INTRODUCTION
Many choices in health care today are made from an organisation-oriented perspective, with considerations of efficiency playing a dominant role. These choices often clash with values such as patient-centredness and continuity of care. Creating more uniformity in care through protocols can hinder doctors in providing personalised care. A choice for task delegation, often necessary in highly pressured healthcare environments, carries with it the risk of putting pressure on the continuity of care. A choice for effective, efficient, and product-oriented care results in not only keeping costs under control but can also lead to increased bureaucracy and less room for teamwork. Important human values that strongly connect with the patient’s perspective are in danger of succumbing to the pressures of efficiency. Patients, after all, express a clear preference for personal attention and a doctor–patient relationship based on trust, with a doctor they know.1 This enables them to share their symptoms, knowledge, emotions, and personal expectations more openly,2 and it makes them feel more involved with the consultation, which in turn leads to greater therapy adherence. For most physicians, the wish to be of importance to their patients is their primary motivation for being a doctor. However, choices in current health care tend to cause more stress, less satisfaction, and a decrease in empathic behaviour in doctors.3
This article aims to explore the essential value of person-oriented doctor–patient contact, using the theoretical principles of three philosophers.
WHAT CAN WE LEARN FROM PHILOSOPHERS?
Various philosophers have written about human interaction. Three themes that play an important role in doctor–patient contact are the human encounter, attention, and equality. Levinas, Baart, and Nussbaum are three philosophers who have studied these themes.
Levinas describes the essence of the human encounter, whereas the Dutch thinker Baart explores, through his ‘presence approach’, how presence and attention influence the intensity of human interactions, in care and other situations. Nussbaum emphasises how equality results in equal opportunities for everyone within the context of care.4
THE HUMAN ENCOUNTER
Whenever a patient consults a doctor there is a human face-to-face encounter between two individuals. Levinas’s work is all about the encounter with the Other. He asserts that, when two people meet each other, both of them automatically put a value on this human encounter. And, whether they like it or not, each of them makes an appeal to the other. Because of the relationship that has come into existence between both individuals there is now room for a narrative, which allows people to better know and understand each other.5
Let’s imagine a patient who, during a busy surgery, comes in with a knee complaint and hints at a larger emotional issue that has been affecting them. Do you, the doctor, take the hint? The patient is obviously making an appeal to you, thereby touching your ‘Self’. This makes us aware of each other. The Other appeals to you to share the responsibility for making the consultation successful.6
Levinas’s perspective of the human encounter makes it easier for us to understand what goes on during a consultation. The consultation is more than just a question-and-answer session. In a successful consultation, telling and listening play a central part and mutual understanding shapes the ongoing process of creating a shared narrative between doctor and patient. This makes patients feel ‘heard’; they feel the doctor is interested in their emotions and needs, and in building a genuine, reciprocal relationship.
ATTENTION
Patients visit their physician in order to seek their attention and advice for a complaint or issue. Especially when patients are at their most vulnerable, for example, when they are terminally ill, receiving attention and feeling certain that the doctor will be there for them, can put them at ease. Baart describes ‘attention’ not only in terms of ‘thinking about someone’ and ‘being attentively present’, but also in more emotional terms such as ‘I care about you’ and ‘I’m here for you’. Being attentive to patients makes the interaction more intense, allows full attention to be given to that which is most important, and enables receptivity. Only in this manner can caregivers look beyond their personal frame of reference and empathise with the patient.7 Practising presence is not easy at all as care tends to explain things in terms of the logic of the system, rather than in terms of the care-receiver. According to Baart it requires flexibility and the introspective and reflective competencies of the caregiver.8 Practically, this means that doctors who ask closed-ended questions or who interrupt patients too quickly will only receive the information they are asking for. They will not get a full picture of the complaint in the context of the patient. A consultation can also be used to make patients aware of their thoughts and feelings. This will only happen when the doctor is attentively present. This allows the doctor to contribute proactively and with full interest in the patient’s thoughts, creating space for the patient to outline the many aspects of the problem. It allows the doctor to create a detailed picture of the patient’s thoughts, assumptions, and context. In this way the presence approach helps in diagnosis and in providing person-centred care.9
EQUALITY
Equality in the manner of communication between doctor and patient leads to a respectful recognition of the other, and being open to equality helps doctors to better help their patients.
In her ‘human rights’ approach Nussbaum posits that all persons possess full and equal human dignity. Commitment to this idea forms the basis of equal opportunities for everyone in health care and nurtures and enhances people’s capabilities.4 Based on this theory, the focus of the consultation should be not only on diagnosis and symptom management, but also on exploring and strengthening the patient’s ideas and capabilities in developing and preserving their good health.10 This stimulates the patient’s ability to adapt and take the reins. Furthermore, it allows the doctor to connect to the preferred view on the definition of health, that is, the ability to adapt and self-manage, within the three domains: physical, mental, and social.11
There are, of course, inherent power imbalances at play in the doctor–patient relationship, but greater equality in the manner of communication between doctor and patient makes it more natural for patients to speak about their wishes, expectations, and ideas. It enables doctors to look at a problem not only with their expertise but also through their patient’s eyes. This approach enables discussion, allows physicians to support patient choices, and engenders greater problem solving in patients as well as more shared decision making.
NEXT STEPS
Thinking about concepts such as ‘the human encounter’, ‘attention’, and ‘equality’ stimulates doctors to work with an open mind, thereby contributing to developing a doctor–patient relationship in which patients are seen as individuals with a context, rather than as bodies with a malfunction. Although they are an essential precondition for the doctor–patient consultation, in current health care these concepts and their application have got frustrated by the organisation and management of care. The strong focus on efficiency and productivity has led to a narrow view, both in medical practice and medical studies.
The question is how the above-mentioned considerations can be incorporated into medical schools and practice. To answer that question, it is necessary to adapt the content of curricula in vocational training as well as in continuing medical education. During training, more attention can be given to the concept of the human encounter by devoting time and space to the narrative aspects,12 and by training students in applying a contextual medicine approach.13 Presence requires a broader introduction of reflection on and evaluation of one’s actions and emotions in health care.14 Equality requires an attitude that values cooperation with patients as meaningful and instructive.
If there is a genuine wish to improve patient care, it is up to the profession to put these considerations into practice during training and continuing medical education, and to make lifelong learning regarding these concepts to be a requirement for re-registration as a medical doctor.
Notes
Provenance
Freely submitted; externally peer reviewed.
- © British Journal of General Practice 2020
