What happened? GPs' perceptions of consultation outcomes and a comparison with the experiences of their patients.

OBJECTIVE: To investigate GPs' perceptions of consultation outcomes and to investigate the associations between these and outcomes perceived by the patients. DESIGN: 25 GPs and 10 patients for each GP filled in a questionnaire about the outcome of the same consultation. The questions in the questionnaires were formulated from concepts found in preceding qualitative studies. Their answers were analysed and compared. SETTING: GPs and patients from 16 group practices in Norrbotten, Sweden. RESULTS: The GPs had the apprehension that their consultations would lead to cure/symptom relief in half of their consultations. They believed that their patients were satisfied up to 90% and that up to 75% had been reassured, understood more or could cope better. The GPs were satisfied themselves with up to 95% of the consultations, they enhanced their relationship to their patient up to 70%. Their affirmative concordance with their patients was high regarding satisfaction, intermediate regarding patient reassurance and patient understanding and lowest regarding cure/symptom relief. CONCLUSION: The GPs' were lacking in their ability to assess the patients' increased understanding and the concordance between their own and the patients' expectation of cure/symptom relief was low.

The doctor, the patient and the body.

Michael Balint has helped us realize that the clinical interaction is, above all, an inter-human interaction. However, the lived experience of the body -- the existential anatomy -- occupies but a very small space in the consciousness of medicine. Even the "psychosomatic body" is a theoretical construct favouring observation rather than understanding. The doctor shares the conditions of embodied life with his patients, and, in addition, has the opportunity to refine his sensitivity to the variations of bodily experience in his work with patients. Thus, a bodily empathic basis for clinical interaction is laid on which understanding and diagnosis may reinforce one another in a common endeavour.

[The human language of medicine. Physical expression of empathy added to diagnosis promotes understanding]. / Medicinens mänskliga språk. Kroppsempati förenar diagnostik och förståelse.

The article consists in a review of the clinical encounter in terms of existential anatomy and bodily empathy. Making a diagnosis and understanding the patient are not seen as discrete, mutually exclusive endeavours. In addition to relying on their biomedical expertise, doctors need to be attuned to their patients' symptom presentations as living, experiential expressions of the body, existential anatomy. By 'sharing' his patients' basic bodily conditions, the doctor accumulates abundant knowledge throughout his professional life. Diagnosis is preceded, and its accuracy enhanced, by grasping the experiential essence of the patient's symptomatology. The doctor's ability to communicate with the patient within the realm of existential anatomy is what is referred to as bodily empathy. It is proposed that satisfactory management is dependent on interplay between diagnostic expertise and bodily empathy.

The clinical method of general practice.

General practice is situated close to the everyday life of the population, and close to the individual patient. Limitations of the biomedical perspective become obvious due to the individuality of the patients' experiences of symptoms and disease, and due to the high prevalence of symptoms without disease. General practice has to face this situation methodically, all through the steps of symptom analysis, diagnostic procedures, and treatment. The significant element of the clinical method is the recognition of clinical practice as an inter0human activity with very practical aims. Within the perspective of this method, symptoms turn out to be symptom presentations, professional objectivity to be an individual readiness to understand, and the patient a responsible individual to be understood and to be invited to become an active party in the process of diagnosis and treatment.

Body-as-nature - Body-as-self.

To biomedicine, the body is an entity possible to observe and understand through scientific theory and technology. To the individual human being, the body is a basis of existence. The correspondence between these two perspectives is only very conditional, a situation often overlooked within biomedically oriented clinical practice. Also, the scientific mapping of the body does in fact challenge the traditional conceptions of a straight-forward bodily logic. Understanding the bodily, existential perspective is therefore often necessary to obtain validity of the clinical dialogue.

Symptoms and symptom presentation.

In the theory of medicine, symptoms are logically related to defined bodily derangements. In the practice of medicine, doctors see patients who experience and present their symptoms in a personal way. With the twofold aim of investigating the clinical significance of this gap and of tracing a practice oriented diagnostic competence, a study was conducted. Thirty-three general practitioners and eleven trainees and locums in primary care made diagnostic judgements, first from 16 symptoms presented in a concentrated written form, and then from the video-recordings of the actual presentations of the same symptoms. The hypothesis formulated was that doctors would increase their diagnostic accuracy after having seen the video-recordings. In the view of doctors, psycho-social causes became more important to their diagnoses after they had seen the video-tapes. When compared to the judgements made by a reference group of three general practitioners who had access to all clinical data on the patients, this change implied an increase of discrepancy of opinion (p < 0.00003) in symptoms of predominantly organic origin. This change was observed irrespective of clinical experience and sex of the doctor. Thus, the gap between theory and practice seems to be significant in terms of diagnostic judgement, but the hypothesis regarding the effect of a possible practice oriented competence could not be confirmed. On the contrary, psycho-social stereotypes regarding patients seem to have a considerable impact on early judgement. Emotional expressions and social characteristics become the targets of diagnosis rather than being regarded as integrated aspects of the symptom presentation.

What is general clinical competence? Facing the theoretical challenge to general practice.

If general practice keeps on resorting almost totally to pragmatism, official features of the profession, such as comprehensiveness, will invite a limitless agenda. This lack of specificity also makes general practice seem replaceable, especially in countries where its traditional position is weak, as in Sweden. Still the majority of practitioners regard the contribution of their profession as specific. This situation offers a theoretical challenge, which if successfully answered could lead to the identification of crucial items of the clinical encounter and to the clarification of the position of general practice in medicine. The challenge lies in understanding and identifying that general clinical competence which mediates between the individual patient and biomedicine and which contributes to the competence of the skilful clinician irrespective of specialisation. The general practitioner is better placed than anybody else to refine that competence, as no distinct professional focus continuously distracts him from the general features of clinical medicine. After having analysed the relevance for "general clinical competence" of clinical epidemiology, of the "patient-centred clinical method ", of different problem-solving strategies and of communication respectively, this paper traces "general clinical competence" to a rather restricted but crucial area of clinical practice, which deals with the understanding of the symptom presentation. Usually this presentation is neither a clear-cut nor a direct offspring of disease but a personal communication of a change within the experience of the own body, "the lived-body". This understanding of the "lived-body" of the patient, which is here called bodily empathy, is often necessary to grasp the character of a symptom, and it is suggested that it is a major constituent of general clinical competence. It is also suggested that bodily empathy constitutes the basis of general practice as a discipline.