- 1) Helman CG (1981).Diseases versus illness in general practice. JRCGP, 31, 548-52.
vendredi 21 juillet 2017
MEDICAL KNOWLEDGE ALONE IS NOT SUFFICIENT TO HEAL THE CONCERNS OF THE PATIENT
Medical Knowledge ALONE is not sufficient to heal
Most people suffer from Illnesses and the medical profession objectifies those symptoms elicited and then gives it a name, and it becomes a Disease. During this objectification, the social, the cultural, the societal, the psychological, the economical aspects of the symptoms are forgotten.
Thus the patient leaves the consulting room with a Diagnosis and a treatment. Whether the treatment is appropriate or consistent with the guidelines of the various medical societies, the majority of the concerns of the patient have not been met.
This is where the questions formulated by the late Medical Anthropologist (my teacher and friend at Brunel University of London) Cecil Hellman come in handy.
Cecil Helman, an anthropologist, suggested that a patient with a problem comes to the doctor seeking answers to six questions:
1) What has happened happened? This includes organising the symptoms and signs into a recognisable pattern, and giving it a name or identity.
2) Why has it happened? This explains the aetiology or cause of the condition.
3) Why has it happened to me? This tries to relate the illness to aspects of the patient, such as behaviour, diet, body-build, personality or heredity.
4) Why now? This concern the timing of the illness and its mode of onset (sudden or slow)
5) What would happen to me if nothing were done about it? This considers its likely course, outcome, prognosis and dangers.
6) What are its likely effects on other people (family, friends, employers, workmates) if nothing were done about it? This includes loss of income or of employment, or a strain on family relationships.
7) What should I do about it -or to whom should I turn for further help? Strategies for treating the condition, including self-medication, consultation with friends or family, or going to see a doctor.
If the Primary Care Providers kept these concerns in their heart, so much distrust and second opinion seeking or seeking of other forms of treatment would become unnecessary.
In the context of taking care of patients with chronic conditions this is even more necessary.
I will give two examples: both of which are Signs or Symptoms and not actually DISEASES, unless the Doctor makes it into a disease.
A man around 30 years old, had been alcoholic for many years and now is seeking and gaining a foothold in the normal world. While he had conquered his Diabetes, Hypercholesterolemia with diet and advice from his counselors, he remains anxious and at times it invading the tranquility of his life and has bad effects on his self esteem.
He had come to see me, a Specialist Physician, An anthropologist: I could delve into the source of his anxiety from a social and cultural point of view and as a Doctor, could prescribe some medications. While I spent time delving into the current and immediate past life of his as well as his aspiration for the future, “I would like to become a productive member of the community”, it would be a crime if I sent him home just on his medications. I sought the assistance of a Psychologist who agreed to see him and help him with his anxiety.
So even though he had come for his anxiety, I would have been, even though I am a specialist Endocrinologist, amiss not to refer him to a psychologist.
I am very grateful for Dr Cecil Helman for the above wisdom and I always remember what a Meskwakia elder said to me: Please make sure that the patient leaves happier than when they came in.
The second context I want to write about is a patient had been told she has Pre-diabetes (in itself a constructed diagnosis) and given medications and asked to come back in three months for further measurements of the parameters that gave her the diagnosis of Pre-diabetes.
The patient all those questions outlined by Dr Cecil Helman.
Why me? Why no? Are there alternative forms of treatment? What will happen to me? To my family?
We are not discussing about the correctness of the diagnosis or the appropriateness of the treatment but whether or not the expectations of the patient had been met. The answer to the former is Yes and as regards to patient’s expectations being met, NO.
She comes to see us. I know her socially, as we know every one in this small village.
What is that I can do to change or reverse the diagnosis? Is this possible? What are the lifestyle adaptations I have to do? And my family? How would they be affected by these changes.
My role is to comfort her, to assure her, not to question the diagnosis or the treatment, but explain the laboratory results in the global perspective of her life, her marriage, her children and her family history of diabetes and her own cultural history and the role of the disease in it.
I needed the more than normal period of consultation to do this but she left the room, happy, ready to follow a prescribed regimen of lifestyle changes which would be good for her and husband and family and with no need for the medications.
She agreed to some basic nutritional changes but more importantly she made promises to keep in touch with the Health Educator and the Nutritional Therapist on a weekly basis and she would come when I am here next month. I was glad to hear that she would like her husband to come when she comes to see the Medical Nutritional Therapist.
In view of the strong family history of Diabetes, she stands a chance of that diagnosis in the future but now she should be given a chance to prove her determination to put a stop to the changes in the blood test.
I wish her well