Primary care: core values Patient centred primary careBMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7148.1882 (Published 20 June 1998) Cite this as: BMJ 1998;316:1882
- Les Toop, Pegasus professor of general practicea
- aDepartment of Public Health and General Practice, Christchurch School of Medicine, Christchurch, New Zealand,
- bSeries editor: Mike Pringle
This is the second in a series of six articles reflecting on the core values that will underpin the development of primary care
The importance and primacy of the clinician-Fpatient relationship cannot be overstated. The perceived intrinsic quality of this relationship initially allows two individuals, previously unknown to each other, to feel comfortable with an often high level of intimacy. With time the relationship may develop to allow safe and constructive discussion of intensely personal and private matters. The bond that forms may be healing in and of itself.1 However, the changing expectations of both clinicians and patients, together with changes to the context in which the interactions take place, challenge the future of this relationship.
In this article, the generic term clinician has been chosen deliberately to reflect the increasing variety of health professionals not just doctors now involved in providing primary health care to individuals in the community.2 The term patient has been retained for want of a better one.3
Although it is central to the discipline of medicine, the clinician-patient relationship is under attack from within through evolving expectations of both parties—and from outside, through changing norms in society
Models of the consultation in which the doctor maintains a more mature, and controlling, role than the patient have persisted through to the present day
The doctor of the future will find that such models are increasingly unacceptable, particularly in primary care
The sustained partnership model ensures a patient centred relationship that does not devalue special skills of the clinician
Pressures from within the consultation
The way the clinician and the patient relate to each other is a major determinant of the outcomes of a consultation. Satisfaction for both and degree of patients compliance with management plans are directly related to the quality of various elements of the clinician-patient relationship. 45 We know much less about the effects of the relationship on measurable health outcomes.
What are the desirable elements of this relationship between clinician and patient and how might these change in the future? Ian McWhinney has described the relationship between clinician and patient as one of open ended commitment on the part of the clinician, a covenant going well beyond the boundaries of any contract with a purchaser of health services.6He has emphasised the importance of both the human and the healing relationships which develop between practitioners and patients, along with the need to provide continuity of responsibility, even if practitioners cannot always be there for patients.
We do not know how many patients want such a covenant. Many clinicians strive to deliver it with various levels of success and at varying costs to themselves and those around them. Expectations are changing and the differences between the two ends of the spectrum, from the traditional practice to the one-stop McHealthcare, are widening. Caring for a diverse population is becoming increasingly complex. The generalist has to cater for an ever widening range of patients' expectations and develop the skills needed to switch between styles of interaction.
Alongside the changing expectations of patients are those of the clinicians. Is their vocation strong and enduring enough to survive the demands of increased expectations of patients and of the system and the competing claims and obligations to self and to family? Judging by the recent difficulties of recruitment and retention to general practice in Britain, 78 it would seem that the scales are tipping and that for many the answer is “no.”
Increased teamwork in primary care should help, in theory, by sharing the burden of responsibility and, in some contexts, on-call commitments. However, teamwork may also blur responsibility and reduce personal care. For many, development and extension of the core primary care team of nurses and doctors working collaboratively offers the way for the future.2 Such development might necessitate more shared multidisciplinary education and training.
In some practices this teamwork approach already exists, seems to work well, and is very acceptable to the users. The potential number of disciplines that might claim to be part of the extended (as opposed to the core) primary care team seems to have no boundaries. Clearly, above a certain size the transaction time and costs of trying to work as a cohesive team are prohibitive.2There is a danger that managing team function and structure becomes an end in itself and that, as a result, the needs of patients become secondary to the process.
Lack of time has become one of the catchphrases of health care in the 1980s and 90s. How can constructive, efficient, caring, and healing relationships be built up with more than a thousand individuals in a series of short and intermittent general practice consultations punctuated by constant interruption and coloured by anticipatory stress of further work commitments? John Howie's work has shown the effects of consultation time on doctors' levels of stress and on patient empowerment.9 There will always be tension between the unpredictable quantum of time needed by individual patients and the competing need to run a system efficient enough to allow patients and clinicians to at least start their interaction in a positive and relaxed frame of mind.
Societal pressures on the consultation
There are of course many other external influences that may cause problems with the clinician-patient relationship. In many countries, legislation on privacy and confidentiality protects and restricts access to health information10and this may obstruct effective teamwork. Respondents to a recent survey in New Zealand were completely divided about who should have access to general practitioners' records: those at one extreme expected access to be restricted to one person only (not even a locum should have access), whereas people at the liberal end thought anyone involved, however peripherally, with their care could see the records.11
Many countries have also enacted legislation on consumer information and protection. Is it always possible for consumers of health care to be fully informed? Concepts such as relative and absolute risk, number needed to treat, cost effectiveness, and resource allocation might not always be explainable to patients, yet these concepts are clearly important if they are to make informed choices. Trying to juggle advocacy for individual patients with decisions on resource allocation for a wider society leaves clinicians with conflicting moral obligations.
The sustained partnership
The positive value of a strong, trusting, and lasting relationship between clinician and patient is as important as ever. Numerous models have been proposed to describe the types of clinician-patient relationship. Twenty years ago Szasz and Hollender described three basic models: the activity-passivity approach based on the parent-infant model; the guidance cooperation approach based on the parent-child; and the mutual participation approach based on the adult-adult interaction.12 In mutual participation the doctor helps the patient to help themselves and the patient is a participant in the “partnership.”
Defining features of sustained partnership
Whole person focus—if The clinician attends “to all health-related problems, either directly or through collaboration, regardless of the nature, origin, or organ system affected”
Clinician's knowledge of the patient The clinician knows not just the patient's medical history but his or her personal history, family, work, and community and cultural context, as well as his or her preferences, values, beliefs, and ideals about health care, including preferences for information and participation in clinical decision making
Caring and empathy—The clinician expresses humaneness toward the patient through such qualities as interest, concern, compassion, sympathy, empathy, attentiveness, sensitivity, and consideration
Patient's trust of clinician—The patient believes that the clinician's words and actions are credible and reliable, that the clinician will act in the patient's best interest based on clinical knowledge and knowledge of the patient, and that the clinician will provide support and assistance concerning treatment and medical care
Appropriately adapted care—The clinician tailors treatment recommendations to reflect the patient's goals and expectations regarding health and health care as well as the patient's beliefs, values, and life circumstances
Patient participation and shared decision making—The clinician encourages the patient to participate in all aspects of care, and treatment and referrals are agreed to by both the clinician and the patient. To the extent that the patient wishes, the clinician informs the patient about diagnosis, prognosis, and treatment options and includes the patient in treatment decisions15
None of these three models is claimed to be better than the others; each has its place and each may be inappropriate at times. Too many doctors may be stuck in the guidance-cooperation model and feel that their authority is threatened if patients are allowed too much autonomy and too great a share of the executive role.13
The patient centred approach (based on mutual participation) has gained increasing support in recent years.14 This approach reaches a shared acceptance of the agreed roles of the clinician and patient, of the nature and extent of the patient's problem, and of the goals each has for the interaction. Equally important is shared responsibility for achieving the agreed goals. There is not yet, however, any solid evidence that patient centred care improves health outcomes.
In 1994 the US Institute of Medicine included in its definition of primary care the concept of a sustained partnership between patient and clinician.1 While denoting participation from both parties, this concept does not necessarily imply equal roles.
This concept has been picked up by Nancy Leopold and colleagues, who have developed an attractive model for this sustained partnership (box).15 The defining features of this model are a focus on the whole person; the doctor's knowledge of the patient; caring and empathy; trust; the choice of appropriately adapted care; and the patient's participation in decision making. Whether one clinician ever could or would provide all of this is a moot point. In primary care teams embodying true collaboration and shared ownership, such a model of sustained partnership should be developed through a successful triad of relationships between the doctor, the nurse, and the patient.
This article has been adapted from Primary Care: Core Values, edited by Mike Pringle, which will by published by the BMJ Publishing Group in July.
I thank Jean Ross for helpful comments on the manuscript.
Conflict of interest: None.