Family Medicine: People Who Are Too Tough

"I felt like I might die a few times recently in the middle of the night.  I had palpitations, dizzyness and shortness of breath and almost passed out when I got up to go to the bathroom.  I almost called the emergency squad but thought that they would think I'm crazy,"  one of my patients in the office with me for their quarterly visit about their diabetes, hypertension and chronic neck pain.

I'm immediately surprised at the implication that they would rather risk death than be embarrassed, or what ever the real message is at the various levels of communication between patient, physician and the world.  I usually seek to clarify how they make their decisions late at night when their life might be on the line before I seek further information about their situation.

Many of these people are what I refer to as "Too Tough".  I hear this type of story two or three times each month.  Occasionally, one of them dies because they wanted to wait until their next office visit to clarify what was happening, or the chest pain didn't hurt like they thought a heart attack would hurt.  Most sports fans are familiar with the stories of an athlete dying of an asthma attack or renal failure during a hot summer practice.  They were very tough people and wanted to keep going instead of "looking like a wimp" or losing the respect of coaches and their teammates.

Each person has their own threshold at which they feel ill.  And another threshold at which it may cause concern.  At yet another threshold, their illness may be called ("diagnosed") a disease.  I found some clarifying comments about this in The Foundations of Primary Care by Joachim P Sturmberg, MBBS DRACOG MFamMed FRACGP PhD (Monash University, Melbourne, Australia).  In an interesting chapter titled "Disease, Illness and Health", he reviews some cultural and historical aspects of personal/patient perceptions.
  
Joachim continues with a discussion of illness, "Though we may construct our own illness in unique ways based on familial, ethnic and cultural beliefs, it is our experience of feeling ill that remains the driver for seeking medical- and at times lay or paramedical- care.  Patients come to see us to share the story of their illness, to make sense of (or find meaning in) it, as well as getting relief from their symptoms."  He questions whether physicians are prepared to help patients to understand their illness because of preoccupation with the process of deciding on a medical diagnosis.

He then refers to a paper "An introduction to medical phenomenology:  I can't hear you while I'm listening", by R Baron in Annals of Internal Medicine. 1985; 103: 606-11.  Baron questions the mind-body dualism that prevents patients and physicians from understanding themselves and others.  Phenomenology also "questions  the erroneous beliefs inherent in Cartesian dualism."   He goes on to define illness as "a loss or disturbance of the unconscious taking for granted of one's body...the disruption of embodiment."  Instead of problems exclusively with individual parts, Baron emphasizes that we have whole person problems, including the parts and the mind.

The "Too Tough", then might not be good at feeling ill.  They might not notice the disruption of their embodiment and they might continue to take their body for granted when others would feel ill and take action consistent with the risk to their wellbeing.  The "Too Tough" might have a powerful mind that seems to be fully in charge and not concerned enough about the body.  This mind-body dualism may be protective at times for individuals and profitable for the business of healthcare, but overall not beneficial to most persons, too costly for the economy and possibly dangerous for the "Too Tough".