The Physician-Patient Interaction, the changing landscape for better care!
Dr. Jackie Gardner-Nix MBBS, PhD; October 2021
Remembering the system in the UK in my childhood more than 60 years ago, our doctor lived on the corner of a street just a short walk up a suburban road of red brick semi-detached homes in a dormitory suburb of London, UK. He easily did home visits and in rare cases, brought consultants to the house, as he did when my younger brother was ill for several months and thought to have rheumatic fever. His consult notes were a few words: “Sore throat, rest and aspirin” written on a brown card, dated, and slotted into a slightly larger brown envelope. We did not make appointments. We sat in the waiting room part of his home and entered his office when the light above door turned green. His word was gospel, though, just as research has shown nowadays in the 2020s, we did not retain much of what was said in that consult. He didn’t have internet to fill his head with the vast amount of information doctors now have to access; he was not checked by a College to see the quality of his notes. He was paid a salary and not a piecemeal fee per patient; and he was held in high esteem. By going into his patients’ homes and living in their community, he knew a lot about our psychosocial situations that subliminally factored into how we were treated. We were probably, in those days, a more homogeneous society, but if seeing a different culture or minority group I feel he would have adjusted and used what is now known as the Platinum Rule: treating his patients how they wanted to be treated, not how he would want to be treated.
Fast forward to the present day: A plethora or information due to the internet, far more sophisticated diagnostic aids, far fewer home visits and many more overt cultural, gender and minority group diversities to take into account. Knowledge volume is so great that specialists have evolved from “internal medicine”, when I went to medical school, to subsections of specialists: Respirology, cardiology, endocrinology, neurology—the list lengthening with time. Now there are subspecialists of specialties, focusing even more narrowly on the part of the body they study.
But in reality, the part of us on which they concentrate their efforts functions only as well or as poorly as the rest of our body, mind, spirit and social circumstances allow. Often the specialist attempts to sum us up on a single consultation, not expected to guess accurately at our background and experiences. With common or acute disorders this works; with complex disorders such as chronic pain, the system is not so surefooted.
It is all connected, mind body and spirit “speaking” to each other, changing together as each part changes, and very in tune with our social circumstances: the social determinants of health. We are biopsychosocial and spiritual animals, and while the specialist can dialogue with us as patients on the “bio” part and have some impressions of us as we sit with them, and we can inform our own knowledge about our diagnosis by consulting Dr. Google, we and our loved ones are the experts on the psychosocial and spiritual environment into which the suggested treatment(s) are being introduced. We won’t have good outcomes if we are food or shelter-insecure or living in a very troubled household.
The relationship with our physician or nurse practitioner is not as paternalistic as it was in the old days but is now to transition to more of a collaborative patient-centred educational and decision-making process. The Ontario Ministry of Health has published a document called “The Patient Family and Caregivers Declaration of Values for Ontario”, detailing what they expect in interactions with their health care professionals. Health providers will need to become familiar with this: it includes elements of empathy and compassion, accountability, transparency (such as in the consultative notes being made available and comprehensible), equity, acknowledgement of inherent bias and adjustment, transparency, respect, and dignity.
But can this happen in reality? Is there the will in the imbalance of the hierarchy between health provider and patient? Is there the time? Do patients even have enough insight to offer psychosocial and spiritual information that is relevant to their management, and not that which isn’t?
There isn’t time in the average consultation to tell a life history nor would many specialists feel competent to integrate those insights into their decision-making—they would claim they are not trained in mental/social/spiritual health. But in complex health conditions those pieces of history influence the treatment choices that are the best fit for us. There is a place for these in the family physician’s office where continuity of care and looking after other family members helps to fill in the jigsaw puzzle of who we are. The other alternative which I used in pain clinics seeing those who had consulted many physicians without finding enough relief, was narrative medicine—I took their life history and explained the pathologies which arose along the way as we explored the “why”. Initial consults took 2 hours and the transcript another 45 minutes. Happier patient indeed, but I could only see a few a day three days a week; a five-day week would have equalled burnout for me.
In the absence of that luxury when in the specialist’s consult room, what can be done to render the best result?
The health provider needs to be open and non judgemental, bringing to the consult a beginner’s mind and awareness of their own “isms”—racism, sexism etc., and biases, hard to do when those instincts have been subliminally installed for years. But if aware of them, they can be mitigated. We must respect the patients’ experience and perspective even when we do not resonate with them, and never dismiss them. We need to express compassion and give hope even when the problem seems to lie outside our area, and not expect that responding with “all your tests are normal, go back to your family doctor” will be met with satisfaction when the patient still suffers: It is not a caring parting of ways. Patients want to know they are believed, that we wish we could help, and that we feel sure there is another health care professional who could shed light on what is going on. They need to hear we will give some thought to it and discuss with our family physician where we could go next for help. A far more compassionate response.
Similarly, in a sparsely populated physician environment with long wait times, patients need to become much more aware of how they function as a linked mind and body and within their social and spiritual environment, and how their experiences in life have played into the path their health has taken. They need to have that discussion with their health provider in complex conditions. Many are very unaware of their bodily reactions to stress, which can often short circuit the mind. Yet there is a large evidence base for stress being a major player in every bodily symptom, manifestation of disease, addiction, and mechanism of healing for aeons. Our life experiences inform how our genes express themselves, hence the field of epigenetics. Courses in Mindfulness, medical education, and cognitive behavioural therapy can sharpen our own knowledge and understanding of our mind-body-social connections; mindfulness training has even been found to reduce the number of health care-patient contacts, because patients can now make their own connections with what is going on in their bodies and do not need as many interventions in the healthcare space.
There is much more to offer in health care now—we are rich in diagnostics and treatments compared to when I was a child. But the psychosocial and spiritual aspects and clues, which are crucial, especially in complex medical situations, have often been lost.
I picked them up again doing home visits when in community palliative care for a few years, and what a joy it was, in that sombre field, to feel that humanity returning as I walked into their homes. Stepping across their thresholds, drinking in those scenes was worth a thousand words. Zoom and other internet platforms that we used during the pandemic revealed snippets of home backgrounds, though many felt reluctant to share them, somehow anxious about what it would reveal about them. But every insight counts.
Patients with complex conditions are more numerous as we age and delay death, and as we exist in multicultural and gender-diverse societies. The nuclear family used to be surrounded by extended family members who took care of us while parents worked and provided the attachments that we crave to thrive. We’re now increasingly sprinkled across the world, with fewer connections to support our health.
I am sure my childhood family doctor would never have imagined seeing a patient through a TV screen in real time. Or where the silos of specialist care have taken us. The advances made in medicine are to be admired and celebrated; but mind body, social and spiritual clues have been sacrificed in the consult rooms.
We need them back.
Dr. Jackie Gardner-Nix is a physician who had a focused practice in chronic pain. She is founder and medical director of the NeuroNova Centre for Mindful Solutions Inc. and an Associate Professor at University of Toronto.
She lives with her husband and Labrador puppy in Port Hope, Ontario.