The standard in medicine has historically favoured an illness- and doctor-centered approach. Today, however, we’re seeing a shift from this methodology towards patient-centered care for several reasons. In the edited excerpt below, taken from Patient-Centered Medicine, David H. Rosen and Uyen Hoang explore four core principles that underlie the foundation of this clinical approach.
Acceptance is a trait that we believe is fundamental to all truly effective patient care. It is important to be clear what we mean by this simple word. Certainly acceptance has many commonplace meanings: acceptance of responsibility, obligation, assignments, and tasks. Of course, we mean all of these, but we also mean something much more specific. In its most fundamental sense, acceptance means the doctor takes the patient—the person as he is—into her mind, her heart, and her conscience. It is not an action, but an encompassing attitude. Furthermore, this attitude is not “mystical.” Rather, it is embedded in what is most basic to the human being. The doctor who fails to perceive this will never understand the essence of patient care and healing.
Why is this concept important? What does it have to do with modern medicine? The answer, we believe, lies in its intrinsic emphasis on receptivity rather than on action. Progressively, medicine has grown more action oriented, yet acceptance reminds us that, at the deepest level, humans need to be received, embraced, taken in, incorporated—all far more quiet and receptive modes of relatedness than those to which we are usually accustomed.
The importance of empathy has been widely stressed along with its dimensions, described by many writers concerned with the doctor–patient relationship. It has been defined variously, with most of the definitions attempting to connote an emotional stance that avoids extremes of over identification on the one hand and excessive emotional detachment on the other. A useful definition describes empathy as the ability to understand and share in another’s feelings fully, coupled with the ability to know those feelings are not identical to one’s own.
Defining empathy may be difficult, but achieving it is even harder. Most students find that they tend to oscillate between periods of over identification with patients and periods of excessive detachment. The notion of striking a balance is obviously appealing but not simple to effect. In truth, accurate and consistent empathy with patients is an exacting skill—one that requires years of experience and effort to develop fully.
Empathy is one of the hardest skills to perfect. It is also one of our most effective tools. Nothing is fool proof, of course, but most situations that go awry do so from lack of empathy. Even enormously explosive situations can often be defused with accurate empathy. Obviously, the uses of empathy are not limited to understanding patients. One can also use empathy better to understand the complex and sometimes painful interactions that occur among various hospital personnel, including ourselves.
The conceptual basis for patient-centred medicine is derived from George Engel’s biopsychosocial model. Essentially, Engel’s thesis holds that no change can occur within one component of a system without eventually making an impact on other components of that system. Further, each system (e.g., a molecule, a human being, a family) holds a lower or higher place in relation to other systems in a hierarchy of systems. Approaching patient care from this perspective requires a shift in thinking away from a simplistic disease orientation toward the more complex and more effective stance that we describe here as patient-centred medicine. To be a good doctor, a truly complete one, physicians must understand molecules and cells, organelles and organs, but they must also understand the complex, ineffable miracle we call “the person.” Even this will not suffice, however; people relate primarily in twos but live in still larger systems—families, communities, and the biosphere itself.
Once upon a time, being a doctor must have seemed easier. Now it is more challenging than ever before. The onslaught of new information at all levels of the systems hierarchy has accelerated at an astonishing rate. These are not trivial advances, but major new trends, fundamental and far-reaching discoveries doctors must integrate and understand.
Ultimately, knowledge and intellect alone are not sufficient to make one a good doctor, but neither are compassion and empathy alone. We are dealing with live patients, real people who place themselves in our hands. What we do or do not do can make the difference between life and death, recovery and degeneration, health and illness. Even if we do not cause disability or death to a patient through gross incompetence, ultimately it is our competence that determines the quality of our patients’ lives on countless levels.
We cannot possibly be all things for all patients. We cannot even be all things for one patient. Yet competence does demand that we do many things. Above all, competence requires one to see the big picture. Finally, when doctors reach a patient they do something special. Perhaps it is just a touch or a look of understanding. One less tiny cut in the patient’s life. A small wound that heals instead of festering. That is competence.
Featured image credit: ‘lone star’ by Amy Humphries. Public Doman via Unsplash.