Intended for healthcare professionals


Take your partners for the dance

BMJ 1999; 319 doi: (Published 18 September 1999) Cite this as: BMJ 1999;319:a

There are two categories of people: those who believe that there are two categories of people and those who don't. More sensibly, there are three ways in which doctors may consult with patients (p 780). In the paternalistic model the doctor decides what to do. In the informed model the patient decides after the doctor explains the options. This theme issue of the BMJ celebrates and explores a middle way: the shared model, where doctor and patient decide together what action to take.

These are models, and reality is more subtle. Individual consultations may have several components. The most radical of patients may sometimes choose for their doctor to be paternalistic. A doctor may operate in every mode during one afternoon of seeing patients. And the patients who never question their doctor often throw away the pills they've been prescribed. Nevertheless, the shared model is now in the ascendancy. Angela Coulter, guest editor of this issue, declares that the paternalistic model is “out of step with other currents in society” (p 719), and the British government is encouraging partnership between doctors and patients (p 788).

Worldwide, the relationship between doctors and patients is changing. Some might argue that the shared model is simply a staging post on the long march from the paternalistic to the informed model, but others think that moving to the shared model may be the most important change in medicine in the next decade—more important even than the arrival of the new genetics or the internet, which itself contributes to changing doctor-patient relationships (p 761). Don Berwick, one of the world's leading thinkers on improvement in health care, believes that “when patients become coequal with care providers in controlling care, making decisions, and treating themselves with coaching, outcomes improve, costs fall, satisfaction rises, and even physiological measures look better.” Some evidence in this issue supports his belief (p 759). Partnership may also lead to better research (p 724) and policy decisions (p 725).

Although sceptical voices are raised in the letters pages (p 783), most of the authors in this issue are committed to the idea of partnership Angela Towle and William Godolphin give guidance on how to work in partnership (p 766). Their “eight competencies” for doctors include establishing the patient's preferences for information and role in decision making. Patients, meanwhile, need to define for themselves their preferred doctor-patient relationship and develop a partnership with their chosen doctors. Partnership means that patients and doctors must change, sharing responsibilities as well as information and decision making. It takes two to tango.


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