My older brother, who is an ecologist (a limnologist, to be specific), once told me that he was sick of hearing people talk about the "balance of nature." He went on to point out that the natural world is in a constant state of flux - anything but balanced. Scientists believe, for instance, that when trees came into existence, they caused nearly 95% of the species present at the time to go extinct. This is not to say that you should not be responsible with the natural world we live in (he is, after all, an ecologist), but it points out the fluid nature of things; the only constant is change in our temporal world.
There is a school of thought in certain circles that embraces the idea of wellness much in the same way that certain naturalists embrace the balance of nature (see http://www.wellness.com/ and http://seekwellness.com ). Much of these ideas are put forth my more alternative practitioners (such as Andrew Weil, MD) in the guise of mainstream medicine.
Wikipedia (the ultimate source of all reliable information, of course) divides wellness into two different definitions:
- Alternative Medicine - Wellness is generally used to mean a healthy balance of the mind-body and spirit that results in an overall feeling of well-being.
- Mainstream Medicine (under the heading health) - In any organism, health is the ability to efficiently respond to challenges (stressors) and effectively restore and sustain a "state of balance," known as homeostasis. Sickness is merely the absence of health. All organisms, from the simplest to the most complex, reside on a spectrum between 100% health and 0% health.
These definitions beg the question: does wellness really exist? Is our goal as physicians to promote wellness, or simply more wellness? I believe that wellness is a concept, not a reality. It may be worthy of our striving, but accomplishing this is not possible. Here are the reasons I think this is the case:
- I disagree with the Wikipedia definition of Homeostasis as a "state of balance." I prefer the dictionary definition: The ability or tendency of an organism or cell to maintain internal equilibrium by adjusting its physiological processes. The body does everything it can to get to a state of "balance," but there are constantly forces moving it out of balance. Even if balance were achieved, it would soon be out of balance again.
- Aging - Aging is the continuing process of anti-wellness. Everyone dies due to a process that is built in to the DNA itself. This is true for every organism. Could wellness really occur when aging is happening. Even children aging, growing bigger and stronger, are in a state of unbalance (as witnessed by my 13 and 14 year olds!). The implication of growth in a child is that the current state needs to be changed. It is pathologic when change stops happening (growth delay, etc.).
- All of nature goes against this. Organisms ultimately die, and this happens because the need for increased diversity and the need for adaptation to environmental changes. We do not exactly fit into our environment, and so there is a homeostatic force on a ecologic basis that pushes toward adaptation to these environmental mismatches.
- Entropy - This is the tendency of things to become increasingly disordered. Although the evolutionary trend toward increasing complexity goes against this in a small area, the overall force is toward disorder. This is one of the laws of thermodynamics (and not one of the suggestions of thermodynamics).
- It is immeasurable. Conceptually it is impossible to prove wellness, even if it were reached. Some of this has to do with the concept of observer effect (as displayed in the Heisenberg Uncertainty Principle). If we measure something, we change it by our act of measurement. This means that if homeostasis is actually attained, it will be disrupted when we assay for it. On a more basic level, however, science deals with disproof much easier than proof. To prove wellness, you have to disprove all forms of illness. This is simply impossible.
Aside: My father is a physicist, and one of his favorite signs he saw was one that read "Heisenberg may have slept here."
So what does this mean for physicians? I think it has a big effect on how we approach problems. Problems are normal and certain problems are physiologic. A good example of this is the rebellious teenager. When a person is transitioning from the dependency of childhood to the independence of adulthood (both relative), there is a period of increased disorder as this transition is made. The child acts up, but does so to some extent to make this transformation. As a parent, we do not always see this behavior as pathological (as annoying as it can be). If this disorder is not present, it is a sign of problems. Our goal as physicians is to oversee this disorder and discern if there is any signs of "abnormal disorder." This poses a great challenge, but is a very important lesson to teach parents. Expect challenges.
Another area of application is in the psychologic realm. We want everyone to be happy all the time - it is part of our natures. Yet we do very poorly when we do not go through hard times. Again, a good example is the "spoiled" child. If a child is given everything they want, they will become a pathologic personality. If a parent does not cause the child to go through sadness and anger, then they are harming the child. I always tell parents that our primary goal is not to make our children happy. Our primary goal is raise good children. If you raise a child with happiness as the primary goal, you will make them neither good nor happy. If you raise them to be good, then they will (more likely) be both.
Treating depression is always a challenge for me. Sometimes I think people are pathologically trying to avoid pain, when that may be what is best for them. But it is very hard for me to be the one to decide what they need in this arena. I do think that sometimes I am doing them a disservice to treat their depression. We need pain to allow us to grow emotionally. Pain is just evidence that we are not yet where we need to be. I use the analogy for patients of chest pain. If we seek simply to treat the pain and ignore the cause of the pain, we can kill the patient. We need to be able to feel pain so that we can know when something more serious is going on.
This is a line that all physicians must draw. To some extent, we are managers of pain, and not promoters of wellness. I do think that wellness as a goal has some merits, but I think that sometimes we "lose the forest for the trees" by not paying attention to the discreet details of illness prevention. There is no balance, just homeostasis. As we help people we need to keep in mind that we are ultimately here to relate to our patients as they go through life and not treat them as a project to complete.
