Structural-phenomenological features of the internal picture of doctors’ illnesses

Lazarenko, V.A. Kursk State Medical University, Kursk, Russia

Nikishina, V.B. Kursk State Medical University, Kursk, Russia

Molchanova, L.N. Kursk State Medical University, Kursk, Russia

Nedurueva, T.V. Kursk State Medical University, Kursk, Russia

The vocational activities of doctors and their social status do not ensure their health (Cui, Jeter, Yang, Montague, & Eagleman, 2007; Garelick et al., 2007; Gual, 2000; Gwen, 2005; Helliwell, 2007). Falling ill, doctors don’t identify themselves with or­dinary patients as they have a deep knowledge of medicine; they themselves diag­nose their pathological conditions, prescribe treatments, and make prognoses for the outcome of the disease. doctors as patients are part of the professional com­munity, which always supports them and is loyal to them. So the problem of the internal picture of doctors’ illnesses is both a research and a practical problem. A study of the problem provides an understanding of its outcome: a healthy doc­tor is healthy medicine! In this regard the purpose of our research was to study the phenomenological features of the internal picture of doctors’ illnesses using the structural approach.

Our study and analysis of the scientific literature showed no common under­standing of the concept of the internal picture of a disease; existing definitions include “consciousness of disease” (Luria, 1977), “attitude to disease” (Tkhostov, 2002, p. 287), and “personal meaning of illness” (Myasishchev, 1995). Scientific in­terest in the internal picture of a disease is focused mainly on studying it from the standpoint of the phenomenological somatopsychic approach (Bukharov & Gol­ubev, 2008; danhauer et al., 2013; Koehler et al., 2011; Nissim et al., 2013; Orlova, 2010; Shtrahova, 2008; Yozwiak, Settles, & Steffens, 2011).

Nikolaev’s approach (1976, pp. 95–98) provides a theoretical and methodologi­cal foundation for the study of the internal picture of a disease. In this approach, the internal picture of a disease has four levels: (1) the level of direct sensory reflec­tion of the disease (caused by feelings and states); (2) the emotional level (immedi­ate emotional reactions to illness caused by feelings and emotional responses to the consequences of the disease in a person’s life); (3) the intellectual level (knowledge about the disease and a rational assessment of it); (4) the motivational level (the emergence of new motifs and reorganization of the premorbid motivational struc­ture). The personal meaning of an illness is based on the integral characteristics in the system of the internal picture of the disease, including the levels (Cui et al., 2007) and the relationship between the individual system of the internal picture of the disease (Luria, 1977, pp. 37–52) (which is positive, negative, or conflictual and is aimed at changing behavior and ways of living) and a quantitative value (Shtra­hova, 2008).

The object of the study was the internal picture of doctors’ illnesses.

The subject of the research was the structural and phenomenological features of the internal picture of doctors’ illnesses.

The hypothesis of the study was that the structure of the internal picture of doc­tors’ illnesses is characterized by complexity and high awareness of health as a value leading to a wholesome lifestyle. When a doctor becomes ill the structure of the internal picture of the illness changes stereotyped representations about the disease at the cognitive level. In addition, distancing on an emotional level and ignoring manifestations of the disease at the behavioral level occur. The personal meaning of the doctor’s own disease comes to have a conflictual character.

Method

Participants

Research was carried with the informed consent of the participants. The total number of participants was 132. The experimental group consisted of 66 sick doctors, differentiated according to the stages of their careers (Zavalishina, 2005). The first stage is vocational training (students). The second stage is professional adaptation (interns). The third stage is full professionalization (doctors). The control group consisted of 66 subjects who did not have any medical education. All the control subjects were hospitalized with chronic diseases during the study period.

We graded and distributed the subjects in the experimental and control groups according to an analysis of their medical records and clinical interviews, and we grouped them according to gender (male and female), age (21 to 55 years), and nosology of the disease, which, in equal proportions, was gastrointestinal, cardio­vascular, and endocrinological (see Table 1).

Table 1. Characteristics of the total sample of subjects (N = 132)

Groups		Social and demographic characteristics		Nosology of the disease
		Sex, m/f	age, Хmed.±σx	Gastroenterological	Cardiovascular	Endocrinological
Doctors	1	12/12	22.05 ±0.91	8	8	8
	2	12/12	24.29±1.42	8	8	8
	3	9/9	44.03±10.33	6	6	6
Patients		33/33	39.80±10.15	22	22	22

Note. 1 — stage of vocational training (students), 2 — stage of professional adaptation (interns), 3 — stage full professionalization (doctors).

Instruments and measuring procedures

The research was carried out using clinical interviews and the archival method (analysis of medical records). The diagnostic instruments included: “Questionnaire related to health” (R. Berezovsky), “Repertory grid technique” (J. Kelly), “Question­naire on time perspective” (F. Zimbardo in A. Syrtsevoj’s adaptation), “Timeline set­tings” (J. Nuttin), “Scale of psychological well-being” (K. Riff in T. d. Shevelenkova and P. P. Fesenko’s adaptation), “Questionnaire of sociopsychological attitudes of a person in need of a motivational sphere” (O. F. Potemkinoy), “Lifeline technique” (autobiographical version) (J. F. Schoots). The statistical methods of research in­cluded quantitative and qualitative methods: descriptive statistics and comparative criteria (Mann-Whitney U test, F-distribution), multidimensional (factor analysis by the principal component with the Kaiser varimax rotation criterion, Karpov’s (1998) structural analysis). Statistical processing was carried out with the use of “Statistica 11.0” software.

Procedure

Structural-phenomenological assessment of the internal picture of a doctor’s own disease was carried out at the following levels of analysis: individual elements, gen­eralized criteria, and integral criteria. The level of individual elements combines the properties, states, qualities, and relations of the individual. The level of generalized criteria combines the set of individual, private indicators in a comprehensive index. The level of integral criteria combines the basic elements in the common space of the subjective manifestations of the internal picture of the disease, given the gen­eral emotional background (the balance of positive and negative states), health, and integrated assessment of the status of the individual.

We used comparative analysis (the Mann-Whitney U test and the F-distribu­tion) for the estimation of the internal picture of the doctors’ and patients’ illnesses at the level of individual elements. The cognitive component consisted of aware­ness and competence in the field of health. The behavioral component consisted of conformity of actions and behavior to the requirements of a healthy lifestyle. The value-motivational component was characterized by the high importance of health in the individual’s hierarchy of values. The emotional component, which dominated in the structure of the internal picture, was characterized by a high level of anxiety in relation to health.

Results and discussion

Sick doctors, compared with patients in the control group, were characterized by negative feelings regarding future life events with personal meaning (see Table 2). The sick doctors also had a high level of psychological well-being. We identified significantly higher values of the indicators “autonomy”, “management of the en­vironment”, “personal growth”, “purpose in life”, and “self-acceptance”. The average values of “psychological well-being” in sick doctors was significantly lower than the attitude of those in the control group, and this result testified to an insufficient level of pleasant and confident attitudes.

As can be seen in Table 2 specificity of the time perspective of the internal pic­ture of a doctor’s illness showed valid significant differences for the “negative past”, “hedonistic present”, “fatalistic present”, and “future”. For the sick doctors compared with the control-group patients past events were unpleasant and caused disgust in a greater degree. The sick doctors were focused on the satisfaction of vital needs. They were not confident in their ability to affect both present and future events.

As can also be seen in Table 2, the level of personal meaning of a doctor’s in­ternal picture was characterized by the presence of valid, significant sociopsycho­logical factors: “result orientation”, “altruism orientation”, and “power (authority) orientation”. The altruistic orientation in the sick doctors indicated their maturity. At the same time these people, who are ready to work very much to the detriment of themselves, need special care because of their altruism. They are usually powerful, reliable, and able to reach good results in their activities in spite of vanity, noise, and interferences.

Table 2. Mean values and significant differences of the internal picture of illness (experimental and control groups) (Mann-Whitney U test, p ≤ 0.05; U^*emp. ≤ Ukr.)

#	Group	Experimental (1)			Control (2)			(1) - (2)
		Хmed.±σx	Me	Mo	Хmed.±σx	Me	Mo	U*emp.	р
	Indicators
Secondary signification
1.	Cognitive component	0.90±0.31	1.00	1.00	0.88±0.33	1.00	1.00	729.00	0.848
2.	Emotional component	0.90±0.31	1.00	1.00	0.63±0.49	1.00	1.00	540.50*	0.010
3.	Behavioral  component	0.79±0.41	1.00	1.00	0.71±0.46	1.00	1.00	675.00	0.397
4.	Value-motivational component	0.79±0.41	1.00	1.00	0.84±0.37	1.00	1.00	702.50	0.574
5.	Past event	3.67±0.30	3.65	Multiple	3.73±0.49	3.70	Multiple	674.50	0.515
6.	Present event	3.79±0.28	3.78	3.90	3.66±0.36	3.65	3.70	559.50	0.071
7.	Future event	18.25±76.50	4.15	4.20	10.57±48.20	3.75	3.70	472.00*	0.007
Personal meaning of the disease
8.	Psychological well-being	52.08±6.26	60.00	62.00	58.48±3.89	50.00	50.00	321.00*	0.000
9.	Autonomy	60.07±3.28	60.00	60.00	51.06±5.65	50.00	49.00	128.50*	0.000
10.	Management of the environment	59.48±3.34	60.00	60.00	50.65±4.73	50.00	Multiple	101.00*	0.000
11.	Personal growth	61.31±3.41	61.00	60.00	52.61±5.54	52.00	50.00	155.50*	0.000
12.	Purpose inlife	59.90±3.12	60.00	60.00	52.10±4.57	51.00	50.00	141.00*	0.000
13.	Self-acceptance	59.62±3.71	60.00	60.00	52.71±5.54	51.00	50.00	242.00*	0.000
14.	Sphere of disease	1.86±0.69	2.00	2.00	2.50±1.00	2.50	3.00	658.00	0.037
15.	Process orientation	8.21±0.98	8.00	8.00	7.98±1.54	8.00	9.00	698.50	0.674
16.	Result orientation	8.66±1.11	9.00	9.00	7.25±1.60	7.00	6.00	363.50*	0.000
17.	Altruism orientation	6.86±0.95	7.00	7.00	5.55±1.33	6.00	6.00	325.00*	0.000
18.	Selfishness orientation	4.45±1.21	5.00	5.00	4.06±1.30	4.00	Multiple	612.50	0.192
19.	Work orientation	6.69±1.07	7.00	7.00	6.61±0.94	7.00	7.00	658.50	0.390
20.	Freedom orientation	8.14±0.74	8.00	8.00	7.69±1.30	8.00	8.00	592.00	0.123
21.	Power orientation	6.76±1.09	7.00	7.00	6.00±1.43	6.00	Multiple	500.50*	0.013
22.	Money orientation	4.55±1.15	5.00	5.00	4.82±1.66	5.00	5.00	699.00	0.678
23.	Negative past	3.50±0.16	3.54	3.60	3.09±0.37	3.15	3.10	199.00*	0.000
24.	Positive past	3.76±0.16	3.77	3.90	3.65±0.42	3.70	Multiple	586.50	0.191
25.	Hedonistic present	3.84±0.15	3.88	3.90	3.58±0.34	3.67	3.70	371.00*	0.000
26.	Fatalistic present	3.95±0.16	3.96	3.96	3.58±0.30	3.63	3.90	200.00*	0.000
27.	Future	4.19±0.18	4.20	4.30	3.70±0.26	3.70	3.80	89.50*	0.000

We used the statistical F-distribution for estimation of the internal pictures of the sick doctors and control-group patients to get the frequency distribution of cog­nitive constructs (р ≤ 0.01). The frequency of the occurrence of simple constructs was 17.53% in the sick doctors and 20.10% in the control group. The frequency of the occurrence of complex constructs was 21.30% in the sick doctors and 7.10% in the control group. The data obtained provide evidence of the cognitive complexity of personal constructs of the internal picture of a doctor’s illness.

To identify the general criteria of the internal picture in the experimental and the control groups, we used the procedures of varimax rotation of the interrela­tionships of these variables: attitude toward the disease, meaning of the disease, mounting and the semantic component, time perspective, and Karpov's structural analysis (Karpov,1998).

The sick doctors had a five-factor structure of the internal picture of illness, in which the first factor was the system factor, with 20.4% of the total variance. This factor consisted of the following variables: “negative past” (0.765), “positive past” (0.795), “autonomy” (0.841), “personal growth” (0.816), “sphere of disease” (0.862) with the largest positive loads, and “money orientation” (-0.706) with a negative load. We interpreted the total factor as “negative past and disease, isolation in inter­personal attitudes, domination, independence, aspiration to self-realization”.

The following four generalized variables of the internal picture of the doctors’ illnesses can be characterized by four generalized parameters: “time perspective” (14.9%), “high awareness in sphere of own health and altruistic values” (14.0%), “money orientation” (13.0%), “optimum uneasiness concerning own health and negative past” (10.1%). The revealed factors explain 72.4 % of the total variance.

The procedure of secondary factorization of  the variables of the internal picture of the doctors’ illnesses revealed the following integrative characteristics (see Figure 1): “negative past and disease, isolation in interpersonal attitudes, domination, independence, aspiration to self-realization” (27.3%), “time perspective” (20.9%), “high awareness of own health and altruistic values” (17.4%), “optimal anxiety con­cerning own health” (10.4%). The identified factors determined 76.0% of the total variance.