a phenomenological analysis of doctor-patient interaction: a case study

Patient Education and Counseling 33 (1998) 83–89

A phenomenological analysis of doctor-patient interaction: a case study

a , b a*¨O. Hellstrom , P. Lindqvist , B. MattssonaDepartment of Family Medicine, Umea University, Umea, Sweden˚ ˚

bDepartment of Psychiatry, Umea University, Umea, Sweden˚ ˚

Received 20 November 1996; received in revised form 25 March 1997; accepted 22 June 1997

Abstract

The fact that the biomedical model has been very successful in practice does not preclude that some health issuescan be understood by way of other health care perspectives. Acquiring skills in meeting patients requires theoriesthat structure other fields of knowledge than the biomedical sciences. An old man, who experiences himself asdeeply misunderstood by the medical profession, is interviewed, his personal life-story is gone into and his caserecords and other available data are analysed. A phenomenological method is used, i.e. disciplined and rigorousreflection upon available data, remaining close to the particular pieces of the patient’s narrative as they stand forthin their contextual relationships. The study shows that the doctors involved did not relate to the patient but to abiomedical image of him. His efforts to make himself understood were converted into instrumentally manageabledisorders. Finally, dialogue medicine is briefly introduced as a model for counselling patients, especially when theyneed assistance to abandon the notion that they have been afflicted with a disease, a perception that might serve thepurpose of keeping a threatening self-image out of consciousness. u 1998 Elsevier Science Ireland Ltd.

Keywords: Phenomenological method; Clinical narrative; Dialogue medicine; Patient counseling

1. Introduction pretation of a ‘‘normal’’ bodily reaction. Theoret-ically, some patients may try to keep an un-

A major challenge for general practitioners wanted self-image out of mind by seeing an(GPs) is to improve their skills with regard to experienced illness as causing the sense of fail-perceiving what is implied and masked in the ure. An attentive and empathic attitude maymeetings with patients. A symptom may repre- facilitate the doctor’s efforts to see when this issent a vague first sign of an already established the case and to understand and meet suchorganic disorder, or alternatively an overinter- patients successfully. The concept of understand-

ing denotes that there is something underneaththe apparent to be captured. When two persons*Corresponding author. Current address: Vansbro Primaryunderstand something together, they share aHealth Care Unit, S-780 50 Vansbro, Sweden. Tel.: 1 46 281

498100; fax: 1 46 281 498116. ‘‘common communicative environment’’ [1].

0738-3991/98/$19.00 u 1998 Elsevier Science Ireland Ltd. All rights reserved.PII S0738-3991( 97 )00058-X

¨84 O. Hellstrom et al. / Patient Education and Counseling 33 (1998) 83 –89

Their expressions refer to this environment, that the field of doctors’ self-understanding whenmediates between them and makes them feel encountering certain (types of) patients. Bendixcoherent. Human beings are nourished by a [5] and Rogers [6] have dealt with the difficult artsense of coherence, i.e. a sense of meaning, of not directing the patient by e.g. asking ques-comprehensibility and manageability [2]. When, tions and giving advice. They argue that thetheoretically, the co-understanding is total, there dialogue can be kept going by nodding or repeat-is an absolute communication via an overarching ing what seems to be most significant and whatshared meaning. We normally use concepts with- the patient has just said. Some authors, e.g.out too much reflection upon their significance as Pendleton et al. [7], seem to focus on simplicitymediators of a feeling of affinity. An unaware- and clarity, sometimes at the expense of recog-ness of what there is that unites, seems to be a nizing the depth of the patient’s message. Mc-precondition of the co-understanding. A twist of Whinney [8] stresses the interactive aspect ofa funny story illuminates this: with laughter, one general practice. He refers to a map metaphorunwittingly indicates that one has heard also for concepts, theories and action programs: ‘‘Ifwhat is not told, i.e. implied by being part of its we are to be healers as well as technicians, wespecific context. To know the end of a joke in have at some point to set aside our maps andadvance reduces the joy. If one does not under- walk hand-in-hand with our patients through thestand a joke in the presence of the group mem- territory’’. The hand-in-hand metaphor bridgesbers who do, one becomes embarrassed, which to the mother-child relationship, which Winnicottmay serve a useful purpose. The demonstrated [9] has analyzed. Finkler [10], a social anth-lack of understanding indicates that one should ropologist, holds that biomedically educatednot be asked to perform the most important somatic doctors tend to focus on bodies rathertasks of the group. than on persons. Neighbour [11] argues that the

In this study an authentic case is analysed by doctor’s view of illness is a decisive part of hismeans of a phenomenological method. It is attitude when encountering patients. He char-meant to demonstrate and highlight an alter- acterizes the humanistic illness model as ‘‘a signnative way of understanding the origin and of frustrated human potential and an opportunitydevelopment of illnesses, where both doctors and for personal growth’’. Although Neighbour andpatients have been too adherent to preset ways many other spokesmen of general practice takeof thinking. We discuss the consequences of up interactionally important issues, the literaturefocusing on a biomedical model, having a diag- seldom considers the patient’s illness as a meansnosis as the primary goal, and also on a perspec- to find a substitute meaning-creating connectiontive where symptoms are seen as part of a human to the prevailing common communicative en-narrative context. Finally we present a dialogical vironment.interaction model for counselling patients ingeneral practice. The model is phenom-enologically inspired, based on the mother-child 3. Phenomenologyrelationship and as far as possible devoid ofbiomedical, psychosomatic, psychoanalytic and Phenomenological methods [12–14] are usefulother theories. A fundamental notion of the for developing knowledge of when and how tostudy is that human beings do not willingly cease find out and attend to the meaning-content ofto search for meaning [3], a propensity that patients’ illnesses. Phenomenological researchdecisively guides their communicative actions. goes back to Husserl [15], who held that con-

sciousness is intentional or directed, i.e. thenature of an object is determined by the subjec-

2. The doctor-patient relationship tive acts of a viewer’s consciousness. Thephilosopher Kay Toombs made a phenomeno-

Balint [4] has had a tremendous impact on the logical psychological investigation of her ownconsultation skills of Western GPs, especially in illness, multiple sclerosis, in order to explore the

¨O. Hellstrom et al. / Patient Education and Counseling 33 (1998) 83 –89 85

meaning of illness [1]. Her method comprises the to his aunt, telling her how he enjoyed himself infollowing: first, an effort to elucidate the manner town. Victor wondered why his aunt did notin which meaning is constituted; second, a com- reply. He stopped writing. (Later he learnt thatmitment to a radical reflection upon lived ex- his letters were not mailed).perience which requires setting theoretical com- After five years in the army, Victor was em-mitments and taken-for-granted common-sense ployed in a bank. At evening school he metpresuppositions aside; and third, an attempt to Anna. They became engaged in 1946. Havinguncover the invariant features of phenomena in similar jobs and much in common, they got onorder to provide a rigorous description of them. well together. Anna became pregnant. VictorToombs holds that phenomenology is an essen- supported her decision to have an abortion. Intially reflective enterprise and she starts with 1948, Anna and Victor ended their engagementwhat is given in immediate experience and turns but continued to see each other as friends. Atto the essential features of it as it presents itself this time Victor experienced that ‘‘something hadto consciousness. She finds that doctors’ and happened within his body’’. He went to see apatients’ respective interpretations of illness dif- doctor six months later and was convinced thatfer radically and suggests that this is a conse- he had been afflicted with a disease. Victorquence of their relating to two disparate com- gradually became tired and irritable and lost hismunicative environments. vigour. He still met Anna during this period,

although their friendship was ebbing away.

4. Material and method 4.2. The research procedure

4.1. The case Is the essence of Victor’s experiences withinthe medical realm to be seen as just a private

When Victor, 80, was first interviewed, one day adventure or is it an illustration of a generalin October, 1995 at two o’clock in the afternoon, pattern and thus of a medical-theoretical inter-he was lying in bed complaining heavily of est? Can the analysis give rise to an improvedweakness and tiredness. For almost 50 years he attitude for meeting patients in general, whosehad tried to get rid of the label ‘‘incipient messages thus might be better understood?schizophrenia’’. Since 1960 he had struggled to The data, collected by one of the authorsbe confirmed as suffering from a chronic fatigue (OH), resulted from an initial audio-taped andsyndrome. transcribed interview with Victor that lasted for

At the age of two Victor was left by his three hours, notes from telephone calls withunmarried mother to a maiden aunt in a small Victor and two meetings with Anna, completefishing village. He often accompanied fishermen photocopied hospital case records from 1949 andout to sea. As a ten-year-old boy he could 1963, correspondence between Victor and differ-manage a boat and all kinds of fishing gear. He ent authorities, and an autobiography written bygrew up and was formed by the sea, among Victor in 1981. Available data were repeatedlyconfident old men, boats, and the smell of tar, gone into and analyzed by the authors individual-and with the warmth of his aunt. Occasionally he ly and co-operatively.saw his natural mother. One day, when Victor, Following Toombs, we tried to discipline our11, had been out to sea and now returned to the presuppositions, put aside our preunderstandinglanding stage, his mother and an unknown gen- and be open to the empirical data in order totleman stood waiting to pick him up and take ‘‘uncover the invariant features of the investi-him back home to a nearby town. He still gated phenomenon’’ [1]. First, we made an effortremembers how he steered with one foot while to get a good grasp of the texts from a holisticthrowing the ropes onto the landing stage. Victor point of view, reading them again and again,abruptly had to say good-bye to his aunt. ‘‘listening’’ attentively and asking no (directed)

His stepfather initially helped Victor to write questions. Thereafter we opened up more inten-


sively to particular text fragments, interpreting in pyjamas, meticulous, creature of habit. Firstthem in the light of the narrative as a whole. he thought that he had got a lung disease,

then malaria. Enjoyed working....

5. Interpretations The psychiatrist seemed to perceive Victor’sposition that he had been afflicted with a contagi-

In 1949, Victor first went to an internist, who ous disease as incoherent or even obnoxious. Thecould not find such signs of a somatic disease as patient was offered a medically recognized thera-would enable him to make a diagnosis. Victor peutic means, insulin injections, meaningful in ainsisted on making himself heard. His voice did biomedical context of that time. The symptomsnot chime with the biomedical model. The doctor were mentioned in Victor’s files and considered,resorted to the ad hoc hypothesis it has to be although rather one-sidedly. The doctors’ opin-something mental, labelled Victor’s behaviour ions of Victor’s attempts to put insidious ques-‘‘incipient schizophrenia’’ and sent him to a tions were frequently to be found in the files. Itpsychiatrist. The psychiatrist wrote in Victor’s was stressed that some examinations and labora-file: tory tests were ordered at the request of the

patient and hardly warranted from a medicalThe patient is as unreasonable now as when point of view. Victor was called ‘‘ixoid’’, whichhe arrived here seven weeks ago. He very connotes that he was perceived as stubbornlyreluctantly agreed to an insulin treatment, but persistent in his attempts to present and hold onthought that it was absolutely useless. When it to his own view. One psychiatrist was explicitlycomes to his subjective symptoms, see his two disappointed that Victor did not understand thatlong written reports. We have made a lot of he suffered from something else than he himselfinvestigations, e.g. spinal puncture, at his own believed.request. All of them, including eye examina- The doctors seemed to watch for a specifiction, have been negative. In spite of all these condition rather than try to understand and meetefforts he has been completely firm in his the patient in his endeavour to be seen andconviction that he suffers from a contagious listened to. They seemed to decide about thedisease. We have been presented with a lot of contents of the dialogue. Victor’s personal viewquestions to reply to, consistently and rigor- interfered with the doctors’ preset idea of how toously structured on a sheet of paper. We have perform meaningful medical actions. What isnever been able to avoid long and difficult missing is any recognition on the part of thediscussions, where his intention obviously has doctors that Victor might have been displayingbeen to make the doctors both present con- secondary gain or unintentional efforts to fill thetradictions and give answers that are meant to unthinkable with an image that certainly de-support his own personal ideas. mands suffering but that nevertheless is still

better to live with than what is suppressed by theAfter having interviewed the mother, the same experienced symptoms. The two parties seemed

psychiatrist wrote: to be captured by their respective preset ideas,the psychiatrists by the prevailing biomedical

In February this year (1949) he began to be diagnostic culture and Victor by his image thatvery complaining and troublesome, everything he had been infected.was wrong. Most of all he was nagging at his The psychiatrist who reflected on the signs ofmother. She was to blame for his having been schizophrenia noted Victor’s tendency to turnborn. Overtime work last winter. Worked until inwards, his compulsive behaviour, lack of amidnight. Then sitting with his corre- sense of humour and insufficient mutual interac-spondence courses, sometimes till half past tions. It was to be noted that the psychiatrists didthree in the morning. Never out, not dressed, not interpret Victor’s actions as representing a


wish to convey something personally significant, disorder. If he had been suffering from a chronicalthough in a disguised way. They focused on psychosis, it is unlikely that he would have kepttraditional medical symptoms and signs and himself as clear and logical as he now appears.asked if Victor had had a temperature, if he hadheard voices, felt himself watched or affected bysomeone or something. Judging from the context, 6. Dialogue medicine and patient counsellingthe questions were intended to confirm or dis-confirm a traditional diagnosis of Victor’s be- Deep knowledge of Victor as a person and ofhaviour. Alternatively, Victor’s presentation of his history is needed in order to understand hishimself as ill could have been ascribed to his actions and the personal context of meaning thathuman option to keep something unbearable out nourishes and gives rise to them. The dataof consciousness. This would have increased their implies that many of the actors involved ascribepropensity to listen to Victor’s ‘‘voice’’ [16]. their preset meaning to Victor’s behaviour. We

According to the psychiatrist’s notes from interpret their actions as if they do not relate tointerviewing Victor’s mother, she preferred a Victor as a person, but to a constructed image,picture of her son’s illness that relieved her affected by the medical context at the time, andconscience from thoughts about her responsibili- of limited use for managing personal issues. Theyty for his childhood and its connection to his seem to comply with a common communicativehealth. Not surprisingly, she held on to an image environment that does not include Victor’s prob-that Victor was afflicted with a disease, for which lem area. Thus they avoid dealing with issuesneither she nor her son could be blamed. (She that they do not know how to manage.was not informed of the abortion). One way to investigate the significance of

When Victor voluntarily re-entered the psychi- Victor’s experiences is to relate to him as aatric clinic in 1963, he was ascribed the diagnosis reader relates to a text [16]. In order to under-of insufficientia astenica prolongata, i. e. long- stand a narrator’s text, generally speaking, onelasting insufficiency because of weakness. This must listen to the meaning that graduallylabelling used to cover a condition characterized emerges. One cannot know the meaning beforeby diffuse and varying symptoms of unknown starting to read. In order to reach the originalaetiology. Victor’s goal in respect of this hospital intention of a text, which gives the story itsstay was to have the diagnosis of incipient authentic consistency, one must, however, beschizophrenia eradicated from his file. He failed, narrative-oriented and open-minded, and resistand decided to stay home from work until this one’s personal need to have the significance ofhad been done. Victor got a disablement pension one’s own ideas confirmed by the text.at the age of 48. His long-lasting struggle was in Judging from what has come out of the data,vain. In 1981, parts of the files were destroyed by from what we now know through talking to him,the expert psychiatrist of the Swedish National and in the light of almost 50 years of illness,Board of Health and Welfare. As Victor’s pri- Victor seems not to manage without an illness.mary goal was to be confirmed as a person We believe that one of Victor’s most significantsuffering from a somatic disease, the reaction of present and past problems is his profound loneli-the authority did not support his efforts to obtain ness. Perhaps he protects himself from self-accu-redress. sation by maintaining a notion that his life-situa-

At present, Victor is confined to his small flat tion is due to something that he can hardlyand has very few social contacts. He maintains direct. Thus Victor lets himself be absorbed bythat he experiences a profound fatigue and the experience of having been afflicted with aseldom leaves his bed, although physically in disease whose presence can be neither confirmedgood shape. What seems to keep him going is his nor disconfirmed. This helps Victor to hold on tocontinuous efforts to be confirmed as suffering the conviction that others are to blame for hisfrom a contagious disease and not from a mental sense of profound meaninglessness. Lately, re-


peated interviews have indicated that Victor in order to find an alternative, diseaseless basispromptly responds with fear when an interpreta- for the patient’s sense of coherence [2]. Accord-tion happens to be implied that contradicts his ing to Strasser [18] the fundamental laws of trueself-image. This might threaten his deliverance dialogue are the following: first, the doctor’sstrategy. Probably it is not by pure chance that adjusting himself to the person in the meeting;he vigorously wants doctors to accept his view of second, complying with the object of thehis suffering. Could one think of a more effective dialogue in companionship with the patient; andway to unwittingly escape from an image that it third, approaching the matter under discussion asis still worse to be aware of? open-mindedly, sensitively, attentively, patiently

Victor’s obsessive idea about being ill as well and hopefully as when the dialogue partneras thwarted drives him into total isolation. He himself is met. The ambition of dialogue medi-dislikes doctors and keeps a distance by being cine is to apply biomedical knowledge withformal during interviews and telephone calls, judgement in order to make room for the patientalways striving to maintain his prevailing self- to dare and find it meaningful and worthwhile toimage. Retrospectively, it might have been quite co-operate in revealing his present image ofa different life for Victor if the doctors in 1949 himself. Together the doctor and the patient tryhad curtailed their ambition to approach him by to find the patient’s uniquely organised way ofmeans of biomedical knowledge and had entered being nourished by a substitute sense of mean-into a dialogical co-operative search for new ing. An opportunity to reach meaning is irresis-meaning. Then they might not have unwittingly tibly attractive for the patient. The dialogueencouraged Victor to hold on to the conviction partner wants to understand him as a person withthat the medical health system was to blame for all his good and bad sides. Ideally, he trusts thethe course of his life. doctor and feels confident enough to accept the

Sometimes patients like Victor seem to need a challenge. According to Crafoord [19], a patientdoctor to help them to regain a constructive can best be perceived as a narrative. Thus thecontact with a sense of coherence and meaning. doctor listens empathetically to the ‘‘text’’, itsAfter having established the necessary relation- emotional resonance and implicit meaning. Heship the doctor can facilitate the growth of a listens to the way the patient addresses him, togenuine dialogue [17] by saying e.g: ‘‘Well, what- the contradictions of the text, to his own feelingsever your problem is, we won’t be delaying the and to what is kept untold. He also tries tofinding of a serious bodily disorder if we don’t follow his own wordless mood. Dialogue medi-make immediate further explorations or let a cine provides the patient with an option to bespecialist see you at once. Anyway it isn’t mental. held [9], seen and heard in an allowing way thatYou have symptoms, haven’t you? By the way, I encompasses much of the relationship between ado hope you see that I’m not saying that you’re ‘‘good enough mother’’ and her child [9].just imagining your problem or that you’re justafter sick-leave’’. If the content of this message(here condensed) is appropriately accepted, the 7. Conclusionpatient might respond: ‘‘It isn’t the body, it isn’tmental, and it isn’t... well, what is it then?’’ To The dominant feature of the phenomenonthis the doctor might respond: ‘‘Yes, indeed, which is the subject of this study is the doctors’what is it? Let us work it out together!’’ [17]. tendency to apply an action-repertoire that relies

Thus the encounter is converted from an exclusively upon a biomedical model that is ofasymmetrical subject-object relationship into a doubtful use for the patient. (Cf. Balint’s conceptsubject-subject relationship, a crucial stage in ‘‘apostolic function’’ [4]). This attitude supportsclinical dialogue practice. The goal of the the patient’s unwitting efforts to maintain hisdialogue is no longer a biomedically oriented self-image as afflicted with a disease. Thus thediagnosis but a co-operation in a shared project doctors overlook the patient’s option to be met


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[1] Toombs SK. The meaning of illness - A phenomeno-logical account of the different perspectives of physician

a phenomenological analysis of doctor-patient interaction: a case study

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