Elsevier

Social Science & Medicine

Volume 73, Issue 6, September 2011, Pages 801-807
Social Science & Medicine

Diagnosis and nosology in primary care

https://doi.org/10.1016/j.socscimed.2011.05.017Get rights and content

Abstract

Diagnosis in contemporary medicine is made using an underlying classification system or nosology, the basis of which was first laid down at the end of the 18th century. The International Classification of Disease (ICD) was constructed to formalise this nosology and successive revisions have attempted to capture technical developments and new discoveries across the diagnostic landscape. The ICD has proved particularly applicable in hospital practice where a selected patient population and access to comprehensive diagnostic aids enables a pathology-based diagnosis. When it came to be applied to primary care in the middle of the 20th century, however, it encountered major problems as general practice struggled to marry a classification of disease to the rawness of undifferentiated human illness and distress. Eventually a classification based on the reason the patient consulted emerged to replace that based on pathology defined disease. Analysis of the frontier zone where a dominant classification system struggles to maintain order reveals the ways in which medical nosologies, through their application in the process of diagnosis, attempt to promote and maintain a certain medical reality.

Introduction

In a recent review Jutel (2009) argued that the sociology of diagnosis was a relatively neglected topic of research and that the classification of disease which underpins the diagnostic process had not drawn the attention it deserved. Yet while direct study of medical classification might indeed be relatively rare, in many ways its presence has underpinned major swathes of sociological analysis over recent decades. When Brown (1995) identified the contestation around certain diagnostic categories (attention deficit syndrome, homosexuality, obesity, etc) as a central part of a sociology of diagnosis, he encapsulated a broad field of research which explored why additional disease ‘cells’ were added or subtracted from the overall classification. The importance of this research focus was also echoed in Jutel’s paper when she pressed for more research to reveal how specific diagnoses were first introduced into clinical practice providing as an example the efforts of Alzheimer to get his new ‘cell’ of the classification table recognised.

Labelling and deviancy theory – and all their associated analyses – when applied to medicine inevitably engage with a contextual classification system even though they might only focus at the cellular level. Equally research into medicalisation has been mainly driven by analysis of struggles to incorporate new cells and/or dimensions into the existing classification table (Conrad and Schneider, 1980, Zola, 1972); and a key concept for analyses of professionalising strategies is the power of medicine to define illness which implies the right to apply a system of medical classification (Abbott, 1988, Freidson, 1970). Even the doctor–patient encounter can be construed as an engagement between two classification systems, medical and lay (Tuckett, Boulton, Olson, & Williams, 1985). The number of sociological studies which engage at least with the ghost of medical classification is therefore extensive. Most of this research though has adopted the cellular approach, addressing illness at the disease level and leaving the classification system as mere context or background, tacit and assumed, a system of knowledge which both defines and limits analytic possibilities.

One of the notable exceptions to the cellular approach to medical classification is Bowker and Star’s monograph Sorting things out: classification and its consequences in which they deployed a functionalist analysis to examine the role of classification systems in communicating moral values. The used the International Classification of Disease (the ICD) to illustrate how the existence of certain disease categories both reflected, and in turn sustained, various state interests. In part this was a cellular analyses of how certain labels, and not others, were accepted as legitimate within the classification but they also argued that classification systems as a whole get used as social resources to be deployed by or fought over by individual actors and interests; they concluded that the pernicious effects of classification systems could only be overcome by ‘flexible classifications whose users are aware of the political and organisational dimensions and which explicitly retain traces of their construction’ (p. 326). For Bowker and Star there was a clear separation between actors and the classification systems which they created or amended, but a more constuctivist approach would hold that if classification systems are so fundamental to social life the individual cannot stand outside of them.

In Elementary Forms of the Religious Life (1912), Durkheim argued that the basic building block of classification was the division of the world into sacred and profane. It is the need to maintain a separation between these two symbolic domains, that of the social and that not of the social, which established both ‘primitive’ classification and formed the basis of all subsequent classifications. In his collaborative work with his nephew Durkheim and Mauss (1903) pointed out how classification both reflected and reproduced the social group: ‘the unity of knowledge is nothing else than the very unity of the social collectivity extended to the universe’ (1903:84). In other words, it is less the need of humans to classify, pace Bowker and Star, than that humanness is itself defined by classification. A different sociological analysis of classification therefore becomes possible: what does medical classification, in its totality, tell us about who we are?

That medical classification is produced by and reflects a particular social group is evidenced by the variation of classification systems by culture and by time. In his book Birth of the clinic, Foucault (1973) identified a fundamental shift in medical perception as occurring at the end of the 18th century which in its turn brought about a revolution in the understanding of illness. This new medicine – and its accompanying novel classification – identified illness as existing in an intra-corporal lesion or abnormality. The search for this lesion through the clinical examination and post-mortem/necropsy meant that bodies became the subject of routine examination (previously the examination consisted at most of feeling the pulse); the idea that disease grew inside the individual body as a pathological lesion, often with the result that the patient died, meant that death was relocated inside the body; and the movement of patients into the neutral space of the hospital bed for medical and nursing surveillance ensured the documentation of individuals. The new pathological medicine, therefore, can be understood as underpinning the nature of what it was to be human; ‘humanity’ was the result of the application of this new classification system and the classification system was a reflection of that same humanness. As Foucault concluded, in the last years of the 18th century a new structure of knowledge appeared in European culture which has come to constitute ‘the dark, but firm web of our experience’ (p.199).

The ICD which emerged in the second half of the 19th century was therefore more than simply a means of organising and ordering medical knowledge. As the ICD formalised the principles of the new medicine by classifying illness according to its pathological types, it mapped out the anatomical/pathological form of the human body. Earlier classifications, which had categorised symptoms, reflected a system of medicine in which disease was neither individuated nor localised to the lesion inside the patient’s body. Such major changes in the very nature of the classification system suggest that the history of diagnostic classification can be concerned with more than ordering a society’s knowledge or with professionalising strategies or with struggles over what is to count as a disease; the underlying classificatory principles – whether of mobile symptoms or anatomically fixed lesions – both constitute and reflect the very nature of identity.

Section snippets

The legacy of the ICD

By the mid-19th century the previous classification system which had ordered patients’ symptoms into genera, species and types was largely replaced as the ascendant pathological theory of disease relegated symptoms to mere indicators of disease. The first International Statistical Congress convened in 1853 formalised this pathological system into a classification consisting of 139 rubrics or categories of the various causes of death. This classification, in its turn, underwent periodic review

The ICD and general practice

In an attempt to measure the illnesses presenting in his general practice just outside London, Fry (1952) devised his own classification system which, for example, divided upper respiratory tract infections into the common cold, ‘febrile catarrh’, acute sore throat, ‘catarrhal children’, influenza, and others (which together accounted for 25% of his overall workload). Other GPs reported similar surveys in the early 1950s (Fry, 1952, Horder and Horder, 1954, McGregor, 1950, Pinsent, 1950), all

Symptoms in the ICD

The main problem in adapting the ICD for use in general practice was how to classify symptoms. Successive adaptations of the ICD for use in general practice had to establish rubrics for symptoms; yet these sat uncomfortably with the other pathology-based diagnoses in the ICD. For example, a cough in general practice might be classified under ‘respiratory symptoms’ yet the ICD demanded its location under the pathological cause of the cough: pneumonia, perhaps, or bronchitis or asthma.

Symptoms, problems and illness

When the World Organisation of National Colleges and Academies of General and Family Practice (WONCA) produced its International Classification of Health Problems in Primary Care (ICHPPC) in 1974 for world use in general practice it attempted to replace the pathological lesion as the classification principle with the notion of the ‘health problem’ whilst maintaining some compatibility with the ICD. The ICHPPC was divided into 18 Sections which corresponded with those of ICD-8 but the 371

The International Classification of Primary Care (ICPC)

The idea of studying, measuring and classifying symptoms in their own right had emerged in the early 1970s (Morrell, Gage and Robinson, 1971). The National Ambulatory Medical Care Survey in the United States developed a Reason for Visit Classification adapted from existing symptom classifications and based around a body system similar to the ICD (Schneider, 1979). This symptom classification could claim to be more suited to primary care as it identified health problems at a more fundamental

Causes and reasons

In 1925 the renowned GP-cardiologist James McKenzie designed a classification for the morbidity he found in his practice. He identified six categories of illness (described in McCormack, 1975). These ranged from ailments ‘most widely understood’ such as an inflamed eye caused by a foreign body like a grain of sand or the colic (pain) caused by the passage of a stone, through diseases which were recognised only by a single symptom, for example, constipation, in which ‘the symptom gives no clue

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