There was a trial published in the NEJM regarding asthma patients, with mild-moderate disease.
http://www.nejm.org/doi/full/10.1056/NEJMoa1103319
They compared treatment with a ventolin inhaler, to treatment with various types of placebos, and to no treatment at all.
They measured peak flow but also asked patients to document their dyspnea score-which was how they perceived their shortness of breath.
Interestingly all forms of treatment had a similar effect on the dyspnea score (as compared to no treatment), but only ventolin led to significant improvement in the peak flow measures.
The conclusion of the authors was that patient subjective scores are unreliable and only objective measurements should be used in clinical trials.
But, there was an editorial that questioned this approach and asked if what we can measure is more important than what the patient feels.
http://www.nejm.org/doi/full/10.1056/NEJMe1104010
After all patients don't come to the physician because they have an abnormal peak flow measurement but because they have breathing difficulties that interfere with their life.
Treatment with ventolin (or any other medication) has its risks and maybe this risk is unjustified if we can achieve the same results with saline.
The question that remains unanswered is what would be the long term outcome of patients with mild-moderate asthma who receive treatment that only makes them feel better, without affecting objective measurable parameters.
Probably there are situations in which it does matter and situations in which it matters less.
But, modern medicine has probably been focusing too much on measurable so-called objective parameters and too little on how patients experience their illness and what makes them feel better (or worse) physically and emotionally.
This very important/essential part of medicine was gradually left in the hands of complementary healers, therapists and probably in recent years also patient support groups. Many physicians have mostly become prescription writing technocrats.
what does a patient want-to have a normal EMG or to be able to walk? To have increased activity measured objectively or to be able to resume his/her social and professional life? To have his own subjective feelings being recognized as real, or to have to constantly find "objective" evidence that serves to prove it? To be given help and support to lead a normal life as possible, or to have normalization of some lab value?
Trying to gain a better understanding of the biology, and possibly better treatment approaches, should not come in place of humanistic skills and a committed and healing relationship based on mutual trust and respect. A physician can't make an amputated leg grow back, but he/she can help that person learn to live with one leg.
Bio-markers and objective measurements should be used in research and to gain a better understanding of the disease, and develop better management approaches. they can also be used to support a sound clinical diagnosis, or as an aid to assess response to treatment , but they should not be used as a way of deciding if a patient is truly ill or not.
Helping patients find better ways to live with their illness, is welcome. Trying to convince them that they are not ill, or that they should receive treatment that clearly makes them feel worse because their measurable tests are normal, is not.
It is also unreasonable to blame patients for focusing too much on their symptoms, when they are constantly sent to find explanations for them so that they will be seen as "real".
Eliot Slater wrote many years ago, what is as true today:
The diagnosis of hysteria is all too often a way of avoiding a confrontation with our own ignorance. This is especially dangerous when there is an underlying organic pathology, not yet recognized. In this penumbra we find patients who know themselves to be ill but, coming up against the blank faces of doctors who refuse to believe in the reality of their illness, proceed by way of emotional lability, overstatement and demands for attention ... Here is an area where catastrophic errors can be made. In fact it is often possible to recognise the presence though not the nature of the unrecognisable, to know that a man must be ill or in pain when all the tests are negative. But it is only possible to those who come to their task in a spirit of humility.
Eliot Slater, Diagnosis of Hysteria, British Medical Journal, 29 May 1965, p. 1399.