Significance of symptoms in oncologic consultations with advanced cancer patients

In 1976, Jewson wrote a paper, published in sociology, entitled “The Disappearance of the Sick-Man from Medical Cosmology” (Jewson, 1976). His main message was that the production of medical knowledge shifted between 1770-1870 from the sick towards medical investigation and from an integrated view of the whole person towards that of particles. Indeed, one can conceive that prior to the introduction of the anatomical-pathological method in medicine, physicians relied on theories and symptoms to diagnose and treat patients. Symptoms were mainly expressed by the patient’s discourse, as illustrated, for example, by the epistolary heritage of Tissot, who diagnosed and treated patients throughout Europe based on correspondence by letter (Barras & Louis-Courvoisier, 2001). The patient or his significant others detailed the bodily experiences of the ill to Tissot, who then responded and provided guidance and advice. In other words, the subjectivity of the patient was the key of the medical profession and oriented its activities. With the anatomical-pathological turn attributed to Bichat (Shoja et al., 2008), who revolutionized medicine by linking lesions observed in autopsies to the symptoms experienced by the diseased, the so-called medical gaze (Foucault, 1973) started its successful journey, later replaced by more and more sophisticated methods to “look into the body”, be it by means of laboratory investigations, biomedical imaging techniques or molecular-biological analysis. These advances not only allowed a considerable progress in fighting diseases, it also – as a side effect – diminished the importance attributed by physicians to the subjective experience of the sick-man. The psychosomatic movement (Wittkower, 1974), raising after World War II, and the subsequent bio-psycho-social model introduced by Engel (Engel, n.d.) in the seventies, aimed to rehabilitate the patient as a whole person and to take into account his subjectivity. However, the biomedical model largely prevailed and despite recent efforts to promote patient-centered medicine, patient empowerment and shared decision-making, it seems safe to say, that patients’ symptom descriptions have lost their status of being one of the royal ways to diagnose and treat diseases. If patients’ symptom descriptions have become less relevant, they are still a potent element in the medical encounter for different reasons. They inform, for example on (i) patient’s illness representations, (ii) relational aspects of the medical encounter, (iii) the psychological state of the patient, or (iv) the way he copes with the disease, and they provide useful cues for the expression of empathy towards the patient. While patients’ symptom expression has been the object of empirical research, the investigations were mainly limited to issues of symptom measurement (Kirkova et al., 2006; Trajkovic-Vidakovic et al., 2012), such as how to evaluate symptom intensity, of attributions to symptoms (Estacio et al., 2017, 2018; Heidrich et al., 2006; Jones et al., 1981; Richer & Ezer, 2000) or cultural determinants of symptom expression (Bell, 2009; Kirmayer et al., 1994; Lobchuk & Stymeist, 1999). Studies assessing the different facets of patient’s symptom expression, collected over a whole consultation (diachronic 3 perspective) are rare (Beach et al., 2005; Estacio et al., 2017). For these reasons, we aimed with this study to shed light on how symptoms expressed by the patient circulate in the medical encounter, how they emerge, disappear and re-emerge, how physicians respond to them and what they are conveying. In other words, we aimed to situate patients’ symptom expressions by studying them in a diachronic way, based on a series of five oncological consultations, which all served to review the patients’ situation by discussing the results of recent diagnostic investigations, organized to document the extent of disease progression