Edvin Schei

Effecting change through dialogue: Habermas’ theory of communicative action as a tool in medical lifestyle interventions

Adjustments of everyday life in order to prevent disease or treat illness afflict partly unconscious preferences and cultural expectations that are often difficult to change. How should one, in medical contexts, talk with patients about everyday life in ways that might penetrate this blurred complexity, and help people find goals and make decisions that are both compatible with a good life and possible to accomplish? In this article we pursue the question by discussing how Habermas’ theory of communicative action can be implemented in decision-making processes in general practice. The theory of deliberative decision-making offers practical guidelines for what to talk about and how to do it. For a decision to be rooted in patients’ everyday life it has to take into consideration the patient’s practical circumstances, emotions and preferences, and what he or she perceives as ethically right behaviour towards other people. The aim is a balanced conversation, demonstrating respect, consistency and sincerity, as well as offering information and clarifying reasons. Verbalising reasons for one’s preferences may increase awareness of values and norms, which can then be reflected upon, producing decisions rooted in what the patient perceives as good and right behaviour. The asymmetry of medical encounters is both a resource and a challenge, demanding patient-centred medical leadership, characterised by empathy and ability to take the patient’s perspective. The implementation and adjustments of Habermas’ theory in general practice is illustrated by a case story. Finally, applications of the theory are discussed.

Decoding the genetics debate: hype and hope in Icelandic news media in 2000 and 2004

The attraction of human genetics is rooted in optimistic projections of possible futures, where present-day problems are to be solved by technologies-to-come. But hyperbolic optimism with its consequent cycles of expectations, investment and disappointment is a threat to users, investors, and the ethical reputation of the biotechnology field. We report a study of the entire news coverage of genetics in Icelandic mass media in 2000 and 2004. All media promoted optimistic industry-based information largely without critical questions concerning scientific uncertainty, health benefits, or ethical challenges. Criticism and deliberation were thematically narrowed down, in 2000 to the issue of “presumed consent” for nationwide participation in a database proposed by the company Decode genetics, and in 2004 to topics concerning Decodes finances. In a discourse of monetary gain and loss, sustained exploration of scientific, moral and cultural issues has little appeal.

Adolescent smoking prevention - primary health care in cooperation with local schools: A controlled intervention study

OBJECTIVE To evaluate a secondary school smoking prevention program in a small rural Norwegian municipality. DESIGN The project applied grade specific intervention strategies to all students grades 6-9 and comprised a total of 32 lessons over a period of 3 years, with high student activity. A non-randomised control group was constituted by all 6th-9th grade students in municipalities of similar characteristics in the same county. Results were recorded in annual class-based surveys. SUBJECTS The intervention group totalled 187 and the control group 364 students. MAIN OUTCOME MEASURES Prevalence of daily and occasional smoking and number of cigarettes smoked, during the intervention period. RESULTS An 80% lower rate of daily smoking and 50% fewer cigarettes smoked by daily smokers. Lower rates of smoking in 9th grade occurred mostly among girls. CONCLUSION The project resulted in a lower recruitment of daily smokers up to grade 9, as well as fewer cigarettes smoked by daily smokers. The intervention was more successful among girls than boys.

Complex Systems and Human Complexity in Medicine

Concepts taken from complex systems theory, such as ‘agents’ and ‘attractors’, have been proposed as metaphors in medical practice. This proposal is assessed by a comparison of the notions of complex adaptive systems (CAS) and human complexity. CAS are characterized by the emergence of sophisticated output features of rule-governed non-linear systems. Human complexity is the result of higher mental capacities and human culture. Failure to understand it in such terms may result in medical failure or medical ‘success’ in which the wrong problem is solved. CAS concepts may thus be useful in the solution of given medical problems, while their application may lead to an undesirable reduction of complexity in cases in which the identifi cation of the medical problem itself is part of the medical challenge.

What is a medical decision? A taxonomy based on physician statements in hospital encounters: a qualitative study

Objective The medical literature lacks a comprehensive taxonomy of decisions made by physicians in medical encounters. Such a taxonomy might be useful in understanding the physician-centred, patient-centred and shared decision-making in clinical settings. We aimed to identify and classify all decisions emerging in conversations between patients and physicians. Design Qualitative study of video recorded patient–physician encounters. Participants and setting 380 patients in consultations with 59 physicians from 17 clinical specialties and three different settings (emergency room, ward round, outpatient clinic) in a Norwegian teaching hospital. A randomised sample of 30 encounters from internal medicine was used to identify and classify decisions, a maximum variation sample of 20 encounters was used for reliability assessments, and the remaining encounters were analysed to test for applicability across specialties. Results On the basis of physician statements in our material, we developed a taxonomy of clinical decisions—the Decision Identification and Classification Taxonomy for Use in Medicine (DICTUM). We categorised decisions into 10 mutually exclusive categories: gathering additional information, evaluating test results, defining problem, drug-related, therapeutic procedure-related, legal and insurance-related, contact-related, advice and precaution, treatment goal, and deferment. Four-coder inter-rater reliability using Krippendorffs α was 0.79. Conclusions DICTUM represents a precise, detailed and comprehensive taxonomy of medical decisions communicated within patient–physician encounters. Compared to previous normative frameworks, the taxonomy is descriptive, substantially broader and offers new categories to the variety of clinical decisions. The taxonomy could prove helpful in studies on the quality of medical work, use of time and resources, and understanding of why, when and how patients are or are not involved in decisions.

Patients’ goals, resources, and barriers to future change: A qualitative study of patient reflections at hospital discharge after myocardial infarction

Background: Myocardial infarction (MI) patients may find it challenging to adhere to lifestyle advice and medications. Understanding motivational factors and barriers to change is crucial. However, empirical evidence on patients’ ability to effect lifestyle changes at the time of discharge is limited. Aim: The aim of this study was to identify at the time of hospital discharge the goals, resources, and barriers to future change in MI patients. Methods: We conducted a qualitative interview study with a purposive sample of 20 MI patients (eight women) in a cardiac department at a university hospital in Norway. All interviews were conducted before hospital discharge, transcribed verbatim, and analysed using qualitative content analysis. Findings: Three themes suggested that, at the time of discharge, patients’ views of their MI were complex and diverse. Patients were motivated to change their lifestyle and contemplated taking their life in new directions, adopting a change of life perspective. Frequently, patients struggled to understand the context of living with an MI, manage symptoms, and understand the precipitating causes of MI. There were also patients who wanted to maintain their present lifestyle and live as normal as possible. They just wanted to keep going. Conclusions and implications: There is a need for a different approach to communicating with MI patients at the time of discharge. Person-centred care that allows personal narratives to emerge may enable health-care professionals to offer more individualised guidance to MI patients that will help them cope with the everyday challenges they experience after discharge.

What constitutes competence? That depends on the task

General practitioners (GPs) are trained for and mandated to provide continuous healthcare to the general, unselected population in a low-threshold, local setting. This presumes as a paramount precondition that the doctor is competent as a medical helper of a large variety of people of all ages attending for an increasing variety of health-related problems or complaints. The central question as regards competence is this: How does the doctor conceptualize and understand the “entity” that enters the GPs office? If one identifies the subject matter of medicine as diseases, carried by (more or less) average patients, then adequate medical competence involves knowledge about diseases. Thus, the wider characteristics of the diseased persons become of secondary significance. Such a framework attributes to diseases the status of essences, affecting people in the same manner, and consequently representing the core entities in medical knowledge production. This view accords with the biomedical framework of human bodies and their functions being the sum of biological mechanisms that can be unambiguously classified, and to which group-based data can be applied to explain dysfunctional states and achieve therapeutic success. If, however, one perceives that what enters the GPs office is persons, who are or feel diseased, in other words “are not at ease with themselves”, quite a different competence is demanded. Then, knowledge of the person becomes key in a double sense: first, to enable the doctor to understand how personhood in general, and this person in particular, is affected by being diseased [1]; and, even more crucially, to make the doctor capable of “reading” the present dysfunctional state as an impact on this persons embodied life [2]. The significance of knowing about a persons lifetime experiences to understand the manifestation of current or chronic sickness has been ever more solidly documented during the last two decades of multidisciplinary research [3]. According to Eric Cassell, a person is “an embodied, purposeful, thinking, feeling, emotional, reflective, relational human individual always in action, (and) responsive to meaning. Virtually all of a persons actions – volitional, habitual, instinctual, or automatic – are based on meanings” [4]. Engaging with a diseased person in an adequate manner demands, consequently, the ability to accrue an understanding of this persons unique biographical and relational context, in other words, a historical, socio-cultural, and linguistic competence. This demand precludes predefined labelling of a persons ailment in general and of reports on complex malfunction in particular. However, both clinical practice and research are currently hampered by the fact that phenomena like complex malfunction, typically termed co- or multimorbidity, are ill defined. This is a consequence of the biomedical concept of the nature of human beings and human bodies, failing to account for the fact that humans are situated beings and, as such, embedded in systems of symbols and of socio-culturally established values [5]. This complexity was recently exemplified in a study of how Nordic GPs perform detached diagnostic labelling of patients. It was based on simulated, video-recorded consultations with a common denominator: a simulated patient presenting so-called subjective health complaints (SHC) to a GP [6]. Such a presumably objective approach to human beings may in itself represent an ethically questionable reduction of both doctors and patients for several reasons [7]. First, the premise is a framework defining the subject matter of the medical encounter to be diseases or symptoms and not persons who experience illness. Second, it is questionable whether concordance in choice of labels is a potential hallmark for system quality, especially when the matter at hand is poorly defined. Third, aiming at labelling instead of understanding means failure to fulfil the central prerequisite for proper treatment. Finally, a detached method, prohibiting a mutual relationship, allows for limited insight. The studys predictable result, a considerable heterogeneity of labels, elegantly demonstrates that the construction called SHC lacks an adequate theoretical basis, and that SHC cannot be classified in a valid and reproducible manner based on the biomedical aspect alone. This fact points to the fallibility of health politics anchored in diagnostically based statistics. It also underscores the need for re-conceptualizing human beings from a medical perspective. Human beings are embodied beings, living their lives incorporated as lived bodies. Consequently, the biomedical framework of the de-contextualized and depersonalized biological body, devoid of history and meaning, is of limited validity. Fortunately, researchers in a broad array of disciplines are currently accumulating knowledge demonstrating the impact of a persons experience on that persons body – and health [8]. In other words: the lived body, a phenomenology-derived concept subverting the mind/body dualism that still haunts biomedicine at its core, is entering into medical awareness [9]. General practitioners in the Nordic countries and, it is hoped, worldwide, may be the medical professionals who will most eagerly embrace this knowledge because it validates what most of them already know through their own accumulated professional and personal experience: human bodies are lived bodies, and lived life and health are indivisible.

Clinicians’ Power and Leadership

Despite medical leaders’ increasing acceptance of the idea that the whole person should be the focus of care, empirical studies show clinicians generally remain focused on narrower goals: disease categories, standardized treatment procedures, and objective measurements of health improvements. We assume doctors want to do a good job, consistent with their perception of the goals and norms of their profession, so they practice medicine based on the illusion that clinical medicine is “knowledge treating disease,” not people treating people. We believe that doctors’ seeming reduction of patients to clinical objects results from not seeing themselves as leaders for their patients or accepting their constructive power in clinical encounters.

[General practioners and patients' general life problems].

BACKGROUND Many contact general practitioners (GPs) about non-medical problems in their lives; a situation which may be frustrating for GPs. MATERIAL AND METHODS Semi-structured in-depth interviews with six Norwegian GPs by e-mail. The interviews were analysed according to a discourse analysis of which role the GPs considered they had, whether they saw themselves as therapists and how they perceived the personal strain related to working in general medicine. RESULTS The majority of GPs did not distinguish clearly between somatic and more general life-related problems. Nevertheless, they defined medical problems as quite strictly somatic and saw themselves mainly as experts in somatic medicine. They described themselves more as spiritual advisers (pastor-like) than as psychotherapists. Some meant that their work had given them more self- confidence and made them more tolerant, but many said they felt helpless in their role as doctors. INTERPRETATION GPs are doctors for all people. They have to relate to healthy and sick individuals with various medical and general life problems, and often experience a discrepancy between their medical competence and the challenges they meet.

Trustingly bewildered. How first-year medical students make sense of their learning experience in a traditional, preclinical curriculum

ABSTRACT Background: Traditional preclinical curricula based on memorization of scientific facts constitute learning environments which may negatively influence both factual understanding and professional identity development in medical students. Little is known of how students themselves experience and interpret such educational milieus.Objective: To investigate first-year medical students’ view of the physician role, and their perception of the relevance and quality of teaching in a science-based preclinical curriculum. Design: Focus group interviews with thematic text analysis. Results: Students portrayed the good physician as communicative, humble, and open, combining biomedical knowledge and moral strength. When asked how medical school supported the development of such characteristics, two partly contradictory discourses emerged. The critical discourse identified decontextualized knowledge, poor pedagogy, lack of critical thinking, and contact with faculty. Students who voiced critical comments also articulated trust that the system would provide the competence they needed, that basic biological knowledge is needed before clinical practice, and that being on your own conveys freedom and responsibility, and helps you grow up. Conclusion: Trust in the educational system, within a substandard learning environment, created cognitive dissonance that students resolved through rationalization, whereby they negated that factual overload and lack of relevance, reflection, and personal feedback was problematic. The cost of this mechanism is possibly that inferior teaching is perceived as normal, necessary, and good enough. If so, these future physicians’ ability to critically evaluate and create quality in medical education and practice, may be weakened.