Most doctors and nurses will have a deep well of patient stories – examples of great fortitude and its converse. It is clear to any clinician that some patients either feel their symptoms (or report them) more than others.
This is well recognised in parts of the medical literature with, for example, the distinction made between irritable bowel syndrome patients and ‘non-patients’ – people with the same symptoms as those who seek care but who never present to services.
I wonder, however, whether stoicism has been neglected in the epidemiological literature. It seems likely to be related to many exposures and many diseases. Association with exposure and with disease are two of the key features of a confounding variable.
Stoicism is particularly likely to be associated with diseases where diagnosis relies on self-reported symptoms. Many diseases fall into this category.
I feel stoicism is likely to be related to exposures such as cycling to work every day, ambient household temperature, and so on. However, it’s not hard to imagine that many health behaviours might be influenced by how stoical people are.
Confounding is well illustrated using a classic example, coffee and cancer. People who drink coffee are more likely to get cancer. They are also more likely to be smokers. The well-established association between smoking and cancer largely explains the association between coffee and cancer. Smoking, in this example, is a confounder.
Epidemiologists try to control for confounders to avoid misleading results.
A Pubmed search for ’stoic*’ AND ‘confound*‘reveals 24 papers, only three of which are even vaguely relevant. None are epidemiological and I can access only one. By failing to control for stoicism in epidemiological studies, do we risk throwing up reams of spurious associations – warmer home environment is associated with fatigue, winter cycling is associated with less chronic low back pain, etc? Will this lead us to spend money trialling useless interventions?
In some cases it may be possible to adjust – person by person – for reported symptoms at another time point. However, to control for confounders, you usually need to be able to measure them.
It is entertaining to think how one might measure stoicism. For example: ‘When you last had a sore throat, did you (a) get on with it (b) have a day off work or (c) go to see your GP?’ We might apply more objective tests – time to first complaint when the waiting room is kept at ten degrees, perhaps? We could devise a scale.
A version of this blog was originally posted at BMJ.com.
In response to your more-objective-test suggestion… The temperatures people put up with in their own home might be very different from the temperatures people would put up with in a waiting room. Putting up with cold at home might indicate stoicism (or stinginess?) whereas putting up with cold in a waiting room might be indicative of a strong desire not to offend or perhaps some variety of the by-stander effect.
Hi Rachel,
That suggestion was a bit tongue in cheek! I agree it has flaws.
I think I stand by my original argument that stoicism or self perception of symptoms could confound attempt to link certain exposures and outcomes, particularly health behaviours and conditions whose diagnosis relies on self reported symptoms.
I was discussing this with a friend who suggested stoicism may be related to social capital, which is an interesting idea.
Hope alls well with you.
Best wishes,
Tom
[…] A new epidemiology blog (there are many fewer epi blogs that econ blogs, alas) asks “Is stoicism an important and neglected confounder?”. […]
So apparently there is a whole field of ‘cognitive epidemiology’, that I’ve missed whilst focussing on microbes. See, for example, http://www.ccace.ed.ac.uk/ and http://bfi.uchicago.edu/humcap/wp/papers/Deary2010PsychSciPubIntintelligencepersonalityhealth.pdf. Thanks to @StuartJRitchie for the heads-up.