Pounds

I just went to my Family Doc this week realizing I haven't checked my elevated cholesterol for a few years. I excused myself previously that in a few weeks, when I took a few more pounds off will be the right moment, which never came. And she is not Sally but Miriam and 93 years old and it is not COPD but …and mind you, I live and practice 10000 miles away and in a different language. In the real world of care, most of the time clinical decisions are taken from the contextual point of view and not according to the evidence (after considering it, hopefully). While doing so, while reflecting on your own healer and person narrative both patient and physician may heal and grow (1 ). A special type of doc's narratives (2) is that which touch "forbidden conversations", those deeds and thoughts that you sometimes whisper in the ear of your closest friend. Mac Baird taught me about it over a decade ago and in a recent AAPP course I learned some more. Sharing those is a special privilege.Thank you , Dean.

1. Reis S, Hermoni D, Livingstone P, Borkan J. An Integrated Narrative- and Evidence-Based Case Report: A Case Report of Paroxysmal Atrial Fibrillation and Anticoagulation. BMJ 2002 ; 325: 1018-1020.

2. Borkan J; Reis S; Steinmatz D; Medalie J. Patients and Doctors: Life-Changing Stories From Primary Care. Wisconsin University Press 1999.

Competing interests:   None declared

I want Dr. Gianakos to be my doctor! His essay illustrates the doctor-patient relationship at its best. This experienced physician does not need to maintain “emotional distance” and he is not afraid to expose his own human failings to his patient, yet in no way does he compromise his professionalism. He respects Sally’s unique perspective about the management of her asthma, even though he would like her to do things differently. He and Sally have negotiated a treatment plan that works for both of them. The fact that this plan would fail the test of adherence to the asthma guidelines(1) only illuminates the limitations of the guidelines approach to the management of chronic illness.

Clearly Sally and Dr. Gianakos have had a long history together. Time has worn the edges off of their relationship. They understand each other’s strengths and weaknesses in a way that would not be possible without this aspect of continuity between them. In this age of managed care, such continuity between a patient and physician is becoming more and more difficult to achieve and maintain.(2) It is reassuring to see that this physician and this patient have maintained their long relationship despite the barriers.

The abstract suggests that this is a story about a noncompliant patient and a noncompliant doctor. I disagree, and I think we should stop using this term in clinical medicine. It implies a paternalistic relationship that is the antithesis of how doctors and patients should be connecting and it certainly is not the relationship described in this essay. Management of chronic illness is always embedded in the context of the rich fabric of the patient’s life as well as the ongoing relationship with his/her physician. That management needs to be informed by available scientific knowledge, but the form it takes will be different for each patient and physician. As Dr. Gianakos so eloquently puts it, “Not much I can teach a spunky 91 year-old woman about how to live her life.”

References

1. Guidelines for the Diagnosis and Management of Asthma: National Institutes of Health National Heart Lung and Blood Institute; July 1997 1997. NIH Publication 97-4051.

2. Flocke SA, Stange KC, Zyzanski SJ. The impact of insurance type and forced discontinuity on the delivery of primary care J Fam Pract. 1997;45(2):129-135.

Competing interests:   None declared