THE STORY OF MEDICINE: FROM PATERNALISM TO PARTNERSHIP

THE STORY OF MEDICINE: FROM PATERNALISM TO PARTNERSHIP !! ! ! Jennifer Lynn Marks ! ! ! ! ! ! Submitted to the faculty of the University Graduate School in partial fulfillment of the requirements for the degree Master of Arts in the Department of Communication Studies, Indiana University August 2012 ii Accepted by the Faculty of Indiana University, in partial fulfillment of the requirements for the degree of Master of Arts. ! ! ___________________________________ Kristina Horn Sheeler, Ph.D., Chair ___________________________________ John Parrish-Sprowl, Ph.D. Master’s Thesis Committee ___________________________________ Kristine Brunovska Karnick, Ph.D. iii ACKNOWLEDGEMENTS First of all, to the wonderfully kind physicians who took time out of their extremely busy schedules to share their stories with me—I want to express my deepest thanks and appreciation. It has been a privilege to speak with each of you, and I am proud to carry your collective voice to others. I would like to thank Kristy Sheeler, my advisor throughout undergraduate and graduate school, for giving me the rhetorical foundation on which I have built my scholastic career. You introduced me to Bitzer and Fisher, whose work became my academic lenses as I made sense of my small place in the world. I also thank you for gently pulling me back when my ideas have been larger than the task at hand. I would like to thank John Parrish-Sprowl for giving me innovative ways to think about things—even those that seem most routine. You exude knowledge during every conversation and help everyone to be cognizant of the fact that learning is a lifelong process. Additionally, I would like to thank Kristine Karnick for always believing that my ideas are interesting and that I have important things to say. That has meant the world to me, especially as a graduate student. I want to give special thanks to my very best friend in the entire world for being my rock in life and always letting me lean on you. I realize I have leaned especially hard throughout my thesis preparation, but your strength and guidance have never faltered. Please know that I could not clear my largest hurdles without your encouragement. When I doubt myself, you restore my faith with your unwavering support and belief in iv me. You understand me like no one else does and help me feel less alone in the world. I will love and appreciate you forever. To my home and work families, I would also like to express my heartfelt love and appreciation for believing in me and accommodating my schedule through the years so that I could achieve my goals. I could not have done this without any of you, and I deeply thank you. v ABSTRACT Jennifer Lynn Marks THE STORY OF MEDICINE: FROM PATERNALISM TO PARTNERSHIP Physicians were interviewed and asked about their perspectives on communicating with patients, media, and the ways in which the biomedical and biopsychosocial models function in the practice of medicine. Fisher’s Narrative Paradigm was the primary critical method applied to themes that emerged from the interviews. Those emergent themes included the importance of a team approach to patient care; perspectives on physicians as bad communicators; and successful communication strategies when talking to patients. Physicians rely on nurses and other support staff, but the most important partnership is that between the physician and patient. Narrative fidelity and probability are satisfied by strategies physicians use in communicating with patients: using understandable language when talking to patients; engaging in nonverbal tactics of sitting down with patients, making eye contact with patients, and making appropriate physical contact with them in the form of a handshake or a light touch on the arm. Physicians are frustrated by media’s reporting of preliminary study results that omit details as well as media’s fostering of expectations for quick diagnostic processes and magical cures within the public. Furthermore, physicians see the biomedical and biopsychosocial models becoming increasingly interdependent in the practice of medicine, which carries the story of contemporary medicine further into the realm of partnership, revealing its humanity as well as its fading paternalism. Kristina Horn Sheeler, Ph.D., Chair vi TABLE OF CONTENTS Abbreviations & Definitions viii Introduction 1 Rationale 5 Literature Review 9 Methodology 16 Analysis Teamwork 20 Physician-Patient Partnership 25 Return to the Theme of Teamwork at Large 35 Physician-Patient Communication 39 Physicians’ Perspectives on Biomedicine 54 Physicians’ Perspectives on Media 66 Conversational/Story Elements 77 Future Research 82 Conclusions 84 Limitations 85 Appendices Appendix A 86 Appendix B 102 Appendix C 113 Appendix D 123 Appendix E 141 vii Appendix F 154 Appendix G 172 Appendix H 182 Appendix I 193 Appendix J 216 Appendix K 233 Appendix L 256 References 277 Curriculum Vitae viii ABBREVIATIONS & DEFINITIONS Angina: Chest pain. Angioplasty: Involves temporarily inserting and blowing up a tiny balloon where an artery is clogged to help widen the artery (Mayo Clinic). Cardiologist: Physician who specializes in treating the heart/cardiovascular system. Cellulitis: “Common, potentially serious bacterial skin infection. Cellulitis appears as a swollen, red area of skin that feels hot and tender, and it may spread rapidly” (Mayo Clinic). Defibrillator: Device used to shock the heart back into a normal rhythm [may be internal, i.e., implantable cardioverter device (ICD) or external, i.e., shock paddles]. Ejection Fraction (EF): “A measurement of how well your heart is pumping” (May Clinic). Electrophysiologist: Cardiologist with special training in treating heart rhythm disturbances. Familial Hypercholesterolemia: Extremely high total cholesterol level that is hereditary in nature. Hyperlipidemia: High level of fats in the blood. Hypertriglyceridemia: A high level of triglycerides, or specific type of fat, in the blood. Hypertriglyceridemia is a type of hyperlipidemia. Low-Density Lipoprotein (LDL): “Bad” cholesterol. Myocardial Infarction (MI): A.K.A., Heart attack—“Occurs when a blood clot blocks the flow of blood through a coronary artery — a blood vessel that feeds blood to a part of the heart muscle.” (Mayo Clinic) Nephrologist: Physician who specializes in treating the kidneys. NPO: Literally, “nothing per oral”- when patients cannot eat or drink anything prior to a test or procedure, they are considered to be of ‘NPO’ status. Patent Foramen Ovale (PFO): “While a baby grows in the womb, there is a normal opening between the left and right atria (upper chambers) of the heart. If this opening fails to close naturally soon after the baby is born, the hole is called patent foramen ovale (PFO).” (U.S. National Library of Medicine) Pulmonologist: Physician who specializes in treating the lungs/respiratory system. ix Stable Angina: Chronic chest pain that responds to medications like sublingual nitroglycerin or ranexa. Stent: “A small mesh tube that's used to treat narrowed or weakened arteries in the body” (National Heart, Lung, & Blood Institute). Unstable Angina: Chest pain that is no longer responsive to medication (like sublingual nitroglycerin or ranexa) and could indicate a life-threatening condition (heart attack). 1 INTRODUCTION Many forms of media, particularly film, depict physicians as cold, uncaring scientists who are incapable of recognizing a patient as anything more than an incubator for disease. Goals such as discovering new cancer treatments with the hope of finding a cure, in addition to the very act of saving lives, are portrayed as selfish and arrogant. The cinematic patient is a victim—not of terminal illness—but of experimental treatments and hasty, hollow, purely obligatory niceties of doctors. I became acutely aware of this phenomenon during a graduate level medical humanities course, “Perspectives on Film in Medicine,” in which I was introduced to films that presented physicians in this way. For instance, while The Doctor (1991) had its positive portrayals, it also had its negatives. Dr. Jack McKee was diagnosed with laryngeal cancer (cancer of the voice box) by an ENT with a severely lacking bedside manner. She did not participate in small-talk and made it clear to him that she was in charge—her schedule mattered more than his. Wit (2001) also centered on cancer diagnosis and treatment overseen by non-empathic, non-sympathetic physicians (www.imdb.com). This film is discussed further below. Having worked with physicians, including oncologists, on a daily basis for a number of years, I knew that these presentations were not telling the whole story. The potential for audience members to perceive these portrayals as true and representative of actual doctors became readily apparent. This led to an IRB-approved research project in which I interviewed undergraduate communication students in conjunction with showing them the film Wit. Emma Thompson stars as a Professor of 17 th Century Poetry who is diagnosed with Stage [...]... framed the image profile of doctors as cold and uncaring The lack of surprise expressed by students who saw this image profile displayed in the film indicated that this is the type of physician they expect to meet in the exam room Additionally, the fact that these students associate who they perceive to be cold, distant physicians with the biomedical model, ties the story of biomedicine to the existing... looking at the values that inform the story (1985, p 350) as well as the values found in characters throughout the story In the context of a patient care team, fidelity is established through the values of community and goodwill toward other human beings The entire healthcare team comes together, in the spirit of community within the healthcare institution, with the goal of restoring patients to good... biological explanation.” One half of each of the groups (50 from the “no story group and 50 from the story group) was given a placebo The remaining group members were not given pills but told their symptoms would likely go away soon Patients returned to see the doctor after two weeks While there was no difference in the “frequency of healing” between the placebo groups, there was a remarkable difference... knew the stories, touted by these films, were not the only stories to be told Rather than add to the existing large volume of patients’ perceptions about experiences with physicians, I want to add to the comparatively small volume of physicians’ perceptions about experiences with patients With that in mind, I really want to make the idea of communicating with physicians tangible for others and to give... team, as made evident by the content of interviews I conducted Contemporary medicine tells a story of partnership: partnership between the physician and patient, between the physician and other members of the healthcare team including other physicians, as well as between other members of the healthcare team and the patient Dr K referred to it as “a circle” of communication that the physician directs”... yet another collection of viewpoints that does not include that of doctors Again, it was my hope to give doctors the opportunity to address the primary claims 5 made about their ability to communicate (or, lack thereof, according to my previous research with the students) as well as the main claims made about the traditional approach to their life’s work My project sought to make the physician’s representative... true when compared to stories told by others (1994, p 24) Therefore, it stands to reason that when other members of the healthcare team supplement the physician’s initial message, and the core information matches as the staff members’ stories are compared to the physician’s story, credibility and trust are fostered between the patient and each of those staff/healthcare team members (Aristotle, Book 2,... is the believability of a story the degree to which a story can be identified with and labeled as true Fidelity is established when the characters and members of the viewing/listening/reading audience share the same values It is also present when these various audience members can see themselves taking the same action or behaving in the same manner as the characters in question should they find themselves... physicians using the concepts of “demons and monsters to explain bacteria and viruses to the general public.” Patients understand biomedicine in simplified terms (p 86) To exemplify the storytelling aspect, Oderwald described a study, conducted in Southampton, which split 200 patients with vague symptoms into two equal groups One group was told no story could explain their symptoms while the other group... views the world through communication-oriented lenses, I am driven to investigate the communication strategies of biomedicine and trace its roots to the extent possible It has been the goal of this research project to reveal the psychosocial behaviors of patients that physicians acknowledge in addition to the biological phenomena, bringing to light the physicians’ understanding of the types of issues they . Introduction 1 Rationale 5 Literature Review 9 Methodology 16 Analysis Teamwork 20 Physician-Patient Partnership 25 Return to the Theme of Teamwork at Large 35 Physician-Patient. Perspectives on Biomedicine 54 Physicians’ Perspectives on Media 66 Conversational/Story Elements 77 Future Research 82 Conclusions 84 Limitations 85 Appendices Appendix. Appendix E 141 vii Appendix F 154 Appendix G 172 Appendix H 182 Appendix I 193 Appendix J 216 Appendix K 233 Appendix L 256 References 277 Curriculum Vitae