The Medical Consultation as a ‘Set Up’
A patient wishes to make
sense of his or her symptoms
and arranges to see a doctor. So an appointment is duly made. Yet
what remains unspoken in the consultation is that it is tacitly
expected to take as its starting point certain unquestioned
assumptions which serve as expected ‘points of departure’ for all
doctor-patient communication. Below I list some of the most basic
tacit assumptions that ‘enframe’ the medical consultation and
constitute expected points of departure for all communication that
occurs within it.
1. It is tacitly understood that we all
know what ‘illness’ and ‘health’ are, that they are
opposites, and that ‘illness’ is something ‘bad’ and ‘health’
something ‘good’.
2. It is tacitly understood and agreed
that the patient arranges the consultation because he is suffering
symptoms of a possible ‘illness’ which he wishes to have
identified and which he or she is therefore prepared to have
diagnosed through examination and testing and be prescribed treatment
for.
3. It is tacitly understood and agreed
that the patient will describe their symptoms and that the physician
will, directly or through further tests, arrive at a medical
diagnosis of the disease, recommend a course of biomedical treatment
aimed at relieving their symptoms or ‘curing’ the disease –
based on knowledge of its biological ‘causes’.
4. It is tacitly understood and agreed
that the patient has just happened to fall victim to their symptoms
‘out of the blue’ – in other words that there is no meaning to
be attached to the specific timing of their appearance in the larger
context of the patient’s life and life history.
5. It is tacitly understood and agreed
therefore, that symptoms have no meaning at all beyond being mere
signs of a possible biological disease or dysfunction.
6. It is tacitly understood and agreed
therefore that ‘making sense’ of symptoms means nothing more than
taking them as possible signs of some biomedical disease – and that
in no case can a biological illness or disease be itself taken as a
symptom of a life-disease – a hidden life problem that manifests in
the patient feeling ‘ill-at-ease’ with their lives.
7. It is tacitly understood and agreed
that the patient’s suffering – their felt pain, discomfort or
‘dis-ease’ – is a mere secondary and subjective ‘effect’ of
an organic disorder or ‘disease’. The contrary notion, namely
that symptoms, illness and disease may be a symbol ic embodiment of a
subjectively felt dis-ease’ – and of particular ways in which the
patient is ‘ill-at-ease’ with their life – is ruled out in
advance. Indeed such a notion constitutes sheer heresy in terms of
the unquestioned dogmas of biomedical ‘science’.
Should a patient reject any or all of these assumptions, or depart from any of the unspoken rules or points of departure in their communication with a doctor, the patient will be immediately classed as a ‘difficult’ or ‘incompliant’ patient or even as deluded. Yet together these tacitly agreed assumptions and points of departure for a biomedical consultation effectively constitute an unspoken ‘set up’ or ‘frame up’ – a framework the patient is expected to compliantly adhere to. The aim of this ‘frame up’ is to enframe the meaning of the patient’s symptoms in the terms of one framework only – that of biomedicine – excluding any other possible ways of making sense of those symptoms. Any attempt by a patient to question this framework – even if only by not immediately accepting certain types of routine biomedical tests or courses of treatment – will arouse indignation and bewilderment, be seen as a threat to the authority of biomedically trained doctors and a waste of the limited time they give to their patients. Instead it could be seen as an opportunity to give themselves more time to learn about the lives of their patients as human beings, to understand their symptoms in the larger context of their life and life world.
Should a patient reject any or all of these assumptions, or depart from any of the unspoken rules or points of departure in their communication with a doctor, the patient will be immediately classed as a ‘difficult’ or ‘incompliant’ patient or even as deluded. Yet together these tacitly agreed assumptions and points of departure for a biomedical consultation effectively constitute an unspoken ‘set up’ or ‘frame up’ – a framework the patient is expected to compliantly adhere to. The aim of this ‘frame up’ is to enframe the meaning of the patient’s symptoms in the terms of one framework only – that of biomedicine – excluding any other possible ways of making sense of those symptoms. Any attempt by a patient to question this framework – even if only by not immediately accepting certain types of routine biomedical tests or courses of treatment – will arouse indignation and bewilderment, be seen as a threat to the authority of biomedically trained doctors and a waste of the limited time they give to their patients. Instead it could be seen as an opportunity to give themselves more time to learn about the lives of their patients as human beings, to understand their symptoms in the larger context of their life and life world.
What Most Doctors Don’t Ask
What follows is a list of some of the
questions that most doctors don’t ask – and yet which are key
questions for both doctor and patient in coming to understand the
life meaning of particular symptoms or a particular illness. They are
the sort of questions central to Life Medicine and those that a Life
Doctor will ask and discuss with you.
When did your symptoms first occur?
Is there anything else in your life that is bothering/distressing you right now?
What was going on in your life in the hours, days, weeks, months or years preceding the onset of your symptoms?
What were the most significant life encounters, events, experiences, dilemmas and decisions that faced you in the period preceding the onset of your symptoms?
What was the underlying mood you experienced in this period and how would you describe it?
What were the most dominant thoughts and emotions you experienced in this period?
What do you tend to think about most when you are most aware of your symptoms?
What feelings accompany these thoughts?
What do you do with those thoughts and feelings when you have them?
What do you tend to do in response to your symptoms themselves?
At what specific times or in what specific life situations do your symptoms tend to occur or intensify?
At what times or in what situations do your symptoms tend to disappear or diminish?
Have you experienced similar symptoms in the past, and if so at what times and in what circumstances?
How do your symptoms – and the thoughts you have around them – affect your emotional life, work and relationships?
What do your symptoms either force you to do or stop you from doing?
Is there any positive benefit you can see from the way your symptoms affect your life?
How would you describe the overall or underlying mood or state of consciousness accompanying your symptoms and/or the thoughts and emotions around them?
How do your symptoms make you feel? In what way does the mood that accompanies them affect not only what you think and how you feel but also who you are – your sense of ‘you’?
Is there any positive side to the different mood and sense of self accompanying your symptoms?
Are there any other ways you could give expression to it in your way of relating to life and other people?
Alternatively, what changes in your way of relating to life and other people do you feel would most help to alter this underlying mood and/or alleviate your symptoms?
What are the most important types of experience you miss or have missed in your life and relationships?
What are the most important potentials or abilities you feel are not or have not been fulfilled or realised in your life?
What are the biggest fears or concerns you have about your symptoms, your illness or its treatment?
What would make you most happy or content in your life – independently of any improvement in your condition?
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