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The Paradox of EmpowermentByPeter Davies, MD This article was originally published in the electronic version of the British Medical Journal in May, 2005, and under embargo for one year. It is reprinted here with kind permission from the author. Only the title has been altered in collaboration with the author. They say that the road to hell is paved with good intentions. And intentions do not come any better than those of the healing professions. We want to help others and so to empower people to be themselves. We are powerfully trained, conscientious, and somewhat driven. And yet despite the empowering efforts of the healing professions the public seems to be developing an ever greater taste and apparent need for the services of our professions. The patient or client base is growing, and all the while the professionals say they are empowering the patients. If patients are really being empowered, how come there are more of them and they are staying around longer? There is a deep paradox between the expressed aim of professional services to empower patients and the ever greater demand for professional services from the thus empowered patients. I want to explore this paradox in this essay. In the classic medical model of disease, patients notice bodily sensations, which they interpret as indicating a problem. Being concerned about the symptoms, a patient will seek the help of many people, including, eventually, the doctor. The doctor goes through the routine of the consultation. Having done this the doctor reaches a diagnosis that sets a disease based frame of reference around the problem. The doctor then uses the diagnosis to advise the correct course of treatment for this particular patient. Ideally, the patient understands and accepts the treatment proposal and implements it. The patient then gets better. Note the ambiguity here: better here means recovered from disease, not better in any moral sense. This is the medical version of the common problem solving paradigm in the West—a linear process of problem identification, problem definition, and then problem solving. Fundamentally the doctor acts as Dr Fix-it, the panacea for ills. The patient is seen as empowered by the very fact of being fixed. Over the past 50 years this simple paradigm has come under much deserved scrutiny. We are now far more aware of factors relating to the patients themselves; factors such as patients' ability to cope, their tolerance thresholds, and their history combine to result in very variable presentations of illness. We now realise that the relation between the presence of symptoms and the presence of disease is indirect and tortuous. Most symptoms presented to GPs [family doctors] have no medical explanation, and even in hospitals the correlation between symptoms and recognised disease is poor. Factors relating to doctors have also been studied. Doctors recognise certain patterns but do not recognise all as valid. Even within a field certain doctors only recognise a subset of all conditions. And then the number of conditions is never static, as new syndromes are continually invented. Where was "female sexual dysfunction" before sildenafil was discovered? It was in the self help pages of Cosmopolitan and not in the doctor's surgery. How has it subtly slipped over the boundary from being a part of life to being a disease? And who says it has, and why? This proliferation of syndromes carries a danger: the assumption that just about all of us have some form of bodily or mental infirmity and that if we set all these infirmities in a disease based frame of reference then we will all be ill in many different ways. Remember the old adage "whoever sets the frame sets the game"? Too much of modern life is played within the medical frame of reference. Normal life becomes a progression of moves from one syndrome to another, with professional help needed at every stage. As Sir William Osler once commented, "Normal? We just haven't examined him closely enough yet!" As the wise doctor in Macbeth (one of the best medical heroes in literature) says, "These things must not be thought of after this fashion. Methinks it will make us mad." He follows up with the line, "Therein the patient must minister to themselves. This malady is beyond my remedy." Hooray. As a doctor I think it is time to celebrate his wisdom, to start the move to reduce the flow of patients to the overpriced and disempowering medical services and back towards having healthy individuals, in healthy life contexts, who see the doctor only when something really is medically wrong with them. The current threshold for diagnosing medical illnesses is too low, and too many doctors and patients are ensnared (wittingly or unwittingly) in a mad dance, chasing phantasmagoria of possible diagnoses because no one will now tolerate doubt, uncertainty, or the existential angst that is part of the human condition. We flee from religion and sacrifice our goods on the altar of high tech scanners. Paradoxically, the more medicine we do the more we discover to do. We urgently need to break free of the bind this paradox imposes on our profession, both in hospital and general practice settings. Not all of life's problems are diseases, and to try to make them such will make us mad and disempower everybody. Dr Peter Davies Keighley Road Surgery Illingworth Halifax HX2 9LL www.krshalifax.co.uk
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