'Only connect': the centrality of doctor-patient relationships in primary care

Celia Roberts. ‘Only connect’: the centrality of doctor–patient relationships in primary care. Family Practice 2004; 21: 232–233. EM Forster's call in A Passage to India to ‘only connect’ is a shorthand for the hundreds of ways in which doctor–patient relationships have been discussed in the literature. As Chew-Graham states, in the parallel editorial, this relationship, and the patient-centred ideology which underpins it, is seen as intrinsically therapeutic. The evidence base for such an assumption is well established, most notably in the literature on quality and continuity of care. There is a strong association between personal continuity, enablement and patient satisfaction.1 Since personal continuity implies both empathy and personal responsibility,2,3 the studies overall show a strong correlation between quality relationships and patient satisfaction. Reviews of patient satisfaction studies show that along with doctors' medical skills, qualities such as listening4 and interpersonal skills5 are rated as highly. Empathy,6 ease of communication and friendship,7 trust8 and commitment are all associated with personal continuity and highly valued by patients. These characteristics are particularly important for patients with chronic illnesses and complex problems, and for the elderly. The young and fit seem less concerned with personal relationships.9 Patients with ongoing problems benefit from ongoing good relations with the GP. As well as the evidence base from patient satisfaction studies, the sociological and linguistic studies of interaction show a strong relationship between involvement in talk and understanding. ‘Troubles telling’10 and patient narratives11,12 show the importance of doctor–patient interactions, which give room for patients to speak throughout consultations and over several consultations. ‘Giving room to speak’ encourages patients to tell their stories. So history taking becomes an interpretive process in which the patient's particular take on their illness is explored.13 The relationship which develops through patient narrative is not only therapeutic in a general sense, it also provides the conditions for understanding and the avoidance of misunderstandings.14 The post-Balint move to more interpretive and empathic consultations is not just a shift to more psychosocial models but is also a shift in interactional models, from hierarchical to more flattened structures and role relationships between GP and patient. More interactional equality is assumed in the current discourses of ‘concordance’ and ‘shared decision making’. Knowledge is shared and outcomes negotiated; resistances are acknowledged. However, more negotiation in the consultation does not fundamentally undermine the power asymmetries of the GP–patient relationship. The professional expertise of doctors pre-determines this imbalance and it is routinely consented to by patients.15 GPs' feelings of disempowerment, according to Chew-Graham, stem from a combination of patients' intractable problems and the fact that creating and maintaining good personal relations undermines their authority to deal with these problems. The argument is not that doctors have less professional expertise but that they are inhibited from exerting their authority to gain compliance from patients. However, the evidence on continuity of care and patient satisfaction referred to above suggests that empowerment for GPs is the result of more concentration on doctor–patient relationships rather than less. The discourses of ‘burnt out doctors’ and ‘heart sink patients’ are understandable defence mechanisms for GPs coping with the levels of chronic illness and complex social problems typical of general practice today. However, rather than turning away from more negotiated and democratic consulting styles, their value as tools of persuasion and joint agreement should be explored further. A sense of powerlessness can lead to feelings of nostalgia for the ‘good old days’ when a GP's natural authority and technical skills led to rational decisions for compliant patients. However, both this technocratic and rational model of medicine and the ideology of authoritarian role relations seem inadequate in the face of increasingly complex medical and social problems, on the one hand, and more general social changes and uncertainties, on the other. Simple distinctions between health and illness, and sickness and recovery, and the clinical goals that these imply, are not always sustainable. Herzlich describes how some chronically ill patients treat ‘illness as occupation’. They work on making adjustments to their lives, rather than assuming that they will certainly get better. They see themselves as creating a new form of life in which they do not define themselves as fundamentally different from healthy people.16 Patients recognize that the illness narrative does not always end in straightforward recovery. Similarly, for a GP, success with a patient may reside in the long-term therapeutic relationship with the patient rather than the happy ending of a complete recovery. The act of supporting the patient in itself is a successful outcome. Maintenance of the relationship and the therapeutic or palliative effect produced can give satisfaction and boost morale for both doctor and patient.17 Such relationships may help the patient to avoid taking strong drugs or help them to manage without being institutionalized.18 The trust, friendship and sense of sustained partnership which personal continuity brings is more likely to improve the taking of medication than an approach which pays less attention to personal relationships.19 Indeed, it is counter-intuitive to assume that GPs are more likely to be able to persuade patients to take medication, give up smoking or alter their diet if there is less concern about creating trust, commitment and a sense of partnership. The sense of frustration and exhaustion that GPs report when working with the often irresolvable problems of the chronically sick stem more from a strict adherence to biomedical goals and an undervaluing of the contribution they can make to the patients' management of their illness. The latter depends crucially on the quality of the personal doctor–patient relationship and the trust, commitment and friendship which, the studies show, are more likely than not to develop. Gray et al. argue that when GPs are not able to develop such relationships they should consider moving to other branches of medicine: “Some doctors are intrinsically unsuited to relationship-based primary care and might be happier moving to a speciality such as accident and emergency medicine”.20 They argue that doctors who have as a goal the understanding of their patients as people and can build up mutual trust with them are much more likely to have a sense of job satisfaction and to feel valued. The expertise and practical wisdom which are being grown in the humanistic undergraduate programmes, in both well-established and new medical schools, share this goal. Tomorrow's doctors are likely to be more equipped to understand, support and work with the chronically ill towards negotiated and achievable outcomes, and to derive a sense of worth and satisfaction from this, but only because the personal doctor–patient relationship is at the centre of their working practices.