Special article
The end of the disease era

https://doi.org/10.1016/j.amjmed.2003.09.031Get rights and content

Abstract

The time has come to abandon disease as the focus of medical care. The changed spectrum of health, the complex interplay of biological and nonbiological factors, the aging population, and the interindividual variability in health priorities render medical care that is centered on the diagnosis and treatment of individual diseases at best out of date and at worst harmful. A primary focus on disease may inadvertently lead to undertreatment, overtreatment, or mistreatment. The numerous strategies that have evolved to address the limitations of the disease model, although laudable, are offered only to a select subset of persons and often further fragment care. Clinical decision making for all patients should be predicated on the attainment of individual goals and the identification and treatment of all modifiable biological and nonbiological factors, rather than solely on the diagnosis, treatment, or prevention of individual diseases. Anticipated arguments against a more integrated and individualized approach range from concerns about medicalization of life problems to “this is nothing new” and “resources would be better spent determining the underlying biological mechanisms.” The perception that the disease model is “truth” rather than a previously useful model will be a barrier as well. Notwithstanding these barriers, medical care must evolve to meet the health care needs of patients in the 21st century.

Section snippets

The problem

Chronic dizziness remains unrelieved; psychological contributors to cardiovascular disease are ignored; 75-year-old patients consume an average of 15 medication doses each day; patients leave the hospital with their pneumonia cured but their cognitive and physical functioning irreversibly impaired. The diagnosis in each of these cases is a primary focus of medical care on disease.

The time has come to abandon disease as the primary focus of medical care. When disease became the focus of Western

A solution

The obvious solution is to better align medical care with health needs by integrating existing knowledge and effective strategies. Rather than waiting until the disease model fails to invoke alternative strategies, the integration and coordination of such strategies should constitute the standard of care for all patients. Clinical decision making should be predicated on the attainment of patient goals and on the identification and treatment of modifiable biological and nonbiological factors,

Challenges and barriers

Attempts to develop a more integrated and individualized model will be met with structural and philosophical barriers. To accomplish its goals, health care must become more interdisciplinary. The lack of coordination, or even communication, among relevant disciplines could worsen the already egregious fragmentation of health care. The increased emphasis on psychological, so-cial, environmental, and other factors will raise concerns about the “medicalization” of life problems (39). Although

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