Sometimes it's not just one thing

When something goes wrong — work, a personal relationship, part of the body — it's always tempting to look for the cause. There must be one thing that went wrong and can be corrected, one single solution to the problem. Sometimes this is the case, and those examples are usually obvious. In the case of the body, obvious causes might be a frank injury like a sprained ankle or broken bone.

However sometimes things aren't so simple. A recent patient of mine exemplified this. He came to me in pain, clutching a sheaf of reports from various investigations. He had seen multiple consultants, been given multiple diagnoses, and tried various treatments, none of which had given lasting relief.

While he described his symptoms to me, I was thinking through the various possibilities for his pains. Certainly there were three or for possibilities, but no single one of them adequately and fully explained his experience. One explanation might account for say 75% of the problems, but then there was the remaining 25% to account for. A different diagnosis, backed up by an MRI report, would account for the pattern of pain he described — fine in the morning, progressively worsening with activity, unchanged over the past three years — but it wouldn't convincingly explain where he felt the discomfort.

During the long discussion we had in that first appointment, I realised that there might be two or even three possible problems all occurring at the same time. Neither one would account for everything, but together they just might.

Sometimes this is the nature of pain and of dysfunction. I often use the analogy of straws on the camel's back, or grains of rice in the sack. No one of the straws or grains is singly responsible for the whole situation. Instead, the sum of the parts is the issue. I think this intuitively appeals to people in many cases. Of course, sometimes people still think that underneath it all there's just one thing that needs fixing. Sometimes that's the case, but often it isn't.

I can't yet predict how this patient and I will tackle the issues that I think he has. Hopefully my approach will chime with him, and together we will work out how we can both influence the problems he faces. It can be empowering to understand that a maze of options lays ahead. There may not be a clear way through, and we may have to double-back occasionally. But simply recognising that the maze exists is a fundamental step to successfully managing and treating many problems.