Post on 16-Jan-2016
Thomas Kühlein, Wonca Basel 19.September 2009
The social construction of our medical reality and the prevention
of overmedicalization
Thomas Kühlein
Why words are important
Thomas Kühlein, Wonca Basel 19.September 2009
Agenda
• Diagnoses and classifications – a short trip to the borders of linguistics and philosophy
• The most difficult thing for doctors and their patients is not to act with good reasons
• Quarternary prevention – the prevention of unnecessary medicine
Thomas Kühlein, Wonca Basel 19.September 2009
Thomas Kühlein, Wonca Basel 19.September 2009
Illness problems are the principal difficulties that symptoms and disability create in our lives
Disease, however, is what the practitioner creates in the recasting of illness in terms of
theories of disorder. Disease is what practitioners have been trained to see through the theoretical lenses of their particular form of
practice. That is to say, the practitioner reconfigures the patient‘s and family‘s illness
problems as narrow technical issue
Arthur Kleinman, The Illness Narratives – Suffering Healing and the Human Condition, Basic Books 1988
Thomas Kühlein, Wonca Basel 19.September 2009
The semiotic triangle of Ogden und Richards
Ogden CK, Richards IA, The Meaning of Meaning: A Study of the Influence of Language upon Thought and of the Science of Symbolism.
Harcourt Brace Jovanovich, Florida 1989
“A sign is always a stimulus similar to some part of an original stimulus and sufficient to call up an engram formed by that stimulus”
concept/ disease
word/ symbol/ diagnosis individual illness
Thomas Kühlein, Wonca Basel 19.September 2009
“The classical categories that we do encounter usually have a special status; they are what
we might call ‘expert categories’. “
Taylor JR Linguistic Categorization, Oxford University Press, Oxford 2003
Who were the experts that taught us the concepts behind
our disease labels and by whom and how are they
influenced today?
Thomas Kühlein, Wonca Basel 19.September 2009
the patients life
The GPs view
the specialists view
Ursus Wehrli, Noch mehr Kunst aufräumen, Kein & Aber Verlag 2006
Ludwig van Beethoven, Für Elise,
The whole is more than the sum of its pieces
Thomas Kühlein, Wonca Basel 19.September 2009
Cited from Taylor JR Linguistic Categorization, Oxford University Press, Oxford 2003
Thomas Kühlein, Wonca Basel 19.September 2009
To utter a word is just as if we strike a key of the piano of
imaginationLudwig Wittgenstein, Philosophische Untersuchungen,
Suhrkamp Verlag, Frankfurt a.M. 2003
Labelling objects has consequences
Thomas Kühlein, Wonca Basel 19.September 2009
If we confuse disease and illness and if we confuse
diagnosis and risk factor we are in danger to miss the needs of
our patients
Thomas Kühlein, Wonca Basel 19.September 2009
Quarternary prevention means to prevent overmedicalization
Thomas Kühlein, Wonca Basel 19.September 2009
two patients groups are especially in danger of overmedicalization
1. The worried well who get risk factors as disease labels by their doctors (their illness is their worry)
2. Patients with somatoform or medically unexplained symptoms who have illness without an acceptable disease label
Thomas Kühlein, Wonca Basel 19.September 2009
1. The risk factor model - a major driver of our fears and
actions in medicine
Thomas Kühlein, Wonca Basel 19.September 2009
“Risk factors provide a…scientifically rationalized framework for managing
uncertainty”
“Contemporary risk factors are often talked about as diseases in
their own right, especially hypertension and hyperlipidemia,
defined by (often arbitrary) statistical cut-offs.”
“… for the physician, the carrot in the national cholesterol campaigns was the creation of new reimbursable medical diagnoses that have specific definitions and treatments, as do other “real” diseases.”
The Social Construction of Coronary Heart Disease Risk Factors,
in Aronowitz RA, Making Sense of Illness – Science, Society and Disease. Cambridge University Press, Cambridge 1998
Thomas Kühlein, Wonca Basel 19.September 2009
2. Somatoform (medically unexplained) symptoms –
an old game between patients and doctors
Thomas Kühlein, Wonca Basel 19.September 2009
“…the volume of perceived aches, pains, and weariness has probably
changed little historically. What changes is people’s readiness to
seek medical help for these symptoms, to define them as
disease, and to give them fixed attributions”
“The surrounding culture provides our unconscious minds with templates, or models, of illness…. Today the media more than any other conduit tell us about the symptom pool”
“…the relationship between doctors and patients is reciprocal: As the ideas of either party about what constitutes legitimate organic disease change, the other member of the duo will respond.”
Shorter E, From Paralysis to Fatigue – A History of Psychosomatic Illness in the Modern Era. The Free Press,
New York 1993
Thomas Kühlein, Wonca Basel 19.September 2009
Reality can be changed, and thus overmedicalization
prevented, if we recognize and keep in mind that major
parts of our medical reality are socially constructed
Thomas Kühlein, Wonca Basel 19.September 2009
Quarternary prevention, the prevention of
overmedicalization, is the task of the general practitioner