The 4D Model: Rehabilitating Unrealistic Medicine

Managing the symptoms of long-term conditions presents a challenge to patients, clinicians and health systems worldwide. In seeking to explain such symptoms, diagnostic models tend to be 2D, and hence unrealistic if reliant narrowly on just Disease processes or Drug effects. Here, I argue that symptoms which appear refractory to pills or procedures can nonetheless be rehabilitated, if a 2D prognostic model is used in addition. Distress and Discouragement are reproducible syndromes defined as arising from prognostic fears for the proper function and integrity of body and self, respectively. Often, these attract just symptomatic treatment, being medicated as anxiety and depression and/or diverted toward talking therapies. But, when managed in isolation, this is just another unrealistic 2D model, analogous to divorcing nausea from chemotherapy or thromboprophylaxis from surgery. Instead, with changes to our clinical manner, a more realistic medicine can diagnose, for each person, how specific elements from their diagnostic model (Disease, Drugs) drive complications in their prognostic one (Distress, Discouragement). Rather than perpetuate a succession of 2D appointments, a holistic dialogue using the 4D model helps patients to formulate how their symptoms fit together. This can support them to soothe and triage their everyday symptom experience. Confidence with the 4D model can then help patients and clinicians advocate for treatments that are better targeted and integrated. This review facilitates clinical use of the 4D model, with example cases and lay explanations-plus its further theoretical development, using the fit with philosopher Elizabeth Barnes' latest accounts of health.