Primary Care/Primarily Caring (III)

“The good physician knows his patients through and through, and his knowledge is bought dearly.  Time, sympathy and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine.  One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.”

— Francis W. Peabody, M.D., “The Care of the Patient” (1927)

Beginning in the 1980s, primary care educators, concerned that newly trained family physicians, freighted with technology and adrift in protocols, lacked people skills, resuscitated an expression coined by the British psychoanalyst Enid Balint in 1969.  They began promoting “patient-centered medicine,” which, according to Balint’s stunning insight, called on the physician to understand the patient “as a unique human being” (J. Roy. Coll. Gen. Practit., 17:269, 1969).  More recently, patient-centered medicine has evolved into “relationship-centered care” (or “patient and relationship-centered care” [PRCC]) that not only delineates  the relational matrix in which care is  provided but also extols the “moral value” of cultivating doctor-patient relationships that transcend the realm of the biomedical.  In language that could just as well come from a primer of relational psychotherapy, these educators enjoin clinicians to embrace the clinician-patient relationship as “the unique product of its participants and its context,” to “remain aware of their own emotions, reactions, and biases,” to move from detached concern to emotional engagement and empathy, and to embrace the reciprocal nature of doctor-patient interactions.  According to this latter, the clinical goal of restoring and maintaining health must still “allow[ing] a patient to have an impact on the clinician” in order “to honor that patient and his or her experience” (J. Gen. Int. Med., 21:S4, 2006).

Recent literature on relationship-centered care evinces an unsettling didacticism about the human dimension of effective doctoring.  It is as if medical students and residents not only fail to receive training in communication skills but fail equally to comprehend that medical practice will actually oblige them to comfort anxious and confused human beings.  So educators present them with “models” and “frameworks” for learning how to communicate effectively.  Painfully commonsensical “core skills” for delivering quality health care are enumerated over and over.  The creation and maintenance of an “effective” doctor-patient relationship becomes a “task” associated with a discrete skill set (e.g.,  listening skills, effective nonverbal communication, respect, empathy).  A recent piece on “advanced” communication strategies for relationship-centered care in pediatrics reminds pediatricians that “Most patients prefer information and discussion, and some prefer mutual or joint decisions,” and this proviso leads to the formulation of a typical advanced-level injunction:  “Share diagnostic and treatment information with kindness, and use words that are easy for the child and family to understand” (Pediatr. Ann., 4:450, 2011).

Other writers shift the relational burden away from caring entirely and move to terrain with which residents and practitioners are bound to be more comfortable.  Thus, we read of  how electronic health records (EHRs) can be integrated into a relational style of practice (Fam. Med., 42:364, 2010) and of how “interprofessional collaboration” between physicians and alternative/complementary providers can profit from “constructs” borrowed from the “model” of relationship-centered care (J. Interprof. Care., 25:125, 2011).  More dauntingly still, we learn of how  relational theory may be applied to the successful operation of primary care practices, where the latter are seen as “complex adaptive systems”  in need of strategies for organizational learning borrowed from complexity theory (Ann. Fam. Med., 8S:S72, 2010).

There is the sense that true doctoring skills (really the human aptitude and desire to doctor) are so ancillary to contemporary practice that their cultivation must be justified in statistical terms.  Journal readers continue to be reminded of studies from the 1990s that suggest an association between physicianly caring and the effectiveness and appropriateness of care, the latter measured by efficiency, diagnostic accuracy, patient adherence, patient satisfaction, and the like (Pediatr. Ann., 40:452, 2011; J. Gen Intern. Med., 6:420, 1991; JAMA, 266:1931, 1991).  And, mirabile dictu, researchers have found that physicians who permit patients to complete a “statement of concerns” report their patients’ problems more accurately than those who do not; indeed, failure to solicit the patient’s agenda correlates with a 24% reduction in physician understanding (J. Gen. Int. Med., 20:267, 2005).

The problem, as I observed in The Last Family Doctor, is that contemporary medical students are rarely drawn to general medicine as a calling and, even if they are, the highly regulated, multispecialty structure of American (and to a somewhat lesser extent, Canadian) medicine militates against their ability to live out the calling.  So they lack the aptitude and desire to be primary caregivers – which is not the same as being primary care physicians – that was an apriori among GPs of the post-WWII generation and their predecessors.  Primary care educators compensate by endeavoring to codify the art of humane caregiving that has traditionally been associated with the generalist calling – whether or not students and residents actually feel called.  My father would probably have appreciated the need for a teachable model of relationship-centered care, but he would also have viewed it as a sadly remedial attempt to transform individuals with medical training into physicians.  Gifted generalists of his generation did not require instruction on the role of the doctor-patient relationship in medical caregiving.  “Patient and relationship-centered care” was intrinsic to their doctoring; it did not fall back on a skill set to be acquired over time.

The PRCC model, however useful in jump-starting an arrested doctoring sensibility, pales alongside the writings of the great physician-educators of the early twentieth century who lived out values that contemporary educators try to parse into teachable precepts.  For medical students and primary care residents, I say, put aside the PRCC literature and introduce them ab initio to writings that lay bare what Sherwin Nuland terms “the soul of medicine.”  I find nothing of practical significance in the PRCC literature that was not said many decades ago – and far more tellingly and eloquently – by Francis W. Peabody in “The Care of the Patient” (JAMA, 88:877, 1927), L. J. Henderson in “Physician and Patient as a Social System (NEJM, 212:819, 1935), W. R. Houston in “The Doctor Himself as a Therapeutic Agent” (Ann. Int. Med., 11:1416, 1939), and especially William Osler in the addresses gathered together in the volume Aequanimitas (1904).  Supplement these classic readings with a healthy dose of Oliver Sacks and Richard Selzer and top them off with patient narratives that underscore the terrible cost of physicians’ failing to communicate with patients as people (such as Sacks’s own A Leg to Stand On [1984] and David Newman’s powerful and troubling Talking with Doctors [2011]), and you will have done more to instill the principles of patient and relationship-centered care than all the models, frameworks, algorithms, communicational strategies, and measures of patient satisfaction under the sun.

Copyright © 2011 by Paul E. Stepansky.  All rights reserved.

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