From wholes to fragments to wholes—what gets lost in translation?

Abstract

The highly demanding and, in a certain sense, unique, working conditions of general practitioners (GPs) are characterized by two phenomena: First, they involve an increasing familiarity with individual patients over time, which promotes a deepening of insight. Second, they enable the GP to encounter all kinds of health problems, which in turn facilitates pattern recognition, at both individual and group levels, particularly the kind of patterns currently termed "multimorbidity." Whereas the term "comorbidity" is used to denote states of bad health in which 1 disease is considered to predate and evoke other ailments or diseases, the term multimorbidity is applied when finding several presumably separate diseases in a person who suffers from them either sequentially or simultaneously. Encounters with patients whose suffering fits the biomedical concept and terminology of multimorbidity are among the most common which GPs face, presenting them with some of their most demanding tasks. The term multimorbidity needs to be examined, however. As it alludes to a multiplicity of diseases, it rests on an assumption of separateness of states of bad health that might not be well founded. An adequate determination of what to deem a "separate" state of bad health would require that the biomedical concept of causation be scrutinized.

Interactions between persons—Knowledge, decision making, and the co‐production of practice

“…There is a growing recognition that patients' knowledge of their own experience is at once authoritative and indispensable, not only in understanding how to manage their condition but also to get an adequate characterization of what their condition really is. 13,[81][82][83][84][85] This section contains three papers that explore patient experience in depth, explaining the importance of recognizing the personhood of the patient. Without an appreciation of the context of a person's life, her goals and values, a description of symptoms can of course tell us something about the nature of "the problem," which may serve our purposes in some contexts, but which in other contexts can be unhelpful or even misleading.…”

En syk kilde

“…Disse grensene begynte å krakelere, og gradvis vokste erkjennelsen frem at psykiske og fysiske traumer kunne igangsette de samme kroppslige fenomenene: kronisk smerte, nedsatt immunologisk respons mot mikrober og avvikende celler, økt inflammasjonsaktivitet, forstyrrelse av glukose-, lipid-og mineralhusholdningen, forstyrrelser i ulike autonome prosesser med økt hvilepuls, blodtrykk og muskelspenning, dårlig søvn og fordøyelse. Her avtegnet det seg en utfordring til biomedisinens tradisjonelle forståelse av kausalitet (13). Å samle slike kunnskapsbiter og se dem gradvis forme et radikalt nytt kart som faktisk samstemmer bedre med den kliniske virkeligheten i medisinfaget, saerlig i allmennmedisinen, kan bli en lidenskap.…”

Treating real people: Science and humanity

“…We are delighted to report that, in the year following these comments, we have received a vast amount of correspondence and submissions from some of the most insightful and influential commentators in health research and practice, taking this “great debate” forward in just the way we had hoped. This thematic edition of the Journal of Evaluation in Clinical Practice (the largest single edition of the JECP in its 24‐year history) includes over 50 papers, reviews, and reports of conferences that reflect the attention being given across the board—by practitioners, guideline developers, systematic reviewers, and philosophers—to the relationship between evidence, science, context, bias, truth, value, and methodology, with the quintessentially pragmatic goal to develop accounts of these concepts to assist decision‐making in practice. It includes specific sections consisting of papers delivered to major conferences on diagnostic categories (focussing on both their limitations and their overuse), clinical guidelines, and mechanisms in medicine .…”

“…Anna Luise Kirkengen draws on her experience as a general practitioner to highlight the importance of getting to know individual patients over time to understanding how to categorize the illnesses of those patients . Specifically, Kirkengen emphasizes the impact of multimorbidity on the practitioner's ability to apply guidelines, insofar as those guidelines tend to reflect an assumption grounding EBM approaches, that illness categories can be delineated even when they are simultaneously experienced by an individual patient.…”