Who are medical professionals
Doctor or medical professional: empathy instead of actionism
The doctor may be a scientist, but the doctor is a cultural scientist, but never an economist.
One of the earliest experiences in my socialization as a doctor was the separation of “medical” and “medical”. So I often heard the following sentence from my doctor's father, and later also from the country doctor with whom I worked as a trainee: This or that measure might be medically indicated, but would not make sense or be responsible on the medical side. Under medical the scientific, rational and in its causalities clear condition, under medical the humane, psychological, cultural-scientific and in its complexity opaque overall situation. In the meantime, the doctor has become more and more a doctor, and he should be: the change in the nomenclature clearly proves this. Clinics have become “medical centers”, medical necessities have the highest, even the only priority. At best, psychosocial measures have the purpose of urging the patient to cooperate, to comply, or to make his lot more bearable - without questioning the direction of the goal.
It is precisely this that differs considerably from that of a medical practitioner: the medical practitioner lives from pathology, the doctor from the need to help the people entrusted to him to become and stay healthy. Good health care is applied science in individual cases, says Jürgen Schölmerich, chairman of the German Society for Internal Medicine (1). Too little pathophysiology and experimental approaches are learned. The choice of words gives a deep insight: The patient should be “cared for” from a pathophysiological point of view and approached experimentally, after trial and error. There is never enough money for this: Expenses for new therapies and diagnostic procedures will exceed all savings
Medicine, as practiced in clinics, medical care centers and practices, essentially consists of prescribing medication. Most of the medical work is devoted to establishing the indications, selecting and evaluating the effectiveness of drugs, ensuring compliance and, to a large extent, treating adverse drug effects. In the short period of time that is available for communication and interaction between doctor and patient, the content is often reduced to this topic, really important things fall by the wayside. Even at information evenings for pregnant women, for example, where important things such as preparation for parenthood, measures to promote bonding and early help should be dealt with, most questions to the pediatrician are about vaccinations. Only for this, for the medication, the doctors are considered competent.
Our understanding of drugs in general is incomplete - both in terms of effectiveness and consequences. Manufacturers and opinion leaders disseminate far too positive, incomplete and "embellished" statements that are only revoked when a newer, more expensive and therefore better drug comes onto the market. Then the previously highly praised predecessor is declared ineffective; or contraindications become indications. Real long-term examinations are rare, are not perceived or reinterpreted, and as a rule it is not a question of whether the patient is doing well or better overall, but rather about the target symptoms.
So everyone is more or less sick
Today, many people suffer from a wide variety of problems that can, but do not have to be, regarded as requiring treatment. Many diseases are only defined as such by the supposed availability of effective treatment methods - a process that the pharmaceutical industry accompanies very effectively with "disease mongering" (2), if not initiated at all. It was only with the establishment of stimulant therapy that attention deficit syndrome was perceived as a disease in its current form, even depression - or awareness of it - only through the availability of antidepressants: “Everything becomes depression because antidepressants affect everything. You can treat everything, but you no longer know exactly what is curable. ”(3) Of course, these diseases were not created, but an awareness of the need for treatment, so that a market is created.
Research in the sense of scientific research into life processes is necessary. The results and progress are fascinating and unmanageable. Molecular mechanisms, receptors and binding sites that are researched in models or on individual cells can be proven and conclusive in the model, but speculation in the entire organism. The immediate and uncritical implementation of biological findings in therapy has sometimes taken on ridiculous forms - think of the gene therapy attempts at cystic fibrosis treatment after the localization of the gene defect was discovered.
If one proceeds from the comprehensive concept of health of the World Health Organization as a state of complete physical, mental and social well-being, there can be no complete health, but only approximations to this ideal. Accordingly, everyone is more or less ill and can be considered as “beneficiaries” of the health system.
So who should set the criteria for defining healthy or sick? The cultural dimension as a parameter for normal (healthy) or abnormal (sick) is at best addressed in psychiatry, but not elsewhere in medicine. What are the criteria for "sick"? If you want to determine this objectively and independently of culture, you can try this on different levels. From a legal point of view, endangering oneself or others and breaking the law are the yardstick for the need for intervention, which can also come into play in cases of parental custody with treatable illnesses of the child, but especially in the case of placements with mental illnesses, but plays a less important role in everyday medical practice . From a purely statistical point of view, an objective definition of certain disease criteria as a standard deviation from a mean value seems possible. If, however, one defines obesity as a disease condition based on the statistical mean value for body weight, this will turn out differently in sub-Saharan Africa than in a western industrial society. If a sixth of all people go through a depressive episode that requires treatment in the course of their lives, is that "normal"? The statistical definition stands and falls with the underlying concept of normality.
Salutogenesis is still not well known
When determining a disease, there is usually a constellation of symptoms that can often, but not always, be explained causally and often neither reliably nor validly reproduced. Take pneumonia, for example: We have symptoms that are clearly ill - perhaps trembling nostrils and faster breathing, including coughing. There is "clinical pneumonia without a radiological correlate" or "the radiologically apparent pneumonia obscuration without clinical signs of pneumonia". What should you stick to? What is the so often diagnosed “budding pneumonia”? In hardly any area of pediatrics is more nonsense produced than in the diagnosis of pneumonia; the agreement between symptoms and classification (reliability and validity criteria) is poor. The same applies to otitis media: when is an effusion, when is catarrhal, when bacterial otitis - and if, why? Here one finds a tumult of opinions instead of the required scientific clarity, which can be complicated by laboratory tests. Does a bacteriological examination find a germ, is it a colonization or an infection? Cause or consequence?
We assume that what keeps us healthy, salutogenesis, is as little known as what makes us sick, pathogenesis. Even a “how” that has been well researched today does not yet explain the “why”. This applies on the physical as well as on the psychological level. Before blind therapeutic action, i.e. therapeutic actionism, causes more harm than good in a complex system, doctors should empathically support and strengthen the patient in the face of this lack of understanding, but above all recognize and remove mechanical, psychological and social obstacles to healing. This does not mean doing nothing in the sense of therapeutic nihilism, but rather including the importance of the human relationship in the healing process, which is always an inner self-healing process.
Awakening resources instead of caring for patients
In his “Dietetics of the Soul”, one of the most successful advisors of the 19th century (4), Ernst von Feuchtersleben preceded the motto “Valere aude” - “Dare to be healthy” and developed a remarkable philosophy of volition that expresses the power of human spirit illustrated through the body. Immanuel Kant even speaks of the power of the mind, which becomes master through the mere resolution of pathological feelings. Of course, it is not enough to tell the patient, "pull yourself together". That would be a complete misunderstanding of this approach. But striving for one's own health, putting salutogenesis before pathogenesis, resilience before deficiency, awakening resources instead of “caring for” the patient, that can be a way out of the bottomless abyss, away from the obsession with health to a self-determined life , to "life without drugs".
Dr. med. Stephan Heinrich Nolte
Email: [email protected]
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