What Truly Matters: Relationships and Primary Care

Mark Marnocha

doi:10.1370/afm.1004

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Extending the concept of "slow medicine"
Alberto Dolara

Published on: 25 August 2009
Evidence and Other Appetites
Howard F. Stein

Published on: 22 May 2009
What Truly Matters: High Quality Medical Outcomes
Thomas L. Schwenk

Published on: 14 May 2009

Published on: (25 August 2009)
Page navigation anchor for Extending the concept of "slow medicine"
Extending the concept of "slow medicine"
Alberto Dolara, Firenze, Italy
I think that the concept of "slow medicine", as recalled in Marnocha Mark 's paper, is not at all in contrast with the scientific and technological advances in medicine ,but it might be adopted with advantage not only by family physicians, but by all doctors who care for patients.
I tried to illustrate the concept in two papers ( Invito ad una slow medicine.Ital Heart J Suppl 2002;3:100-101; Avoiding haste in c...
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I think that the concept of "slow medicine", as recalled in Marnocha Mark 's paper, is not at all in contrast with the scientific and technological advances in medicine ,but it might be adopted with advantage not only by family physicians, but by all doctors who care for patients.
I tried to illustrate the concept in two papers ( Invito ad una slow medicine.Ital Heart J Suppl 2002;3:100-101; Avoiding haste in clinical cardiology. Acta Cardiol 2005;60:569-73).
Competing interests: None declared
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Competing Interests: None declared.
Published on: (22 May 2009)
Page navigation anchor for Evidence and Other Appetites
Evidence and Other Appetites
Howard F. Stein, Oklahoma City, OK, USA
I appreciate Dr. Marnocha's editorial essay which sets the stage for, and endorses the primacy of relationships in, Dr. Loxterkamp's four essays/stories in the same issue of Annals of Family Medicine. I want to draw attention to the language of one sentence: "Whereas trials, meta- analyses, and guidlines serve the appetite for good evidence, personal reflections satisfy another appetite." I fully recognize that there is...
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I appreciate Dr. Marnocha's editorial essay which sets the stage for, and endorses the primacy of relationships in, Dr. Loxterkamp's four essays/stories in the same issue of Annals of Family Medicine. I want to draw attention to the language of one sentence: "Whereas trials, meta- analyses, and guidlines serve the appetite for good evidence, personal reflections satisfy another appetite." I fully recognize that there is a very specific language for, and very specific assumptions behind and methods in, the clinical school of thought called "evidence-based medicine." What I want to argue is that the world of relationships and reflections that Dr. Marnocha and Dr. Loxterkamo immerse us in is ALSO good clinical evidence, but evidence in a different voice, of "another appetite." We are, I think, talking about different kinds and sources of evidence, not "evidence" and leftovers.
It implicitly sabotages the strength of our argument to call scientific/ rational/ parsimonious data "evidence" and what we learn from and about relationships to be something else. I think it implicitly accepts the pernicious distinction between "hard science" or "real medicine," and "soft science" or "the soft stuff." Doctor-patient relationships, countertransference, family dynamics, cultural health beliefs and rituals, and community networks are every bit as real and understandable as is biomedical evidence. I would go so far as to say that the thoughts and feelings expressed in poems, stories, movies, plays and other "humanities" can open us to crucial clinical evidence that we might otherwise overlook if we strictly followed rational-scientific canons of evidence. In this view, "art" can help "science" be even more scientific!
Very practically, one of the common sources of conflict in physician- patient relationships is where doctor and patient (and family, and community, and workplace) have differing "explanatory models," and in turn different standards of evidence, for understanding what is wrong and how to address it. It is important for the physician to take an interest in how the patients thinks. In short, I think that we need to rethink how we use the word "evidence" in our clinical work and in our reflections on it.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (14 May 2009)
Page navigation anchor for What Truly Matters: High Quality Medical Outcomes
What Truly Matters: High Quality Medical Outcomes
Thomas L. Schwenk, Ann Arbor, USA
Dr. Marnocha's essay is eloquent and passionate, as are those of Dr. Loxtercamp, but neither author is unequivocally clear as to whether the physician-patient relationships described are means to an end, or ends onto themselves. Is building the relationship itself, in all of its complexity and glory, the fundamental professional goal of family physicians, or is the relationship, however deep and powerful, merely a mean...
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Dr. Marnocha's essay is eloquent and passionate, as are those of Dr. Loxtercamp, but neither author is unequivocally clear as to whether the physician-patient relationships described are means to an end, or ends onto themselves. Is building the relationship itself, in all of its complexity and glory, the fundamental professional goal of family physicians, or is the relationship, however deep and powerful, merely a means to provide patient-centered, evidence-based medical care of the highest quality?
I suspect both authors would endorse the latter, but also suspect that they may secretly wish for the former.
It is the degree to which Family Medicine is unclear about this critical distinction that is the degree to which our ultimate success will be compromised. I worry that family physicians define themselves too frequently according to their success in building relationships (frequently measured in terms of how "nice" we are in contrast to how "un- nice" other physicians and the system are), and too little in terms of our ability to deliver the highest quality of medical care as measured by the subtle and intricate balance of patient values and biomedical outcomes.
The patient-centered medical home is still a relationship-centered means to deliver medical care, not a medical office whose fundamental purpose is to build relationships.
Competing interests: None declared
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Competing Interests: None declared.