It may also include the interpretation of various sociocultural aspects of the clinical encounter, such as the patient's and provider's interpretation of their own roles in the patient-provider relationship.
The provider's interpretation of their role may include a conception of their professional duties and responsibilities, as well as the patient's rights and responsibilities, the standard of care for the given clinical problem, the best way to fulfill the standard of care, and the best way to address the patient's concerns and expectations. The patient's interpretation of their role may include an expectation to be informed of the nature of their medical condition, as well as an expectation to be informed of the planned diagnostic approach, the possible burdens and side-effects of treatment, and the best course of treatment.
Since a successful outcome of the clinical encounter depends on clear and effective communication, core competencies for clinicians include communicative competence, cultural competence, interpersonal skills, professionalism, medical knowledge, practice-based learning (including evidence-based care, and consideration of recent improvements in patient care), and systems-based practice (including accessing of healthcare system resources in order to provide the best possible care).1
Medical interpretation may also be a means of communicating with patients, e.g. through a medical interpreter or translator when a patient speaks a foreign language that isn't understood by the healthcare provider or has some other difficulty communicating (for example, due to speech, hearing, or cognitive disability).
Correct interpretation of clinical findings may depend on consideration of epidemiological data such as risk factors for a given disease-process in a particular patient population.
Correct interpretation of laboratory test results may also depend on awareness of their sensitivity, specificity, and predictive accuracy for the disease-process in question in the given patient group, community, or population. It may also depend on awareness of the possible causes of false-positive and false-negative test results.
Radiological interpretation may include interpretation of radiological images and reports, combined with the ability to determine the diagnostic certainty of positive or negative findings, and the ability to determine an appropriate response to uncertain or indeterminate findings.
Narrative interpretation in medicine may include interpretation of patient narratives (oral, written, and behavioral) and narrative reports, as well as illness-related and historical narratives presented by medical records, office notes, and procedure notes.
Hermeneutics is traditionally defined as the art or science of interpretation. Friedrich Schleiermacher (1838) defined it as the art of correctly understanding the meaning of another person's utterance, and he contrasted it with criticism as the art of correctly determining the truth or falsity of another person's utterance.2
Hans-Georg Gadamer (1975) explains that while traditional literary and theological hermeneutics attempted to be an art or science of interpretation, the hermeneutics he proposes is not a method of interpretation or understanding, but rather an attempt to describe the conditions under which interpretation and understanding are possible. A condition of understanding a text's meaning is that in order for understanding to occur, it must have a historical background. Our understanding of a text's meaning is always influenced by our own historical situation. A text to be interpreted always speaks to a situation that's conditioned by previous opinions and interpretations.3 The interpretation of a text therefore requires us to be aware of our preconceptions about the text and of how they may contribute to our understanding (or misunderstanding) of it. The hermeneutical experience also requires us to recognize that the nature of our understanding may change over a period of time, and that our interpretations of textual meaning are always situated within an ongoing hermeneutical tradition, to which we contribute.
Paul Ricoeur (1981) defines hermeneutics as the theory of the operations of understanding in relation to the interpretation of texts,4 and he defines a text as any discourse fixed by writing.5
However, as Gadamer showed, the meaning of texts is never fixed or unchanging, and it may depend on (social, cultural, and historical) context. The meaning of a text may be changed by the way in which we "read" or experience it. Our interpretation or understanding of a text may change each time we reread or reexperience it.
Wolfgang Iser (1978) argues that every text may have "gaps" or "blanks" or "places of indeterminacy" in its meaning that the reader must try to fill in, by questioning the text and by determining its "projected" meanings, in order to fulfill the task of interpretation. What isn't said by the text is relevant to what is said. The implications of a text may be a key to understanding its meaning. Thus, the "gaps" in the text may function as a hinge or pivot of the whole text-reader relationship.6
Umberto Eco (1979) explains that the interpretation of a text depends on the sharing of a code between author and reader that assigns content to the various expressions the author uses in the text. A code is a set of rules that determines how the expression of signs is to be correlated to their content. Because texts often have to be interpreted against a background of codes that may differ from those intended by the author, a distinction can be made between an "open" text that can be interpreted in a variety of ways and a "closed" text that aims for a precise response from the reader.
Stephen L. Daniel (1986) proposes that the interpretation of medical signs, symptoms, and other clinical data may be analogous to the interpretation of a literary text and may therefore be described by a hermeneutical model of clinical decision-making. The patient is the primary text, while the secondary text is provided by the healthcare provider's documentation of the clinical encounter, including the case summary, diagnosis, treatment plan, and progress notes in the patient's record.7 From a multiplicity of possible meanings of a patient's clinical signs and symptoms, the provider must determine the true meaning so that appropriate diagnostic modalities can be employed and appropriate treatment can be provided. The hermeneutical process may therefore proceed on four levels: (1) interpretation of the patient's history and physical findings, (2) interpretation of the diagnostic data, (3) clinical decision-making regarding treatment, and (4) change in both the patient's and provider's life-worlds (including the experience of healing for the patient) as a result of the clinical encounter.8
Drew Leder (1990) explains that medical hermeneutics may include the interpretation of a variety of "texts." He accepts Daniel's definition of a text as any group of signs or set of elements that constitute a whole and that take on meaning through interpretation.9 While the "person-as-ill" may be the primary text, there may also be secondary texts, such as (1) the "experiential text" provided by the patient's experience of their own illness, (2) the "narrative text" provided by the patient's account of their symptoms and medical history, (3) the "physical text" provided by the physical findings on patient examination, and (4) the "instrumental text" provided by diagnostic technologies. All of these texts may define or shape the encounter of the patient with the provider and healthcare system. One of the tasks of the provider may then be to "read" or understand these texts in such a way that they have a coherent meaning. The patient and provider may collaborate in this activity. Careful listening, mutual dialogue, and explanation are therefore fundamental aspects of the clinical encounter.10
It may be noted that the intertextuality or transtextuality of the clinical encounter may be defined by the fact that the primary and secondary texts described by Leder may all be in dialogue and may communicate with one another.
It may also be noted that a particular kind of understanding may be required for each of the kinds of secondary texts that Leder describes: experiential understanding, narrative understanding, physical understanding, and instrumental understanding.
Richard J. Baron (1990), however, questions "textual" interpretation as a metaphor for the clinical encounter between patient and provider. He argues that the shifting nature of the clinical "text" leads to the question of whether there is actually any text at all. The text (which is actually the patient-provider relationship) is dynamic and changing, rather than fixed and static, and it's mutually created by the participants. Thus, patients and providers shouldn't distract themselves by looking for, or trying to define, a text to be interpreted; they are the text.11
Baron seems to assume, however, that if something is a text, then it must be fixed, and its meaning can't be uncertain or indeterminate. He acknowledges that "patients are busy interpreting themselves all the time, and any presentation to the doctor is only one frame in a very long movie,"12 so he recognizes that interpretations may change, just as our presuppositions about, and experiences of (clinical, social, and cultural) texts may change.
Fredrik Svenaeus (2000) also argues that it's false to assume that medical hermeneutics must be a method of textual interpretation. He says the metaphor of "reading a text" may be inadequate as a theoretical model, and that medical hermeneutics is a dialogic activity rather than one consisting of textual interpretation. He also explains that the methodology of textual interpretation may be replaced by "an ontological and phenomenological hermeneutics in which understanding is a necessary feature of the being-together of human beings in the world."13
FOOTNOTES
1Accreditation Council for Graduate Medical Education, "The Milestones Guidebook," Version 2020, online at https://www.acgme.org/globalassets/milestonesguidebook.pdf
2Friedrich Schleiermacher, Hermeneutics and Criticism, and Other Writings, translated and edited by Andrew Bowie (Cambridge: Cambridge University Press, 1998)
3Hans-Georg Gadamer, Truth and Method (New York, The Seabury Press, 1975), p. 429.
4Paul Ricoeur, Hermeneutics and the Human Sciences (Cambridge: Cambridge University Press, 1981), p. 43.
5Ibid., p. 145.
6Wolfgang Iser, The Art of Reading: A Theory of Aesthetic Response (Baltimore: Johns Hopkins University Press, 1978), pp. 167-169.
7Stephen L. Daniel, "The Patient as Text: A Model of Clinical Hermeneutics," in Theoretical Medicine, Volume 7 (1986), p. 202.
8Ibid., p. 195.
9Drew Leder, "Clinical Interpretation: The Hermeneutics of Medicine," in Theoretical Medicine and Bioethics, Volume 11, Issue 1, March 1990, p. 11.
10Ibid., p. 17.
11Richard J. Baron, "Medical Hermeneutics: Where is the "Text" We are Interpreting?", in Theoretical Medicine and Bioethics, Volume 11, Issue 1, March 1990, pp. 27-28.
12Ibid., p. 27.
13Fredrik Svenaeus, "Hermeneutics of Clinical Practice: The Question of Textuality," in Theoretical Medicine and Bioethics, Volume 21, 2000, p. 180.
OTHER SOURCES
Umberto Eco, The Role of the Reader: Explorations in the Semiotics of Texts (Bloomington: Indiana University Press, 1979).
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