We found that the doctors' involvement with their patients could be classified according to three different dimensions: medical concern, courteousness and existential care.
The doctors' medical concerns were mainly directed at how patients' health was impaired and how their medical knowledge could help. This was evident from how they followed up patients' complaints and how their time was prioritised and could be seen as part of the core contract between doctor and patient. Their strong sense of medical concern often caused the doctors to treat their patients as medical objects. Nevertheless, most related to their patients as more than mere objects, but the doctors interacted with their patients as human beings in a trivial manner. We have used the term courteousness to describe how the doctors often displayed a friendly attitude, kept a good tone and emphasised the social relationship with patients. By courteousness we refer to a display of general respect for the patient as a fellow human being, but it is not to be taken as any deeper concern for the life of the patient. On the contrary, the doctors showed little curiosity about the individual and neglected more personal aspects of the patients' conditions, showing little or no existential care. The patients frequently spoke of their personal feelings—for example, describing how they had experienced the current event and how it had affected their lives, but this was rarely addressed or pursued by the doctors, who instead directed the focus away from personal meanings onto medical facts.
These three dimensions of doctors' involvement emerged as a result of the analysis of the entire material; the cases presented below are observed encounters that are selected simply as illustrations of these dimensions.
Case I: visiting the pulmonary specialist
The doctor greets the patient, a middle-aged man, inviting him to sit. He says he now has recovered from what was probably just an infection. The doctor turns to the computer, nodding occasionally while attending to the screen. The patient suddenly speaks up: “I have really been physically healthy all my life, right until my wife died three… three years ago. Three years ago.” The doctor looks at her computer, showing no reaction: “Yes.” Patient: “And… and then a great deal seemed to happen… and so the last three years there has been a lot concerning my heart and so, but… otherwise… I guess I am… relatively…” The doctor: “…But otherwise you have been healthy, yes?” Patient: “Yes…” The doctor pulls her chair over to the patient and smiles: “Then there is the big question that is asked of everyone who comes here: Do you smoke?”
The doctor says she has some extra time and enthusiastically draws a curve explaining the effects of smoking on lung function. The patient tells her that he was healthy until his wife's death, and the doctor commends his healthy look. Suddenly she asks if he has any symptoms, which is denied. She says this makes him difficult to diagnose and they both laugh. Referring to the computer system requiring a diagnosis she enters ‘COPD’. The patient says another doctor suggested asthma: “…my son has asthma, but it…was also what my wife died from, and… And asthma runs in the family.” The doctor stares at the screen, nods and states that further follow-ups are unnecessary. The patient says that he agrees, but goes on to raise additional concerns. The doctor quickly raises her head: “Is there anything else you would like to ask?” “No!” he vigorously declares and rises to leave. The doctor leads him out and wishes him well.
The doctor's first concern is to define the medical problem, and she focuses more on the computer than on the patient. She relies on medical facts from the records, which are read out loud. The doctor overlooks the patient's own accounts of his life and he is declared healthy on the basis of a test result.
When the patient plucks up the courage to mention that his wife has died, the doctor ignores it. Instead of addressing this existential aspect, she quickly changes the subject with a medically focused question about smoking. The next time the subject is brought up, the doctor comments on the patient's physical condition instead. The patient mentions his deceased wife three times, finally revealing that she died of asthma, but any potential anxieties related to his own lung condition are not touched upon. The doctor explicitly states that she has plenty of time, but even so the clearly existential dimensions of the patient's suffering are avoided.
Nevertheless, they speak in a jovial manner. The doctor politely stands up to greet the patient and invites him to sit. She does not rush the consultation, answers the patient's questions about lung function and exercise and takes time to explain matters in detail. Smiling and laughing, she appears to value the social contact. An ambiguous element to the expressed courteousness is revealed, however, when the doctor's otherwise polite request for questions actually serves to interrupt the patient and bring an end to the consultation; a sign the patient seems to sense.
Case II: the anaesthesiologist's round
An elderly woman sits in bed, glancing regularly at the door. “Mrs Peterson, is that you?” The doctor smiles, introduces himself as an anaesthesiologist and gets a chair. The patient asks whether he is going to carry out the sedation or the operation, but the doctor says no to both. In a friendly voice, he asks brief questions about her medical history, completing an anaesthesia form. The patient answers carefully. She is upset that her daughter had to take care of her because her current leg pain was not taken seriously. The doctor looks down, answering “yes” and “I see”. The woman's phone rings and he waits for her to finish.
When the doctor starts to tell the patient about the epidural procedure, she looks uneasy. She asks repeatedly about medication and the possibility of a general anaesthetic. In a friendly voice, but hastily, the doctor explains the advantages of an epidural and proposes tranquillisers. The patient says she already has “such tiny, tiny little candies that do no good”, and they both laugh heartily. After gathering himself, the doctor asks if she has any questions. She looks serious: “Oh, I wonder about many things.” Doctor: “Yes, but to do with the sedation?” Patient: “Only that and not the surgery?” Doctor: “No. Only that.”
The patient looks anxious and asks about pain and if she will be awake during the surgery. The doctor reassures her in a friendly voice, but in a quick and impatient manner, and looks at the records: “Okay?” She hesitates: “Okay.? I'm nervous. Terribly nervous. I am.” He promises her tranquillisers and repeats: “Okay?” She expresses insecurity about the surgeon and says the anaesthesiologist should be present. He laughs and stands: “Yes, I should. But I am unfortunately doing something else tomorrow.” He shakes her hand, wishes her good luck and leaves. The patient looks out the window. She sighs heavily.
The patient looks anxious from the beginning, and the doctor approaches her in a friendly and trustworthy way. He takes time to sit down, addresses her directly, looks straight at her and maintains reciprocal contact, demonstrating his courteousness. Seemingly encouraged, the patient eagerly answers his questions and shares her personal frustrations. After establishing this social contact, the doctor maintains a medical focus, framing his questions to deal with the anaesthesia form, taking no notice of the patient's account of her distressing and humiliating experiences. When he has completed his medical tasks, he tries to end the consultation by almost compelling the patient to agree that everything is now “okay”, displaying again his delimited medical concern.
The doctor's courteousness seems to be important to the patient, both as he patiently waits while she answers her phone and when they both start laughing. And yet, at this very moment, the doctor explicitly delimits his relationship with her and returns to his medical tasks. Although the doctor's medical responsibilities may be limited to the anaesthetic procedure, existential care cannot be delimited as easily. Both the patient's manner and her repeated questions about pain reveal her anxiety about the surgery. An attempt to deal only with the component of her fear that relates to an epidural procedure demonstrates an avoidance of her existential needs and is also ineffective. Only allowed to ask about the anaesthesia, the patient tries to frame her questions in terms of sedation, and ultimately states in general terms that she is ‘terribly nervous’. But the doctor never addresses the existential dimension of this fear and proposes the medical solution: more sedatives.
Case III: a cancer follow-up visit
A 60-year-old man enters with his wife. Diagnosed with metastasising cancer a year ago, he has undergone an operation and seven subsequent chemotherapy sessions. The doctor looks forthcoming and attentive and presents the medical history while glancing at the patient for confirmation. From the computer he identifies the current issue as the growth of one of the metastases. The patient explains that he can feel the tumour growing and the doctor asks about symptoms like urination problems, pain and nutrition. The patient describes a gradual loss of appetite, which his wife confirms. Looking at the computer, the doctor nods. “Yes. Yes, I can see that… Yes, I can tell from your blood results that you… you are in what we call a catabolic state, which means that you break down a little more than you build up.” When the wife expresses concern about her husband's weariness, the doctor attempts to quantify his daily activities. Afterwards, he examines the patient's stomach and exclaims: “Yes! But this we can… We can manage to radiate this one, I'm sure.”
Left alone for a moment, the patient and his wife express anxiety at the rapid progress of the disease. In a timid voice, the wife questions the treatment when the doctor re-enters the room, and he briefly explains why radiation is the preferred treatment, going into details about the radiation procedure while the patient listens and nods. He sums up the plan, but the patient makes no move to leave. The wife brings up the liver metastasis, but the doctor dismisses her. The patient nods: “Right, right. Yes, yes.”, but he does not move. After a moment of silence, the patient finally rises: “Well, well… But then… I guess it sounds okay then.” The doctor smiles, says “see you later” and shakes their hands.
Again, the doctor's strong medical concerns guided the conversation, overshadowing other important matters. Even though all the treatment is palliative, the patient's underlying existential agony is never addressed, and is even actively disregarded. The doctor focuses on the medical data and only allows the patient to comment on this. The computer, rather than the patient, is asked about the reason for the consultation, which is defined as ‘growth of one of the metastases’.
The doctor avoids obvious existential concerns; when the patient talks about the tumour, the doctor does not address the underlying fear but asks about symptoms. Likewise, when the patient's increasing tiredness is brought up, he is made to quantify his activity levels. Explicit worries are met with medical answers, and the patient's dying process is even described as ‘a catabolic condition’. The tacit existential dimension appears uncomfortably present at the end, when the fears that are unaddressed seem to prevent the patient from leaving.
But the doctor also shows courteousness, and is attentive to both the patient and his wife, maintaining a good atmosphere and often smiling. He is polite, listens patiently, takes time to answer questions and does not hurry the patient out. Still, the light tone and the almost cheerful doctor make a stark contrast to the patient's grave situation. These contrasts are highlighted at the end of the consultation when the doctor says he will see them later, when they are probably all aware that there might be no “later” for this patient.