December 02, 2014

My Paradigmatic Assumptions

As a family physician with an undergraduate degree in cellular/molecular biology and a relationship-centric graduate and post-graduate training, I possess a blend of different paradigmatic assumptions.  On the one hand, positing initial conditions with cause-effect relationships seen in the physical sciences, I believe in the ability of Science to justify and explain phenomena that we experience. I take it on faith that we all experience slivers of a True Reality through our perceptions.   (This is called Positivism by my own admission of prior ontological and epistemological  programming as a scientist.)  On the other hand, I also believe that a simplistic, reductionist approach pursuing an "objective, external truth" removes a key humanist component in appreciating a "shared social 'reality'" and a "shared social good," a category in which non-physical phenomena dwell.

I do believe there are demonstrable benefits in medicine and science for pursuing an external, objective "one Truth, one Disease" reality when a physician meets a patient and diagnoses them, with say, hypertension.  However, I also acknowledge that our collective beliefs shape our "shared social 'reality'" and our approach to disease.  Each person possesses a unique blend of background human in-born traits like race/sex/personality.  In contrast, sociocultural and epigenetic factors like ethnicity/gender/socioeconomic status. are constructed over time atop these background traits and become structural fixtures as well.  (This is called Constructivism in which truth only gains meaning [and is only known] through social construction.)

Two patients with the same disease may act in very different ways, since they have different constructs.  Similarly, two physicians may act very differently, depending on whether or not they treat the disease... or they treat the patient... the community... or even society itself.

I plan to propose a robust and evocative model that addresses the philosophical differences between the Positivist and the Constructivist, as well as the potential conflicts between patients and physicians.  Firstly, [my thesis] draws upon the positivist principles of natural order-assembly present in physics in phase-change states, and biology in the synthesis of organic molecules like proteins or DNA.  Secondly, it accounts for constructivist scaffolding structure of inborn traits, epigenetic components, sociocultural factors, and educational influence as the basis for idea generation.  Concepts like a disease-diagnosis form, catalyzed by principles of pathophysiology, cognitive "toolkit" heuristics, or past experiences.  The core of the diagnosis is primed by an organized, medicalized mental case presentation pattern-matching to prior illness scripts (or instance scripts.)  In looping back and engaging patients in education and shared-decision-making, aligning a patient's self-perception of disease empowers them to change themselves in cases where a disease is in part a social construct -- moving from a disease-oriented model to a patient-oriented health model.

For example, a physician may react to a patient with hypertension as a machine with an elevated number that can be titrated downward with successive dosing of medications to relax the internal blood pressure.  In contrast, another physician may view hypertension itself as a result of structural violence resulting from generations of low socioeconomic status, poor education, low literacy, living in a food desert without access to healthy low-salt options, lacking safe places to exercise and all things considered, a lower priority given to costly medications relative to other financial imperatives.  Yet another physician may try to advocate for policy on improving access to care and reversing the obesity epidemic.

Alternately, the relationship of the doctor-patient on the subject of an "invisible, risk-factor" disease like hypertension or early stages of type II diabetes is strictly paternalistic.  The physician requests a bond of trust that the number they report (be it blood pressure or blood sugar) is elevated to an unhealthy or possibly even dangerous degree and the patient has to decide whether or not this is credible data.  Do some patients see a physician in the same light as a mechanic who may try to convince a naive car owner to pay for additional parts and labor for something that they don't understand?

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