Heroes Not Zombies

Here are two questions which are in my mind during every consultation I have with a patient.

What kind of world does this person live in? and What coping strategies does this person use?

Of course like every doctor I will have a number of questions in mind during a consultation. The primary goal of undergraduate Medicine is to teach diagnosis (as best I conceive it, “diagnosis” is an “understanding” – an explanation for what the patient is experiencing). So that is likely to be one of the main goals of all consultations – what’s the diagnosis? Having achieved an understanding/explanation/diagnosis, the doctor then wants to answer the question “what am I going to do about this?” What the doctor does might be to further examine, investigate, or seek the opinion of a specialist. Or what the doctor does might be a therapeutic act – the most common being either the prescription of a drug, or the carrying out of a surgical procedure.

In other words, the same two questions are important for the doctor too. What kind of world does the doctor live in? And what are his or her coping strategies?  The world view frames the diagnosis, and the coping strategies determine the actions.

The current dominant practice of Medicine has emerged from a particular world view, and this world view is the basis of the actions chosen. So what is that world view? (I’m not going to try and nail down a label for the current Medical orthodoxy, but others have termed it “biomedicine”, “Western Medicine”, or even “scientific Medicine”. Whatever the label, I’m referring to the type of Medicine most commonly practised in the UK, and, yes, of course, you’ll see that is very similar to the commonest practices in many other countries too)

The world view from which the current orthodoxy emerges is based on certain postulates –

1. There is only one reality.
2. Reality can be “partialised”. It can be divided into parts which can be studied separately in order to know the whole.
3. Knowledge can be acquired by an observer who is separate from, and stands apart from, reality.
4. Observing has no influence on what is observed. (or the influence can be isolated or “controlled”)
5. The observer’s values and meanings can be isolated and suspended.
6. Two events related in time can be assumed to be causative – “A is the outcome of B”.
7. Specifics can be generalised i.e. an explanation from one time and place can be applied to other times and places.
8. Reality can be described in terms of “laws” and “norms”.

I don’t find these postulates either helpful or convincing. What are the postulates behind my world view as a doctor?

1. There are multiple realities. No two individuals experience identical realities.
2. The multiple realities are inextricably interconnected to create the whole. As such no single part can explain the whole.
3. No-one is outside of reality.
4. Every act of observation influences (creates even) what is observed.
5. The observer’s values and meanings create their reality. They can’t be suspended. (Points 3 and 4 are connected to there being no object which can be known without the active involvement of a subject)
6. Complexity and chaos theories show us that reality is non-linear. Causation can never actually be proven.
7. Specifics always occur embedded in multiple contexts and as such are always unique. Generalisation involves ignoring the contexts.
8. Laws and norms are cultural constructions to describe common patterns. Nature is diverse and natural phenomena are emergent (continually evolving and developing into different patterns)

How do you think these different world views affect firstly the diagnosis, and secondly the actions taken?