In: Ideological Debates in Family Medicine Editors: S.A. Buetow and T.W. Kenealy, pp.

ISBN 1-60021-616-1 © 2007 Nova Science Publishers, Inc.

Chapter 15

FAMILY MEDICINE SHOULD SHIFT ATTENTION FROM RATIONALITY TO EMOTIONS: AFFIRMATIVE POSITION Kirsti Malteruda,1 and Hanne Hollnagelb a

Section for General Practice, Department of Public Health and Primary Health Care, University of Bergen, Bergen, Norway b Central Research Unit of General Practice, Panum Institute, University of Copenhagen, Copenhagen, Denmark

ABSTRACT Medicine has evolved from an empirical art to a biomedical science. The family physician frequently encounters challenges related to diagnostic perception and individualized care where a complex mode of professional understanding is needed. Rationality-based principles of knowing, including the more recent strategies of evidence-based medicine, will only provide limited answers to the questions asked and the needs raised by patients and their problems in family practice. In this chapter we explore the nature of clinical knowing in this specific context, discussing what is needed to remain a scientific basis of knowledge. While biomedical rationality has a strong case in the history and culture of medicine, emotions have usually been dismissed to the domain of care. We argue that an improved balance between the physician’s emotions and rationality is needed for adequate problem identification and solving in family practice. Since the scientific rationality constitutes the taken-for-granted bottom line, an increased awareness of emotional issues –including the physician’s own feelings – can only be achieved by shifting attention from rationality to emotions. Epistemological challenges arising from this claim are explored and discussed. 1

Corresponding author: Kirsti Malterud, Section for General Practice, Dept. of Public Health and Primary Health Care, University of Bergen, Kalfarveien 31, N-5018 Bergen, Norway. Tel: +47-55-586133; Fax: 47 55 58 61 30. Email: [email protected]

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During the last century, medicine has evolved from an empirical art to a biomedical science. This development has produced progress and challenges for medical theory and practice. The family physician frequently encounters challenges related to diagnostic perception and individualized care where a complex mode of professional understanding is needed. Drawing on the tools of the biomedical trade in the era of evidence-based medicine, the scientific rationality will never be forgotten by the physician. In this chapter we argue that an improved balance between the physician’s emotions and rationality is needed for adequate problem identification and solving in family practice. We therefore suggest that such a balance, omitting none of these issues in research or practice, can only be achieved by shifting attention from rationality to emotions – including the physician’s own feelings.

MEDICAL PROGRESS – FROM EMPIRICAL ART TO BIOMEDICAL SCIENCE The American physician Lewis Thomas (1913-1993) wrote in his autobiography ‘The Youngest Science’ about the development and nature of medicine [1]. He takes us for a journey through the period when medicine evolved from an empirically based art into a biomedical science. The history starts out in the 1920s when he watched his father, a family physician, doing house-calls. Trained as a neurologist and researcher in immunology and microbiology, Thomas became the dean of New York University Medical School and the Yale School of Medicine. From these positions, he reflects upon the similarities and differences between the medicine his father practiced, and the potentials and limitations of modern medicine. He describes how the challenges, procedures, and possibilities for problem identification and solving have changed enormously within the gap of time covered by his observant participation. Thomas not only writes about the positive sides of development, but also points to the problems of modern medicine. First and foremost, however, he submits his lifelong love of medicine. In this book, he calls attention to the emotional foundations of his professional practice. A broader foundation for development and application of clinical knowledge in medical practice has been provided by the progress of systematic reviews of medical studies within the last decade. Yet, controlled experiments, which most frequently form the subject of these reviews, are rarely the sole basis of clinical decisions and care for the individual patient. David Sackett, the founding father of evidence-based medicine, wrote: Evidence based medicine, whose philosophical origins extend back to mid-19th century Paris and earlier, is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient [2].

As a medical discipline, family medicine today comprises a complex span of professional competences and mind-sets drawing on rationality as well as emotional sources. The former is fully acknowledged as a base of knowledge, while the latter is consigned to the domain of care. However, most of us still enjoy the basic challenges of learning to know our patients and their diseases and illnesses in the context of their family and local community. Such a foundation for professional identity and knowing was portrayed by John Berger and Jean

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Mohr in their photographic essay ‘A Fortunate Man – The Story of a Country Doctor’ [3]. We are given access to the life and practice of Dr. John Sassall, an English family physician, and the challenges upon his personal life as well as the problem solving encountered in this medical subdiscipline. Dr. Sassall never advanced the skills of evidence-based medicine, and he did not own a computer. Still, he was able to trust his basic experience and medical knowledge, founded on a lifelong understanding about people, their lives and their diseases. The story also tells about the costs and benefits of the emotional involvement of such a professional role. Yet, such issues are usually considered to belong to the personal or private domain of the physician, rather than to the core values of the discipline of family medicine. In this chapter, we want to highlight the balance where the physician’s vulnerability is just as important for professional quality as is cognitive rationality.

CLINICAL PRACTICE – PERSONAL AND PRAGMATIC UNDERSTANDING According to Levenstein et al, we have available the well-tried biomedical clinical methods for understanding diseases, but no equivalent method for understanding patients [4]. Indeed, even the seemingly clear-cut medical tasks are not always as scientifically founded as we would like to believe. Clinical decision-making is not such a rational process as we often like to believe. There is for instance considerable interobserver variation in the accuracy of clinical data assumed to be objective facts, such as the reading of mammographic images [5]. Also laboratory research findings are influenced by people’s manipulation and interpretation [6]. The medical gaze is certainly shaped by human mind and touch, and the diagnosis is not merely a matter of objectively observable facts [7]. Nagel disputes the belief of a neutral observer that is widely held in medicine, which he calls ‘a view from nowhere’ [8] – that is, in this case an understanding of the doctor as a neutral and objective observer and interpreter of symptoms and signs. Haraway similarly rejects the neutrality of observation, and asserts that the perspective of the observer is always limited and determines what can be seen [9]. Therefore, says Haraway, objectivity requires that the observer takes responsibility for the site and position of knowledge construction, including also the emotional components. For medicine to remain a scientific discipline, such epistemological perspectives are more adequate than the traditional biomedical notions of objectivity. The American philosopher Donald A. Schön wrote about how experienced practitioners reflect on their intuitive knowing in the midst of action – reflection-in-action [10]. Reflection-in-action comprises the practitioner's unconscious and inarticulate conversation with the situation, where reframing and reworking of the problem leads to restructuring of the problem. The practitioner's repertoire of examples, images, understandings and actions – rarely made explicit in action – embraces a capacity for dealing with unique cases and individuals. This practical, clinical knowledge is gradually developed to a more advanced capacity as the practitioner moves from novice to a more experienced level. Clinical knowledge based on ‘current best evidence’ embraces interpretative matters and social interaction – acts involving human relations, minds, and experiences [11]. The seasoned practitioner is acquainted with the discrepancies between actual everyday practice

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and accepted clinical standards, which commonly occur even within a discipline devoted to scientific knowledge [12]. Tacit knowing constitutes a foundation for diagnostic reasoning and judgment of medical conditions [13]. Medicine is more than a science; it is also a pragmatic practice of knowledge construction based on experience, judgment, proficiency and research. However, trusting the pragmatic practice of medical knowing may be a risky business. At worst, clinical practice may be a private enterprise, shut off from outside assessment, where pitfalls and fallacies are legitimized and reproduced through subjectivism and empiricism. The more isolated my practice, the higher the possibility that I create and follow my own rules of thumb, just because I believe they work. At best, the tacit knowing and experiences held and applied by proficient practitioners may represent diamonds of relevant, valid and reflective clinical knowledge. The physician’s good and less good personal attributes are imperceptibly merged with the cognitive process of medical problem solving. We know for example that stereotyping related to gender, occupation and class subtly influences diagnosis and treatment [14]. Yet, personal impact and emotional cues are not necessarily improper bias. Reflexivity, including a critical self-awareness of the physician’s own personhood, emotions, and perspectives, is a professional skill opposing the belief that observations can be made with a view from nowhere. Clinical knowledge, drawing on experiences and emotions, holds the potential to be described, shared, and contested [11, 15, 16]. The qualitative research methods do not oppose, but rather complement, the traditional biomedical research methods. To recognize the impact of one’s own emotions is an essential dimension of the intersubjectivity needed for reflection-on-action beyond subjectivity [10, 17]. Reflexivity involves awareness of emotions – the interface where the balance of reason and feelings complement each other. None can do without the other, even when they appear to raise conflicting perspectives.

RECOGNIZING THE PARTICULAR – UNDERSTANDING THE OTHER Contextual awareness and narrative understanding may be essential to understanding the ambiguous and sometimes contradictory signs or symptoms presented to the family physician [18]. Diagnosis is seldom arrived at along a straight-forward linear and explicit path of deductive hypothesis testing, but rather is more often constructed by means of a complex mode of activity where cognitive and affective matters merge. From a biomedical perspective, some of the diagnostic strategies frequently applied in family medicine might be classified as second-class short-cuts. They could, however, alternatively be interpreted as distinguished indications of very specific problem-solving skills [19, 20]. Emotions can be essential sources for knowing. Writing about the clinical ontology of emotions, the American bioethicist Allyson L. Robichaud claims that emotions are not just feelings – they are also cognitive [21]. Emotions can provide information about values and beliefs and are also necessary to understand suffering. The Canadian family physician, Ian R. McWhinney, has made a strong call for medicine as a science of particulars, which he regards as the foundation of clinical wisdom. He

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remarks that general laws always have to be applied in a particular context, and that family medicine, as a human science, essentially is about meaning. Personal involvement is necessary to approach meaning, says McWhinney. Proposing a method of inquiry for family medicine, he writes: There is no objective test for meaning. The only way to establish what an experience means to a person is to enter into a dialogue with him or her, from which the meaning gradually emerges [22].

In family medicine, the skills of individualized knowing are especially important. This is firstly, for diagnostic reasons, since so many patients present in the early stages of disease when symptoms often are undifferentiated and intricate to understand. Secondly, there are reasons of clinical management, since many patients suffer from chronic disorders where cure can rarely be expected, and care may be at least as important. How then can the biomedical understanding of detached objectivity stay alive side by side with the commitment needed for individualized cure and care? How can these qualities complement each other in the best conceivable balance needed for the interpretive action of clinical knowing in family medicine? Professional ideals are often different from the operative norms of performance. The sociologist, Talcott Parsons, describes the foundations of the authority exercised by the professional practitioners, where the institutionalized rationality of science provides normative standpoints such as 'objective truth' [23]. Since the professional role is grounded on technical competence, disinterestedness is of great functional significance to the modern professions, especially for medicine, says Parsons. Yet, objects another sociologist, Eliot Freidson, medical practitioners clearly differ from scientists in their commitment to action [24]. Freidson concludes that physicians’ attitudes are marked by a profound ambivalence. On the one side they have more than an ordinary sense of uncertainty and vulnerability; on the other, they have a sense of virtue and pride, if not superiority.

EMPATHY – A PATH FOR UNDERSTANDING FOUNDED ON EMOTIONS In 1986, Levenstein et al. wrote that the task of the physician is twofold: to understand the patient and to understand the disease: Entry into the patient’s world is a difficult art, requiring of the physician human qualities of empathy, non-judgemental acceptance, congruence and honesty. It also requires a skill in the practice of certain techniques, and it is our conviction that these techniques can be learned and taught. Moreover, the physician cannot be patient-centred unless he has selfknowledge and is prepared to make the changes in attitude and behaviour needed for such an approach [4].

From our own practices, we have frequently experienced how the all-encompassing heritage of the technical rationality of modern medicine cannot only obstruct the relationship

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between doctor and patient, but also disturb the communication needed to understand what is wrong and what can be done. Empathy is defined as: … the action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another of either the past or present without having the feelings, thoughts, and experience fully communicated in an objectively explicit manner; also: the capacity for this [25].

In two out of three consultations the patient’s story is more essential for the diagnosis than are the findings from clinical examinations or laboratory investigations [23]. A skilled reading of the patient’s story can only be accomplished when the physician is able to relate to the foundations of what was said, and why so, by listening also on an emotional level. The empathy needed in medical practice is hence not only about caring and compassion, but also about clinical understanding. Yet, it is never possible to achieve a full understanding of the emotional meanings of another person [26]. The balance between rationality and emotions can help the physician find the adequate level of empathy in the individual case. Yet, a comprehensive interpretation of illness and disease in human individuals requires more than psychological emotions. In his article ‘The doctor, his patient and the body’ the Swedish family physician, Carl Edvard Rudebeck, proposes that clinical medicine neglects not only emotions but even more the lived and experienced body [27]. Paraphrasing Balint [17], he claims that the broom of objectivity sweeps the clinical room clean from lived experience. Drawing on phenomenological perspectives, he presents the concept of ‘bodily empathy’ as a clinical skill that the physician needs to understand the patient’s symptom experiences. Bodily empathy can only be exercised by physicians if they have learnt to appreciate reflexivity on a personal level. Realizing this, it can be possible to bridge the body-mind-connection and disturb the traditional dichotomy between emotions and rationality.

UNDERSTANDING SUFFERING – PREVENTING HUMILIATION Symptoms, worries and diseases may cause suffering. Patients see their physicians for treatment and cure, but also for support and consolation. Still, the physician-patient relationship holds the potential for abusive humiliation as well as healing therapy. Unfortunately, the former occurs more often than physicians realize. Patients with mental illness, chronic pain, or medically unexplained disorders have reported experiences of being met with scepticism and lack of comprehension, feeling rejected, ignored, belittled, and blamed for their condition [28, 29, 30]. Exploring power issues in clinical medicine, Thesen describes how and explains why doctors may take up the role of oppressor, realizing that most intimidations are unintended and even unrecognised by the oppressor [28]. From our own experiences, we know that this may happen in situations when we are more preoccupied with our best intentions than with the consequences of these for the patient. Although we never meant to intimidate him or her, patients are at risk of experiencing shame and humiliation in any medical encounter [31, 32].

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The Polish-British sociologist Zygmont Bauman explores tendencies in modern culture, taking the horrors of the Holocaust as his point of departure [32]. It is difficult to harm a person we touch. Bauman’s analysis explains how responsibility can arise out of the proximity of the other, while the invisible other is ‘a morally lost other’. With distantiation, I loose the sight of the person and thereby my moral responsibility to him or her. Bauman claims that the more rational the organization of action, the easier it is to cause suffering. The evils of the Holocaust cannot be inferred to the medical consultation, but the trends of rationality, efficiency and distantiation can clearly be recognized in the medical culture. Bauman’s analysis distinguishes between evil individuals and malevolence rendered possible by cultural traits. Thus, the issue of proximity may point to matters relevant for the unintended intimidations in clinical encounters. Normative ideals from biomedicine such as objectivism, distantiation and clinical detachment might contribute to the foundations of degrading behavior between human beings in clinical practice. Obeying the professional values of the system, including the measurable criteria of evidence, doctors can compromise their preconditions for moral performance. Yet, the moral systems of medicine also include a strong commitment to humanist values. We do not value emotions over reason. Still, we have demonstrated above that raising an awareness of the considerable importance of emotions, and thus contributing to a better balance between rationality and emotions, would make an essential difference to family medicine [33].

REFERENCES [1]

Thomas L. The Youngest Science: Notes of a Medicine-watcher. New York: Viking Press, 1983. [2] Sackett DL. Evidence-Based Medicine: How to Practice and Teach EBM. New York: Churchill Livingstone, 1997. [3] Berger J, Mohr J. A Fortunate Man: The Story of a Country Doctor. London: Readers Union, 1968. [4] Levenstein JH, McCracken EC, McWhinney IR, Stewart MA, Brown JB. The patientcentred clinical method. 1. A model for the doctor-patient interaction in family medicine. Fam Pract 1986; 3:24-30. [5] Elmore JG, Miglioretti DL, Reisch LM, Barton MB, Kreuter W, Christiansen CL, et al. Screening mammograms by community radiologists: variability in false-positive rates. J Natl Cancer Inst 2002; 94:1373-80. [6] Latour B, Woolgar S. Laboratory Life: the Construction of Scientific Facts. [New ed]. Princeton, NJ: Princeton University Press, 1986. [7] Malterud K, Candib L, Code L. Responsible and responsive knowing in medical diagnosis - The medical gaze revisited. Nora 2004; 12:8-19. [8] Nagel T. The View from Nowhere. New York: Oxford University Press, 1986. [9] Haraway DJ. Simians, Cyborgs, and Women: The Reinvention of Nature. London: Free Associations Books, 1991. [10] Schön DA. From Technical Rationality to Reflection-in-action, 1983.

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[11] Malterud K. The art and science of clinical knowledge: evidence beyond measures and numbers. Lancet 2001; 358:397-400. [12] Stein H. The role of some nonbiomedical parameters in clinical decision making: An ethnographic approach. Qualitative Health Research 1991; 1:6-26. [13] Polanyi M. The Tacit Dimension. Glouchester, Mass: Peter Smith, 1983. [14] Skelton AM, Murphy EA, Murphy RJ, O'Dowd TC. General practitioner perceptions of low back pain patients. Fam Pract 1995; 12:44-8. [15] Malterud K. Reflexivity and metapositions: strategies for appraisal of clinical evidence. J Eval Clin Pract 2002; 8:121-6. [16] Malterud K. Qualitative research: standards, challenges, and guidelines. Lancet 2001; 358:483-8. [17] Balint M. The Doctor, his Patient and the Illness. London: Pitman Medical, 1971. [18] Launer J. Narrative-Based Primary Care: A Practical Guide. Oxford: Radcliffe, 2003. [19] Undeland M, Malterud K. Diagnostic work in general practice: more than naming a disease. Scand J Prim Health Care 2002; 20:145-50. [20] Howie JG. Diagnosis-the Achilles heel? J R Coll Gen Pract 1972; 22:310-5. [21] Robichaud AL. Healing and Feeling: The Clinical Ontology of Emotion. Bioethics 2003; 17:59-68. [22] McWhinney IR. 'An acquaintance with particulars...' Fam Med 1989; 21:296-8. [23] Parsons T. Essays in Sociological Theory. Revised edition. New York: Free Press, 1964: 34-49. [24] Freidson E. Profession of Medicine: A Study of the Sociology of Applied Knowledge. New York: Harper and Row, 1970:158-84. [25] Encyclopædia_Britannica. Empathy. Online Academic Edition. http://search.eb.com/dictionary?book=Dictionary&va=empathy&vao=Entry+Word&rh =&rho=Rhyme&fl=&sl=&et=&dt=&df=&dfo=Defining+Text Accessed May 10 2006. [26] Code L. "I know just how you feel". Empathy and the problem of epistemic authority. In: More ES, Milligan MA. (eds.) The empathic practitioner. Empathy, gender, and medicine. New Brunswick, NJ: Rutgers University Press, 1994:77-97. [27] Rudebeck CE. The doctor, the patient and the body. Scand J Prim Health Care 2000; 18:4-8. [28] Thesen J. From oppression towards empowerment in clinical practice-offering doctors a model for reflection. Scand J Public Health Suppl 2005(66):47-52. [29] Johansson EE, Hamberg K, Lindgren G, Westman G. "I've been crying my way": Qualitative analysis of a group of female patients' consultation experiences. Fam Pract 1996; 13:498-503. [30] Malterud K. Humiliation instead of care? Lancet 2005; 366:785-6. [31] Lazare A. Shame and humiliation in the medical encounter. Arch Intern Med 1987; 147:1653-8. [32] Bauman Z. Modernity and the Holocaust. Cambridge: Polity Press, 1989. [33] Malterud K, Hollnagel H. The doctor who cried: a qualitative study about the doctor's vulnerability. Ann Fam Med 2005; 3:348-52.