'Partners in pain'--the game of painmanship revisited

Chew-Graham CA and May C. ‘Partners in pain’—the game of painmanship revisited. Family Practice 2000; 17: 285–287. Chronic low back pain is common in primary care, and there is no doubt that some of its manifestations are demoralizing and dispiriting for the GP.1 Sufferers often present without identifiable organic pathology, and their condition appears intractable. Here we suggest that GPs' own ideas about the consultation and the moral nature of the doctor–patient relationship in general practice may themselves go some way towards constructing this ‘intractable’ state. Our objective is to reflect on the possibility that current ideas about good clinical practice might themselves be iatrogenic. The interaction between doctor and patient, embodied in the ‘consultation’, is the cornerstone of contemporary general practice.2 An average GP, in an average practice, will be involved in some 8000 consultations a year.3 Over time, the consultation has come to be attributed great importance not simply as the occasion for medical work (diagnosis, treatment, management and so forth), but also as an interaction that is structured around a ‘meeting’ of individuals and the presentation of symptoms4—often undifferentiated—to the GP. Through the course of this century, the various dimensions of this interaction, both verbal and non-verbal, moral and technical, have been emphasized increasingly by clinical authorities. In 1927, Peabody stressed its value as an ‘intimate personal relationship’.5 For the embryo National Health Service, it was constituted as an attribute of the ‘good doctor’,6 and, more recently, as the ‘very task of medicine’ itself.7