Norbert Donner-Banzhoff | Exploring Diagnosis

DMacA:  Let’s move on to your own career, because you’ve covered a whole range of areas in general practice/ family medicine but your main interest appears to be diagnosis. Tell me about your interest in diagnosis.

N D-B: That began with my international experience. As a medical student, I went to the UK for a year.  My girlfriend found out that medical training was much better in the UK than in Germany and she suggested that we go to the UK. I went with her and it was life changing. This was in Swansea in South Wales, before Swansea had a medical school and it was an arrangement by the German Academic Exchange Service. So, I was one of the very first medical students in Swansea before the official medical school started.

I had two attachments with general practice and the impression was just overwhelming. So I decided that general practice was the thing to do for the rest of my life. And the interest in diagnosis came because I discovered that diagnostic thinking and acting was different in British doctors than in doctors in continental Europe. For instance, at the ward round in cardiology at the hospital, I remember a patient with chest pain and the group of white coats around the bed discussed the quality, the location, and appearance of his chest pain for ten minutes or so. This never happened in any German hospital at all or in a continental European Hospital. And I thought, this is interesting, what they are doing is completely different.

And I was fascinated. They were listening to the patient, drawing conclusions from what patients said. They’re not just ordering the tests but they make use of the history and the physical examination. I found that fascinating. And in noticing the differences, it becomes more interesting. You question what you have done until this point or what your teachers have told you.

And, from that, my interest in diagnosis started and by some strange coincidences, I ended up as an academic at the university so I have had plenty of opportunity to take these thoughts and ideas further.

DMacA: You have written a book which is a very comprehensive exploration of diagnosis, and I was fascinated by some particular aspects. One was your description of how, in the scientific context patients have a disease, but in practice patients come with an illness. That’s a big difference.

N D-B:  It is the big difference although, I must admit, I had not discovered the difference between the two.  Wise people had done that before me. But this is, of course, a fundamental distinction.

Illness is what I have on my way to the doctors and the disease is what I take home. What is important here is that our idea, or our categorization, or what we formulate in terms of disease, is always only preliminary. It’s an hypotheses which is being tested all the time.

And I think that’s why GP’s are such modest people, because they test their hypothesis all the time. We realize how often we have to reject what we formulated the last time, and our hospital colleagues, they are so lucky they don’t have this kind of hypothesis testing. For that reason, they are much more self-confident.  Whether they are happier than we are, I don’t know, that’s a tricky question.   But, reality teaches us that modesty and that is the important thing.  

And what I think is new or unusual in the book is that I try to bring together the diagnostic task, all the instruments that we find in clinical epidemiology but, on the other hand, to reflect the symbolic transactions that we have.  And here, medicine is very old fashioned. It’s an archetypical archaic activity. And whether, what we do, what we say, what we investigate, has any objective biomedical relevance doesn’t matter at all at this level, and this symbolic level is there all the time with any healing person, any healing profession in the world. But whether its an academic tertiary care centre or in my practice,  it doesn’t matter, it is always there. We can’t abolish it and we should not abolish it, we should use it. And that’s a big responsibility.

I’ve developed a model that consists of four layers. And these layers can be linked to certain stages of the history of medicine and health care. And at the bottom you have this archetypical healer and this tectonic level always exists. And in modern times, we are a bit ashamed of this, we all try to ignore or oppress it, but we shouldn’t. We should realize, well, this is our role, these are the effects that we have. And then I have developed a way to navigate these contradictions, these different layers and the roles they are linked to, all these contradictions that we are struggling with in our everyday care about how you can manage those so that your patients are happy, that doctors are happy, and they health care system is happy.

DMacA: You have a line that caught my imagination, that ‘X rays and injections are powerful rituals.’

N D-B:  Yes, that’s what this archetypical healer does. He or she, is not so much working with words or being effective at that level, but by symbolic action. In Germany I think that, maybe in general, we are a bit more superstitious. We use many more things such as injections for musculoskeletal pain, and these are still used by many elderly GP’s.  And, in a modern guideline on low back pain but you can’t just say leave that out.  That’s tricky because patients and doctors will ask, what can I do instead? If I don’t give injections anymore there’s a vacuum and I have to develop completely new strategies to fill that. But that takes a long time. But I’m optimistic in this regard. The changes we have brought into medical teaching in this country, and I mean of general practice/ primary care, I think that gradually changing and improving and people have become more critical. But, we never get rid of our role, our task as the archetypical healer, which is always there.  We should no misuse it, but should reflect on it.