Second Opinion

Doctors should help patients fight disease and treat their well-being, too, according to medical journal essay

An essay in the British Medical Journal urges doctors and patients to start thinking differently about what it means to be returned to health. It envisages medicine that doesn't stop at the hospital door, but also sets conditions for a healthy life even among people who live with chronic conditions.

A British Medical Journal essay urges doctors to think of what happens after their patients are discharged

Doctors are focused on treating the disease, but a British Medical Journal essay argues there should be more emphasis on rebuilding the patient's life. (David Donnelly/CBC)

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An essay in the British Medical Journal urges doctors and patients to start thinking differently about what it means to be returned to health.

Ian Hargraves, lead author of "Towards regeneration: The evolution of medicine from fighting to rebuilding," says he envisions medicine that doesn't stop at the hospital door, but also sets conditions for a healthy life.

As more people live and die with chronic conditions or as survivors of cancer, the emphasis should be on how to live as a healthy person with these conditions, rather than just on treating the disease, said Hargraves, a service designer and researcher with the Mayo Clinic's knowledge and evaluation research unit.

"We should pay attention to what we're building amidst the highly technical process of treatment," he said.

Within health care systems, he envisages having "rehabilitation disciplines integrated within surgical teams to lay the ground for building anew" in patients' lives after they are treated.

"Switching to building health requires the health and the health care systems to work closely together, something that is not existent," Hargraves said.

War metaphors not always helpful for patients

The military metaphors often used in medicine — that talk about "fighting" disease or a "battle" with cancer — are dated when the "defeat" of an enemy is not achievable, he said. If medicine is couched in terms of winning and losing, patients may be left with a sense of failure if disease persists.

"There are times when it might be helpful, or accurate, when you identify a bacteria or something singular with a means to make it go away," Hargraves said.

"But we see in obituaries, 'Joe was a good fighter and died after a battle with Alzheimer's.' The fact is, he's not going to win that one."

After patients receive treatments for a serious illness, they need lifestyle support, spiritual support and psychological support, says Dr. Victor Montori of the Mayo Clinic. (Getty Images/Cultura RF)

Take the heart attack patient who is admitted to hospital, has a clot removed with a balloon and stent and is told he is lucky to be alive. He's released with anti-platelet drugs and a prescription for cardiac rehab. His family treats him as if he's fragile and he's afraid to make love to his wife. The diet and exercise changes he needs to make are left up to him in the long term.

After the heart attack, preventing another

"Right now, the person leaves the hospital and we're done," said Dr. Victor Montori, a professor of medicine at the Mayo Clinic and one of five co-authors of the BMJ essay.

"If a person has a heart attack, we treat the heart attack, but they are afraid to have sex again in case they have another heart attack and they die," he said. "Clearly that's a bit of regeneration we didn't do — we didn't restore them to sexual health again when they came in with a heart attack."

The medical system needs to work early with the patient to create conditions that will restore normal life functions and prevent another health crisis, the BMJ article says. That could include working from the start with both the patient and his family on diet and exercise and counselling the couple to help them get over their fear of physical activity.

"The point is not simply to fight against what you're trying to cure, but almost simultaneously or right after to start rebuilding health," Montori said.

Dealing with 'existential' questions

With the prospect of more regenerative medicine, which can rebuild damaged organs with stem cells or new drugs and technologies, Montori suggests the rehab process should include linking the patient with an online community of people who have had similar experiences.

"When someone has survived a life-threatening circumstance, a number of existential questions come up," he said. "It's part of the process of rebuilding to enable the community of that person — could be the family, could be an online community — to help the person identify what their function in the world is and who they are now they have survived the challenge."

Dr. Robert Maunder, a psychiatrist at Mount Sinai Hospital in Toronto whose specialty is treating people with physical illness, said he agreed with the call for a different way of understanding and thinking about illness.

"I think that's an important conversation to have — I'd like to see that change over time," said Maunder, who was not one of the authors of the essay.

"Medicine focuses on disease," he said. "We talk about promoting health and a lot of doctors would like to engage in that, but here they're actually talking about shifting toward a different goal."


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