PeterEliasMD

During my thirty-some years as a primary care physician (and for some years before that, listening to and observing my father) I have seen the practice of medicine move steadily away from a rigidly patriarchal approach to a far healthier patient-centric approach. This process, or at least my appreciation of it, has been uneven and far from painless. Since cultures and societies must evolve (or collapse), this remains a work in progress.

Clinicians tend to focus on medical content. Evidence-based practice and data-driven protocols have brought valuable improvements, and progress in the sciences has been nothing short of breathtaking. But content isn’t everything. Presentation also counts. A lot.

Consider the restaurant business, where poor presentation can ruin a great meal. Outstanding food at a meal with a disliked colleague and served in a noisy environment by a rude waiter with no sense of personal hygiene on dirty plates is likely to be far less enjoyable than a mediocre meal taken with a special person and served graciously by candlelight in a romantic setting.

I was fortunate to spend my medical school years at the University of Rochester during the time George Engel was developing his biopsychosocial model. (More here and here and here.) I came away believing that the clinician only brings one of the three key components of patient care to the relationship: deep knowledge of the biology of health and illness. The other two components of health and illness are the patient’s psychology or internal milieu, and the patient’s social context. Both of these are resources much more accessible to the patient than to the clinician. The clinical task is to explore and understand the patient’s experiences of her health or illness, and then help the patient understand the biology in order to make decisions or take action. Properly done, the ‘taking of a history’ and subsequent conversation involves a journey with the patient in a way that allows the clinician to understand the patient’s experience and the patient to understand and use the science.

A second major influence on my approach to patients had been clinical hypnosis. I first experienced this as a patient while in medical school (for a dental procedure) and later observed it being used effectively in primary care by one of our faculty at the University of Wisconsin (Madison) Family Practice Residency. Several years into practice, I decided to obtain the training to use this tool in my own practice. While I do formal clinical hypnosis only occasionally these days, I depend on the basic principles every day.

Collaboration is a better paradigm than participation. One participates in an activity but collaborates on achieving a goal. I find collaborating with patients on their health a better approach than letting them participate in my care of the them. I am also uncomfortable with discussions about empowering patients, because this approach assumes that we own the power, that it is ours to bestow – or withdraw. The reverse is (or should be) true. We don’t empower our patients to participate in their care, they empower us to work with them for their benefit. (More here.)

Here I offer a collection of examples drawn from my experience and based on my style. These are not scripts. Memorizing and reciting them will not work. I share them, along with some deconstruction and comments, in the hope that it will help others to think about collaborative relationships and collaborative language.