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EDUCATION AND DEBATE: Colin Campbell and Gill McGauley Doctor-patient relationships in chronic illness: insights from forensic psychiatry BMJ 2005; 330: 667-670 [Full text]

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Lessons from the care of children with chronic illness

John G Reiss   (22 March 2005)

It`s all about Loving your Patients and expressing it

girish chawla   (23 March 2005)

Doctor-patient relationship: Lessons learned from two decades managing patients with HIV

Robert Horne, Martin Fisher   (29 March 2005)

Lessons from the care of children with chronic illness 22 March 2005
John G Reiss, Associate Professor University of Florida Gainesville FL USA 32610 Send response to journal: Re: Lessons from the care of children with chronic illness	I congratulate Campbell and McGauley on the insights they share from forensic psychiatry about doctor-patient relationships in chronic illness. I believe that their observations have relevance to a new and emerging issue in chronic care – the transition of youth and young adults with chronic health conditions from child-centered (pediatric) to adult-oriented health care. Over the last 25 years, research literature and practice guidelines published both in the UK and USA on the care of children with chronic health conditions has emphasized the importance the development of a positive therapeutic relationship between the physician or health care team and the family/patient; promoting a family-professional partnership in goal setting and decisions making; and promoting a "strengths based perspective" that promotes optimal functioning while acknowledging that there may be no cure. Recent research in the pediatric literature, including an article published in the January 2004 issue of Pediatrics by my colleagues and myself, notes that some young adults and their families experience what can be described as "culture shock" when transferring from pediatric to adult-oriented care; and from what patient/families describe as supportive and compassionate care to what is perceived as an adult system that is formal, business-like, distant, rigid in therapeutic approach, and less interested in the family/patient's perspective of the illness, goals, and effective therapeutic interventions. Campbell and McGauley's description of the "negative" dynamics in the adult care system regarding patients with "incurable" conditions confirms, in part, the perceptions of a difference the culture of pediatrics and adult medicine. It also provides guidance to adult providers who are assuming responsibility for young adults about the importance of building a positive patient relationship; eliciting the patient's perspective on the illness, developing flexible, individualized treatment plans. Our work also suggests that adult providers need to attend to the fact that the young adult has had to end what may have been a positive, long-term psychologically-important relationship with pediatric providers and that the adult provider may need to help the young adult achieve a sense of closure with previous providers before the patient can develop a positive therapeutic relationship with new adult providers. Finally, Campbell and McGauley have focused their discussion on the patient as an individual. I suggest that those caring for patients with chronic conditions may need to view the family, rather than the individual, as the unit of care. Doctor-family relationships in chronic illness can be especially important since the patient's significant others (spouse, children, parents, extended family) can play a major role promoting adherence to the therapeutic regimen; monitoring health status, identifying exacerbations of the chronic condition, etc. Competing interests: None declared
It`s all about Loving your Patients and expressing it 23 March 2005
girish chawla, sho in ITU WALLSGRAVE HOSPITAL, COVENTRY, CV2 2DX Send response to journal: Re: It`s all about Loving your Patients and expressing it	Its a great article and i would like to convey my regards to the authors and the members of publishing team for this article. As an Intensive care doctor i have experienced, how important it is to involve family members and friends in the care of your patients . It all comes to the basics which were shown by great people like Florence Nightingale and Mother Teresa ie. we need to love our patients and express it to them so that they develop that faith and trust in you which will help them and the family members. Life is so uncertain, we never know , we might in that side of the court anytime , all medical students should be made to think that great people who had been pefectlly fit have developed chronic diseases and needed care for rest of there life. As medical proffesionals god has given us this opportunity to bring smiles to their face and look after them with whole heart. Unfortunately we all love acute medicene as we get good results and we satisfy ourselves that we cured the patient, chronic patients might not get better but if we can bring one smile on their face i feel we have done our days job. The message is love your patients and express it to them. Try to bring smiles on their face. When someone is going through a chronic disease, he needs a lot of emotional support, we can at least provide some of it. Kind Regards Girish Chawla Competing interests: None declared
Doctor-patient relationship: Lessons learned from two decades managing patients with HIV 29 March 2005
Robert Horne, Professor of Psychology in Health Care University of Brighton, Falmer Campus, Brighton BN1 9PH, UK, Martin Fisher Send response to journal: Re: Doctor-patient relationship: Lessons learned from two decades managing patients with HIV	We welcome the article by Campbell and McGauley (Doctor-patient relationships in chronic illness: insights from forensic psychiatry. BMJ 2005; 330:667-670) identifying an important source of distress for clinicians. We would like to add our perspective and insight from the management of patients living with HIV. When HIV was first described over 20 years ago infection was characterized by a chronic but ultimately fatal disease course. In the absence of effective therapies management of HIV was overseen by a multidisciplinary team consisting of physicians, nurses, pharmacists and psychologists. Terminal care consisted of symptomatic relief often in the setting of a hospice or specialized HIV ward. This was a challenging time for health care professionals and patients alike and was associated with a high rate of morbidity and mortality. Since the introduction of the first antiretroviral AZT (zidovudine) in the late 1980’s there has been a steady stream of new drugs introduced for the treatment of HIV with around 20 drugs now licensed for the treatment of the disease. This has heralded a new treatment paradigm consisting of drug cocktails (typically 3-4 drugs) known as highly active antiretroviral therapy with patients now living longer and transforming the disease into a chronic albeit serious manageable condition in many patients. Whilst this advance must be welcomed unreservedly it has brought with it further challenges for both patients and the health care team managing patients. With the availability of 20 different drugs from 4 different classes an almost infinite number of different therapy combinations are possible each with its advantages and disadvantages. Factors that need to be considered include potency, convenience, drug interactions, side effects and the ability to maintain the high levels of adherence that HIV therapy requires to prevent the emergence of drug resistance. Price or adequacy of funding may also play a role in treatment decisions. Tension may therefore arise from the potentially opposing demands of evidence based medicine and patient choice. In particular the advice of the payer in the form of guidelines and the evidence base may be at odds with the preferences of the patient, creating a potential dilemma and source of stress for the clinician. Physicians are under constant pressure to reconcile these differences. Campbell and McGauley identified the importance of medical education; we feel that in addition it is imperative that further research is conducted in order to better understand these pressures. This would also ensure that the education provided was tailored for different clinical management settings. During the last decade there has been a huge increase in research investigating patient perspectives. While this has improved our understanding of patient needs and beliefs about illness and treatment decisions relatively little research has been published on how this matches physician perspectives and how this may lead to conflicts. Research into the physician perspective is therefore overdue and we would welcome new impetus into this type of research. Only from this type of research can we has heath care providers understand how physicians perceive chronically ill patients and their treatment options and the cognitive and emotional factors influencing their behaviour. In order to develop methods for supporting physicians to be more effective in their communication and delivery of care to chronically ill patients, from prescribing medication to communicating and dealing with medical uncertainty, we need a better understanding of the factors influencing physician behaviour. Competing interests: None declared