We are all patients

Rodger Charlton

HK Pract 2014;36:81-82

There is nothing like being a patient to focus our minds to remind us how important it is to have ready access to a doctor and why, when illness strikes.

Access to physicians is changing worldwide, not least through social media, the use of email and smartphones. But, the basic idea of the doctor-patient relationship, the consultation, is essentially the same. However, the value of access to physicians varies from country to country and also within countries where socio-economic status is a large determinant.

The role of family physicians and secondary care specialists differs in that family physicians are likely to see the same patient many times and learn a new part of their life story or narrative in relation to their health and possible illness. It is the family physician's, or personal physician's ability to provide continuity of care through the episodic nature of an illness and ongoing pro-active and reactive care for those with long-term conditions that is most valued by patients.

Doctors are generally held in very high esteem by the public and for this reason patients have considerable expectations in relation to the consultation and getting satisfaction from each meeting with their doctor. I attended a lecture many years ago given by a doctor who worked for social services and I still recall the four points that she made about the possible outcomes of the consultation. These were: (1) being given a prescription, (2) getting a referral to a specialist, (3) being given a sick note and (4) the fourth, which is perhaps the most important of all; receiving a bit of love. The best doctor is the one who perhaps himself has been there, in the seat of the person opposite with an illness and so one who is able to understand, or failing this, the one who at lease tries to understand a patient's plight and circumstances.

Times of distress, which may be brought on by illness or complicated by psychosocial issues in patients' lives, are times of extreme vulnerability and our patients may hang on every word that a doctor says. But, it is not just the words that the doctor utters, but the manner in which the words are delivered that matters, showing whether the doctor is seen as sympathetic and where possible, empathetic. So frequently in medical school teaching, we emphasise communication, both verbal and non-verbal, but do we ensure it is always delivered to the highest quality possible?

A general practice (GP) professor, Professor Roger Neighbour, is best known in the United Kingdom for his book and consultation model, "The Inner Consultation".¹ There are many consultation models and it could be argued that there is no ideal model and eventually each doctor develops their own individual style. I was privileged to listen to Professor Neighbour recently speaking at a postgraduate meeting and he has come up with an alternative model which is very straight forward and has come about following considerable reflection. It is: (i) shut up, (ii) listen, (iii) know your medicine and (iv) care. It is the latter that is so important and is contained within the College mottos of the United Kingdom, New Zealand and Australian Royal Colleges of General Practice; "Cum Scientia Caritas", which means "scientific care with loving kindness".²

But it is more than sympathy, empathy, care and, the term that now attracts much of our attention in medical education, "professionalism." Sadly, it is possible to demonstrate professionalism, but sometimes without truly caring. And perhaps it might be best to go back to the phrase 'bedside manner', which has been superseded by the word professionalism. Genuine professionalism must include compassion.

Compassion is almost undefinable, but the current pace and pressure of modern medicine means it is squeezed out as we see more patients, more frequently and with shorter consultation time. Compassion is more than empathy, it is the wish to relieve suffering, where the degree of compassion is our desire to want to help and so, in turn, to show kindness (love) and care. This is the embodiment of altruism in health care. Caritas, continuity and compassion are what GPs do best and it is time to embed it as a theme in health care for the foreseeable future. With an increasingly frail elderly population with multiple co-morbidities through long-term conditions, the emphasis should be on caritas balanced appropriately with scientia. The 3Cs for us in the future will be continuity, caring and compassion and these Cs should be the new professionalism.