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.
This is an excellent observation on the breakdown of the therapeutic relationship between doctor and patient.
I can only speak of the practice I attend which comprises of one ‘partner’ and four salaried GPs. Moral among the salaried GPs appears low and there is a regular turnover of said GPs.
When I first attended this practice over twenty years ago it consisted of four partners and the GP I chose to be my family doctor became a ‘surgery’ friend, such was the rapport we had. He knew me and my family and would ask after them should I have an appointment and the interest was genuine. He told me about himself, his history and his family. This relationship was beneficial to us both of us as he knew me, respected me, made me feel comfortable and therefore I trusted and respected him. The practice was busy and bustling reflecting the confidence patients held for their doctors.
For various reasons by 1999 it was a single handed practice, that of my GP. He retired in ?2003 and the practice is now a satellite of a larger practice in a nearby town. It has become a barren place and the list is low and I can understand why patients abandon it.
I feel quite strongly, based on the little a salaried GP once told me, that he – now long gone – and his colleagues felt undervalued by and unimportant to the partner. Their low moral reflected in patient care – for a patient cannot be ‘happy’ if the GP is not happy. This state of affairs appears to continue.
I (generally) only visit my GP – not that I have a ‘my GP’ anymore – six monthly for a meds review. I hate it and come away feeling like a nothing, the disinterest is loud, the approach almost hostile and if I didn’t have to attend, I surely wouldn’t.
There is a constant turnover of staff, this including nurses and back office. If someone asked me who my doctor was, I couldn’t tell them as I no longer know. Much of the ‘minor’ stuff is delegated to the practice nurse, minor ops once done in the surgery are now – and have been for a long time – commissioned out to a private ‘NHS’ clinic in a nearby city which unless you are a car driver, has to be a taxi job as there is no direct bus route.
The waiting room, once almost a comfortable lounge is now a sterile white room with the obligatory TV facing row upon row of chairs. Modern impersonal technology abounds and pretty soon you won’t even have a need – or not be allowed – to speak to reception staff.
You are buzzed in by the GP, God help you if you are deaf or demented or have poor vision – because you will not be aware that it is now your turn.
I hate going to the docs as I come away feeling that I am trivial, a nothing.
Bring back family GPs who you knew and trusted and who knew you. Please.
We learn so much about human nature too. Often, you cannot know if anything is trivial until much later.
We have to keep non medical people away from meddling.
The Cockroach Catcher
Have been trying to contact you to ask if I may put this brilliant letter up on http://www.after-cancer.com. I started this website as a way of telling other cancer patients that we are not alone on the production line that is today’s cancer treatment. But – we will probably all agree that we often no longer have any confidence in doctors, who delight in prescribing the latest ‘IN’ drug – then shying away from the awful side effects. And as for the nurse who told me “you are only a cancer patient….!” I don’t have any words for her!