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The Two Diagnoses

There was a time, a few decades ago, when most everyone interested in bringing together healthcare and the Christian faith was familiar with Dr. Paul Tournier and his work. In this article published in the fall 2017 edition of Today's Christian Doctor, Dr. Wilson Grant explores how Dr. Tournier's message and style of medical practice is increasingly

by Wilson Wayne Grant, MD

There was a time, a few decades ago, when most everyone interested in bringing together healthcare and the Christian faith was familiar with Dr. Paul Tournier and his work.

Dr. Tournier, a Swiss physician, emerged onto the world stage after World War II as he shared his professional and spiritual journey through a series of popular books. Trained in traditional medicine, he was committed to the day-to-day care of his patients as a family physician. But early in his medical career, he realized psychological and spiritual issues played a significant role in the physical illness and subsequent recovery of his patients. He was intrigued by the tight weaving together of the physical, spiritual and psychological wellbeing of these patients, as well as how all these components affected the health of his patients. He came more and more to practice what he called “Medicine of the Person.” He first outlined his concepts in the popular book The Meaning of Persons, which was published in English in 1957. A later book, A Doctor’s Casebook in the Light of the Bible, expanded on the concept that mind, body and spirit are indelibly linked together influencing each other in dynamic ways.

Following the success of The Meaning of Persons, Tournier continued to write, authoring more than 30 popular books during his career. He wrote on numerous subjects, but his works focused largely on medicine, family life and human relationships. His books were popular with physicians as well as laymen. He went on to be in great demand as a speaker in both Europe and America, before his death in 1986. In 2006, Christianity Today ranked The Meaning of Persons as one of the 50 most influential books that have influenced the way evangelicals think, talk, witness, worship and live—rating it as number 24 on the list.1

In the time since his death, Dr. Tournier’s work appears to have faded out of prominence in healthcare. Perhaps that’s a result of the boom of medical technology and the rise of electronic medical records. However, his message and style of medical practice is increasingly relevant to today’s healthcare professionals because he anticipated the loss of personal touch in the practice of healthcare. His practice, as well as his writing from decades ago, continue to stretch us, reminding us that our patients are persons with hopes, dreams and feeling, not simply bodies with a disease.

As defined by Dr. Tournier, “Medicine of the Person” is not just another branch of medicine. It is an all-inclusive approach to patient care that sees the patient as a “whole person” whose life and health are conditioned by family, community, body and spirit. In his view, care to the physical, psychological and spiritual components of the person are integral to the restoration and maintenance of health. For Dr. Tournier, “Medicine of the Person” is a spirit, an attitude and a way of relating that applies to all areas of healthcare. It is a way of focusing on the integration of the whole person—body, mind and spirit—in the healing process.

We health professionals living in the 21st century, surrounded by our technological marvels, can learn much from Dr. Tournier about how to effectively minster to hurting people. The following excerpt from A Doctor’s Casebook in the Light of the Bible reminds us how Dr. Tournier’s insights continue to be relevant to the effective care of our contemporary patients:

Clearly, any kind of illness raises questions of two quite distinct orders: firstly, scientific—questions concerning the nature of the malady and its mechanism: diagnosis, aetiology, pathogensis; secondly, spiritual—questions concerning the deep meaning of the illness, its purpose. We may say, then, that every illness calls for two diagnoses: one scientific, nosological and causal, and the other spiritual, a diagnosis of its meaning and purpose.

Dr. Tournier then points out that both diagnoses are in play whether the symptoms are mild or serious, the diagnosis minor or life threatening.

The first diagnosis is objective. It is we doctors who make it on our patient. Of course we need his collaboration, but it might be termed a passive collaboration. It is much more difficult to tend a brother doctor than any other patient, precisely because the former seeks to take part in the working-out of the diagnosis. All we require of our patient is that he furnish us with the data on which to base our judgment, to tell us what he feels and the diseases he or his forbears have had previously.

The second diagnosis, on the other hand, is subjective. It is the patient himself, and never the doctor, who can make it through the impulse of his inmost conscience. We in our turn can help him to establish this diagnosis, but here again passively; that is to say, not by suggesting a diagnosis to him, but through the climate of spiritual fellowship that we offer him.

From the point of view of the patient’s eternal destiny, the second diagnosis is much more important than the first. But from the strictly medical point of view they are of equal importance.3

Until a few decades ago, accurate physical diagnosis was primarily intuitive and depended on a thorough dialogue with, and exam of, the patient. Treatment was based on anecdotal experience. Today, healthcare professionals rely on their experience aided by highly sophisticated technology to make the first diagnosis. They have an array of effective tools to help make the medical diagnosis with speed and accuracy.

The second diagnosis is much harder for today’s healthcare professional to make—or even contemplate. In fact, healthcare professionals can become so enraptured with their technological capability that they easily ignore the significance of the second diagnosis all together. Our modern tools allow the clinician to make the medical diagnosis and even perform treatment with minimal touching or talking to the patient.

Dr. Tournier’s point that the second diagnosis (the meaning that any malady has for the patient) has equal importance in the patient’s treatment is seldom understood by today’s healthcare professionals. However, the reality of this point continues to be relevant. As healthcare professionals, we must admit that the faithfulness with which the patient submits to the diagnostic tools, or follows our prescriptions (written and otherwise), depends largely on the patient’s understanding of the illness and its meaning.

One of the defects of modern healthcare is that we are so preoccupied with the treatment of disease that we often fail to focus on the healing of the sick person in front of us. The technological atmosphere today tempts us to see the sick person as a body with a broken bone to be fixed, a chemical imbalance to be restored or a cancerous part to be removed, rather than a human being of value and worth with feelings, hopes and dreams.

The wonderful tools that modern medicine has placed in the hands of healthcare professionals greatly increase their effectiveness. But at the same time, this technology interfaces between the patient and the physician. If we are not careful, the clinician begins to treat lab results and x-ray pictures rather than a person with feelings.

Unfortunately, one of the major barriers to come between our patients and us today is the computer screen. One of the main pressures on the healthcare professional is the demand to maintain patient volume while creating a comprehensive electronic medical record for each patient. As many of us can attest, it is often hard to maintain good eye contact and communication with patients while completing their electronic records. In the process, the patient can easily feel ignored.

Several recent studies have evaluated the effects of novel technologies on interactions between the patient and healthcare professionals. In a 2014 edition of the International Journal of Medical Informatics, Enid Montague, PhD, and Onur Asan, MS, examined eye gaze patterns between patients and healthcare professionals while electronic medical records were used to support patient care.4 Gaze was studied because it provides a more objective indicator of attention and communication. In their study, patient visits were recorded using three high-resolution video cameras placed at different angles. A total of 100 patients and 10 healthcare professionals participated in the study. The results showed the healthcare professional spent on average nearly one-third of the visit’s length gazing at the electronic medical record. When paper medical records were used, healthcare professionals spent approximately 9 percent of the visit’s length gazing at the record.

We certainly cannot throw away the technological helps and the precision of diagnosis and treatment these tools provide. But we must realize that one side effect of the gadgets and sophisticated tools is they can become screens between our patients and us. To be effective in dealing with both diagnoses, we need to deliberately look past the instrument or latest test result, and we need to deliberately look past the computer screen in order to focus on the patient. As one of my colleague’s patient lamented, “My doctor hardly ever talks with me anymore. He mostly looks at the computer screen and asks me the same questions from the computer every time I visit. There’s not much time for me to ask my questions.”

As healthcare professionals, we must be ready to sit down by the bedside, take the hand of the patient, look them in the eye and communicate with them as a person. The patient needs to know their healthcare professional is thorough and is considering all the available options. And we need to be sure we have heard all the patient’s questions. While speaking at a conference for healthcare professionals that I attended in 1984, Dr. Tournier stated, “All sick people have a question which they hide in their pocket. They will take the question out of their pocket and share it only when they feel they can trust the doctor and that the doctor will truly listen to them.”

Making the two diagnoses is important if we are to ever fully understand our patients. In The Meaning of Persons, Dr. Tournier wrote, “Through information I can understand a case; only through communication shall I be able to understand a person.”5 As we use our technology effectively, we are called to remember that our encounter with our patients has meaning above and beyond our diagnosis and therapeutic intervention. Most of all, we are called to listen to our patient’s story and the meaning that story has for the patient as a person. The more we attend to their story, and their interpretation of that story, the more effective we will be as healthcare professionals and as people.


BIBLIOGRAPHY

1 http://www.christianitytoday.com/ct/2006/october/23.51.html
2 Tournier, P., MD. (1960). A Doctor's Casebook in Light of the Bible. New York: Harper's Brothers. p. 13.
3 Ibid.
4 Montague, E., & Asan, O. (2014). Dynamic modeling of patient and physician eye gaze to understand the effects of electronic health records on doctor–patient communication and attention. International Journal of Medical Informatics, 83(3), 225-234. doi:10.1016/j.ijmedinf.2013.11.003.
5 Tournier, P., MD. (1957). The Meaning of Persons. San Francisco: Harper and Row. p. 25.


ABOUT THE AUTHOR

Wilson Wayne Grant, MD, has been a member of CMDA since 1965 and continues to be active in the San Antonio, Texas chapter of CMDA. He is a pediatrician who retired in 2015.

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