Résumé. En partant d’une description des nombreux changements de la pratique médicale depuis quelques décennies, la thèse étudie divers aspects constitutifs du malaise du médecin. L’accroissement de la puissance médicale qu’a permis la technoscience est analysée et remise dans un contexte plus large où les technologies de l’information ont une grande place. L’augmentation considérable des connaissances pose un problème de maîtrise de la science médicale. La multiplicité des observations fait qu’il y a discordance de certaines d’entre elles avec les théories médicales largement acceptées. De cette manière, le gain d’efficacité est associé à une perte de la cohérence du discours médical. Le rôle du médecin disparaît derrière la technique, qui semble pouvoir, seule, rendre tous les progrès accessibles. Le médecin devient alors un simple distributeur de services et, à ce titre, développe parfois des offres de pratiques sans fondement, voire dangereuses. Le pouvoir du médecin est évoqué, et se ramène in fine à la fourniture d’un diagnostic et d’une explication de sa maladie au patient. Le rôle des explications particulières que donne le médecin au malade est exploré à la lumière d’une conception narrative et évolutive de la vie humaine. Le rôle du médecin apparaît alors comme d’aider le patient à réécrire a posteriori le fil d’une histoire qui apparaît initialement comme interrompue par la maladie. Le rôle social de maintien de l’ordre de la pratique médicale est alors évoqué. Ensuite, par une approche descriptive du phénomène religieux, on montre que la médecine du XXIe siècle a les caractéristiques d’un tel phénomène. Entités extrahumaines, mythes, rites, tabous, prétention à bâtir une morale, accompagnement de la vie et de la mort, miracles, promesse de salut, temples, officiants sont identifiés dans la médecine « classique » contemporaine. Seule la fonction de divination de l’avenir d’un homme précis est devenue brumeuse, la technoscience permettant régulièrement du « tout ou rien » là où auparavant un pronostic précis (et souvent défavorable) pouvait être affirmé. L’hypothèse que la médecine est devenue une religion du XXIe siècle est confrontée à des textes de S. Freud, M. Gauchet et P. Boyer. Non seulement ces textes n’invalident pas l’hypothèse, mais la renforcent même. Il apparaît que le fonctionnement de l’esprit humain favorise l’éclosion de religions et donc la prise de voile de la médecine. La dynamique générale de la démocratisation de la société montre que la médecine est une forme de religion non seulement compatible avec une société démocratique, mais est peut-être une des formes accomplies de celle-ci, où chaque individu écrit lui-même sa propre histoire. Le danger qu’il y a, pour le patient comme pour le médecin, si ce dernier accepte de jouer un rôle de prêtre, est ensuite développé. Enfin, la remise dans le cadre plus général de l’existence humaine, l’évocation de la dimension de révolte de la médecine, de son essentielle incomplétude, l’acceptation d’une cohérence imparfaite permettent au médecin de retrouver des sources de joie afin de, peut-être, ne tomber ni dans un désinvestissement blasé, ni dans un cynisme blessant. Summary From a description of the many changes medical practice has undergone for a few decades, the work goes on to study many sides of the modern doctor’s malaise. The gain of power made possible by technoscience is put on a larger stage where information technologies play a major role. The abundance of knowledge makes health literacy more difficult. the great number of observations makes discrepancies with general theories more frequent. The gain in power is associated with a loss of coherence of the medical speech. The doctor’s role vanishes behind technology that seems to be the only access to all medical progresses. Doctors becomes mere service providers and go on to offer unvalidated or even harmful services on the market. Modern medical power resumes into the explanations and diagnosis given to the patient. The role of medical explanations is explored through an evolutive and narrative vision of human life. The duty of the doctors then appears to allow a new narration of the self that bridges the gap disease introduced into the patient’s life. The role of medicine in maintaining social order is mentioned. Through a sociological approach of the religious phenomenon, one can see that XXIst century medicine is such a phenomenon. Medicine knows of extrahuman entities, myths, rites, taboos, miracles, temples; priests are present in modern mainstream medicine. Some want to derive objective moral values from medicine, and it brings companionship to man from birth to death. The only departure from old religions was the weakened ability to predict the future of an individual patient: for some diseases for which survival was known to be very poor, the possibilities are now long-term survival with cure, or early death from the treatment. The hypothesis that medicine is a religion is confronted to texts from Freud S., Gauchet M. and Boyer P. Not only do they not invalidate the hypothesis, but they bring enrichment to it. Brain/mind dynamics is such that the appearance of religions is frequent, and makes the transformation of medicine into a religion easier. Society’s democratisation confronted to religion’s history shows that medicine is the most compatible form of religion within a truly democratic society, where each individual writes his own story. To become a priest brings some dangers for the patient, but also for the doctor. These dangers are discussed. This discussion is put into the larger context of human life. The revolt dimension of medicine is discussed, as is its never-ending task. Their acceptance, as that of a lack of total logical coherence can open the possibility for the doctor to enjoy his work, without being neither unfeeling nor cynical.

The patient-doctor relationship (PDR) as perceived by the patient is an important concept in primary care and psychotherapy. The PDR Questionnaire (PDRQ-9) provides a brief measure of the therapeutic aspects of the PDR in primary care. We assessed the internal and external validity of the German version of the PDRQ-9 in a representative crosssectional German population survey that included 2,275 persons aged$14 years who reported consulting with a primary care physician (PCP). The acceptance of the German version of this questionnaire was good. Confirmatory factor analysis demonstrated that the PRDQ-9 was unidimensional. The internal reliability (Cronbach’s a) of the total score was .95. The corrected item-total correlations were$.94. The mean satisfaction index of persons with a probable depressive disorder was lower than that of persons without a probable depressive disorder, indicating good discriminative concurrent criterion validity. The correlation coefficient between satisfaction with PDR and satisfaction with pain therapy was r = .51 in 489 persons who reported chronic pain, indicating good convergent validity. Despite the limitation of low variance in the PDRQ- 9 total scores, the results indicate that the German version of the PDRQ-9 is a brief questionnaire with good psychometric properties to assess German patients’ perceived therapeutic alliance with PCPs in public health research.

The patient-doctor relationship (PDR) as perceived by the patient is an important concept in primary care and psychotherapy. The PDR Questionnaire (PDRQ-9) provides a brief measure of the therapeutic aspects of the PDR in primary care. We assessed the internal and external validity of the German version of the PDRQ-9 in a representative crosssectional German population survey that included 2,275 persons aged$14 years who reported consulting with a primary care physician (PCP). The acceptance of the German version of this questionnaire was good. Confirmatory factor analysis demonstrated that the PRDQ-9 was unidimensional. The internal reliability (Cronbach’s a) of the total score was .95. The corrected item-total correlations were$.94. The mean satisfaction index of persons with a probable depressive disorder was lower than that of persons without a probable depressive disorder, indicating good discriminative concurrent criterion validity. The correlation coefficient between satisfaction with PDR and satisfaction with pain therapy was r = .51 in 489 persons who reported chronic pain, indicating good convergent validity. Despite the limitation of low variance in the PDRQ- 9 total scores, the results indicate that the German version of the PDRQ-9 is a brief questionnaire with good psychometric properties to assess German patients’ perceived therapeutic alliance with PCPs in public health research.

Recent decades have seen increasing recognition of the importance of patient involvement during patient-professional interactions and promotion of preventative and long term approaches to healthcare for those with long-term conditions. The concepts of 'shared decision making' and 'personalised care planning' have both been advocated by patient groups, policy-makers, professional bodies and academia as best practice. During shared decision making, patients and healthcare professionals work in equal partnership to decide the best course of action. Shared decision making is a central tenet of personalised care planning, as it aims to foster partnerships between patients and healthcare professionals when making decisions, but personalised care planning also describes an overall approach to healthcare that is forward-planning and preventative, rather than episodic and reactive. Despite the breadth of support for such approaches, in reality they are not routinely adopted. Multiple Sclerosis (MS) is a heterogeneous neurodegenerative long term condition, which is unpredictable with limited treatments available. Such uncertainty and complexity position MS as an interesting long term condition to explore decisional and information needs. This doctoral research comprises of three methods stages. Firstly, two systematic reviews assessing the effectiveness of personalised care planning for people with long-term conditions and people with MS were carried out. Secondly, 22 in-depth semi-structured qualitative interviews were carried out with people with MS across the UK to explore experiences of decision making and interactions with healthcare professionals. Purposive sampling was carried out and data saturation determined sample size. A modified grounded theory approach was used and thematic analysis of interview data was carried out. Lastly, a series of structured qualitative interviews were carried out with 6 consultant neurologists. This stage was iterative in that problematic areas identified during analysis of interview data from stage 2 were presented to neurologists in infographic form to further examine issues raised. Framework analysis was carried out on neurologist interview data to examine their interpretations and potential solutions. Although there appears to be some evidence demonstrating that personalised care planning is effective for people with long term conditions, such favourable effects were not demonstrated in the context of MS. Based on the findings from the systematic reviews it is unclear whether personalised care planning is effective for people with MS and there is a clear gap in the literature examining this. Findings from the interview stages suggest there are key areas which are lacking in terms of information and decisional support. Such areas included the type and amount of information around the time of diagnosis, support when choosing disease modifying drugs and discussions about approaches outside mainstream medicine. Findings from neurologist interview data corroborated those from MS interview data, but through examination of issues raised it also highlighted some of the complexities and challenges of involving patients and enacting shared decision making in reality. This research identified key areas that require improvement for people with MS in terms of provision of the information and decisional support. Although in theory personalised care planning and shared decision making are positioned as best practice, in reality it is unclear whether they are effective or appropriate for people with MS. The way in which such approaches are enacted are complex and require careful consideration. Potential barriers and pitfalls identified within this study suggest a lack of clarity in how to respond to challenges and further investigation into how patient involvement is enacted is needed.

The subject of this thesis is one very important relationship of health care - the doctor- patient-relationship. During a recent decades a big attention was paid to this theme both on international and czech field. In the Czech Republic the doctor-patient-relationship went through the essential change, when instantly changed from a paternalistic relationship to a partnership. Many legal changes followed this change finishing it by accepting the Act on Healthcare Services which for example describes rights and duties of subjects of this relationship. The first part is dedicated to a doctor-patient-relationship itself. Its history and evolution, placement in a legal system, legal form. One part is dedicated to an ethic aspect of doctor-patient-relationship. The second part discusses about rights and duties of both participants of this relationship. Specifically, rights determined by the Act on Healthcare Services. The third part is dedicated to detailed analysis of some basic patient's rigths and the doctor's duties characterizing doctor-patient-relationship in its current form. These are informed consent, where I describe, why it is needed. I was concerned about its requisites, possibility to abandon informed consent, to informed dissent including its form while a short look on an issue of...

En partant d’une description des nombreux changements de la pratique médicale depuis quelques décennies, la thèse étudie divers aspects constitutifs du malaise du médecin. L’accroissement de la puissance médicale qu’a permis la technoscience est analysée et remise dans un contexte plus large où les technologies de l’information ont une grande place. L’augmentation considérable des connaissances pose un problème de maîtrise de la science médicale. La multiplicité des observations fait qu’il y a discordance de certaines d’entre elles avec les théories médicales largement acceptées. De cette manière, le gain d’efficacité est associé à une perte de la cohérence du discours médical. Le rôle du médecin disparaît derrière la technique, qui semble pouvoir, seule, rendre tous les progrès accessibles. Le médecin devient alors un simple distributeur de services et, à ce titre, développe parfois des offres de pratiques sans fondement, voire dangereuses.<p>Le pouvoir du médecin est évoqué, et se ramène in fine à la fourniture d’un diagnostic et d’une explication de sa maladie au patient. Le rôle des explications particulières que donne le médecin au malade est exploré à la lumière d’une conception narrative et évolutive de la vie humaine. Le rôle du médecin apparaît alors comme d’aider le patient à réécrire a posteriori le fil d’une histoire qui apparaît initialement comme interrompue par la maladie.<p>Le rôle social de maintien de l’ordre de la pratique médicale est alors évoqué. Ensuite, par une approche descriptive du phénomène religieux, on montre que la médecine du XXIe siècle a les caractéristiques d’un tel phénomène. Entités extrahumaines, mythes, rites, tabous, prétention à bâtir une morale, accompagnement de la vie et de la mort, miracles, promesse de salut, temples, officiants sont identifiés dans la médecine « classique » contemporaine. Seule la fonction de divination de l’avenir d’un homme précis est devenue brumeuse, la technoscience permettant régulièrement du « tout ou rien » là où auparavant un pronostic précis (et souvent défavorable) pouvait être affirmé.<p> L’hypothèse que la médecine est devenue une religion du XXIe siècle est confrontée à des textes de S. Freud, M. Gauchet et P. Boyer. Non seulement ces textes n’invalident pas l’hypothèse, mais la renforcent même. Il apparaît que le fonctionnement de l’esprit humain favorise l’éclosion de religions et donc la prise de voile de la médecine. La dynamique générale de la démocratisation de la société montre que la médecine est une forme de religion non seulement compatible avec une société démocratique, mais est peut-être une des formes accomplies de celle-ci, où chaque individu écrit lui-même sa propre histoire.<p>Le danger qu’il y a, pour le patient comme pour le médecin, si ce dernier accepte de jouer un rôle de prêtre, est ensuite développé. Enfin, la remise dans le cadre plus général de l’existence humaine, l’évocation de la dimension de révolte de la médecine, de son essentielle incomplétude, l’acceptation d’une cohérence imparfaite permettent au médecin de retrouver des sources de joie afin de, peut-être, ne tomber ni dans un désinvestissement blasé, ni dans un cynisme blessant.<p><p>From a description of the many changes medical practice has undergone for a few decades, the work goes on to study many sides of the modern doctor’s malaise. The gain of power made possible by technoscience is put on a larger stage where information technologies play a major role. The abundance of knowledge makes health literacy more difficult. the great number of observations makes discrepancies with general theories more frequent. The gain in power is associated with a loss of coherence of the medical speech. The doctor’s role vanishes behind technology that seems to be the only access to all medical progresses. Doctors becomes mere service providers and go on to offer unvalidated or even harmful services on the market.<p>Modern medical power resumes into the explanations and diagnosis given to the patient. The role of medical explanations is explored through an evolutive and narrative vision of human life. The duty of the doctors then appears to allow a new narration of the self that bridges the gap disease introduced into the patient’s life.<p>The role of medicine in maintaining social order is mentioned. Through a sociological approach of the religious phenomenon, one can see that XXIst century medicine is such a phenomenon. Medicine knows of extrahuman entities, myths, rites, taboos, miracles, temples; priests are present in modern mainstream medicine. Some want to derive objective moral values from medicine, and it brings companionship to man from birth to death. The only departure from old religions was the weakened ability to predict the future of an individual patient: for some diseases for which survival was known to be very poor, the possibilities are now long-term survival with cure, or early death from the treatment. <p>The hypothesis that medicine is a religion is confronted to texts from Freud S. Gauchet M. and Boyer P. Not only do they not invalidate the hypothesis, but they bring enrichment to it. Brain/mind dynamics is such that the appearance of religions is frequent, and makes the transformation of medicine into a religion easier. Society’s democratisation confronted to religion’s history shows that medicine is the most compatible form of religion within a truly democratic society, where each individual writes his own story.<p>To become a priest brings some dangers for the patient, but also for the doctor. These dangers are discussed. This discussion is put into the larger context of human life. The revolt dimension of medicine is discussed, as is its never-ending task. Their acceptance, as that of a lack of total logical coherence can open the possibility for the doctor to enjoy his work, without being neither unfeeling nor cynical.<p> / Doctorat en philosophie et lettres, Orientation bioéthique / info:eu-repo/semantics/nonPublished