On the construction of reality and its medical implications
Peter L. Berger and Thomas Luckmann will be long remembered for having authored the widely acclaimed book The social construction of reality: A treatise in the sociology of knowledge. In this jewel of sociology they argue that there is not just one reality but many. According to their theory, reality is nothing but a social construct, an idea that is created billions of times a day by every single living individual. Reality therefore represents no more and no less than the totality of its creator's perceptions and interpretations of what is.1
In medicine knowing the patient is key. However, even more important is to understand the reality they live in. In other words, it is impossible to know a patient without knowing their reality, that is, their life. In 1977 this idea was put on paper by the psychiatrist George L. Engel who called for a new biopsychosocial model of human health. He also considered his patients to be more than just their illnesses and asked his colleagues to give particular attention to their patients' lives in its entirety.2 Since then the biopsychosocial model has experienced a story of unprecedented success. Although the theory has been criticized for many reasons and despite being far from flawless, its core however, that lives and not just illnesses matter, has never really been challenged.3,4
In this context narrative medicine (a term coined by the general practitioner Rita Charon) has emerged to offer a conceptual framework to put the daily experiences of doctors and patients into words. When told, their stories echo not only the different realities in which patients and doctors live, but they also accentuate the longitudinal aspect of human health and illness.5–7 This is of uttermost importance since most doctors (and in particular clinicians) might otherwise just catch a glimpse of what is actually happening—a snapshot in time that obscures more than it reveals. It is the luxury of the general practitioner to accompany his patients over many years, to see them flourish and wither, like a biographer of human life.
Something that all three concepts, reality as social construct, the biopsychosocial model, and narrative medicine, share is their determination in understanding the different dimensions of human life. For a doctor it is impossible to heal a patient by just focusing on a disease. In fact, curing a patient from a specific disease is much easier than healing somebody, in terms of helping a patient to remedy a disturbance in any sphere of their complex life. Therefore, being a doctor is more than just being a medical specialist, it is also being a psychologist, being a social worker, and (perhaps most importantly) being an attentive listener.
For doctors it is crucial to connect to their patients and to be granted entry into the very personal and unique reality of their patients. Nothing is more rewarding than learning more about another human being. At the same time it gives access to non-medical aspects of life which would otherwise remain carefully hidden from peeking eyes. It is nowadays considered almost a universal truth that social circumstances can make us ill.8,9 In 2008 the United Nation's Commission on Social Determinants of Health published its extensive final report which also stressed the importance of social, economical, and environmental factors and their impact on human health.10 However, it is only the trusted doctor who can see behind the curtain and understand the complexities of a patient's life. All those who have failed to really connect to their patients and to establish a relation of mutual trust can only assume what remains hidden in the dark.
Though appearing impeccable in theory, the application of these three concepts in daily practice can present major challenges. Possibly the greatest danger comes from intergroup bias, in other words, a systematic preference of individuals that belong to the same group as oneself.11 In doctor-patient relationships, that would be the doctor who favors patients that live in close proximity to his reality over those whose reality of life is more distant. Assuming that doctors form only a very small group of the overall population (and therefore their realities represent only a small and probably very skewed part of society), there is considerable risk that they might jeopardize patients' health. This is especially worrisome as discrimination itself poses just another hazard to patients' health.12 However, doctors who are aware of this bias might be able to mitigate it by means of frequent introspection and questioning of their own actions.
"He took me seriously . . ."
Marianne, a 29 year old woman, describes her first encounter with her new general practitioner: "He listened to what I was saying, and he took me seriously. So I felt that it was I who was important."13
In the same study, other patients gave similar accounts when asked about what matters in a doctor-patient relationship. "Being taken seriously" might seem to be quite an elusive description of interpersonal relationship at first, but it actually gets right to the heart of it. It is all about recognizing the patient and accepting them as they are. Building a trustful relationship is a bidirectional process which requires an attentive doctor who is willing to listen and to impartially accept what is being said and a patient that wants to share her reality. However, sometimes communication fails. This can especially be the case if the doctor gives a psychosomatic diagnosis which might be experienced as humiliating by the patient.13
"Being taken seriously" can mean very different things to various persons, all depending on the reality in which they live, as Berger's and Luckmann's theory reminds us. Therefore the doctor that affronts her patients has most likely not succeeded in connecting with them and as a consequence does not know how to avoid the pitfalls of those very distinctive relationships. However, communication will thrive when the doctor starts to explore the reality the patient lives in. It needs to be treated like a precious flower, one wrong gust of words can take its life, but when watered with attentive curiosity it will blossom in a previously unknown beauty. It is the essence of being a good doctor to learn about all those little peculiarities everyone keeps hidden in the attic of one's mind. Knowing them enables the doctor to bring up more delicate topics which had been previously avoided to allow both doctor and patient to connect to each other.
Ronald Epstein and Richard Street coined the term "shared mind" to describe exactly this process of decision-making whereby two individual minds (the doctor's and the patient's) converge to one "shared mind" which finally decides. It is of course still the patient who takes the decision, but she has been supported by the collaborative efforts of her doctor. It is he who attunes to his patient's reality, who reinforces and complements her cognitive faculties, and who can provide sense in times of information overload.14
However, today's fast-paced world and economic constraints put these cherished relationships under pressure. Regularly, personal continuity of care is balanced against speed of access.15 Though patient satisfaction and valued doctor-patient relationships have so far been postulated to be closely linked to continuity, this association might not be as strong as previously assumed. Recognition, that is, respecting and accepting a patient as a person and remembering past encounters, might be more important than a regular "own" doctor.13,16 Indeed, familiarity between doctor and patient does not seem to influence content of consultations in primary care which might be a sign of great communication skills on the side of primary care physicians.17 Nevertheless, attending to psychosocial aspects remains crucial to establish a trustful connection and to empower patients.18 In the end, content appears to beat both length of consultation as well as duration of the relationship, in other words, continuity.13,18
The concept of patient-centered medicine has evolved as the logical progression of the biopsychosocial model and has superseded the paternalistic communication style. In patient-centered medicine, the focus of attention, which traditionally lies on the disease, has shifted towards the patient's experience of being ill. It is no longer for the nearly omniscient doctor to explain the concept of disease to the patient; on the contrary, it is now his turn to listen to the patient's subjective narrative on being ill.19,20
It is not treating patients what makes a "medical specialist" to be a doctor. It is quite the contrary: adapting to her patient's reality—and accepting it without bias—is essential for connecting with the patient. And it is this connection that makes patients feel taken seriously and that gives doctors the chance to not only cure symptoms but to work on the root of any problem. However, those who do not get involved with their patients will never understand the plurality of human life as they will rest confined to their reality, which in this case would be more of a cage. To heal one must be ready to immerse oneself in the different worlds of one's patients and only those who can endure those varieties of being a human being and the different realities in which we all live will re-emerge as true doctors.
1. Berger, P. L. and Luckmann, T. (1967, ©1966) The social construction of reality: A treatise in the sociology of knowledge. Doubleday, Garden City, N.Y.
2. Engel, G. (1977) The need for a new medical model: a challenge for biomedicine. Science 196(4286): 129–136. doi: 10.1126/science.847460
3. Borrell-Carrió, F., Suchman, A. L., and Epstein, R. M. (2004) The Biopsychosocial Model 25 Years Later: Principles, Practice, and Scientific Inquiry. Ann Fam Med 2(6): 576–582. doi: 10.1370/afm.245
4. Ghaemi, S.N. (2009) The rise and fall of the biopsychosocial model. The British Journal of Psychiatry 195(1): 3–4
5. Charon, R. (2001) Narrative medicine: form, function, and ethics. Ann Intern Med 134(1): 83–87
6. Charon, R. (2001) The patient-physician relationship. Narrative medicine: a model for empathy, reflection, profession, and trust. JAMA 286(15): 1897–1902
7. Woods, A. (2011) The limits of narrative: provocations for the medical humanities. Med Humanit 37(2): 73–78. doi: 10.1136/medhum-2011-010045
8. Braveman, P. and Gottlieb, L. (2014) The social determinants of health: it's time to consider the causes of the causes. Public Health Rep 129 Suppl 2: 19–31
9. Marmot, M. and Allen, J. J. (2014) Social determinants of health equity. Am J Public Health 104 Suppl 4: S517-9. doi: 10.2105/AJPH.2014.302200
10. World Health Organization (2008) Closing the gap in a generation: Health equity through action on the social determinants of health. Commission on Social Determinants of Health final report. World Health Organization, Commission on Social Determinants of Health, Geneva, Switzerland.
11. Hewstone, M., Rubin, M. and Willis, H. (2002) Intergroup bias. Annu Rev Psychol 53: 575–604. doi: 10.1146/annurev.psych.53.100901.135109
12. Krieger, N. (2014) Discrimination and health inequities. Int J Health Serv 44(4): 643–710
13. Frederiksen, H. B., Kragstrup, J. and Dehlholm-Lambertsen, G. (2009) It's all about recognition! Qualitative study of the value of interpersonal continuity in general practice. BMC Fam Pract 10: 47. doi: 10.1186/1471-2296-10-47
14. Epstein, R. M. and Street, R. L. (2011) Shared mind: communication, decision making, and autonomy in serious illness. Ann Fam Med 9(5): 454–461. doi: 10.1370/afm.1301
15. Guthrie, B. and Wyke, S. (2006) Personal continuity and access in UK general practice: a qualitative study of general practitioners' and patients' perceptions of when and how they matter. BMC Fam Pract 7: 11. doi: 10.1186/1471-2296-7-11
16. Pandhi, N. and Saultz, J. W. (2006) Patients' perceptions of interpersonal continuity of care. J Am Board Fam Med 19(4): 390–397
17. Jabaaij, L., Fassaert, T. and van Dulmen, S. et al. (2008) Familiarity between patient and general practitioner does not influence the content of the consultation. BMC Fam Pract 9: 51. doi: 10.1186/1471-2296-9-51
18. Lemon, T. I. and Smith, R. H. (2014) Consultation Content not Consultation Length Improves Patient Satisfaction. J Family Med Prim Care 3(4): 333–339. doi: 10.4103/2249-4863.148102
19. Taylor, K. (2009) Paternalism, participation and partnership - the evolution of patient centeredness in the consultation. Patient Educ Couns 74(2): 150–155. doi: 10.1016/j.pec.2008.08.017
20. Ishikawa, H., Hashimoto, H. and Kiuchi, T. (2013) The evolving concept of "patient-centeredness" in patient-physician communication research. Soc Sci Med 96: 147–153. doi: 10.1016/j.socscimed.2013.07.026
JULIUS KREMLING, Ruhr University Bochum, Bochum, Germany.