thomas kühlein, wonca basel 19.september 2009 the social construction of our medical reality and...

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


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


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


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


“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?


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


Cited from Taylor JR Linguistic Categorization, Oxford University Press, Oxford 2003


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


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


Quarternary prevention means to prevent overmedicalization


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


1. The risk factor model - a major driver of our fears and

actions in medicine


“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


2. Somatoform (medically unexplained) symptoms –

an old game between patients and doctors


“…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


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


Quarternary prevention, the prevention of

overmedicalization, is the task of the general practitioner

thomas kühlein, wonca basel 19.september 2009 the social construction of our medical reality and...

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