Elementary concepts of medicine: VIII. Knowing about a client's health: gnosis

In the preceding essays on elementary concepts relevant to thought in all specialties of medicine, our focus has mainly been on what medicine is about: illness. We have addressed the essence of illness first and foremost, then more specifically the potential manifestations of the somatic anomaly as well as the somatic anomaly itself that is involved in the essence, and also both the genesis and course of illness. The phenomena relating to illness, following somatic normalcy, we have described as beginning with the pre-illness anomalous process of pathogenesis initiated and/or driven by the causal forces of aetiogenesis; as this followed by the phase of latent illness and then, possibly, by patent illness, manifest in sickness; as the illness potentially causing other illnesses as complications; and if it runs its full course, as ending in illness outcome in terms of sequelae or fatality or return to somatic normalcy. With the nature of the phenomena of and surrounding illness thus understood, medical practice concerns about these topics are first and foremost cognitive (Miettinen 2001b). In the context of an individual's known state of freedom from a particular illness, one may be concerned to know about the risk of future development of this illness; and once the illness may already be present, one's concern is to know the truth about its presence/absence. If the illness is known to be present, the first concern may be to know about its pathogenesis and/or aetiogenesis; but regardless, the medical mind turns to its concern to know about the future course – notably as to manifestations and consequences – of the illness. In both of those prospective types of cognitive pursuit, risk-oriented in pre-illness and course-oriented in illness, consideration of prospective intervention(s) – preventive and therapeutic, respectively – is prone to be involved. Central in these cognitive pursuits in clinical medicine is that of diagnosis. Medical dictionaries define this core concept of medicine as: ‘(1) the determination of the nature of a case of disease; (2) the art of distinguishing one disease from another’ (Dorland 1994); or ‘the determination of the nature of a disease’ (Stedman 1995). We find these definitions too restrictive as expressions of the concept of diagnosis that prevails in medical minds. First, they imply that diagnosis pertains only to situations in which it is already known that some illness is present, so that only its nature remains to be determined; but surely it also is a diagnostic concern in medicine to determine whether any illness is present (in a particular organ or system), or whether a particular illness is present (Miettinen 2001b). Second, there is diagnosis of defect and injury as well as of disease. Third, while these definitions are limited to rule-in diagnosis, there is rule-out diagnosis as well (Miettinen 2001b). And finally, determination denotes a level of certainty that is not inherent in diagnosis (Miettinen 2001a,b). We also find these definitions to be off focus. They specify diagnosis to be a process concept – at variance with the meaning of gnosis in general usage and that of prognosis in medical usage (see below), and also with what we believe to be the proper meaning of diagnosis itself. To us, clinical diagnosis is, at whatever stage of the diagnosis-oriented process of fact-finding, the corresponding perception of a person's current (or past) state of health. In these terms, diagnosis of a particular illness is perception of its presence/absence first and foremost; and if clearly perceived to be present, more detailed diagnosis is perception of particulars of that case of the illness (at the time). Our medical dictionaries define prognosis as: ‘a forecast as to the probable outcome of an attack of disease; the prospect as to recovery from a disease as indicated by the nature and symptoms of the case’ (Dorland 1994); ‘a forecast of the probable course and/or outcome of a disease’ (Stedman 1995). As a matter of requisite editings, we first eliminate that ‘as indicated by’ note; for, forecast is forecast irrespective of what indications it is based on, and scarcely is prognosis forecast on some a priori limited basis (specifically by only the symptoms involved in the prognostic profile, exclusive of prospective interventions, even). We also eliminate ‘outcome’, as its forecast is subsumed under forecasting of the course. As forecast inherently envisions ‘the probable course’, we delete this pleonastic element. We also delete the indefensible limitation to ‘disease’ (as above) but introduce another: prognosis, like diagnosis, is an ad hoc concept; it is not about health in the abstract. In these terms we have: Forecast of the course (prospective) of a case of illness. (Definition A) This, however, is not satisfactory either. Forecast in medicine naturally can be about the future course of health in the narrow meaning of health, about prospectively continuing freedom from illness, and thus not merely about the future course of already existing illness (which also is a matter of health). Upon adjustment for this we have, for clinical prognosis: Forecast of the course (prospective) of health in an individual. (Definition B) Finally, the medical concept of prognosis is scarcely limited to such futuristic ideas in the doctor's mind as translate to communicating to the client statements of the form of: ‘my forecast is that you will remain free of illness I’, and ‘my forecast is that you will not experience course C of your illness I.’ One indeed forecasts the probable (cf. dictionary definitions above); but medical prognosis is about the improbable just the same – just as diagnosis can amount to practically ruling out a particular illness. Upon adjustment for this we arrive at our concept of clinical prognosis (cf. definition of diagnosis above): Perception of a person's future course of health. (Definition C) Now, there is a tendency to conceive of diagnosis, notably a firm, rule-in diagnosis, in terms of what actually is only the initial diagnosis of the case. In subsequent encounters, however, it may be necessary to diagnose whether the illness still is present; and if so, it may be necessary to rediagnose its particulars when it has a dynamic course – as a disease or injury always has, different from a defect. Thus, diagnosis must be understood to have a particular temporal referent. Moreover, diagnosis – a matter of probability-setting whose theoretical framework, even, remains poorly understood (Miettinen 2001a,b) – is prone to remain subjective for the foreseeable future, with a particular diagnostician thus another part of its referent. Prognosis in respect to whatever aspect of the course of health in a particular person, just the same, is prone to evolve over successive encounters and vary according to who the prognostician is. The concept of good prognosis in whatever instance of prognostication should be understood properly to be not favourable prognosis but justifiable prognosis, notably as to the degree of credence that is attached to any given course being considered. And in particular, then, the ultimate criterion for good prognosis is not that the particular course which was forecast (perhaps unjustifiably) indeed materializes; analogously, of course, for bad prognosis, and good or bad diagnosis. Gnosis is not gambling but knowing on a justifiable level of (un)certainty. Illness at any given diagnosis along its course has not only its basic nature and current particulars as well as its future course; it also has its past (its history of pathologic development) from pathogenesis or external infliction of the initial, definitional somatic anomaly all the way to its current particulars, together with causal influences that have had bearing on this entire development up to the most recent diagnosis. By analogy with updated diagnosis and prognosis, there might be a concern to perceive/know the pathogenesis – a matter of pathognosis? – all the way to the most recent state of the somatic anomaly, and the concept of aetiognosis (Miettinen 1998, 2001b) also can be extended to apply to perception of the causal origin (aetiogenesis) of the most recent state of the anomaly. But, just as diagnosis and prognosis are usually given the time referent of the initial diagnosis, so there is a tendency to think of pathogenesis and aetiogenesis specifically in reference to the time antecedent to that as of which the illness-defining somatic anomaly first was present. Given mastery of the concepts – tenable concepts – of and surrounding health and, especially, illness, thinking about health and illness in the abstract is possible. The first added prerequisite for ad hoc thinking of – and especially for genuine knowing about – these in the client in medical practice is possession of a tenable concept of gnosis in general and also of its principal subcategories. Then come the concepts of correct gnostic probabilities (Miettinen 2001b) and, finally, the requisite inputs of knowledge, or mere evidence perhaps (Miettinen 1998), in such theoretical frameworks.

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