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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Understanding the relationship
It is really about friendship
Continuity and the Doctor-Patient Relationship
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Margaret M. Love, Lexington, KY, USA Assistant Professor of Family Practice and Community Medicine at the University of Kentucky
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The article by Mainous, Goodwin, and Stange is particularly interesting because they studied the relations among different aspects of the patient-physician relationship: the length of the relationship (i.e., number of years), what happens in the relationship (i.e., shared experience), and what the relationship means to the patient (i.e., value of continuity). The results suggest that there is more to building a relationship than time. Valuing continuity of care was positively related to shared experience, not to the length of the relationship, and was significantly related to the interaction between shared experience and length of the relationship. For patients that had “been through a lot with their physician,” length of relationship did not make as much difference in valuing continuity as it did for patients that disagreed they had been through a lot with their physician. For these patients, did time in the relationship lead to valuing continuity, or did valuing continuity keep them in the relationship longer? That is one of several intriguing questions to be sorted out in future research. For example, what constitutes having “been through a lot together”? Is it a key event, such as a crisis or rescue? Or is it the ongoing – but nonetheless challenging – struggle to work together toward appropriate diagnosis, treatment, or lifestyle change? Certain medical conditions, such as asthma, may involve a combination of the two. Many patients seem to value continuity of care over time with the same physician. On average, the patients in this study valued continuity higher than a “4” on a five-point scale. Yet some patients value continuity more than do others. By studying its value in relation to both shared experience and length of relationship, this study helps us understand why. Competing interests: None declared |
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Bruce Bagley, Leawood, KS USA Medical Director for Quality Improvement American Academy of Family Physicians
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Mainous, Goodwin and Stange, attempt to validate what we all believe in our hearts is true about the magical doctor-patient relationship. Continuity is only one factor that contributes to a positive relationship from the viewpoint of the patient and the physician. Insight into this complex relationship is not easily gained by observational studies and surveys alone. For the most part, the doctor-patient relationship is no different than any other “friendship.” It will grow over time with mutual trust and understanding based on shared experiences and respectful dialogue. Just as some people are not capable of making and maintaining friendships with others, some physicians may be lacking the social skills to truly engage patients in a mutually satisfying relationship. There are some aspects of medical care that may not require this relationship for the best outcome. The Future of Family Medicine report lists, as one of the unique characteristics of family doctors is that they exhibit “a commitment to multidimensional accessibility.” Among other things, this means open and honest communications and the willingness for the physician to expose his or her humanness and spirituality. These are the makings for any good friendship. The Institute of Medicine Report, “Crossing the Quality Chasm,” sets the six aims for the healthcare system of the future. The care should be safe, effective, patient-centered, timely, efficient and equitable. They go on to list the ten basic rules that we must follow as we redesign the healthcare system for the 21st Century. It is no surprise that the first rule is that “care must be based on continuous healing relationships.” Bruce Bagley, M.D. Medical Director for Quality Improvement American Academy of Family Physicians Competing interests: None declared |
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John G. Scott, New Brunswick, USA Assistant Professor of Family Medicine UMDNJ-Robert Wood Johnson Medical School
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Previous research on continuity of care has made the implicit assumption that all relationships between doctors and patients are equal, essentially a matter of knowledge transfer. The longer the relationship between the doctor and patient, the more knowledge the doctor will acquire about the patient, and may therefore deliver better care. Those of us who actually care for patients know that this is poppycock. Doctor patient relationships come in all flavors and qualities, and are dependent on the personhood of both doctor and patient. In many ways the doctor is the therapy, and how he or she and the patient connect to each other determines the effectiveness of treatment, particularly of chronic illness.[1] Policy makers, managed care companies and employers, however, view doctors as interchangeable (except a few who simply need a knowledge infusion). Continuity of knowledge is valued (hence the emphasis on electronic medical records) but not continuity of relationship. One study documented that even in 1997, 25% of patients in the study population had to change physicians in one year because of changes in health insurance plans.[2] The study by Mainous, et al, is a quantitative breath of fresh air on this topic. The authors have made creative use of the DOPC data to demonstrate the complexity of how shared experiences between doctors and patients influence, and are influenced by duration of relationship, chronic illness, and patients’ value of continuity. They use sophisticated and rigorous analytic methods to support their conclusions. As with all good research, this study generates more questions than it answers. What are the determinants of an effective doctor-patient relationship? How does such a relationship affect patient outcomes in chronic illness? What is the best way to define outcomes in chronic illness? How do scientific knowledge and personal knowledge interact? Answering these questions will require the best efforts of both qualitative and quantitative researchers. Dr. Mainous and his colleagues have set us on the right path. 1. Cassell, E.J., The nature of suffering and the goals of medicine. 2nd ed. 2004, New York: Oxford University Press. xx, 313 p. 2. Flocke, S.A., K.C. Stange, and S.J. Zyzanski, The impact of insurance type and forced discontinuity on the delivery of primary care. J Fam Pract, 1997. 45(2): p. 129-35. Competing interests: None declared |
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