What is happening to the therapeutic relationship?
The myth of the ‘trivial consultation’
Despite the best efforts of a modern, scientific medical education, most GPs realise that when a patient presents, the pathological process is only one of several processes, (social, psychological, economic, environmental, spiritual, etc.) that contribute to the patient’s sense of illness or well-being.
The nature of general practice, by which a doctor gains, over time, a knowledge of their patients lives enables them, through the development of a therapeutic relationship, to act as a holistic practitioner, understanding their presenting symptoms in the context of a broad range of contributing factors.
The trivial consultation.
Increasingly we complain about ‘trivial consultations’, and eager to support us, politicians, policy makers and managers help us think up creative ways to ease the burden of the General Practitioner so that someone (or something) else; a nurse or pharmacist, or their assistant or deputy, or perhaps a receptionist or NHS direct, an Internet site, in fact, anyone -or anything- paid less, can deal with them so that the overworked, over qualified and over-paid GP can concentrate on the type of complicated, high risk consultation that their expensive years of education and indemnity premiums justify.
There can be little doubt that education can inform and empower patients to manage many health matters without the interference of their GP, or for that matter anyone else, just as there is no doubt that the other sources of advice and treatment listed above can offer an excellent service -many as good, and some -for some patients with some conditions in certain circumstances, better than a GP. Patients have always made use of a wide range of advice and treatment options and the majority of ailments have always been managed without the ministrations of the GP. This will always be the case. What is changing is the range and number of options that come with our approval and encouragement, increasingly also assessed as being ‘quality’, ‘efficient’ or most of all, ‘evidence based’ and ‘cost-effective’.
Under pressure, either implicit or more direct, patients are encouraged not necessarily to deal with problems themselves, but by exploring a plethora of other alternatives, to avoid bothering their GP unless absolutely necessary. The GP is increasingly being marketed as a last resort, rather than a first line. Once the patient has tried the advice of friends and family, taken some over the counter medicines, searched for advice on the Internet, seen the herbalist, read the practice leaflets and made a case for their need to see a doctor to the interrogatory receptionist, passed the triage nurse and taken the course of antibiotics prescribed by the nurse practitioner, they finally see the stranger whose name is on their NHS card. At this point they are faced with a stranger, a doctor in name who knows nothing of their lives, their relationships or their experiences of illness and health, hopes, fears or expectations, someone who they have been deprived of the opportunity to grow to know and trust.
Continuity of care is being increasingly devalued and undermined, not only by the factors outlined above, but by the loss of personalised lists, subcontracted out-of-hours work, reduced home visiting, and increasing amounts of management and administrative responsibility. As we lose continuity we will lose the ability to form therapeutic relationships and act as holistic practitioners.
Increasingly patients are turning to alternative models of healthcare that attempt to integrate a more holistic approach. Whilst offering varying degrees of holism, none of these view the patient from such a range of perspectives as offered by a GP with the knowledge gained over years.
If we believe in treating patients rather than conditions and see each consultation as an opportunity to develop a relationship with our patients, then we will become more effective and more satisfied with our work. To do so involves a change in attitude towards each patient consultation and the right conditions to allow us to develop relationships with our patients.
This was originally written for the New Generalist magazine in 2006. The magazine no longer exists. It is exactly as I wrote it then. My concerns about the changing nature of primary care started long before this government.