The Medical Consultation as a ‘Set Up’

A patient wishes to make sense of his or her symptoms and arranges to see a doctor. So an appointment is duly made. Yet what remains unspoken in the consultation is that it is tacitly expected to take as its starting point certain unquestioned assumptions which serve as expected ‘points of departure’ for all doctor-patient communication. Below I list some of the most basic tacit assumptions that ‘enframe’ the medical consultation and constitute expected points of departure for all communication that occurs within it.

 1. It is tacitly understood that we all know what ‘illness’ and ‘health’ are, that they are opposites, and that ‘illness’ is something ‘bad’ and ‘health’ something ‘good’.

2. It is tacitly understood and agreed that the patient arranges the consultation because he is suffering symptoms of a possible ‘illness’ which he wishes to have identified and which he or she is therefore prepared to have diagnosed through examination and testing and be prescribed treatment for.

3. It is tacitly understood and agreed that the patient will describe their symptoms and that the physician will, directly or through further tests, arrive at a medical diagnosis of the disease, recommend a course of biomedical treatment aimed at relieving their symptoms or ‘curing’ the disease – based on knowledge of its biological ‘causes’.

4. It is tacitly understood and agreed that the patient has just happened to fall victim to their symptoms ‘out of the blue’ – in other words that there is no meaning to be attached to the specific timing of their appearance in the larger context of the patient’s life and life history.

5. It is tacitly understood and agreed therefore, that symptoms have no meaning at all beyond being mere signs of a possible biological disease or dysfunction.

6. It is tacitly understood and agreed therefore that ‘making sense’ of symptoms means nothing more than taking them as possible signs of some biomedical disease – and that in no case can a biological illness or disease be itself taken as a symptom of a life-disease – a hidden life problem that manifests in the patient feeling ‘ill-at-ease’ with their lives.

7. It is tacitly understood and agreed that the patient’s suffering – their felt pain, discomfort or ‘dis-ease’ – is a mere secondary and subjective ‘effect’ of an organic disorder or ‘disease’. The contrary notion, namely that symptoms, illness and disease may be a symbolic embodiment of a subjectively felt dis-ease’ – and of particular ways in which the patient is ‘ill-at-ease’ with their life – is ruled out in advance. Indeed such a notion constitutes sheer heresy in terms of the unquestioned dogmas of biomedical ‘science’.

Should a patient reject any or all of these assumptions, or depart from any of the unspoken rules or points of departure in their communication with a doctor, the patient will be immediately classed as a ‘difficult’ or ‘incompliant’ patient or even as deluded. Yet together these tacitly agreed assumptions and points of departure for a biomedical consultation effectively constitute an unspoken ‘set up’ or ‘frame up’ – a framework the patient is expected to compliantly adhere to. The aim of this ‘frame up’ is to enframe the meaning of the patient’s symptoms in the terms of one framework only – that of biomedicine – excluding any other possible ways of making sense of those symptoms. Any attempt by a patient to question this framework – even if only by not immediately accepting certain types of routine biomedical tests or courses of treatment – will arouse indignation and bewilderment, be seen as a threat to the authority of bio-medically trained doctors and a waste of the limited time they give to their patients. Instead it could be seen as an opportunity to give themselves more time to learn about the lives of their patients as human beings, to understand their symptoms in the larger context of their life and life world.

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