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Patients,
partners and paternalism Dr Dermot
Ward TheBMJ takes
itself very seriously, very cutting-edge, 'where it's at' and
suchlike ephemera. In
its backward rush to the future it not long ago banned Latin
phrases from its pages; and also you will be hard pressed to
find whether an author has a medical qualification or not. It's
18 September 99 issue, for those who didn't see it had a cover
page with a `noir` photo of a tangoing twosome behind
a slogan "embracing patient partnership". It seems the doctor patient relationship, as we have known
it, has had its last tango in medicine. Or has it? Its guest
editor, Angela Coulter (executive director, policy and development,
King`s Fund...thus), rails against the paternalistic
model in which the doctor decides and sees the partnership model
as required to replace it. And
would you believe it, Angela Coulter (who?) declares
the paternalistic model is "out of step with other currents in
society". What currents. Export
trends? Rave parties
or international
bee-keeping practices? She
opines that the shared model may be a "staging post" in the way
to the "informed model" and, wait for it, may be "the most
important change in medicine in the next decade - more important than
the arrival of the new genetics or the Internet". Can she
be serious? She mentions that Don Berwick (who?) "one of the world's leading
thinkers on improvement in health care believes that when patients
become co-equal with care providers in controlling care, making
decisions and treating themselves with coaching, outcomes improve...." One problem
with so much of this particular theorising is the absence of
basic rationale such as what exactly is meant by a paternalistic
model of medical practice. We
get a clue from the emotive language and hyperbolic claims that
paternalism has really nothing to do with most of us fathers
and mothers but has much to do about been pejorative concerning
the way doctors practise. My 1996
Collins English Dictionary defines paternalism as "the attitude
or policy of a government or other authority that manages the
affairs of a country, company, community etc. in the manner of
a father, especially in usurping individual responsibility and
the liberty of choice". Webster's
1998 dictionary defines it as "the care or control of a country,
community, group of employees etc. in a manner suggestive of
a father looking after his children". I
prefer the Webster declaration because it doesn't suggest there
is something inherently antisocial in being fatherly just as
neither of them suggests there is anything remotely subversive
in maternalism.
Is it wrong,
as some would aver, to place an empathic (critics would call it paternalistic)
hand on the arm or shoulder of a greatly distressed patient. I
don't for a moment suggest that the tenor of the relationship at
that time should necessarily remain in such comforting mode. Good
practice would dictate that it would change with improvement and
recovered competence and capacity, should they occur, in that patient. Most doctors as they mature in their practice fine-tune their
responses to patients to take account of the nuances of different
patient need at varying phases in illness, different age groups,
some frail, perhaps dying, those in almost rude good health who believe
themselves to be ill, all with different levels of stress and distress. They
(doctors) have been working too for decades to explicate the subtleties
of their special interaction with patients in the ultimate interest
of better patient care. We
aspire to, but will never reach, perfection in our performance. Complacency
has never had a place in our therapeutic armamentarium. No doctor
worth his or her salt should be rude, brusque, bossy or otherwise
discourteous to patients. If
they are so, they deserve appropriate consequences. But
let us be quite clear, fashionable sloganising amongst the healthcare
sideline chattering classes merely desiccates rather than enriches
understanding of the complexities of the doctor-patient relationship. By the way,
England`s politicians have decided recently to reinstate Latin
in the school curriculum. Gosh, another problem for the BMJ. |
