It also hurts if he has a day when he spends a long time on his feet or has to do a lot of walking. He cannot say with any certainty that it has improved. He is tender on palpation but the location is vague. He is not a medical practioner
    After three months will you reassure/dismiss him without performing any investigations?

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    1. Yes, if I can't find much, I often reassure patients and see how happy they are with that decision. If they want to pursue investigations then I do that, but this is to miss the point of my post.

      The difference between your patient and me is in the choice to seek treatment. My point is that the option of carrying on, rather than seeking recourse through the medical system is not often considered, and I think it should be - it is underrated, and the ability of medicine to make you better is overrated.

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    2. anonymous person,

      I'm sure Dr. Skeptic still performs a sound patient interaction. A thorough history, application of evidence (knee/ankle/c-spine rules, etc) and physical examination can effectively rule out the need for advanced imaging or treatment. Should imaging be ordered, the absence of findings should further aid in re-assurance.

      The practitioner should keep it simple and resist the urge to provide noceboic explanations.

      The 50+ year old individual should not be surprised by continued pain. Anyone with a basic pain neuroscience understanding will be able to explain to the patient that pain is a NOT reliable indicator of tissue status.

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  4. Great blog post! I'll share it as evidence that physicians don't think everything amis should be treated. Give the body a chance to heal!

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  5. Hi Doc,interestingly I felt my right foot on waking this morning. I'm a physio with similar high levels of scepticism regards biomechanical/tissue based explanations/treatments for musculoskeletal pain which was reinforced when I read The Last Well Person by Hadler a number of years ago.
    I lived through about 18 months or more worth of an intermittantly quite painful right foot. It would have been diagnosed as plantar fascitis( no matter how i tried to explain the wierd various pain patterns i was actualy experiencing) with lots of faffing around with biomechanics stretches ect ect. I did the usual stretches ect but nothing really made any difference but mostly got on with things as best i could. Eventually it disappeared and everynow and then like this morning I feel it again in the morning.
    I have a similar story about a back with refered pain and a spondylolithesis that i almost cracked and had a fusion done on. 80% better now . once i stopped thinking about the miracle cure got on with dealing with the real issues in my life and began looking after it better- feldenkrais type awareness/movement practices to improve my sensory feedback , motor output.

    regards
    Lloyd

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    1. Thanks. Your foot problems sound like mine (same age maybe?). My right foot now only really bothers me in the morning when I get up. I am now running 10k faster than ever and pretty happy. Good news about your back as well.

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  6. This comment has been removed by a blog administrator.

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  7. As someone who used to wake up every morning with both feet with sharp pain that would remit into dull yet numbish pain (oxymoronic, I know) in the feet for the rest of the day, might I ask if you have done any consistent stretching or exercise regimen?

    I don't mean the standard plantar fasciitis protocol (I'm assuming you've probably done them and found them to be rather repetitive and ineffective) but actually stretches for the hips. I found stretches for the deep rotators, the hip flexors, and quads were extremely helpful in getting the foot pain to gradually and noticeably change over time (i.e. if I compared my pain levels after periods of consistently doing those stretches versus other stretches and versus periods of time of NO stretches, there was a noticeable and repeatable difference).

    Two years of constant foot pain went away with consistency and a few strengthening exercises for my hips (again tested against other exercises and no exercise self-treatments).

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    1. Thanks for the tip, but it eventually got better anyway. I occasionally feel it when I wake up for the first few steps, but that's about it.

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