The Illness-Wellness Continuum
One of the first ideas I was introduced to in my education as a functional medicine doctor was the illness-wellness continuum. To me the idea that each of us lives on a scale between perfect wellness and utter illness at any given moment in time is important not only philosophically, but from a practical viewpoint. This idea applies when I am seeing my patients or thinking about my own health. To illustrate a point I would like to share a favorite medical school story about my rotation in Grady Memorial Hospital’s labor and delivery ward. The medical students had the honor of assisting with deliveries, and usually had one or two opportunities to catch the newborn infant as it emerged into the world. The tradition at the time was that the delivery room nurses would announce the Apgar score of the baby. These scores, given by the nurse at 1 and 5 minutes postpartum, reflect how well the baby tolerated the birthing process and its function outside of the womb. Nine is a perfect Apgar score, and I noticed that no matter how good the baby looked the nurse never gave the baby a 9, never at 1 minute, and never at 5 minutes. The baby might get an 8 (still good), but never a 9. One day I decided to ask the nurse why none of the babies ever scored a nine? My answer was, “because only the Baby Jesus gets a 9.”
The moral of the story of Grady’s labor and delivery is that no baby was perfect, and, of course, no human being is perfect. None of us score a 100% on the test of health. In reality, we are all somewhere on the illness-wellness continuum. But I want to go a little further.
How often do we take the big picture view of ourselves, the look in the mirror, and gauge health? If I look healthy does that mean I am healthy? Does the absence of an acute or chronic disease diagnosis mean I am healthy? Dr. Mark Hyman and other functional medicine thought leaders like to talk about the patient who goes to the doctor with mildly elevated blood sugar on routine examination. On the surface that patient may not present with a blood sugar high enough to make the diagnosis of diabetes. The doctor may warn the patient, or dismiss the finding, but nothing is done. This ritual of going to the doctor repeats itself each year, with each year a trending high blood sugar. Finally, the patient presents to the doctor after several years of “well-patient” visits and the blood sugar has passed the critical mark. The patient is diagnosed with diabetes. It’s as if they were trying out for the varsity football team, Dr. Hyman would say, and turned away year after year until they finally made it. “Congratulations,” the saying goes, “you made the team.” Did that patient get sick the day the doctor made the diagnosis of diabetes? Of course not. The illness evolved over several years as the patient became increasingly insulin resistant.
And then there are all the other metabolic consequences of hyperglycemia related to the effects of chronic inflammation and oxidative stress. The body is a veritable war zone at the cellular and molecular level. Illness is a process and the cut offs we use to define disease, here diabetes, are to some extent arbitrary cut offs. They are useful in their own right, but they may give the impression that until the patient was actually diagnosed with diabetes the patient was not ill.
People like Hyman, and his mentor, Dr. Jeffrey Bland, go further to say that diseases as we think of them don’t really exist. They rightly criticize the current diagnostic coding system invented by bureaucrats, ICD-9 and its new iteration ICD-10, as artificial constructs. Hyman will refer to the management of all disease as a matter of “taking out the bad stuff and putting in the good stuff.” Dr. Jeffrey Bland, perhaps the father of functional medicine, writes in his book, The Disease Delusion, that illness is merely a consequence of imbalances within a handful of basic biological systems, the so-called functional medicine matrix, at the center of which is the mental-emotional-spiritual core of the human being. The truth is that we do tend to be overly focused on the downstream expressions of disease processes—Diabetes, Alzheimer’s disease, Rheumatoid Arthritis—and rather than consider root cause imbalances we offer a drug or a surgical remedy for the thing that is right in front of us. All too often we seek out the simple cause in order to intervene on its presumed effect. This is the “pill for an ill” approach.
But I am digressing from what I want to say in this essay because I am sure I am touching on themes I will return to again and again. I want the reader, or my patients, to think about that illness-wellness continuum and embrace it as a path we walk in both directions at different times in our lives. Sometimes it may seem like one step forward and two steps back, and other times two steps forward and one step back. We will never, in our lifetime, reach a state of 100% perfect health, the “Baby Jesus,” and even in death—the inevitability for all of us—hopefully we will achieve some level of awareness, growth, spiritual healing, or closure—so that when we exit from our earth-bound bodies we will not have died in a state of 100% disease, dis-ease. Also, in my office, as a functional medicine doctor, I do focus on those root imbalances and guide my patients, through an understanding of their uniqueness as human beings, toward the wellness side of the continuum. I use a tracking tool called the Medical Symptoms Questionnaire where the lower score signifies fewer symptoms and a higher score signifies more symptoms. While in a relatively short time it is possible to see impressive improvements in the MSQ, the commitment to wellness remains a lifetime journey, a means rather than an end. The journey will require that we dig down to that mental-emotional-spiritual level to achieve the healing that all of us want, uncomfortable as that may be for some. This is slow medicine. We have been coddled by drugs and surgery that on the surface seem to offer a quick fix, but rarely actually address the underlying problems.
When I started to develop my skills as a functional medicine doctor I found I was good at taking a life history—a functional medicine timeline—and performing an examination. I was good at synthesizing the information. After all, I had been doing something like this for nearly 20 years as a conventional allopathic physician. Strangely, I was uncomfortable with the first follow up visit. The part of me that unrealistically expected to see rapid resolution of the chronic illness had a hard time accepting the imperfection of the moment. But I’ve come to accept my own story of the Grady labor and delivery ward. I am not sure when exactly it happened, and I cannot say that I am there all of the time, everyday, without exception. With this shift I have also come to accept and appreciate these subtler forms of healing. I can walk with my patients at their pace. I can move, like a shaman, in dimensions different from the rapid-fire precision of a drug where symptoms are suppressed, but imbalances still exist. Today, I understand that rebalancing and rebuilding is the journey and more importantly today I understand the present is a good place to be.
Ken Sharlin, M.D.