Seeing the doctor

Chapter 45 Seeing the doctor


Every weekday in the UK, almost 1 million people consult their GP. The consultation between patient and doctor is at the core of all medical practice, be it with a GP or hospital doctor, be it in the UK or elsewhere. Although an intensely personal and private meeting, usually conducted behind closed doors or curtains, there are rituals and social norms (expected ways of behaving) that provide structure and coherence to what happens in a particular culture.



Doctor–patient relationship


Four models of the doctor–patient relationship have been described: (1) paternalistic; (2) mutual; (3) consumerist; and (4) default.



Paternalistic


The paternalistic relationship or disease-centred approach has, until recently, been the most commonly observed type of relationship. The doctor, a medical expert, makes a systematic enquiry with the patient answering relatively specific and closed questions, carries out appropriate tests and reaches a diagnosis or a range of possible diagnoses. The doctor then decides on the appropriate treatment, which the patient is expected to follow without question. The process is relatively technical and specific to the symptoms/problem that the patient presents.


In the 1980s, studies of doctor–patient relationships demonstrated that patients, particularly those with chronic illnesses, were also ‘experts’ in what the symptoms/problem meant to them and their families (Tuckett et al., 1985). This and other research suggested that patients sometimes held different ideas from their doctors about their illnesses, why they were ill or what they wanted to do about it.



Mutual


The mutual relationship is now becoming more common, partly as a result of greater patient knowledge, particularly about chronic disease, and partly because of a general cultural shift for individuals not to be passive followers of authority but autonomous agents in their own right. It is characterized by the doctor recognizing both this patient autonomy and the importance of the patient’s own beliefs and knowledge of health and illness, and the social context in which the illness is dealt with. This model involves the doctor working with a patient-centred approach and is discussed in more detail below.



Consumerist


The consumerist relationship is becoming more common in the UK as a result of the extension of private health insurance, the introduction of patient charters, the increasing emphasis on extending patient choice and initiatives to provide quicker access to a doctor. It is characterized by patients ‘shopping around’ for their preferred care and is accompanied (as exemplified in the USA) by relatively high levels of investigation and treatment, and litigation.



Default


The fourth model, sometimes labelled default, is characterized by low levels of engagement between doctor and patient. It can be observed in situations where the doctor can find nothing organically wrong to explain the patient’s symptoms, and where the patient is labelled as somatizing. There are very particular problems associated with the way patients and doctors respond to such situations, and there is a considerable risk that patients will become trapped in a cycle of overinvestigation and treatment.



The patient-centred approach


In its recommendations for undergraduate education in the UK, the General Medical Council (2002) emphasized the importance for all students of learning the patient-centred approach. Box 1 highlights five key features of the approach.



Box 1 Patient-centred care



image Explores the patient’s main reason for the visit, concerns and need for information

image Seeks an integrated understanding of the patient’s world – that is, the patient as a whole person, his or her emotional needs and life issues

image Finds common ground on what the problem is and mutually agrees on management

image Enhances prevention and health promotion

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Jun 10, 2016 | Posted by in PSYCHOLOGY | Comments Off on Seeing the doctor

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