Elementary concepts of medicine: IX. Acting on gnosis: doctoring, intervening

Once a physician – a doctor – has completed the pursuit of gnosis, (s)he turns to the next principal task of medical practice. At issue is doctoring, of course; and the essence – the concept – of this flows naturally from that of doctor. One of our medical dictionaries (Dorland 1994) defines the concept of doctor as: ‘1. a practitioner of the healing arts, one who has received a degree from a college of medicine, osteopathy, chiropractic, optometry, podiatry, pharmacy, dentistry, or veterinary medicine, licensed to practice by a state. 2. a holder of a diploma of the highest degree from a university, qualified as a specialist in a particular field of learning.’ The other one (Stedman 1995) gives: ‘1. A title conferred by a university on one who has followed a prescribed course of study, or given as a title of distinction; as d. of medicine, laws, philosophy, etc. 2. A physician, especially one upon whom has been conferred the degree of M.D. by a university or medical school.’ In both of these definitions, the medical concept of doctor is not properly distinguished from the academic concept of Doctor. As for the medical concept of doctor, simply put, the first definition makes it to be that of a licensed practitioner of medicine, and the second one specifies it as a physician. The first concept of doctor is our concern here. Neither definition expressly indicates what the practice – doctoring – is about, but the first one suggests that doctoring is a matter of healing. Our medical dictionaries define practise of medicine as: ‘the exercise of one's knowledge in the practical recognition and treatment of disease’ (Dorland 1994); or ‘the exercise of the profession of medicine’ (Stedman 1995). The key idea here is exercise – application – of medical knowledge. And indeed, the term ‘doctor’ has been applied to practising physicians ever since the Renaissance (Marti-Ibanez 1962; p. 230), when there first were university-educated practitioners of medicine and the time was ripe for the concept of physician as practitioner of a learned profession (following the slave physician of ancient Rome and the priest physician of Rome in the Middle Ages). We think of doctor-defining practice of medicine as practice that, for a start, brings genuine knowledge, learnedness, to the knowledge–practice interface, to the gnosis aspect of practice. Our concept of doctor also involves ‘teaching’ of the client about their own health (Miettinen 2001a; Miettinen & Flegel 2003). After all, the word ‘doctor’ etymologically means teacher. On the other hand, we do not see ‘treatment’, or more generally ‘intervention’, as being in the essence of doctoring: the 19th century was commonly one of doctoring in the framework of ‘therapeutic nihilism’ (Marti-Ibanez 1962; p. 243); and even today, therapy or other intervention may still not be available; and when it is, the doctor may delegate it to another professional or advise the client to carry it out. Different from our conception of the essence of doctoring, the definitions of medicine – doctor's work in practice – in our medical dictionaries involve the intervention-related word ‘treatment’ in one (Dorland 1994), ‘preventing’ and ‘curing’ in the other (Stedman 1995). These dictionaries define intervention itself as: ‘1. the act or fact of interfering so as to modify. 2. specifically, any measure whose purpose is to improve health or to alter the course of a disease’ (Dorland 1994); or ‘an action or ministration that produces an effect or that is intended to alter the course of a pathologic process’ (Stedman 1995). We agree that medical intervention is a purposive action, and that the purpose is not to learn about health (as with gnosis-oriented actions) but to change the course of health (Miettinen 2001b,c,d). The action may fail to produce the intended change, and therefore it is not definitional to medical intervention that it actually ‘produces an effect’. What generic changes, then, are the intended effects of medical interventions? We take it to be too restrictive to say that the purpose is ‘to alter the course of a pathologic process’. This tends to leave out prevention of (the pathogenesis of) disease and defect, and, even more clearly, the prevention of injury. It also leaves out rehabilitation. And it limits treatment to curative treatment, exclusive of palliative treatment, and to treatment of process-type illness (disease, injury), exclusive of defect. We take all of these restrictions to be at variance with the medical concept of intervention (Miettinen 2001b,c,d). The preventive purpose is not to improve health but to maintain it; and the therapeutic purpose is not inherently to alter the course of illness, as this applies to curative treatment only. All of this is to edit the definitions above to the following: Action intended to maintain health or to ameliorate illness. (Definition A) This definition begs the question of what the nature of the ‘action’ itself is. In particular, are medical advice-giving, prescription-writing and recommendation of surgery in themselves actions in the meaning of ‘medical intervention’? Or, is it instead that the corresponding actual interventions are advice-induced change in environment and/or behaviour, prescription-provided use of medication and recommendation-based submission to and execution of surgery? Or, as yet another possibility, are health-motivated change of environment and/or behaviour, medication use and surgery in themselves medical interventions, even in the absence of medical recommendations for them – inclusive of those actions when medically recommended against? Toward choosing among these three points of view it is relevant to note, first, that in the first option the purposiveness criterion applies only to the physician, in the second one not only to the physician but also to the client (seeing purpose in following the recommendation), and in the third one to the ‘intervened-upon’ person alone. On this basis, the third option is readily discarded: a person's health behaviour independent of physician's recommendation is an extramedical matter. It seems incontrovertible to us that a medical intervention is a physician-induced change in a person's causal determinants of health, that is, a change that in itself, all else remaining the same, is presumed to improve the recipient's future course of health, potentially at least. Recommendation does not, in itself, change the recipient's health, nor does receipt of prescription, just as application of a diagnostic or a screening regimen does not (Miettinen 2001b,c,d). We thus are left with the second option above and are, more specifically, led to posit this definition for medical intervention: Physician-induced (recommended and/or effected) change in the client's (person's or community’s) causal determinant(s) of health, intended to have desirable effect(s) on health. (Definition B) In this, ‘health’ has the inclusive meaning that encompasses not only illness and its associated sickness but normal sickness as well. ‘Physician-induced’ means that the determinant change represents a departure from what otherwise would have taken place, so that if a physician's recommendation merely reinforces what the client was going to do anyway (as to diet, say), no intervention is taking place. Finally, yet another aspect of wholesome conceptualization of medical intervention deserves note. The intended effect not only is prospective but has a particular time horizon in the future. In this context, a properly conceptualized intervention is not only an algorithm of prospective action but one whose duration is coextensive with the time horizon of the intended effect, long-term effect of a short-term action, with subsequent actions unspecified, being a malformed concept (Miettinen 1998).

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