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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
To Care is to Coprovide: Semantics or an important difference?
Coprovision
Caring connections
Going Beyond the Coprovision of Care
Health Care Partnerships – “But Not by Prescription”
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William T Branch, Jr, MD, MACP, Atlanta, GA, USA Director, Division of General Internal Medicine, Emory University School of Medicine, Nathan Spell, MD, FACP
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Stephen Buetow proposes that true primary care requires coprovision or sharing of care between patient and provider.(1) Consumerism and paternalism in his words “should no longer be regarded as care.” Is Buetow simply restating that partnership is ideal, whereas consumerism and paternalism are less desirable ends of the spectrum? We think there is more here than semantics. One of us (WTB) has previously argued for several related points. To begin, the philosophy of caring, first developed by feminist philosophers, best defines the doctor’s relationship to the patient.(2) Also, because physicians have the preponderance of power in the relationship, the physician’s ethical duty to enhance his or her patient’s autonomy in order to work with the patient as a partner is absolutely crucial.(3) Finally, Suchman and WTB explored the enormous rewards that clinicians derive from their personal engagement in caring for patients.(4) But also, patients care for their doctors. We base our comments on this idea of mutual caring. By mutual caring, we conceive of a sincere and appropriate attitude on the doctor’s part. On the patient’s part, there should also be sincere and appropriate participation in the relationship. And, patients do care for their doctors—in the manner of positive regard, often not overtly, but in ways one can sense. Ultimately, this is why we physicians strive so hard for excellence. Excellence is personal, not impersonal, because it derives from the caring relationship. And, this is why the caring relationship is truly the central tenet of doctoring. Everyone can name exceptions to the mutual caring role. Buetow lists some of them: the incompetent patient, the patient who doesn’t want a mutual relationship, and so forth. But as a physician, if you put your all into building relationships with your patients, these become no longer barriers; they are just the way a particular relationship unfolds. There may be an optimal place along the spectrum between consumerism and paternalism that we do not achieve in every situation, and the lack of a mutually caring relationship will impede us. But, a skillful physician builds this caring relationship with each interaction, aware of what the patient needs to become an informed, autonomous and engaged partner in the coprovision of care. Encounters with patients that fail to meet this exacting standard need not be a waste. Rather, they should be seen by us as an opportunity to connect on this journey of care. William T. Branch, Jr., MD, MACP, Director, Division of General Internal Medicine, Emory University School of Medicine, William.Branch@emoryhealthcare.org Nathan Spell, MD, FACP, Associate Clinical Chief, General Internal Medicine, The Emory Clinic, Inc., Nathan.Spell@emoryhealthcare.org References 1. Buetow SA. To care is to coprovide. Annals of Family Medicine. 2005; 3:553-555. 2. Branch WT Jr. The ethics of caring and medical education. Acad Med. 2000; 75:127-132. 3. Branch WT Jr. Is the therapeutic nature of the patient-physician relationship being undermined? A primary care physician’s perspective. Archives of Internal Medicine 2000; 160:2257-2260. 4. Branch WT Jr. Suchman AS. Meaningful experiences in medicine. Am J Med. 1990; 88:56-9. Competing interests: None declared |
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Daniel L Zerbe, Perry, NY USA family physician
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The word "coprovision" grabbed my attention at first glance as possibly meaning something to do with staring at stool. D Zerbe Competing interests: None declared |
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Rod MacLeod, Auckland, New Zealand Palliative care physician
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Five years ago there was a relative dearth of literature on the medical aspects of caring. Thankfully this is beginning to change and Stephen Buetow’s reflection is a positive contribution to this discussion. I read this paper on the same day that I received Moira Stewart’s article “Reflections on the doctor-patient relationship: from evidence to practice”(1) which adds a different dimension to this debate. Buetow’s definitions of caring are interesting in that he appears to play down the ethics of caring so eloquently described by William Branch(2). Branch feels that the ethics of caring assumes that connection to others is central to what it means to be human; that relationships rather than alienation give meaning to our existence. This ethic he states is “based on the desire to be receptive to and responsible for others – to be a caring person”. This would initially seem to be at odds with what Buetow is suggesting but beneath the discussion of coprovision as the use of clinical expertise or the knowledge and experience the patient has of his/her body there is an unstated understanding perhaps of the human element of care. That care however, I would assert, can constitute paternalistic behavior – the idea that ‘doctor knows best’ is sometimes how the patient and family want it to be. Dealing with very sick and dying people we find that there are often too many things to be concerned about without having to negotiate elements of clinical intervention. In many ways therefore a paternalistic approach (or perhaps more accurately a parental approach) is called for and accepted. I would entirely agree that we must stop thinking of all clinical practice as care. If you ask patients if their doctor cares for them or about them it is surprisingly common for them to say no. By highlighting the need to reframe notions of medical care Buetow contributes much to this important debate. 1. Stewart M Reflections on the doctor-patient relationship: from evidence to practice Brit J Gen Pract 2005 55: 793-801 2. Branch WT The ethics of caring and medical education Acad. Med. 2000 75: 127-132 Competing interests: None declared |
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John G. Bruhn, Ph.D, Scottsdale, AZ, USA Medical Sociologist, Northern Arizona University
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I like Professor Buetow's concern that any interaction that does not meet patient needs is not care. He calls for the coprovision of care taking us beyond the clinician-patient interaction. I would stress that to care is to take even a broader view that extends beyond the key players in providing care, and include the many alternative therapists such as PT,OT, music therapy, massage therapy, pet therapy, and chaplains, who are also players in coproviding care. The clinician has to be aware of, and believe that these interventions can meet patient's needs and contribute to their care. However, what level of care a patient can receive, or how well their needs can be met is dependent upon how they will pay for their care. The 40 some million Americans with no health insurance and who use the ER for their care will never experience what Dr. Buetow is advocating. Competing interests: None declared |
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Eva Kahana, Ph.D., USA Robson Professor of Sociology, Case Western Reserve University
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Buetow’s essay “To Care is to Coprovide” merits attention because, in principle, it encourages dialogue about health care partnerships that involve 'co-important' contributions of clinicians, patients and caregivers in health care. The author advocates for coprovision as the true formula for care provision in Family Medicine. While the tone of this essay is proscriptive, the elements of the formula are not unpacked and are difficult to grasp. Coprovision is described as involving clinicians and patients, both of whom must be other regarding and self regarding at the same time. Clinicians and patients are each expected “to provide the expertise in health care” that they have the capacity to bring to each encounter. Coprovision is contrasted with undesirable orientations such as paternalism and consumerism. The conceptualization of coprovision is discussed in the context of social movements such as feminism and socialism and is presented as an antidote to paternalism and consumerism. The author urges his readers to adopt the semantics of coprovision as defining all care. By equating goals of “self regard” and “other regard”, he creates ambiguity between altruistic and self-serving values held by clinician and patient. The adverse evaluation of consumerism offered may also be hasty. While the early literature in sociology presented health care consumers in a conflict oriented perspective (Haug, 1996), recent conceptualizations regard proactive health care consumers as building collaborations with physicians (Kahana & Kahana, 2003). A model linked to “isms” has little appeal to many patients and clinicians who seek greater openness and mutual acceptance rather than ideological orthodoxy in developing health care partnerships. In health communication both ‘content’ and ‘affect’ are important (Kreps, 2003). The ‘content’ of this essay could benefit from more careful definition and specification, while more positive ‘affect’ toward readers with diverse viewpoints could foster reader responsiveness. Challenges to implementation of the coprovision of care should also be considered. For example, the expertise contributed by patients and clinicians may be symbolically parallel but implementing a system where each contributes “according to his ability” while meeting the needs of the other could prove to be difficult. Ultimately, Buetow aims to pursue a noble cause in advocating for greater recognition of real contributions of all members of the health care partnership. Recognizing the family and patient centered roots of primary care, one simply needs to add a bit of clarity and flexibility to his model. References Haug, M.R. (1996). The effects of physician/elder patient characteristics on health communication. Health Communication, 8(3), 249-262. Kahana, E., & Kahana, B. (2003). Patient proactivity enhancing doctor- patient communication in cancer prevention and care among the aged. Patient Education and Counceling, 50(1), 67-73. Kreps, G.L. (2003). The impact of communication on cancer risk, incidence, morbidity, mortality, and quality of life. Health Communication, 15(2), 161-169. Competing interests: None declared |
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