Doctor-patient relationships in chronic illness: insights from forensi
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《英国医生杂志》
1 St. George's Hospital Medical School, London, SW17 0RE
Correspondence to: G McGauley gmcgaule@sghms.ac.uk
Collaborative management of chronic illness is undermined by neglect of emotional and psychological factors in both the patient and doctor
Most medical students want to become doctors to heal patients.3 In reality, most will spend much of their time caring for patients for whom no cure is possible. Medicine's success in the pursuit of cure has fundamentally changed the expectations of doctors; medical success has often become equated with cure and medical failure with the absence of effective treatments and resort to palliative care.4 The treatment of chronic disease conflicts so fundamentally with these expectations that it tends to be neglected.
Medical education may contribute to the development of negative attitudes towards people with chronic illness. Studies report medical students' ambivalence towards the management of chronic illnesses, even if these attitudes were absent before medical school, and a trend towards cynical and self protective strategies as training progresses.5 Furthermore, medical students are deterred from choosing specialties that involve managing chronically ill patients.4 This is perhaps unsurprising given that the dominant model of medical education remains disease oriented, hospital based, and intent on cure. This mismatch between the way that medical education is delivered and the reality of medical practice can lead to disillusioned doctors and poorly served patients.
Relevance of forensic psychiatry to management
Various strategies have been used to aid management of chronic illness. These include policy driven initiatives such as the introduction of national service frameworks, enhancing collaboration between service providers and patients, enabling patients to take an active role in their care and more intensive follow-up and monitoring of adherence to treatment and outcome.2 8 Literature on collaborative management of chronic illness emphasises the concept of patient as partner.9 Ensuring the cooperation and motivation of the patient is a multifaceted task requiring an understanding of the patient's attitudes and beliefs about their illness as well as their coping strategies, within the context of their life experiences.
The need to attend to the emotional aspects of the patient's chronic illness in collaborative care is acknowledged.10 However, this is assumed to be achieved mainly through efficient information sharing and collaborative development of a self management plan using cognitive-behavioural principles in conjunction with evidence based knowledge and sensitive communication skills. Sole reliance on these techniques may be suboptimal because patients' decision making and capacity to engage collaboratively in these strategies may also involve seemingly irrational processes, arising from their perceptions of and attitudes towards their illness. These, in combination with the doctor's expectations and attitudes, may evoke emotional reactions in the doctor. Meaningful appreciation of these experiences and reactions is not straightforward; it requires reflective work by the doctor. Decoding these dynamic reactions and their influence on the doctor-patient relationship may enhance collaborative care strategies and interventions.
The importance of this process is illustrated by the long tradition of reflective practice based on the Balint movement in vocational training in general practice. Although valued across primary care and mental healthcare settings, service pressures can easily erode time set aside for self reflection.11
Bridging the collaborative gap
It is easy to see how treating chronic illness can threaten the sense of satisfaction that comes from treating patients who more closely resemble Main's description. Doctors may become aware of a sense of frustration with, or ambivalence towards, patients who do not seem to get better. This arises from unrealistic aspirations of care giving and equating their professional capacity to heal with their sense of self worth. Some doctors may have to redefine their expectations and reformulate their own attitudes, particularly in relation to their perceived capacity to help.
Taking the patient
Patients' experience of their illness is also coloured by the system's response, whether this is represented byprimary healthcare teams, multidisciplinary teams, or institutions. As chronic care is generally multidisciplinary care, the therapeutic relationship between team and patient is also key.15 Although the most obvious aspect of security in forensic services is the walls and locks, relational security is also vitally important. This arises from a therapeutic understanding of the relationship between staff and patients and involves fostering a robust therapeutic alliance. Good relational security provides opportunities for patients to talk about the frustrations of chronic illness and explore alternative approaches to stressful situations. It also allows staff to monitor the patients' psychological state and provide extra support during vulnerable periods.
Box 2: Guiding principles in teaching chronic illness care
Knowledge, skills, and attitudes relating to acute disease cannot always be applied to chronic conditions
Learning is best achieved in the context in which it will be applied
Many acute conditions are superimposed on chronic ones
Emphasis on real world problems—not all patients are able, articulate, and willing
Foster positive attitudes by exposure to chronic illness early in training
Facilitate longitudinal, interdepartmental training
Recognition that clinical uncertainty is both inevitable and acceptable
Although in high secure and mental health settings the patient generally establishes a relationship with a team rather than with the single practitioner, the concept of relational security is not dissimilar to that of relational or personal continuity in primary care. This is the ongoing therapeutic relationship between a practitioner and a patient that extends beyond specific episodes of illness or disease.16 Although the structure and process for multidisciplinary working differs between primary and secondary care, this difference may diminish as primary care professionals take on wider roles in managing chronic illness, aimed at reducing the need for hospital admission.8
A threat to good relational security or continuity occurs when teams become split and staff hold polarised views about a patient. When differences are attended to they can inform management; the ability to constructively hold in mind opposing views is one indication of a cohesive team. These team divisions often result from a splitting process arising within the mind of the patient, which is not under the patient's conscious control. In other words, it is not the patient who is splitting the team but the team who need to take responsibility for their division. In these circumstances patients are often regarded as being manipulative when they are only showing their divided reaction to their illness and difficulties. For example, a patient's emotions may oscillate between angry resentment about their vulnerability and dependence at one moment and dismissal and denial of difficulties at another.
When staff identify exclusively with one aspect of a patient's experience and recruit this to resurrect pre-existing rivalries major fault lines can split the team. In such a climate the care of patients suffers a double blow: their needs are lost and they are held responsible for the divisions within the team. At the extreme end of the spectrum the psychological processes that result in splitting also contribute to other toxic processes.
Toxic processes
Although medical schools seem to agree about the importance of skills in managing chronic illness, the level of teaching in the undergraduate curriculum varies widely.18 Doctors report feeling inadequately trained to teach chronic care.19
Box 3: Skills required in the management of chronic illnesses
Therapeutic relationship
Eliciting patients' perspectives on their illness
Attending to your own response to the patient
Accurately assessing the therapeutic relationship
Developing and reviewing individual management plans
Within teams
Appreciation of roles within multidisciplinary and primary healthcare teams
Interpersonal skills to be an effective team member
Openness to acknowledging ambivalent or negative reactions
In the wider system
Applying disease prevention and health promotion strategies
Employing strategies that empower patients and carers
Participating in health service development and evaluation
Effective multiagency liaison
Summary points
Collaborative care strategies underplay the effect of managing chronic illnesses on doctors and the therapeutic relationship
Overemphasis on acute hospital based specialties in medical education may foster negative attitudes to chronic illness
Mismatch between doctors' and patients' beliefs and expectations may undermine collaborative care
Reflective practice directed at understanding personal and system responses to chronically ill patients may optimise collaborative care
The General Medical Council has identified the need to train students to relate better to patients and their problems.20 Evidence on such training is sparse, but some guiding principles seem to emerge (box 2).
Box 3 lists the skills that are central to the management of chronic illnesses and could be taught in the curriculum. Many of the skills could be incorporated into the undergraduate personal and professional development theme or could form the basis of a special study module. Teaching of acute medicine could be refocused to place greater emphasis on the doctor's role in the multidisciplinary team, the role of carers, discharge planning, and liaison with primary care.21
Some innovative courses have been developed that introduce students to patients with chronic illnesses and aim to develop skills that can be applied across a range of chronic conditions.22 Most students report appreciating the extended contact with patients and encountering real problems.22 For many, it may be the first time they have met patients whose views and attitudes on treatment and compliance may not match their own. These courses all encourage students to elicit patient's beliefs and expectations and to evaluate their responses to their patient while providing a safe environment in which to express ambivalence and uncertainty. Their success and popularity may lie in their effectiveness in closing the gap in collaborative care that we have described. Greater use of this teaching strategy could strengthen the future collaborative management of patients with chronic illnesses.
We thank Roger Neighbour, Christine Barry, and Shehla Baig for their helpful comments.
Contributors and sources: CC is a specialist registrar in forensic psychiatry at Wandsworth prison. GM is a consultant forensic psychotherapist at Broadmoor Hospital. The idea for the article arose from a series of teaching days that the authors organised at Broadmoor Hospital for graduate entry medical students from St George's Hospital Medical School. CC proposed the original idea. Both authors planned the article, wrote and critically reviewed drafts, and approved the final version. CC is the guarantor.
Competing interest: None declared.
References
World Health Organization. The world health report 2003—shaping the future. Geneva: WHO, 2003.
Von Korff M, Glasgow RE, Sharpe M. Organising care for chronic illness. BMJ 2002;325: 92-4.
Lloyd-Williams M, Dogra N. Attitudes of preclinical medical students towards caring for chronically ill and dying patients: does palliative care teaching make a difference? Postgrad Med J 2004;80: 31-4.
Edwards M. Modern medicine and the pursuit of cure. Med Educ 1999;33: 704-6.
Davis BE, Nelson DB, Sahler OJZ, McCurdy FA, Goldberg R, Greenberg LW. Do clerkship experiences affect medical students' attitudes toward chronically ill patients? Acad Med 2001;76: 815-20.
Grumbach K, Bodenheimer T. A primary care home for Americans: putting the house in order. JAMA 2002;288: 889-93.
Butwell M, Jamieson E, Leese M, Taylor P. Trends in special (high-security) hospitals. II. Residency and discharge episodes, 1986-1995. Br J Psychiatry 2000;176: 260-5.
Lewis R, Dixon J. Rethinking management of chronic diseases. BMJ 2004;328: 220-2.
Holman H, Lorig K. Patients as partners in managing chronic disease. BMJ 2000;320: 526-7.
Turner J, Kelly B. Emotional dimensions of chronic disease. West J Med 2000;172: 124-8.
Samuel O, Sackin P, Salinsky J, Suckling H, McKee A, Pinder R. Balint in GP vocational training schemes. Work Based Learning in Primary Care 2004;2: 26-37.
Main T. The ailment. Br J Med Psychol 1957;30: 129-45.
Sollod RN. Beyond a sense of safety: A psychologist's tale of serious chronic illness. Psychother Pract 2002;58: 1397-409.
Malan DH. Individual psychotherapy and the science of psychodynamics. London: Butterworths, 1990: 1-15.
Wagner EH. The role of patient care teams in chronic disease management. BMJ 2000;320: 569-71.
Haggerty JL, Reid RJ, Freeman GK, Starfield BH, Adair CE, McKendry R. Continuity of care: a multidisciplinary review. BMJ 2003;327: 1219-21.
Watts D, Morgan G. Malignant alienation: dangers for patients who are hard to like. Br J Psychiatry 1994;164: 11-5.
Pham HH, Simonson L, Elnicki M, Fried L, Goroll AH, Bass EB. Training US medical students to care for the chronically ill. Acad Med 2004;79: 32-41.
Darer JD, Hwang W, Pham HH, Bass EB, Anderson G. More training needed in chronic care: a survey of US physicians. Acad Med 2004;79: 541-8.
General Medical Council. Tomorrow's Doctors. London: GMC, 1993.
Nair BR, Finucane PM. Reforming medical education to enhance the management of chronic disease. Med J Aust 2003;179: 257-9.
Collinson S, Bliss L, Rickets M, Lobo E, Lumb A. Seeing old people with real problems like leaving the gas on: students' and tutor' reflections after piloting the second phase of a new, community-based course for second year medical students. Med Teach 2002;24: 327-36.(Colin Campbell, lecturer in forensic psy)
Correspondence to: G McGauley gmcgaule@sghms.ac.uk
Collaborative management of chronic illness is undermined by neglect of emotional and psychological factors in both the patient and doctor
Most medical students want to become doctors to heal patients.3 In reality, most will spend much of their time caring for patients for whom no cure is possible. Medicine's success in the pursuit of cure has fundamentally changed the expectations of doctors; medical success has often become equated with cure and medical failure with the absence of effective treatments and resort to palliative care.4 The treatment of chronic disease conflicts so fundamentally with these expectations that it tends to be neglected.
Medical education may contribute to the development of negative attitudes towards people with chronic illness. Studies report medical students' ambivalence towards the management of chronic illnesses, even if these attitudes were absent before medical school, and a trend towards cynical and self protective strategies as training progresses.5 Furthermore, medical students are deterred from choosing specialties that involve managing chronically ill patients.4 This is perhaps unsurprising given that the dominant model of medical education remains disease oriented, hospital based, and intent on cure. This mismatch between the way that medical education is delivered and the reality of medical practice can lead to disillusioned doctors and poorly served patients.
Relevance of forensic psychiatry to management
Various strategies have been used to aid management of chronic illness. These include policy driven initiatives such as the introduction of national service frameworks, enhancing collaboration between service providers and patients, enabling patients to take an active role in their care and more intensive follow-up and monitoring of adherence to treatment and outcome.2 8 Literature on collaborative management of chronic illness emphasises the concept of patient as partner.9 Ensuring the cooperation and motivation of the patient is a multifaceted task requiring an understanding of the patient's attitudes and beliefs about their illness as well as their coping strategies, within the context of their life experiences.
The need to attend to the emotional aspects of the patient's chronic illness in collaborative care is acknowledged.10 However, this is assumed to be achieved mainly through efficient information sharing and collaborative development of a self management plan using cognitive-behavioural principles in conjunction with evidence based knowledge and sensitive communication skills. Sole reliance on these techniques may be suboptimal because patients' decision making and capacity to engage collaboratively in these strategies may also involve seemingly irrational processes, arising from their perceptions of and attitudes towards their illness. These, in combination with the doctor's expectations and attitudes, may evoke emotional reactions in the doctor. Meaningful appreciation of these experiences and reactions is not straightforward; it requires reflective work by the doctor. Decoding these dynamic reactions and their influence on the doctor-patient relationship may enhance collaborative care strategies and interventions.
The importance of this process is illustrated by the long tradition of reflective practice based on the Balint movement in vocational training in general practice. Although valued across primary care and mental healthcare settings, service pressures can easily erode time set aside for self reflection.11
Bridging the collaborative gap
It is easy to see how treating chronic illness can threaten the sense of satisfaction that comes from treating patients who more closely resemble Main's description. Doctors may become aware of a sense of frustration with, or ambivalence towards, patients who do not seem to get better. This arises from unrealistic aspirations of care giving and equating their professional capacity to heal with their sense of self worth. Some doctors may have to redefine their expectations and reformulate their own attitudes, particularly in relation to their perceived capacity to help.
Taking the patient
Patients' experience of their illness is also coloured by the system's response, whether this is represented byprimary healthcare teams, multidisciplinary teams, or institutions. As chronic care is generally multidisciplinary care, the therapeutic relationship between team and patient is also key.15 Although the most obvious aspect of security in forensic services is the walls and locks, relational security is also vitally important. This arises from a therapeutic understanding of the relationship between staff and patients and involves fostering a robust therapeutic alliance. Good relational security provides opportunities for patients to talk about the frustrations of chronic illness and explore alternative approaches to stressful situations. It also allows staff to monitor the patients' psychological state and provide extra support during vulnerable periods.
Box 2: Guiding principles in teaching chronic illness care
Knowledge, skills, and attitudes relating to acute disease cannot always be applied to chronic conditions
Learning is best achieved in the context in which it will be applied
Many acute conditions are superimposed on chronic ones
Emphasis on real world problems—not all patients are able, articulate, and willing
Foster positive attitudes by exposure to chronic illness early in training
Facilitate longitudinal, interdepartmental training
Recognition that clinical uncertainty is both inevitable and acceptable
Although in high secure and mental health settings the patient generally establishes a relationship with a team rather than with the single practitioner, the concept of relational security is not dissimilar to that of relational or personal continuity in primary care. This is the ongoing therapeutic relationship between a practitioner and a patient that extends beyond specific episodes of illness or disease.16 Although the structure and process for multidisciplinary working differs between primary and secondary care, this difference may diminish as primary care professionals take on wider roles in managing chronic illness, aimed at reducing the need for hospital admission.8
A threat to good relational security or continuity occurs when teams become split and staff hold polarised views about a patient. When differences are attended to they can inform management; the ability to constructively hold in mind opposing views is one indication of a cohesive team. These team divisions often result from a splitting process arising within the mind of the patient, which is not under the patient's conscious control. In other words, it is not the patient who is splitting the team but the team who need to take responsibility for their division. In these circumstances patients are often regarded as being manipulative when they are only showing their divided reaction to their illness and difficulties. For example, a patient's emotions may oscillate between angry resentment about their vulnerability and dependence at one moment and dismissal and denial of difficulties at another.
When staff identify exclusively with one aspect of a patient's experience and recruit this to resurrect pre-existing rivalries major fault lines can split the team. In such a climate the care of patients suffers a double blow: their needs are lost and they are held responsible for the divisions within the team. At the extreme end of the spectrum the psychological processes that result in splitting also contribute to other toxic processes.
Toxic processes
Although medical schools seem to agree about the importance of skills in managing chronic illness, the level of teaching in the undergraduate curriculum varies widely.18 Doctors report feeling inadequately trained to teach chronic care.19
Box 3: Skills required in the management of chronic illnesses
Therapeutic relationship
Eliciting patients' perspectives on their illness
Attending to your own response to the patient
Accurately assessing the therapeutic relationship
Developing and reviewing individual management plans
Within teams
Appreciation of roles within multidisciplinary and primary healthcare teams
Interpersonal skills to be an effective team member
Openness to acknowledging ambivalent or negative reactions
In the wider system
Applying disease prevention and health promotion strategies
Employing strategies that empower patients and carers
Participating in health service development and evaluation
Effective multiagency liaison
Summary points
Collaborative care strategies underplay the effect of managing chronic illnesses on doctors and the therapeutic relationship
Overemphasis on acute hospital based specialties in medical education may foster negative attitudes to chronic illness
Mismatch between doctors' and patients' beliefs and expectations may undermine collaborative care
Reflective practice directed at understanding personal and system responses to chronically ill patients may optimise collaborative care
The General Medical Council has identified the need to train students to relate better to patients and their problems.20 Evidence on such training is sparse, but some guiding principles seem to emerge (box 2).
Box 3 lists the skills that are central to the management of chronic illnesses and could be taught in the curriculum. Many of the skills could be incorporated into the undergraduate personal and professional development theme or could form the basis of a special study module. Teaching of acute medicine could be refocused to place greater emphasis on the doctor's role in the multidisciplinary team, the role of carers, discharge planning, and liaison with primary care.21
Some innovative courses have been developed that introduce students to patients with chronic illnesses and aim to develop skills that can be applied across a range of chronic conditions.22 Most students report appreciating the extended contact with patients and encountering real problems.22 For many, it may be the first time they have met patients whose views and attitudes on treatment and compliance may not match their own. These courses all encourage students to elicit patient's beliefs and expectations and to evaluate their responses to their patient while providing a safe environment in which to express ambivalence and uncertainty. Their success and popularity may lie in their effectiveness in closing the gap in collaborative care that we have described. Greater use of this teaching strategy could strengthen the future collaborative management of patients with chronic illnesses.
We thank Roger Neighbour, Christine Barry, and Shehla Baig for their helpful comments.
Contributors and sources: CC is a specialist registrar in forensic psychiatry at Wandsworth prison. GM is a consultant forensic psychotherapist at Broadmoor Hospital. The idea for the article arose from a series of teaching days that the authors organised at Broadmoor Hospital for graduate entry medical students from St George's Hospital Medical School. CC proposed the original idea. Both authors planned the article, wrote and critically reviewed drafts, and approved the final version. CC is the guarantor.
Competing interest: None declared.
References
World Health Organization. The world health report 2003—shaping the future. Geneva: WHO, 2003.
Von Korff M, Glasgow RE, Sharpe M. Organising care for chronic illness. BMJ 2002;325: 92-4.
Lloyd-Williams M, Dogra N. Attitudes of preclinical medical students towards caring for chronically ill and dying patients: does palliative care teaching make a difference? Postgrad Med J 2004;80: 31-4.
Edwards M. Modern medicine and the pursuit of cure. Med Educ 1999;33: 704-6.
Davis BE, Nelson DB, Sahler OJZ, McCurdy FA, Goldberg R, Greenberg LW. Do clerkship experiences affect medical students' attitudes toward chronically ill patients? Acad Med 2001;76: 815-20.
Grumbach K, Bodenheimer T. A primary care home for Americans: putting the house in order. JAMA 2002;288: 889-93.
Butwell M, Jamieson E, Leese M, Taylor P. Trends in special (high-security) hospitals. II. Residency and discharge episodes, 1986-1995. Br J Psychiatry 2000;176: 260-5.
Lewis R, Dixon J. Rethinking management of chronic diseases. BMJ 2004;328: 220-2.
Holman H, Lorig K. Patients as partners in managing chronic disease. BMJ 2000;320: 526-7.
Turner J, Kelly B. Emotional dimensions of chronic disease. West J Med 2000;172: 124-8.
Samuel O, Sackin P, Salinsky J, Suckling H, McKee A, Pinder R. Balint in GP vocational training schemes. Work Based Learning in Primary Care 2004;2: 26-37.
Main T. The ailment. Br J Med Psychol 1957;30: 129-45.
Sollod RN. Beyond a sense of safety: A psychologist's tale of serious chronic illness. Psychother Pract 2002;58: 1397-409.
Malan DH. Individual psychotherapy and the science of psychodynamics. London: Butterworths, 1990: 1-15.
Wagner EH. The role of patient care teams in chronic disease management. BMJ 2000;320: 569-71.
Haggerty JL, Reid RJ, Freeman GK, Starfield BH, Adair CE, McKendry R. Continuity of care: a multidisciplinary review. BMJ 2003;327: 1219-21.
Watts D, Morgan G. Malignant alienation: dangers for patients who are hard to like. Br J Psychiatry 1994;164: 11-5.
Pham HH, Simonson L, Elnicki M, Fried L, Goroll AH, Bass EB. Training US medical students to care for the chronically ill. Acad Med 2004;79: 32-41.
Darer JD, Hwang W, Pham HH, Bass EB, Anderson G. More training needed in chronic care: a survey of US physicians. Acad Med 2004;79: 541-8.
General Medical Council. Tomorrow's Doctors. London: GMC, 1993.
Nair BR, Finucane PM. Reforming medical education to enhance the management of chronic disease. Med J Aust 2003;179: 257-9.
Collinson S, Bliss L, Rickets M, Lobo E, Lumb A. Seeing old people with real problems like leaving the gas on: students' and tutor' reflections after piloting the second phase of a new, community-based course for second year medical students. Med Teach 2002;24: 327-36.(Colin Campbell, lecturer in forensic psy)