[Hans-Christian Deter (Hrsg): Die Arzt-Patient-Beziehung in der modernen Medizin]

 Wilhelm Rimpau <sup>1

1</sup> Berlin, Germany

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Bibliographical details

Hans-Christian Deter

Die Arzt-Patient-Beziehung in der modernen Medizin

Verlag Vandenhoeck &amp; Ruprecht, Göttingen

year of publication: 2010, € 19,95, 344 pages

Recension

To mark his retirement as Director of the Department of General Medicine, Naturopathy, Psychosomatics and Psychotherapy at the Benjamin Franklin Campus of Berlin’s Charité University Hospital, Dr. Hans-Christian Deter has gifted himself and readers with a compilation of articles presented at and resulting from a symposium held in 2009 to commemorate the 30th anniversary of the establishment of the Department of Psychosomatics at the Benjamin Franklin Clinic in Berlin. According to the forward written by Günther Jonitz, President of the Berlin Chamber of Physicians, the 40 contributing authors answer the question as to the importance of physician-patient interaction. David Sackett, the father of evidence-based medicine, once observed that “the most powerful tool you’ll ever have is your own personality.” Jonitz breaks down this statement into four areas which he feels should be addressed: “narrative-based medicine,” in which the physician learns to understand the patient’s story; the “medical humanities,” which use art, literature, history, religion and, dare I add, philosophy to sensitize medical professionals to their patients; “health literacy,” which serves as a means of improving patients’ ability to evaluate scientific information; and the “shared decision-making model,” which views the physician-patient relationship as a partnership when making medical decisions. Together, these topics along with the book’s title reflect “modern medicine.”

In current scientific literature, the trend is to cite sources that are no more than 10 years old based on the assumption that earlier research findings and literature are “prescientific.” Deter’s reference to Michael Balint in the introduction and the four articles in the chapter on “Continuity and change in the physician-patient relationship” controvert and disprove this belief. D. Janz’s short article recalling Viktor von Weizsäcker’s pathic pentagram “as the basis for understanding the physician-patient relationship” is particularly impressive as he demonstrates how it represents an attitude required for both compliance - or, better yet, adherence - and shared decision-making. A group of researchers from Heidelberg call shared decision making a new “form of the physician-patient relationship.” But, is it really new? When reading the article, it is striking to see just how shared decision making is becoming a “field of research on physician-patient interaction.”

In 2001, the protagonists advocating a reform of medical research, practice and education wrote an article for this journal discussing the most important implications of 20th century developments for 21st century practice (H.G. Pauli, K.L. White, I.R. McWhinney [1]). It is extremely interesting to be able to draw comparisons between their article “Medical Education, Research, and Scientific Thinking in the 21st Century” and the collection of hypotheses and conclusions in Deter’s book that have since been lived, researched, experienced, reflected on and acknowledged by both a patient and representatives from the fields of psychosomatics, psychotherapy, internal medicine, orthopedics, occupational medicine, neurology, psychiatry, general medicine, psychology, social medicine, the history of medicine, offices of student affairs, nutrition education, physiotherapy and expressive therapy. The reason for the one-sidedness of science-based medicine was and is the linear cause-and-effect model stemming from the work of Descartes and Newton. The result: a monocausal and reductionist biomedical paradigm, or “belief system” [2]. Thomas S. Kuhn’s world-renowned analysis states that, at any given point in time, science is based on certain paradigms that usually change. However, the extreme successes of medicine’s currently established paradigm have kept it from undergoing such a shift. “Soft” sciences are often compared to the “hard sciences” and marginalized, and diseases are still seen as “entities.” A highly productive biomedical approach to medicine has come to dominate all aspects of medical research, education and care. Opposition to the established reductionist paradigm occurs today by “theorizing” about enhancing “conventional” medicine with “alternative” medicine or about the non-contradictory nature and possible combination of high-tech medicine and humanism, with the latter referring to an attitude requiring that physicians “be kinder to patients.” The decades-old theory of the inseparability of the observer and the observed has been almost completely disregarded. According to this theory, the observing “subject” has a significant influence on the way he or she perceives more complex observed “objects,” which means that it is possible for physicians and patients to experience a shared reality. Together, Jakob von Uexküll’s “functional circle” and “theory of meaning,” Viktor von Weizsäcker’s “Gestaltkreis,” and Thure von Uexküll's “situational circle” form the “somatopsychosociocultural model” necessary for enhancing the current “basic sciences.” Epidemiology, psychology, sociology and narrative-based medicine would then become the pillars of medicine. Otherwise, it wouldn’t be medicine at all. For medical education and continuing education, this means asking not only the didactic question of “how,” but also the questions “where” and “what.” However, how can any reform take place when medical education curricula have been decided solely from the ivory tower of the highly specialized academic elite? In 1961, K.L. White wrote an article describing the ecology of medical care. Researchers then updated his findings in 2001 [3]. White’s initial report found that out of 750 individuals experiencing illnesses or injuries, 250 visited their physician, nine were hospitalized and only one was treated at a university medical center. If the mere one individual referred to a university medical center represents what students and aspiring medical specialists have to study from, where does that leave room for the breakthroughs of public health, the salutogenic research of Aaron Antonovsky, and Viktor von Weizsäcker’s concepts of a combined social and general medicine ? in other words, a “biosemiotic way of thinking”? Pauli et al.’s proposed mission for the 21st century is to close the gap between the natural sciences and the humanities. The studies included in the seven chapters of Deter’s book cover issues which Pauli et al. felt needed to be addressed in order for this to take place, making the book a truly valuable resource, as it contributes to a long-needed new way of thinking and serves as a practical account of and guide to the everyday work and experiences of physicians.

A group of researchers from Freiburg explain in their article that the physician-patient relationship should no longer be considered “metaphysical” since it has a neurobiological correlate in the mirror neuron system. The article “The use of narrative in treating severe emotional stresses” discusses the topic of narrative-based medicine which has come to be the focus of numerous studies, including those on somatic illnesses, over the last 20 years [4]. In everyday practice, physicians administer placebos in 60-70% of patient cases. In this book, the role of “The physician as a placebo” is only examined within the hidden treatment paradigm. The article discusses the power of suggestion, therapeutic rituals, attachment and physicians’ emotional skills, but does not discuss potential nocebo effects. Although patients’ expectations and previous experiences with a desired outcome have a crucial impact on the effect of a placebo, the effect of the behavior and expectations of the one administering the placebo - namely, the physician - could also be addressed. When studies are presented today comparing treatment groups to placebo groups, is it still acceptable to disregard such a Hawthorne effect? K.L. White wouldn’t think so. The findings of a conference of experts seeking to obtain “An interdisciplinary view of a ‘good doctor’” show that although the medical knowledge and skills of medical students is increasing, their communication and psychosocial skills are decreasing. Over the years, the Murrhardter Kreis, a research group on medical education, has developed recommendations for meeting the needs and changing the face of future physicians, with focus being placed on physician skills [5]. Do the findings of the expert conference then mean that the recommendations proposed by the Murrhardter Kreis in 1995 have not been implemented? As attested by the well-written contributions from Basel discussing the learnability of good physician interview skills and from Berlin on the physician-patient relationship in the medical curriculum at the Charité University Hospital, curricular reforms have, in fact, started to remind university medical centers that student needs are just as important as external funding and research. Hopefully, this is also a good sign amidst the crisis with the reformed medical program in Berlin. A well-founded study from Sweden describes the psychosocial risk factors for cardiovascular diseases, the consequences of certain behaviors, and pathogenic mechanisms. As an example of findings from public health research, the article provides evidence of a correlation between higher levels of morbidity and mortality and lower social status. Finally, an argument that it is better to focus on the actual relationship between physician and patient when talking about the physician-patient relationship rather than simply looking at the individual situation of a physician treating a patient. A study from Berlin on chronic pain sufferers confirms the old clinical observation that pain and imaging findings are not always necessarily correlated. As an example, the study reported findings from another study which performed magnetic resonance imaging on the lumbar spine of individuals not experiencing any pain and found that, depending on age, 20-40% had herniated disks, 60-80% had bulging disks and 34-93% had degenerated disks. The contributing physiotherapist was right then when she experienced that “the back is closely linked to the ‘soul’.” Another article from Berlin depicts just how “endlessly painstaking” the therapeutic relationship with eating disorder patients can be. Two other pieces are dedicated to the unique conditions of psychotherapeutic care in former East Germany and to the trauma of political incarceration and persecution still being experienced by people even 20 years after the fall of the Berlin Wall. Clear examples of the transcultural characteristics of the physician-patient relationship are provided by an article describing experiences with Turkish migrants in a practice in the Kreuzberg district of Berlin and one describing observations of a communication training workshop held with oncologists in China. The take-home message from these two articles that should shape the way we treat the people making up nearly 20% of the German population is that “migrants should not be seen as ‘deficient’ citizens, but as people with their own traditions and backgrounds.” As one patient reported: “Other doctor talk and talk, does not touch, does not make things better, does not understand anything about me.” This “understand” here means understanding the patient not as an individual, but as a part of an ethnic group. In such cases, treatment becomes family therapy. Whereas most German patients are accustomed to having their symptoms fit a single diagnosis, the same is not the case for migrants or the Chinese. Dörner’s proposal [6] that a third party be brought in to help facilitate interaction between the physician and patient seems to be a particularly attractive option for such cases. A study seeking to determine why “young medical professionals in Germany turn their backs on German hospitals” found that one of the main reasons is that health is threatening to become a mere commodity associated with a tendency to dehumanize the patient. In line with these findings, a task analysis of physicians’ activities conducted as part of a study from the field of occupational medicine revealed that physicians have a mere two minutes to speak with each patient each day. Astonishingly, up to 400 different forms of psychotherapy have developed since Freud’s analysis of transference in 1912. Approximately 5 million people in Germany require psychotherapeutic treatment each year. In this book, light is shed on the role of the physician-patient relationship in individual psychotherapy. In addition, two forms of psychotherapy - long-term psychoanalysis and short-term psychotherapy - are compared for their effectiveness and cost-effectiveness in reducing symptoms (PAL Study). Essentially, no differences were found between psychoanalysis and psychotherapy.

This book is recommended to a wide range of readers who are able grasp Deter’s view of human medicine as “an action science and not just a natural science”. According to the historical and practical experiences recounted in this book, it is both possible and necessary for this society “to want and be able to sustainably practice person-centered medicine” without having to “reinvent the wheel.” To quote D. Janz, the senior of the book’s authors, “being right always gives a sense of satisfaction, doesn’t it?”

Competing interests

The author declares that he has no competing interests.

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References

[1] Pauli HG, White KL, McWhinney IR. Medizinische Ausbildung, Forschung und wissenschaftliches Denken im 21. Jahrhundert. Z Med Ausbild. 2001;18:191-205.
[2] Engel GL. Wie lange noch muß sich die Wissenschaft der Medizin auf eine Weltanschauung aus dem 17. Jahrhundert stützen? In: Adler RH, Herrmann JM, Köhle K, Schoenecke OW, von Uexküll T, Wesiak W (Hrsg). Psychosomatische Medizin. München: Urban & Schwarzenberg; 1996. S.3-11.
[3] Green LA, Fryer GE Jr, Yawn BP, Lanier D, Dovey SM. The ecology of medical care revisited. N Engl J Med. 2001; 344(26):2021-2025. DOI: 10.1056/NEJM200106283442611
[4] Greenhalgh T, Hurwitz B. Narrative-based Medicine – Sprechende Medizin. Bern: Huber; 1998.
[5] Murrhardter Kreis. Das Arztbild der Zukunft. Analysen künftiger Anforderungen an den Arzt. Konsequenzen für die Ausbildung und Wege zu ihrer Reform. Gerlingen: Bleicher; 1995.
[6] Dörner K. Der gute Arzt – Lehrbuch der ärztlichen Grundhaltung. Stuttgart: Schattauer; 2003.