As intended, there was considerable diversity among patients, clinical problems, professional environments, and doctors’ personalities. Despite these differences, it soon became clear that the doctors approached the clinical situation basically the same way. Irrespective of the problem presented, the doctors struggled to handle each particular problem within the limits of medicine, and this shaped their approach to patients and clinical cases. Their mutual way of handling clinical issues was best understood as a process we have called ‘essentialising’.
Essentialising roughly consisted of deconstructing the situation at hand and the patients’ concerns, and reconstructing selected elements into a specific clinical problem. Through this reconstruction of the clinical problem, it became possible to handle the problem within the scope of biomedicine. Essentialising was a way of addressing the complexity of a practical case and come out with a defined clinical problem. The process consisted of several interrelated, but distinct, ways to modify and direct the problem at hand. These were not explicit actions, but altogether common and ever recurring parts of their clinical practice.
Break down
A distinct feature of the doctors’ clinical approach was
break down of the situation or patient information. Doctors split the situation into smaller units for easier systematisation of the situation. The patients could present vague symptoms or complex medical problems with other enmeshed anxieties. To handle such compound enquiries, the doctors broke the problem down into smaller, more manageable parts. By doing this it was possible to address each component of the problem separately:
A female patient enters the practitioners’ office, seems stressed and talks fast in broken Norwegian. She sinks into a chair. Patient: “I’m so ill; I do not have the energy to do anything. My neck hurts, I’m freezing, I’m weak, I have to do an assignment, but this is not working out…” Doctor: “Your neck hurts?” Patient: “Yes, my throat is soar and I’m aching here [pointing at the side of her neck]. I always get a soar throat, maybe every month. I thought I should have an operation…” Doctor: “Does it hurt anywhere else?” Patient: “Yes, my back hurts. And my chest. And my legs are hurting a bit too.” Doctor: “A little bit of everywhere, I gather? Do you have fever?” Patient: “Yes.” Doctor: “Have you measured your temperature?” Patient: “No, I do not have a thermometer.” Doctor: “Then you must get hold of one! Do you have fever now?” Patient: “No, I don’t think so.” [Feels her forehead] Doctor: “Do you have a cough?”. (Doctor 10)
In order to better understand the patient’s vague illness, the doctor breaks down the clinical situation into concrete questions that the patient is able to answer.
Although the patients often presented the problems through the use of continuous and narrative stories, the doctors were not concerned with the narrative, and interrupted to fragment the patients’ stories so that they could obtain the medically relevant information:
The patient sighs heavily as she sits down. Patient: Well, now it has got to the other shoulder! She pats her right shoulder. Doctor: What do you do for a living? Patient: I work in the home nursing care. Doctor: As…? Patient: An enrolled nurse. Doctor: Yes. It is hard work? Patient: No, not especially. It was worse back when I was working at the nursing home, then you just had to take whatever turned up. You know, I had to change my workplace when the trouble started in my other shoulder… Doctor [takes a look at his computer]: Then you were on sick leave for two years? Patient: Yes, and now it has got to my other shoulder… Doctor: Yes. What do you want me to do for you then? (Doctor 13)
We here sense that the patient wants to tell the story of her former work, how her shoulder afflictions made her quit her job, and her anxieties about it now reoccurring. The doctor, however, wants to cut the story short and pay attention to the facts necessary for intervention.
Concretising
Another aspect of the doctors’ clinical approach was
concretising the situation and the patients’ complaints. When doctors discussed cases with colleagues, they stressed often visible or measurable aspects such as blood pressure, blood tests, radiographs, and clinical findings:
Doctor I: She has been admitted for rehabilitation. She is poorly mobilised and nourished, and she is low in albumin. Nurse: Is she the one with the black toes? Doctor II: They are not black; they are poorly circulated. Doctor I: We have to at least mobilise her into a chair. Doctor II: She also has diarrhoea and a positive Hemofec. It is somewhat hard to interpret. But judging her blood values, everything looks better. (Doctor 6 and colleague)
This patient is no clear-cut medical case, but the doctors are defining the problem in terms of concrete bodily functions and test results.
Patients were also asked to point out the precise location of their problem, to quantify their pain, and to specify their worries. Concretising was used as a means of clarifying what the patient was actually talking about. Bodily experiences are of such a private nature that it can often be difficult to establish what a particular patient means when describing a sensation. Concretising was a way in which doctors could objectify the patients’ descriptions and thus reach mutual understanding of the problem:
A consultant talks to an elderly male patient during rounds: “How much pain are you in?” Patient: “Well …” Consultant: “Is it any better now than when you arrived, or is it just as painful?” Patient: “Well … It is what it is … sometimes better, sometimes worse.” Consultant: “Sometimes better and sometimes worse, eh?” Patient: “It’s worse when I stand still. It’s somewhat better to walk a little.” Consultant: “Indeed? When you walked over here from your room, how much did it hurt? On a scale from 1 to 10?” Patient: “2.” Consultant: “How far could you walk then?” Patient: “To the kiosk.” Consultant: “Did you walk all the way to the kiosk upstairs? How painful was that, on a scale from 1 to 10?” (Doctor 9)
The patient is very vague about his afflictions, so to establish whether or not the treatment has been beneficial, the doctor is forcing him to state a precise level of pain and distance of walking.
Categorising
A third part of the doctors’ clinical approach was
categorising the information. When patients described an affliction, doctors placed it into an appropriate medical category. In this way patients’ feelings and statements were categorised as distinct medical symptoms, which could then be entered into the medical record:
Interviewer: “Your first patient today mentioned that she had discomfort in her chest. What were your thoughts about that?” Doctor: “She brought it up somewhat late in the consultation and I was beginning to run out of time. It didn’t sound that serious, and it wasn’t anything acute, she had had it for several years. I could have taken a spirometry of course… Most likely it is muscular, she is sitting quite tense, like this.” [Shows her posture] (Doctor 3)
Although the doctor had ignored the patient’s expressions of chest discomfort in the consultation, he had actually noticed her complaint. Because of the circumstances of the case, the medical history, the patient posture and the timing in the consultation, he categorised the complaint as nothing serious, likely muscular—and not in need of medical attention.
When the doctors examined their patients, they defined their results as medically normal or abnormal in a definite way, thus categorising their own observations as distinct medical findings:
A resident confers with the attending physician about a middle-aged female patient. Attending: “Where is her pain situated?” Resident: “She has pain everywhere!” Attending: “Does it hurt when you touches her nose? [Laughs] I’m exaggerating, but it’s important to check if the patient expresses pain wherever you touch her, because then it reflects something else.” (Doctor 4)
The resident has examined the patient and found that her whole body is hurting, and he does not know how to deal with such an extensive pain. The attending insinuates that the resident has just described the patient’s expressions, and not categorised it into a clinical finding. He implies that if the patient utters pain during the whole examination, it should not be categorised as medically relevant pain.
Existential filtering
Breaking down, concretising and categorising can be seen as purely practical ways of addressing a complex reality, but essentialising also entailed ways of handling the more value-laden aspects of the situation. In an effort to direct their focus of attention, the doctors undertook an
existential filtering. When approaching a case or a patient, the doctors systematically ignored the more existential meaning in order to direct the medical issue. The problems were faced at a practical level in order to reach the functional elements that the doctors could do something about:
An elderly female patient is discussed at sitting rounds. Doctor: “We have discontinued treatment on this patient. How is she?” Nurse: “She is getting worse. She does not want any care and pushes us away.” Doctor: “Her CRP-level is about to explode! You have to take her temperature.” Nurse: “But is she going to have any medication? We are not able to give her anything to swallow anyhow.” Doctor: “No, she will not have any; we have discontinued her treatment.” Nurse: “But in that case you have to record it on the medical chart, because she has been given medication these last 24 hours.” Doctor: “Precisely. Well, then I will withdraw this: Antibiotics, anti-coagulation…” (Doctor 1)
The situation is obviously existential for this patient, who is about to die, but the medical discussion does not evolve around the patient’s anticipated death. Instead, they discuss test results, medication, and practical issues concerning chart registration.
Existential filtering took the focus away from the patients’ private feelings and what the suffering meant to the particular patient. The subjective meaning of the condition was not addressed by the doctors, and sometimes even actively suppressed:
A disconsolate patient who had recently had an extra uterine pregnancy explains that her husband recently told her that he had developed a Chlamydia infection. She is crying. Patient: “And now I do not know if this could have caused my extra uterine pregnancy!” The doctor does not answer this question. Doctor: “But did you not take a Chlamydia test while you were pregnant?” Patient: “No … I don’t know.” Doctor: “It is one of the standard tests.” He looks in her record. Patient: “This other doctor went so far as to imply that my husband had been cheating on me. He said that anything else would be very unlikely.” Doctor: “I’m sorry he was so determined. There are two alternatives: one is that you have had a latent infection, or else he has infected you. You talk to your husband, and I will call the microbiologist to get hold of your test results from the pregnancy.” (Doctor 15)
Here, the underlying issue is of utmost importance to the patient: Is her husband cheating on her? Although aware of it, the doctor does not address this question directly. This existential aspect of the clinical issue is left to the patient, and the doctor limits his effort to the practical question of whether or not this is a newly acquired infection or a reactivation of an earlier one.
Functional focus
While existential filtering divested the case of certain values, others were accentuated. Through their
functional focus, the doctors draw the focus of attention to the patients’ physical and mental function. Irrespective of how a problem was presented, the aim was understood in terms of improving the patient’s functional abilities:
A terminal cancer patient is discussed during sitting rounds: Nurse: “She wants to go home.” Doctor: “Yes, I have spoken to her regular doctor about how we should handle her. She has these reconstruction plans for her house in preparation for returning home. We cannot tell her too brutally. We cannot demolish her psychological defences. She became aggressive once when we tried to address her unrealistic arrangements. At the same time she knows how serious this is. It is a psychological defence, and the only thing preventing deep depression. So we must allow her that.” (Doctor 6)
The patient does not seem to be aware of the gravity of her own illness, and the staff is struggling with how much of the truth to reveal. The doctor phrases this into a question of what will benefit the patient’s psychological function.
The functional focus was implicitly present in most of the doctors’ clinical practice, and in many instances they also explicitly defined the motivation for their actions in terms of benefiting the patient’s function:
Doctor: “We had an elderly lady here last month with lots of different somatic problems, and she was confused too. She was referred to different departments around the hospital, and every department only cared about their little detached parts, fixed it and sent her home. And she kept coming back to the doctor. Last time, she was having surgery in her bladder, but they postponed it. She was kept fasting for days – an elderly woman with such tiny reserves! If we could fix her somatic problems and calmed the environments around her, I’m sure she could function a lot better.” (Doctor 12)
The doctor rejects the fragmented treatment of this elderly patient, not because he considers it dehumanising to the patient, but because a different approach would benefit her functional level.
The elements here presented describe different aspects of essentialising, but are fundamentally interrelated, and often occurred simultaneously in a single encounter or case discussion. Breaking down and concretising the patient’s complaints could enhance the existential filtering of a case, and categorising the problem in medical terms often involved a functional focus.
Essentialising is not an explicit method, but a theoretical concept that describes doctors’ clinical work in a useful way. It reveals some of the difficulties of clinical work, and what the doctors’ are striving to come to terms with in each particular case. Essentialising describes doctors’ practical manner of handling multifaceted and often ambiguous clinical situations in a medical way. By systematically reframing the problems into questions that could be answered within the medical framework, they sought to pinpoint those elements of the patients’ suffering that they could do something about. In addition to being a practical method of deconstructing a complex reality, it was also a way of establishing the purpose—or essence—of clinical intervention.
1 Reidun Førde,2 and Åge Wifstad3
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