2.7 The doctor as St Peter - approving access to illness

The doctor has not only to act as watchmaker: often he is also a gatekeeper, guarding the entrance to specialist care or to the state of illness.

2.7.1 Having and being - disease and illness

A person has a disease but is ill: a disease is something you have, illness is an altered state of being.

Although the words 'disease' and 'illness' are sometimes used as synonyms, most people appreciate the distinction between them, even though they have never read the work of sociologists like Talcott Parsons and David Mechanic, who analysed and described the concept of illness and the behaviour associated with it.

2.7.2 Illness has privileges

Ill people have power and enjoy two types of privileges because of that power:

• increased sympathy and attention, and
• freedom from normal societal obligations such as working, or attending school

2.7.3 Illness also has rules

The 'rewards' of illness are obviously attractive and it is not surprising that some people seek to become ill even though they have no disease. Society has a whole set of checks and balances to regulate illness behaviour as anyone who has been a parent well knows - for example: 'if you don't go to school on Friday, you cannot go out to the disco on Saturday'. Similar rules apply for adults: those who claim the benefits of illness have to display the following behaviours:

• trying to get better, that is conforming to lay or medical advice
• relinquishing normal social pleasures such as going out to the cinema or parties
• going to see the doctor if the state of illness lasts more than a few days

Miss A was a schoolteacher who had frequent short-term sickness absences from the school in which she worked. She usually seemed in the best of health and these short-term absences were a considerable annoyance to her colleagues because they were rarely accompanied by a sick note from the doctor. However, for several years her behaviour had been tolerated without explicit comment from colleagues or the Headmaster until the occasion when, after being off work ill on Thursday and Friday, she was photographed sitting proudly on the first ever Park and Ride bus to go into the city centre at 8.30 on the Saturday morning, smugly celebrating her small place in history, preserved in a photograph for the local paper. Her colleagues at school, however, found it completely unacceptable that someone who had been off sick on Thursday and Friday should have recovered so dramatically by the Saturday morning, and on her return to school on Monday morning she received both direct criticism from her colleagues and a disciplinary talk from her Headmaster.

To be recognised as really ill, the claimant has to have their claim validated by a doctor, and the 21st century doctor has many more powerful tools to confirm or refute the claim by diagnosing a disease that can explain the patient's symptoms and feelings of illness.

2.7.4 Going to see the doctor to validate real illness

The right to claim the privileges of illness is open to all, but only for a limited period of time. The individual who claims he or she is 'really ill' and unable to work, either for pay or within the household, will not be allowed to claim the privileges for long without being advised, encouraged or required to see the doctor by those who have to shoulder the consequences by doing extra work themselves.

This advice, encouragement, or requirement is sometimes made in the best interests of the person claiming the rights of illness, but it is not for nothing that the word 'pretender' came to mean more than its original definition of 'claimant' and is now imbued with the implication of acting. The person who pretends to be ill is required to undergo a test to make sure they are not acting, and the doctor carries out that test, rarely enthusiastically, because many doctors are annoyed that they have to operate the rule and act as lie detector, distinguishing those who are really ill from those who should be denied the rights of illness and returned to their normal societal obligations when a bid for the power that comes from being recognised as really ill is thwarted.

The doctor is expected to act like St Peter, holding the keys to illness, to unlock the door through which many wish to pass.

2.7.5 Doctors as society's risk managers

Doctors, general practitioners in particular, are sometimes described as gatekeepers, deciding which patients shall be referred to hospital. The term 'gatekeeper' implies that the job of the doctor is to separate those who need specialist care from those who do not, as the shepherd separates ewes from lambs when shedding his flock. The doctor's job is not, however, as easy as the shepherd's. It is sometimes easy to distinguish the patients who need specialist care but often it is not. The general practitioner who has some anxiety about the child who is ill or the patient who feels tired could make a referral, but they may desist to spare the patient unnecessary tests and anxiety, and to spare the hospital service from work with which it could not cope. The doctor, however, has to carry the anxiety that results from the decision not to refer. The anxiety may not be great for any single decision but the cumulative effect of the hundreds of decisions of this sort is a heavy burden that the doctor bears for society in managing these risks.

2.7.6 Being ill in the 21st century

More people can now validate illness. Because of the growing workload of doctors, their gatekeeper function is being reduced, and self-certification of illness is now an option for many employees. In addition, there are now numbers of other health professionals whose word will be taken as evidence of real illness, ranging from those whose credibility is almost universally accepted, such as the chiropractor or the homeopathic clinician, to those whose validation is not generally recognised, for example the acupuncturist or the herbalist whose opinions will be accepted by friends if not by the employer.

The increase in the power of medicine to diagnose disease is also changing the passage to illness in the 21st century, making it more difficult. Consider the person who tells his doctor that he has no energy and feels weak. These symptoms could be due to a wide range of different diseases - tuberculosis, cancer, or thyroid disease. In the 19th century, diagnostic accuracy was limited and the fact that the doctor could not diagnose a disease did not mean that no disease was present. In the last hundred years this has changed, and if the doctor uses the full range of diagnostic tests and finds no sign of disease, the probability that the person has a disease, although it exists, is very low. If the doctor can find nothing wrong, the symptoms may disappear, but they may persist in a condition called MUPS - medically unexplained physical symptoms - and the person may also find it very difficult to be accepted as being really ill unless he seeks another clinician to validate his claim, or enters the shadowy lands of illnoids - hypochondriasis and malingering.

2.7.7 Anxiety as illness, clinician as treatment

Because the patient's symptoms may stem solely from, or be aggravated by, anxiety, the interaction with the doctor can, if it alleviates anxiety, cure or mitigate the problem - with the doctor acting as the drug.

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