From Ariadne's Thread to the Labyrinth Itself - Nosology and the Infrastructure of Modern Medicine.
From Ariadne's Thread to the Labyrinth Itself - Nosology and the Infrastructure of Modern Medicine.
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DOI：
10.1056/nejmms1913140
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发表时间：
2020-03-26
期刊：
影响因子：
--
通讯作者：
Greene JA
中科院分区：
文献类型：
--
作者：
Kveim Lie A;Greene JA
今年5月，世界卫生大会悄悄地通过了第11版国际疾病分类（ICD-11），这是第一个完全电子化的版本。之所以需要数字格式，部分原因是汇编本身已经变得太大而无法打印：ICD-11包含了55，000个病理实体，比其前身ICD-10的大约14，400个代码增加了近四倍。[1]就像21世纪的潘多拉魔盒，ICD-11突然向世界引入了4万种新的瘟疫，这一举动将对医学知识的组织和医学实践的后勤产生重大影响。但日内瓦的活动相对来说没有引起太多关注，因为疾病分类通常被认为是一件无聊、平凡的事情--与更具新闻价值的流行病或新疗法的报道相去甚远。尽管ICD-11的不断变化的代码看起来很平凡，但我们用来对疾病进行分类的系统以实质性和强大的方式塑造了医学和公共卫生的本质。目前，世界卫生资源的70%是根据ICD数据分配的。2作为临床医生，我们根据由不同疾病类别组成的鉴别诊断来解释患者的症状，然后使用ICD代码绘制最终诊断，以获得保险公司的报销。作为流行病学家，我们使用根据这些商定的类别编制的统计数据，然后在按疾病标记的期刊上发表我们的发现。作为患者，我们也越来越了解自己的疾病名称，这些名称适用于我们的症状，然后使用这些名称通过搜索引擎和社交媒体寻求更多信息。正如内科医生克努德·费伯（Knud Faber）在近100年前所总结的那样，现代医生“不能在没有病态类别概念的情况下生活、说话或行动”。[4]然而，在医学史上的一个更长的时期，情况并非如此。对诊断分类的痴迷是现代医学的一个标志，追溯自1700年以来医疗实践中疾病分类的历史可以揭示当今支撑医学知识和医疗实践的基础设施的实质性变化。
This May the World Health Assembly quietly adopted the 11th version of the International Classification of Disease (ICD-11), the first of its kind to be fully electronic. The digitalonly format is needed in part because the compendium has itself become too big to print: weighing in at a hefty 55,000 pathological entities, the ICD-11 represents a nearly fourfold increase from the roughly 14,400 codes in its predecessor, the ICD-10. 1 Like a 21st-century Pandora’s Box, the ICD-11 suddenly introduced 40,000 new plagues into the world, a move that will have major impacts on the organization of medical knowledge and the logistics of medical practice. But the Geneva event received relatively little fanfare, as the classification of disease is typically understood to be a boring, mundane affair—a far cry from more newsworthy stories of pandemics on the move or new cures in the making.As mundane as the shifting codes of the ICD-11 may seem, the systems we use to classify disease shape the nature of medicine and public health in substantial and powerful ways. Seventy percent of the world’s health resources are now allocated based on ICD data. 2 As clinicians, we interpret a patient’s symptoms in light of a differential diagnosis comprised of different disease categories and then plot the final diagnoses using ICD codes to get reimbursement from insurers. As epidemiologists we use statistical data compiled on the basis of these agreed-upon categories and then publish our findings in journals that tag by disease. As patients, too, we increasingly understand ourselves in regard to disease names that are applied to our symptoms, 3 and then use these names to seek more information via search engines and social media. As the internist Knud Faber concluded almost 100 years ago, the modern physician “cannot live, speak, or act without the concept of morbid categories.” 4 Yet for a larger period in the history of medicine, this was not the case. Obsession with diagnostic classification is a hallmark of modern medicine, and tracing the history of disease classification in medical practice since 1700 can reveal substantive changes in the infrastructures that undergird medical knowledge and medical practice in the present day.