Doctors, Patients and Relationships
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L_I " Tony Dixon, MD, CCFP Doctors, Patients and Relationships THE THEME of this month's is- else than the manifold relations in a social system with the heterogen- sue is the relationship between between these two groups. The icity of solid, liquid, and gaseous doctors and their patients. It is not a history of medicine, therefore, phases in the physico-chemical sys- topic with which physicians have al- cannot limit itself to the history of tem. This connection found its ex- ways been very comfortable. Indeed science, institutions and characters pression in a classic paper entitled some would suggest, as did W.R. of medicine, but must include the "The doctor and patient as a social Houston' back in 1938, that it seldom history of the patient in society, system",4 the central thesis of which enters their professional conscious- that of the physician, and the his- is that through their relationship phy- ness: tory of the relations between phy- sician and patient eventually reach a Historians sentimentalize the prac- sician and patient. state of interdependent balance. tical values of ancient medicine. This idea that the relationship was Henderson's ideas were taken fur- One scans the pages of Hippoc- related not just to two individuals, ther by the American sociologist Tal- rates in vain for any treatments of but to the society to which they be- cott Parsons,5 for whom the central specific value. The pages of medi- longed was also expressed by Bastide3 theme of illness was the risk it offered cal historv read like the loi of an when he wrote: to such a balance: %" AAX1716jL AII%_ ALK%A_ XWss5 %-I "II old fashioned ocean voyage, in which it is noted that on such a day a whale spouted, on such a day a flying fish was sighted, or a bit of driftwood, but in which no men- tion is made of the huge prevailing fact that what was constantly seen day to day, almost to the exclusion of other sights, was the unending green waste of water. And this in- evitable circumambient ocean is, by analogy, in medical history the personal relationship between doctor and patient. It seems a little unfair to put all the blame on historians for ignoring this relationship when physicians seem to have studiously avoided the topic themselves. But if historians were to blame, it was an historian, Henry Sig- erist, who set about redressing the balance. Sigerist was one of the first to express the idea that what he called the "medical ideal" was differ- ent in different periods of history, and that this ideal was determined by the structure of the society at the time and by its general conception of the world. He looked at the relative places of physicians and patients in different societies and concluded:2 In every medical action there are always two parties involved, the physician and the patient or, in a broader sense, the medical corps and society. Medicine is nothing CAN. FAM. PHYSICIAN Vol. 35: JANUARY 1989 Behind the patient is the whole weight of collective representa- tions which he and his friends have of.. .illness, and behind the doctor are the systems he learned in books and during his training. The therapeutic dialogue is therefore an exchange between two ele- ments of society rather than two individuals. How can such a relationship be described? How is it possible to grasp such an abstract concept? Unlikely as it may seem, it was the field of physi- cal chemistry that was to provide a powerful and enduring analogy. L.J. Henderson was a physical scientist (his name was immortalized in the Henderson-Hasselbach equation, which those of my generation may re- member wrestling with during the darker days of medical school life), who later in his career turned to the social sciences. His early work was influenced by Willard Gibb, who had proposed a generalized physico- chemical system of a unified whole composed of interdependent parts, in which change in any one part of the system sets off variations throughout the whole of the system until a state of balance is regained. Later, when the Italian sociologist Pareto described a social system made up of individuals, Henderson saw an analogy between the hetero- genicity of individuals as components The problem of health is intimate- ly involved in the functional pre- requisites of the social system- ...too high an incidence of illness is dysfunctional...because illness incapacitates for the performance of social roles... In so far as it is controllable, through rational ac- tion or otherwise, it is clear that there is a functional interest in its control... Parsons saw the central dilemma of medicine as the question of how the physician may best help the patient get better, in order that the needs of society might be met. He viewed the relative social positions of the doctor and the patient - the powerful and the relatively powerless - as a "ther- apeutic assymetry" which enables the physician to influence the recovery of the patient. Both Henderson and Parsons were conservatives, and their work re- flected their political orientation. A very different view was held by Ralf Dahrendorf,6 who called for a conffict model of sociology, and whose ap- proach was extended to medicine most forcefully by the medical sociol- ogist Elliot Friedson. While Hender- son and Parsons had made the under- lying assumption that the relationship between physician and patient could best be understood as a search for balance or homeostasis, for Friedson the paradigm was quite different, as- 9 -----------
Transcript of Doctors, Patients and Relationships
L_I "
Tony Dixon, MD, CCFP
Doctors, Patients and RelationshipsTHE THEME of this month's is- else than the manifold relations in a social system with the heterogen-sue is the relationship between between these two groups. The icity of solid, liquid, and gaseous
doctors and their patients. It is not a history of medicine, therefore, phases in the physico-chemical sys-topic with which physicians have al- cannot limit itself to the history of tem. This connection found its ex-ways been very comfortable. Indeed science, institutions and characters pression in a classic paper entitledsome would suggest, as did W.R. of medicine, but must include the "The doctor and patient as a socialHouston' back in 1938, that it seldom history of the patient in society, system",4 the central thesis of whichenters their professional conscious- that of the physician, and the his- is that through their relationship phy-ness: tory of the relations between phy- sician and patient eventually reach a
Historians sentimentalize the prac- sician and patient. state of interdependent balance.tical values of ancient medicine. This idea that the relationship was Henderson's ideas were taken fur-One scans the pages of Hippoc- related not just to two individuals, ther by the American sociologist Tal-rates in vain for any treatments of but to the society to which they be- cott Parsons,5 for whom the centralspecific value. The pages of medi- longed was also expressed by Bastide3 theme of illness was the risk it offeredcal historv read like the loi of an when he wrote: to such a balance:%" AAX1716jL AII%_ ALK%A_ XWss5%-I "II
old fashioned ocean voyage, inwhich it is noted that on such a daya whale spouted, on such a day aflying fish was sighted, or a bit ofdriftwood, but in which no men-tion is made of the huge prevailingfact that what was constantly seenday to day, almost to the exclusionof other sights, was the unendinggreen waste of water. And this in-evitable circumambient ocean is,by analogy, in medical history thepersonal relationship betweendoctor and patient.It seems a little unfair to put all the
blame on historians for ignoring thisrelationship when physicians seem tohave studiously avoided the topicthemselves. But if historians were toblame, it was an historian, Henry Sig-erist, who set about redressing thebalance. Sigerist was one of the firstto express the idea that what hecalled the "medical ideal" was differ-ent in different periods of history,and that this ideal was determined bythe structure of the society at the timeand by its general conception of theworld.He looked at the relative places of
physicians and patients in differentsocieties and concluded:2
In every medical action there arealways two parties involved, thephysician and the patient or, in abroader sense, the medical corpsand society. Medicine is nothing
CAN. FAM. PHYSICIAN Vol. 35: JANUARY 1989
Behind the patient is the wholeweight of collective representa-tions which he and his friends haveof...illness, and behind the doctorare the systems he learned inbooks and during his training. Thetherapeutic dialogue is thereforean exchange between two ele-ments of society rather than twoindividuals.How can such a relationship be
described? How is it possible to graspsuch an abstract concept? Unlikely asit may seem, it was the field of physi-cal chemistry that was to provide apowerful and enduring analogy. L.J.Henderson was a physical scientist(his name was immortalized inthe Henderson-Hasselbach equation,which those of my generation may re-member wrestling with during thedarker days of medical school life),who later in his career turned to thesocial sciences. His early work wasinfluenced by Willard Gibb, who hadproposed a generalized physico-chemical system of a unified wholecomposed of interdependent parts, inwhich change in any one part of thesystem sets off variations throughoutthe whole of the system until a stateof balance is regained.
Later, when the Italian sociologistPareto described a social systemmade up of individuals, Hendersonsaw an analogy between the hetero-genicity of individuals as components
The problem of health is intimate-ly involved in the functional pre-requisites of the social system-...too high an incidence of illnessis dysfunctional...because illnessincapacitates for the performanceof social roles...In so far as it iscontrollable, through rational ac-tion or otherwise, it is clear thatthere is a functional interest in itscontrol...
Parsons saw the central dilemma ofmedicine as the question of how thephysician may best help the patientget better, in order that the needs ofsociety might be met. He viewed therelative social positions of the doctorand the patient - the powerful andthe relatively powerless- as a "ther-apeutic assymetry" which enables thephysician to influence the recovery ofthe patient.Both Henderson and Parsons were
conservatives, and their work re-flected their political orientation. Avery different view was held by RalfDahrendorf,6 who called for a conffictmodel of sociology, and whose ap-proach was extended to medicinemost forcefully by the medical sociol-ogist Elliot Friedson. While Hender-son and Parsons had made the under-lying assumption that the relationshipbetween physician and patient couldbest be understood as a search forbalance or homeostasis, for Friedsonthe paradigm was quite different, as-
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suming as it did that the separateworlds of experience and reference ofthe layman and professional workerare always in potential conflict.7
In place of the mutuality and reci-procity dynamics of the Parsons "so-cial system", Friedson substitutedhostility, ambivalence and conflict.8The conflict arises from the very situ-ation that Parsons considered to betherapeutic, the assymetric relation-ship between doctor and patient. InFriedson's formulation the result is a
struggle rather than homeostasis.In a step that in retrospect was per-
haps a timid attempt at liberalization,Szasz and Hollender,9 two physicians,proposed three basic models of thedoctor-patient relationship: activity-passivity, in which the physician doessomething to an inert or unresponsivepatient; guidance-co-operation, inwhich the physician tells the patientwhat to do and the patient obeys;and, finally, mutual participation,when the physician helps the patientto help himself and the patient partic-ipates as a partner.While Szasz and Hollender were
prepared to propose a relationship ofmutual sharing between patient andphysician, they did not go so far as topropose the possibility of a patient-dominant relationship. This omissionlaid them open to the scorn of Fried-son, who scoffed that:
This lack of concern for being logi-cally consistent and systematic ischaracteristic of virtually all writ-ing about the doctor-patient rela-tionship by medical men...so longas medical writers persist in crip-pling their logic by normative con-siderations, they cannot expect se-rious intellectual consideration.10
Thus two very different models ofthe doctor-patient relationship devel-oped, emerging from the differentpolitical and sociological orientationsof their major proponents. The"functionalist" standpoint is best ex-pressed as the professional relation-ship in which the patient is encour-aged to trust the physician, who hasthe patient's best interests at heart, a
stock of knowledge at his disposal,and a position of power tempered bya code of ethics and responsibility.
In contrast to this professionalmodel of unconditional trust, theconflict school of sociology espousesa consumer model of health care
based on the principle of Caveatemptor: Let the buyer beware. Physi-cian and patient may come intoconflict as a result of a clash of per-
spectives resulting from their sepa-rate worlds of experience and refer-ence, and may also clash over theresources to which the physicianholds the key. Such a conflict or con-
sumer model suggests that obtaininggood health care requires active cop-ing by the patient, rather than passivecompliance with the doctor's orders:
The doctor-patient relationship isan organized system of social be-haviour, which consumers mustlearn about in order to negotiateeffectively for services.11
Somewhere between these ex-tremes lie the interactional models ofthe doctor-patient relationship,12 var-iously labelled as models of mutualparticipation, negotiated consensus,communication, medical transfer-ence, and human encounter. Allthese models take as a starting pointthe notion that patients have specificneeds and requests in mind that theyare willing to share with the clinicianunder the proper conditions, and thatan active process of interaction willlead to an outcome satisfactory toboth parties.
Sociological models of the doctor-patient relationship are most often,then, concerned with issues of powerand control. By contrast, perhaps themost far-reaching exploration of therelationship undertaken by physicianswas initiated by Dr. Michael Balindand took place within a very differentfield of beliefs and practices that Mar-shall Marinker13 describes as "dy-namic psychology". Balint encour-aged his students to consider thedoctor as having the properties of adrug, and Metcalfel4 comments that:
By making us look at the drug
"doctor" as we would look at oth-er agents he forced us to abandonthe cool, emotionally uninvolved,professional self-image and exam-ine the ways in which our own
feelings are generated, affect ourclinical behaviour and are re-sponded to by the patient.
Balint's approach focused the spot-light very squarely back on the con-
sultation as the core of the medicalendeavour. Sir James Spence perhapscaptured the primacy of the consulta-tion best when he wrote:15
The real work of a doctor is onlyfaintly realized by many lay peo-ple. It is not an affair of healthcentres, or public clinics, or oper-ating theatres, or laboratories, orhospital beds. These techniqueshave their place in medicine, butthey are not medicine. The essen-tial unit of medical practice is theoccasion when, in the intimacy ofthe consulting room or sick room,a person who is ill, or believeshimself to be ill, seeks the adviceof a doctor whom he trusts. This isa consultation and all else in thepractice of medicine derives fromit.
This view of the consultation, then,sees the relationship not as a by-prod-uct of the medical enterprise but as itscore. In Metcalfe's words,14 the con-sultation is a crucible in which physi-cians try to refine the rich, many-faceted, and sometimes confusingperceptions of the patient into clinicalreality. Within this crucible, the rela-tionship takes on both diagnostic andtherapeutic properties, and in manycases the encounter may be regardednot just as a process but also as anoutcome in itself.
In recent years studies of consulta-tions and the relationships that makethem up have become the daily gristof family-medicine training, and inthe report of the Task Force onCurriculum'6 sponsored by the Sec-tion of Teachers of the College ofFamily Physicians, the relationshipbetween the patient and the physicianis seen as one of four basic concepts
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CAN. FAM. PHYSICIAN Vol. 35: JANUARY 198910
to be taught in training programs. TheDepartment of Family Medicine at theUniversity of Western Ontario hastaken a lead in exploring the implica-tions of a patient-centred medical re-lationship, and some of their observa-tions are reported this month.
An urgent task is now to describeconsultations and relationships insuch a way that all family physicianscan understand and translate the re-sulting ideas into everyday practice.The doctor-patient relationship, likelove, is a many splendor'd thing but,like love, may mean different thingsto different people. There is a dangerthat the relationship may take on thecharacteristics of an icon, only to bedescribed in hushed tones and cir-cumspect words. Hanley andGrunberg17 reflected on this dilemmaback in 1961:
Nowadays it has become commonto speak of the doctor-patient rela-tionship as reverently as we men-tion the Grey Cup game or the in-stallment buying contract. In aworld of rapid and profoundchange, we are urged to maintainthe sanctity of this relationship asdiligently as our spiritual forebearsguarded the Ark of the Covenant,and somewhat more diligentlythan we are expected to care forthe marriage relationship. But thegeneral concept of the doctor-pa-tient relationship, a phrase that of-ten becomes a shibboleth, requiresa little closer scrutiny if it is tohave any real meaning in the dailypractice of medicine...Whatevercourse it may take, the doctor-pa-tient relationship is not directedfrom above by Aesculapius, is nottaught in medical school, and isnot simplified or understood onewhit by solemnly referring to it assacred.
If relationships are not to remainthe unending green waste of waterdescribed by Houston, we need to de-velop an oceanography and a lan-guage that will allow us to plumbtheir depths. U
References1. Houston WR. The doctor himself as atherapeutic agent. Ann Int Med 1938;11:1416-25.2. Sigerist HR. The physicians professionthroughout the ages. In: Marti-Ibanez F,ed. Henry Sigerist on the history of.medicine. New York: MD Publications,1960: 3.3. Bastide R. Sociology of mental disor-der. McNeil J, trans. London: Routledgeand Keegan Paul, 1972.4. Henderson LJ. Physician and patientas a social system. N Engl J Med 1935;212:819-23.5. Parsons T. The social system. NewYork: The Free Press, 1951: 428.6. Dahrendorf R. Out of Utopia: towardsa reorientation of sociological analysis.AmJ Soc 1958; LXIV: 115-27.7. Friedson E. Dilemmas in the doctor-patient relationship. In: Cox C, Mead A,eds. A sociology ofmedical practice. Lon-don: MacMillan, 1970: 285-98.8. Bloom SW, Wilson RN. Patient practi-tioner relationships. In: Freeman HE,Levine S, Reeder LG, eds. Handbook ofmedical sociology. NJ: Prentice Hall,1972: 315-39.9. Szasz TS, Hollender MH. Contribu-tion to the philosophy of medicine: thebasic models of the doctor patient rela-tionship. Arch Int Med 1956; 97:585-92.10. Friedson E. Client control and medi-cal practice. Am J Soc 1960; 65:374-82.11. Pratt LV. Reshaping the consumerposture in health care. In: Callagher EB,ed. The doctor patient relationship in thechanging health scene. Washington, DC:U.S. Dept. of Health, Education andWelfare, (MH 78-183): 197-214.12. Brody DS. The patient's role in clini-cal decision making. Ann Int Med 1980;93:718-22.13. Marinker M. Communication in gen-eral practice: new consultations for old.In: Pendleton D, Hasler J, eds. Doctorpatient communication. London: Aca-demic Press, 1983: 275-85.14. Metcalfe D. The crucible. J R CollGen Pract 1986; 36:349-54.15. Spence J. The purpose and practice ofmedicine. London: Oxford UniversityPress, 1960: 273-4.16. College of Family Physicians ofCanada. Report of the task force oncurriculum. Willowdale, Ont.: The Col-lege, April, 1985.17. Hanley FW, Grunberg F. Reflectionon the doctor-patient relationship. CanMed Assoc J 1962; 86:1022-4.
GoPRESCRIBING tINFORMATION
COMPOSITION:
of GAVISCON liquidcontains sodium alginate, 250 mg; aluminum hydroxide,100 mg.Each GAVISCON tablet contains alginic acid, 200 mg;aluminum hydroxide, 80 mg; magnesium trisillicate,20 mg.INDICATIONS: For symptomatic treatment of heartburnand oesophagitis associated with gastric acid reflux. Thisoften accompanies ineffective lower oesophagealsphincter tone as in hiatus hernia, or pregnancy andnasogastric intubation.DOSAGE: Adults: 10 to 20 mL (2 to 4 tsp) of GAVISCONLiquid, or 2 to 4 GAVISCON tablets, 1 to 4 times daily, aftermeals and on retiring.ACTION: GAVISCON liquid or GAVISCON tablets, whenchewed, produce a viscous, demulcent antacid foamwhich floats on the stomach contents serving as aprotective barrier for the oesophagus against reflux ofgastric contents. The alkaline foam readily flows into theoesophagus during reflux, aiding in the neutralization ofrefluxed gastric acids. Gaviscon also effectively reducesthe frequency of reflux episodes.ADMINISTRATION: GAVISCON liquid may be followed bya sip of water, if desired. GAVISCON tablets must bechewed thoroughly,and maybefollowed bya drinkof wateror milk if desired.CONTRAINDICATIONS: There are no specific contraindi-cations for GAVISCON LIQUID and GAVISCON FOAMTABS.See 'Precautions' below.PRECAUTIONS: Each 5 mL of GAVISCON liquid containsapproximately 30 mg and each GAVISCON tablet containsapproximately 22 mg of Na+ which should be noted forpatients on severely restricted sodium diets. The divalentcations of magnesium and aluminum interfere with theabsorption of tetracycline, iron and phosphate. In addition,oral magnesium may accumulate in the plasma of patientswith impaired renal function. Each 5 ml of GAVISCONliquid contains 20 mg of sodium cyclamate, an artificialsweetener. Each GAVISCON tablet contains 1.2 gof sucrosewhich is equivalent to 4.7 calories.ADVERSE EFFECTS: Nausea, vomiting, eructation, fla-tulence.OVERDOSAGE: Should overdosage occur, gastric disten-tion may result and is best treated conservatively.PRESENTATION: GAVISCON LIQUID is a light tan-coloured,pleasantly flavoured suspension supplied in plastic boftlesof 340 mL. GAVISCON FOAMTABS are round creamy-white bufterscotch flavoured tablets with the name'GAVISCON' imprinted on one side and the lefter "W"imprinted on the opposite side. Supplied in plastic boftlesof 36 and 100 tablets.STORAGE PRECAUTIONS: GAVISCON liquid should bestored in a cool place. GAVISCON tablets should be storedin a dry place.REFERENCES1. Goodall, J.S., Orwin, J.M., and Imrie, M.J., A Combined pHand X-Ray Study of a Liquid Alginate/Antacid FormulationUsing a Novel X-Ray Contrast Medium. Acta Therapeutica3:141-153,1977.2. Beckloff, G.L., M.D., Chapman, J.H., M.D., andShiverdecker, P Objective Evaluation of an Antacid withUnusual Properties. J. of Clin. Pharm. 12:11-21,1972.3. In Vitro experiment, data on file, Winthrop Laboratories,Aurora, Ontario.4. Stanciu, C. and Benneft, J.R. Alginate/Antacid in theReduction of Gastro-Oesophageal Reflux. Lancet January26,: 109-111, 1974.5. McHardy, G. and Balart, L. Reflux Esophagitis in the Elderly,with Special Referenceto Antacid Therapy. J. Amer. Ger. Soc.20:293-304,1972.6. Williams, D.L., Haigh, G.G. and Redfern, J.N., TheSymptomatic Treatment of Heartburn and Dyspepsia withLiquid Gaviscon: A Multicentre General Practitioner Study. J.Int. Med. Res. 7,551-555,1979.7. McHardy, G., A Multicentric, Randomized Clinical Trial ofGaviscon in Reflux Esophagitis, Southern Med. J. 71, Supp.No. 1:16-21, 1978.8. Chevrel, B., A Comparative Crossover Study on theTreatment of Heartburn and Epigastric Pain: Liquid Gavisconand a Magnesium-Aluminum Antacid Gel. J. Int. Med. Res.8:300-302,1980.
Winthrop Laboratornes (hi
D)ivision of Sterling DrugLtd."/I*Reg.TradeMark [iII]CAN. FAM. PHYSICIAN Vol. 35: JANUARY 1989
Tony Dixon, MD CCFP
Relation patierLE THEME du numero de ce mois-ciporte sur la relation qui s'etablit entreles medecins et leurs patients. Lesmedecins n'ont pas toujours t al'aise d'aborder ce sujet. Certainsvont meme jusqu'a suggerer, commel'a fait W.R. Houston' en 1938, qu'ilsen sont rarement conscients dansleurs activites professionnelles:
Les historiens ont des reactionssentimentales face aux valeurs pra-tiques de la medecine ancienne.On peut feuilleter en vain les pa-ges d'Hippocrate a la recherche detraitements ayant une valeurspecifique. Les pages de l'histoiremedicale se lisent comme le jour-nal de bord d'un voyage en meraux temps anciens, oiu il etait notequ'un certain jour, une baleineavait ete apercue, qu'un autre jouron avait vu un poisson-volant ouun morceau de bois flottant, maisoui il n'est jamais fait mention del'element dominant, c'est-a-direde ce qui etait vu jour apres jour,presqu'a l'exclusion des autreschoses visibles, soit la vaste eten-due d'eau verte jusqu'a l'infini. Etl'omnipresence inevitable de cetocean est, par analogie, la relationpersonnelle entre le medecin etson patient dans l'histoire medi-cale.
Il peut sembler un peu injuste derejeter tout le blame sur les historienspour avoir ignore cette relation alorsque les medecins semblent, pour leurpart, avoir deliberement evite le su-jet. Mais si les historiens ont eu leurstorts, c'est aussi un historien, HenrySigerist,2 qui a retabli l'equilibre. Si-gerist fut l'un des premiers a expri-mer l'idee que <l'ideal medical>> aconnu des variations selon les diff&rentes epoques de l'histoire et que cetideal fut determine par la structure de
CAN. FAM. PHYSICIAN Vol. 35: JANUARY 1989
it-medecinla societe et par la conception gene-rale que cette derniere avait du restedu monde.
Observant les positions relativesoccupees par les medecins et les pa-tients dans les differentes societes, ilconclut:2
Toute action medicale impliquetoujours deux partenaires, le me-decin et le patient ou, dans un sensplus large, le corps medical et lasociete. La medecine n'est riend'autre que les multiples relationsentre ces deux groupes. Par con-sequent, l'histoire de la medecinene peut se limiter a l'histoire de lascience, des institutions et des per-sonnages medicaux, mais doitaussi inclure l'histoire du patientdans la societe, celle du medecinet celle des relations entre le me-decin et son patient.
Cette conception que la relationn'impliquait pas seulement deux indi-vidus mais englobait aussi la societe alaquelle ils appartenaient fut expri-mee en ces termes par Bastide:3
Derriere le patient repose tout lepoids des representations collecti-ves que lui-meme et ses amis sefont de...la maladie, et derriere lemedecin se cachent tous les sys-temes qu'il a appris a connaitredans les livres et au cours de saformation. Le dialogue therapeuti-que devient donc un echange entreces deux elements de la societeplutot qu'entre deux individus.
Comment est-il possible de decrirecette relation ? Que faire pour saisirun concept aussi abstrait ? Aussi in-vraisemblable que cela puisse parai-tre, c'est a la chimie physique quenous devons une analogie solide etpersistante. L.J. Henderson etait unphysicien-chercheur (son nom fut im-
mortalise dans l'equation Hender-son-Hasselbach, qui a fait suer ceuxde ma generation dans les jours som-bres de leurs etudes medicales) quiorienta eventuellement sa carriere ensciences sociales. Ses premiers tra-vaux de recherche ont ete influencespar Willard Gibb, qui avait proposerepresenter l'etre humain comme unsysteme physico-chimique global for-mant une entite unifiee, compose departies interdependantes oCu un chan-gement dans l'une ou l'autre des par-ties du systeme entralnait des varia-tions dans le systeme tout entierjusqu'au retablissement de l'equili-bre.
Plus tard, lorsque le sociologue ita-lien Pareto decrivit un systeme socialcomiipose d'individus, Henderson y vitune analogie entre l'heterogenicitedes individus composant un systemesocial et l'heterogenicite des phasessolides, liquides et gazeuses du sys-teme physico-chimique. Ce lien trou-va son expression dans l'oeuvre clas-sique intitulee <<Le medecin et le pa-tient comme systeme social>>,4 dont lathese centrale impliquait que, par lebiais de cette relation, medecins etpatients atteignent eventuellement unetat d'equilibre interdependant.
Les theories d'Henderson furentreprises par le sociologue americainTalcott Parsons,5 pour qui le themecentral de la maladie etait le risquepermettant d'atteindre un tel equili-bre:
Le probleme de la sante est inti-mement lie aux exigences fonc-tionnelles du systeme social...unetrop forte incidence de maladie estdysfonctionnelle...parce que lamaladie paralyse la performancedes roles sociaux... Dans la me-sure ou elle est controlable, par lebiais d'actes rationnels ou autres,
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il est evident qu'il existe un interetfonctionnel a la controler...
Parsons situait le dilemme centralde la medecine autour du meilleurmoyen a la disposition du medecinpour ameliorer l'etat de son patient,de faron a repondre aux besoins de lasociete. La position sociale respectivedu medecin et du patient, c'est-a-direle pouvoir et l'impuissance, etait per-cue comme une <<asymetrie therapeu-tique» permettant au medecind'influencer le retablissement du pa-tient.Henderson et Parsons furent tous
deux conservateurs, et leurs travauxont trahi leur orientation politique.Ralf Dahrendorf6 developpa un con-cept tout a fait different, se ref6rant aun modele sociologique conflictuel,mais c'est le sociologue medical ElliotFriedson qui appliqua cette approcheavec force vigueur a la medecine.Alors que Henderson et Parsonsavaient seulement insinue que la rela-tion entre le medecin et le patientpouvait etre interpretee comme etantla recherche d'un equilibre ou d'unehomeostasie, dans le cas de Friedson,le paradigme fut tres different, allantmeme jusqu'a presumer que l'expe-rience et la competence du profane etdu professionnel sont toujours dansun etat de conflit potentiel.7
Les dynamiques de mutualite et dereciprocite du osysteme social> deParsons devinrent chez Friedson desdynamiques d'hostilite, d'ambiva-lence et de conflit.8 Le conflit seraitimputable a la situation meme queParsons considerait comme therapeu-tique, c'est-a-dire la relation asyme-trique entrt medecins et patients.Selon l'enonce de Friedson, la resul-tante en est une d'antagonisme plutotque d'homeostasie.Dans un effort qui, en retrospec-
tive, etait peut-etre une faible tenta-tive de liberalisation, Szasz etHollender,9 tous deux medecins, ontsuggere l'existence de trois types derelations patient-medecin: celle baseesur l'activite et la passivite, oiu lemedecin agit sur un patient inerte ouinactif; une autre faite de conseils etde collaboration, oiu le medecin dit au
patient ce qu'il doit faire et oiu le pa-tient lui obeit; et, finalement, une re-lation basee sur la participation mu-tuelle, oiu le medecin aide le patient as'aider lui-meme et oiu le patient par-ticipe comme partenaire.Meme si Szasz et Hollender etaient
determines a proposer une relationbasee sur le partage mutuel entre lemedecin et le patient, ils ne sont pasalles jusqu'a proposer la possibilited'une relation dominee par le pa-tient. Cette omission leur attira lemepris de Friedson qui repliqua ences termes:
Ce manque de rigueur dans laconstance et la systematisation dela logique caracterise presque tousles ecrits des medecins sur la rela-tion patient-medecin .... aussilongtemps que les redacteurs me-dicaux persisteront a etouffer leurlogique dans des considerationsnormatives, ils ne pourront pass'attendre a ce qu'on les considereserieux du point de vue intel-lectuel.10Deux modeles tres differents de re-
lation patient-medecin ont ainsi vu lejour, a partir des orientations politi-ques et sociologiques de leurs princi-paux adeptes. La meilleure definitiondu 4fonctionnalisme>> est celle d'unerelation professionnelle oui le patientest encourage a faire confiance aumedecin, lequel a a coeur les interetsdu patient, ayant a sa disposition unbagage de connaissances et un pou-voir tempere par un code d'ethique etun sentiment de responsabilite.
Par opposition a ce modele profes-sionnel de confiance inconditionnelle,l'ecole conflictuelle de sociologieepouse un modele de consommationau niveau des soins de sante base surle principe de «caveat emptor>>: il re-vient a l'acheteur d'etre circonspect.Patients et medecins peuvent entreren conflit a cause des differences deperspective resultant des experienceset competences de chacun et aussi acause des ressources dont le medecindetient la cle. Un tel conflit ou mo-dele de consommation insinue quel'obtention de soins de sante ade-quats presuppose une implication ac-
tive de la part du patient plutotqu'une observance passive des con-seils du medecin:
La relation patient-medecin est unsysteme de comportement socialorganise que les consommateursdoivent apprendre a connaitre s'ilsveulent negocier efficacementleurs services.11Entre ces deux extremes se situent
les modeles des interactions de la re-lation patient-medecin,12 modeles eti-quettes de participation mutuelle,consensus negocies, communication,transference medicale et contacts hu-mains. Tous ces modeles ont commepoint de depart la notion que les pa-tients ont des besoins et des exigencesspecifiques en tete qu'ils acceptent departager avec le clinicien dans desconditions propices et qu'un proces-sus actif d'interaction entrainera unresultat satisfaisant pour les deux par-ties.
Les modeles sociologiques de la re-lation patient-medecin s'attardent laplupart du temps aux questions depouvoir et de controle. Par opposi-tion, 1'exploration possiblement laplus considerable concernant la rela-tion, initiee par Michael Balint et en-dossee par les medecins, s'est effec-tuee dans un contexte de croyances etde pratiques tres different que Mar-shall Marinker13 decrit comme «psy-chologie dynamique>>. Balint a encou-rage ses etudiants a considerer le me-decin comme s'il avait des proprietesmedicamenteuses, et Metcalfe14 com-mente en ces termes:
En conside'rant le me'dicament«medecin>> comme nous le ferionspour d'autres agents, il nous a for-ces a abandonner l'image que nousavions de nous-memes, c'est-a-dire froids, non impliques sur leplan emotionnel et retranches der-riere un r6le professionnel, et aexaminer comment sont generesnos propres sentiments, commentils affectent notre comportementclinique et comment aussi nos pa-tients y reagissent.L'approche de Balint ramene car-
rement le debat sur la consultation
CAN. FAM. PHYSICIAN Vol. 35: JANUARY 1989
sommonommmoommm= mmommum monsom mmmolmmiimmmm
14
comme etant le centre du comporte-ment medical. C'est peut-etre Sir Ja-mes Spence qui a le mieux saisi la pri-maute de la consultation lorsqu'ilecrivit ces lignes:15
La plupart des profanes sont peuconscients du veritable travail dumedecin. Ce n'est pas une affairede centres de sante, de cliniquespubliques, de salles d'op6ration,de laboratoires ou de lits hospita-liers. Ces techniques ont leur placeen medecine, mais ne constituentpas en soi la medecine. L'elementessentiel de la pratique medicaleest cette circonstance oiu, dans l'in-timite d'une salle de consultationou de soins, une personne malade,ou se considerant malade, desireobtenir les conseils d'un medecinen qui il a confiance. Ceci definit laconsultation, et tous les autreselements de la pratique medicaleen decoulent.Ce concept de la consultation con-
sidere donc la relation comme etantnon pas un sous-produit de l'entre-prise medicale mais plutot commeson pivot. Selon Metcalfe,14 la consul-tation est un creuset dans lequel lesmedecins tentent d'epurer la richessedes perceptions, avec ses nombreusesfacettes parfois deroutantes afin d'ob-tenir une realite clinique. Dans cecreuset, la relation prend des pro-prietes diagnostiques et therapeuti-ques et, dans bien des cas, le contactpourra etre considere non seulementcomme un processus mais aussicomme un aboutissement en soi.
Ces dernieres annees, des etudesportant sur les consultations et les re-lations qui en decoulent font partiede la formation quotidienne en mede-cine familiale, comme en temoigne lerapport du Groupe de travail sur lecurriculum16 mandate par la Sectiondes enseignants du College des mede-cins de famille. Le rapport considereque la relation entre le patient et lemedecin constitue l'un des quatreconcepts fondamentaux devant etreinclus au curriculum des programmesde residence. Le Departement demedecine familiale de l'UniversiteWestern Ontario est le premier a ex-
plorer les implications d'une relationmedicale centree sur le patient, etleurs observations sont d'ailleurs pu-bliees ce mois-ci.
Il est devenu urgent de decrire lesconsultations et les relations de fagona ce que tous les medecins de famillepuissent comprendre et transposerces notions dans leur pratique quoti-dienne. La relation patient-medecin,tout comme la relation amoureuse,est une chose merveilleuse mais,comme l'amour aussi, celui qui la vitpeut l'interpreter a sa facon. Il estdangereux que la relation prenne lesallures d'une icone dont on parlera 'avoix basse et avec des mots circons-pects. Hanley et Grunberg17 se sontpenches sur ce dilemme en 1961:
Il est devenu courant de parler dela relation patient-medecin de fa-con aussi reverencielle que d'unmatch de la Coupe Grey ou d'uncontrat d'achat a credit. Dans unmonde oiu le changement est ra-pide et enorme, on nous incite amaintenir le caractere sacre decette relation avec la meme vigi-lance dont ont fait preuve nospredecesseurs spirituels gardiensde l'Arche de Noe et avec plusd'egard que nous n'en accordons al'institution du mariage. Mais leconcept general de la relation pa-tient-medecin, une expression quidevient parfois un mot de passe,necessitera une reflexion plus ap-profondie si on veut lui donner sonsens veritable dans la pratiquequotidienne de la medecine...Quoi qu'il advienne, la relationpatient-medecin ne nous est abso-lument pas dictee par Esculape,n'est pas enseignee dans les facul-tes de medecine et le fait qu'onl'1eeve au niveau de <<sacre»eo ne larend ni plus comprehensible nimieux comprise.
Si les relations sont appelees 'a de-venir autre chose que cette grandeetendue d'eau verte sans fin decritepar Houston, il faudra developperl'oceanographie et le langage quinous permettront d'en sonder les pro-fondeurs. U
References1. Houston WR. Doctor himself as a the-rapeutic agent. Ann Int Med 1938;11:1416-25.2. Sigerist HR. Physicians professionthroughout the ages. Dans: Marti-IbanezF, ed. Henry Sigerist on the history ofmedicine. New York: MD Publications,1960:3.3. Bastide R. Sociology of mental disor-der. McNeil J, trad. London: Routledgeet Veegan Paul, 1972.4. Henderson LJ. Physician and patientas a social system. N Engl J Med 1935;212:819-23.5. Parsons T. Social System.New York:The Free Press, 1951:428.6. Dahrendorf R. Out of Utopia: towardsa reorientation of sociological analysis.Am J Soc 1958; LXIV: 115-27.7. Friedson E. Dilemmas in the doctor-patient relationship. Dans Cox C, MeadA, dd. Sociology ofmedical practice. Lon-don: MacMillan, 1970:285-98.8. Bloom SW, Wilson RN. Patient practi-tioner relationship. Dans: Freeman HE,Levine S, Reeder LG, ed. Handbook ofmedical sociology. NJ: Prentice Hall,1972:315-39.9. Szasz TS, Hollender MH. Contribu-tion to the philosophy of medicine: thebasic models of the doctor patientrelationship. Arch Int Med 1956; 97:585-92.10. Friedson E. Client control and medi-cal practice. Am J Soc 1960; 65:374-82.11. Pratt LV. Reshaping the consumerpasture in health care. Dans: CallagherEB, 6d. Doctor patient relationship in thechanging health scene. Washington, DC:U.S. Dept. of Health, Education andWelfare, (MH 78-183): 197-214.12. Brody DS. Patient's role in clinicaldecision making. Ann Int Med 1980;93:718-22.13. Marinker M. Communication in ge-neral practice: new consultations for old.Dans: Pendleton D, Hasler J, ed. Doctorpatient communication. London: Acade-mic Press, 1983:275-85.14.-Metcalfe D. Crucible. J Roy Coll GP198e; 36:349-54.15. Spence J. Purpose and practice of me-dicine. London: Oxford University Press,1960:273-4.16. College des medecins de famille duCanada. Rapport du Groupe de travail surle curriculum. Willowdale, Ont.: Le Col-lege.17. Hanley FW, Grunberg F. Reflectionon the doctor-patient relationship. J AssMid Can 1962; 86:1022-4.
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