The Missing Half of Medical Education: Why Pathogenesis Must Be Taught Together with Sanogenesis

 

A declaration for recovery-centered medicine

Modern medicine has achieved extraordinary success by identifying the causes of disease, explaining pathological mechanisms, preventing complications, and developing effective interventions. Antimicrobial therapy, surgery, intensive care, trauma medicine, pharmacotherapy, public-health measures, and preventive care demonstrate the indispensable value of etiological and pathogenetic reasoning. No serious reform of medical education should diminish this achievement.

Yet medical education remains conceptually unbalanced. Students are taught, often in great detail, how disease begins, progresses, damages organs, produces symptoms, and ends in complications or death. They are taught to identify causal factors, pathological changes, dysfunctional mechanisms, and therapeutic targets. Far less systematically, however, they are taught how the organism resists injury, maintains viability, compensates for loss, repairs damage, reorganizes function, and returns—fully or partially—to a viable life.

This is the missing half of medical education.

The problem is not that medicine is indifferent to recovery. Medicine already studies inflammation, immunity, adaptation, compensation, tissue repair, regeneration, remodeling, neural plasticity, rehabilitation, resilience, behavior, and social reintegration. The problem is that these phenomena are usually dispersed across separate disciplines and treated as disconnected topics. They are not consistently brought together into a unified model of disease, recovery, clinical reasoning, and therapeutic action.

We call this missing organizing framework sanogenesis.

The organism is not passive

The body does not possess one set of mechanisms for ordinary life and a separate, special set of mechanisms solely for “fighting disease.” The same integrated mechanisms that sustain life in physiological conditions—neural regulation, endocrine coordination, metabolism, circulation, immunity, cellular repair, tissue remodeling, behavior, and social interaction—change their organization when the organism encounters injury, infection, trauma, deprivation, overload, toxicity, or other threats.

Under pathological conditions, these mechanisms can change profoundly in intensity, duration, hierarchy, coordination, and biological cost. They may look dramatically different from the physiological state. Yet they remain the activity of the living organism attempting to preserve itself under altered circumstances.

A diseased organism is therefore not merely a normal organism plus pathology. It is an organism whose regulatory systems have been reorganized by a challenge and whose outcome depends on the changing balance between damage and the capacity to survive, compensate, repair, adapt, and recover.

This is why disease cannot be adequately understood only as a deviation from normality. It must also be understood as a dynamic process in which the organism attempts to establish a new, viable order in the face of injury.

Pathogenesis and sanogenesis

Pathogenesis describes the processes through which disease is initiated, amplified, maintained, and expressed: causal injury, dysregulation, destructive feedback loops, functional loss, structural damage, and complications.

Sanogenesis describes the protective, compensatory, reparative, regenerative, regulatory, behavioral, and social processes through which the organism attempts to maintain viability, limit injury, restore disturbed self-regulation, and regain function.

In pathophysiological traditions that explicitly use this concept, sanogenesis is understood as a complex of defense-adaptive processes that restore or preserve homeostasis and disturbed self-regulation. Pathogenesis and sanogenesis are described as simultaneous and interacting processes that begin before medical attention and continue throughout care.[medicine-journal.spbu][amu.edu]

They are not two separate chronological stages in which pathogenesis occurs first and sanogenesis begins only after disease has been eliminated. A patient’s protective and reparative mechanisms begin acting from the earliest moment of disturbance. At the same time, damaging processes may continue, accelerate, or become self-sustaining.

The disease trajectory can therefore be represented as:

\text{Disease trajectory} =
\text{pathogenetic injury and amplification}
\;\leftrightarrow\;
\text{sanogenetic protection, compensation, repair, and adaptation}

The balance is never static. It changes according to the nature and magnitude of injury, the patient’s biological reserve, developmental stage, comorbidity, psychological state, social conditions, treatment, and time.

The dual meaning of clinical manifestations

Every clinical sign, symptom, laboratory change, or functional disturbance should be interpreted in two dimensions.

First, it may reveal pathological injury, dysfunction, escalating disease activity, or a complication. Second, it may reflect the organism’s attempt to protect itself, compensate for impairment, limit further injury, repair damage, or adapt to a changed physiological situation.

This does not mean that every symptom is beneficial, nor that harmful manifestations should be romanticized or left untreated. It means that each manifestation deserves a dual clinical interpretation.

The relevant questions are:

• What pathological process does this sign reveal?
• What protective, compensatory, or reparative process may it also express?
• Is that response useful at this phase of illness?
• Is it insufficient, exhausted, excessive, or maladaptive?
• What is the likely effect of suppressing, modifying, redirecting, or supporting it?
• How can intervention move the patient toward the best attainable recovery?

A response may initially protect the organism and later become a source of further damage. A process may be insufficient to prevent injury but still represent a recovery resource worth preserving. Another response may be so dangerous that it requires immediate suppression despite its original adaptive logic. Clinical reasoning must therefore be phase-specific, patient-specific, and trajectory-oriented.

The physician should not ask only, “What is wrong?” The physician must also ask, “What is the organism trying to accomplish through this altered state, and how can that effort be made more effective and less destructive?”

Evolutionary meaning

An evolutionary perspective makes this framework more coherent. The human organism has not been shaped for perfect health, unlimited longevity, or complete recovery from every insult. It reflects evolutionary trade-offs, developmental constraints, limited energy and reserve, and adaptation to environments that may differ substantially from contemporary conditions.

Many costly biological responses exist because, in some contexts, they improved survival or reproduction despite their disadvantages. The existence of such responses does not imply that disease itself was selected “for recovery,” nor does it imply that every response should be preserved. Rather, evolutionary reasoning asks why a vulnerability or response exists, what it may protect, what costs it imposes, and under what circumstances it becomes maladaptive.

Evolutionary biology has been proposed as a basic medical science because it gives a dynamic framework for understanding genetic, environmental, and infectious disease and can be integrated across organ-system and disease teaching.[pmc.ncbi.nlm.nih][pnas]

The integration of evolutionary medicine and sanogenesis would allow students to understand illness not only as a mechanism of failure, but as a changing conflict between injury, defense, trade-offs, compensation, repair, and environmental conditions.

What is wrong in teaching

The dominant structure of disease education is usually linear:

\text{Etiology} \rightarrow \text{pathogenesis} \rightarrow \text{manifestations} \rightarrow \text{diagnosis} \rightarrow \text{treatment}

Recovery is commonly added later under prognosis, convalescence, rehabilitation, follow-up, or quality of life. This ordering subtly conveys the idea that recovery begins after the disease has been controlled.

The result is a series of conceptual and practical limitations.

First, students may learn the mechanisms of tissue injury in greater depth than the mechanisms of successful recovery. They become highly skilled at recognizing deviation from normality, but less prepared to identify the capacities through which the organism may restore regulation and function.

Second, medical knowledge becomes fragmented. Inflammation may be taught in immunology, repair in pathology, compensation in physiology, plasticity in neurology, rehabilitation in a separate clinical discipline, and social reintegration in public health or social medicine. The student may never be taught that these are connected dimensions of one recovery process.

Third, technical success may be confused with clinical recovery. Correction of an anatomical defect, removal of a cause, normalization of a biomarker, or resolution of an acute emergency may be essential, but it does not by itself restore the whole person. Recovery still requires biological repair, regulatory reorganization, functional adaptation, psychological safety, participation, and social support.

Fourth, students may develop an overly antagonistic image of disease: pathology is the enemy, symptoms are obstacles, treatment is the weapon, and the patient is the site of intervention. This framework can obscure the patient’s role as an active recovering system.

Finally, students may fail to recognize that clinical interventions themselves alter a dynamic living system. They must learn to predict not only immediate effects but also delayed consequences, feedback loops, compensatory shifts, unintended harms, and opportunities to strengthen recovery. Systems thinking emphasizes precisely such attention to interactions, time, feedback, and the structure that generates behavior. 

Why this reform is necessary

The need for this reform is scientific, clinical, ethical, and educational.

Scientifically, a model of disease that separates injury from recovery is incomplete. Pathogenesis alone cannot explain why patients with apparently similar pathology experience different trajectories, why some recover unexpectedly, why others deteriorate despite technically correct treatment, or why restoration of function often requires more than removal of the original cause.

Clinically, the reform would improve therapeutic reasoning. Treatment should not be understood only as suppression, removal, or correction of pathology. It should also be understood as the deliberate creation of conditions in which recovery can proceed. The therapeutic task is to remove or reduce causal injury, interrupt destructive feedback loops, preserve useful adaptation, prevent maladaptive persistence, support repair, enable functional reorganization, reduce avoidable suffering, and restore the best attainable level of life.

Ethically, this perspective restores the patient to the center of medicine. The goal is not merely survival, anatomical correction, biochemical normalization, or discharge from hospital. The goal is the greatest attainable restoration of function, agency, dignity, participation, and meaningful life.

Educationally, this approach equips future physicians to think across time. They learn to see not only an isolated pathological state but also the trajectory that preceded it, the biological and human resources still available, the likely effects of intervention, and the conditions required for durable recovery.

A proposal for reform

This reform does not require another isolated course in an already crowded curriculum. It requires a reorganization of questions across existing disciplines.

Pathophysiology, pathology, physiology, pharmacology, surgery, internal medicine, pediatrics, psychiatry, neurology, rehabilitation, family medicine, and public health should teach each disease process through both pathogenetic and sanogenetic lenses.

For every disease process, students should be expected to ask:

• What initiates and sustains injury?
• Which mechanisms amplify dysfunction or create destructive feedback loops?
• Which protective, compensatory, reparative, and adaptive processes are active?
• Which responses remain useful, and which have become insufficient, exhausted, excessive, or maladaptive?
• Which intervention removes a barrier to recovery?
• Which intervention may preserve or support the organism’s recovery capacities?
• What outcome measures demonstrate genuine restoration rather than temporary stabilization?
• Which biological, psychological, social, and environmental conditions determine whether recovery can continue?

This approach should also be reflected in assessment. Students should be evaluated not only on their ability to name disease mechanisms and prescribe interventions, but also on their ability to identify recovery mechanisms, anticipate maladaptation, formulate longitudinal recovery goals, and justify treatment in terms of the whole disease trajectory.

Lessons of medical history

The history of medicine repeatedly shows that incomplete models of disease can produce ineffective, harmful, or poorly timed interventions. Progress has depended on replacing simplistic explanations with better accounts of causation, host response, environment, and treatment consequences.

The appropriate historical lesson is not that physicians should avoid intervention or that symptoms should be regarded as inherently protective. Such conclusions would be dangerous. The lesson is that visible abnormality alone is not a sufficient guide to treatment. Medical action must be based on an evolving understanding of the relationship between causal injury, host response, adaptation, compensation, repair, and functional outcome.

Pathology must remain explanatory, not merely descriptive. A lesion, a physiological disturbance, or a symptom acquires clinical meaning only when it is situated in the larger process of disease and recovery. 

Declaration

We affirm that pathogenesis is indispensable but insufficient as the sole organizing framework of medical education.

We affirm that disease is a dynamic trajectory in which pathogenetic and sanogenetic processes coexist, interact, and change their relative significance over time.

We affirm that the organism is not a passive recipient of pathology. It is an active system of regulation, defense, compensation, repair, adaptation, and recovery.

We affirm that every clinical manifestation should be interpreted not only as evidence of damage or dysfunction, but also as a possible expression of the organism’s protective, compensatory, reparative, or adaptive activity.

We affirm that the physician must distinguish beneficial adaptation from maladaptation; immediate stabilization from meaningful recovery; and technical success from restoration of the patient’s life and function.

We call upon medical schools, textbook authors, curriculum committees, accreditation bodies, specialty boards, researchers, and health systems to make sanogenesis visible, teachable, assessable, and clinically applicable.

Medicine must continue to fight destructive processes whenever they threaten life, function, and dignity. But it must also learn to recognize, protect, guide, and optimize the processes through which life restores itself.

You can learn more by reading our e-book

Mykola Iabluchanskyi together with Andriy Yabluchanskiy