I have toyed with this post for some time. I might be out my depth here, but finally decided to write. Some time ago I read a new manifesto for primary care. I do believe that the manifesto comes from a deep concern about how medics care about me and opposition to paternalistic medicine which knows better, and for which I am only an object of actions. And I do agree. And yet, I want to respond.
The main argument the authors make is this:
However, we consider that recovering a sense of self, for both patients and doctors, is an essential prerequisite for making genuinely person-centred primary care a practical reality.
They say that this recovery of the self can be seen in terms of “five key polarities, related to the selves of patients and GPs, visible or potential within every consultation” The five polarities are as follows:
- passive and active patients – some patients are more active than others;
- attached and detached clinicians – it’s about the balance between seeing biology and a human being;
- bureaucratic and autonomous encounters – instrumentality in approaching clinicians and patients;
- individual and social selves – the authors put a question mark on patients as making rational, informed choices;
- physicalist or humanist theories – the authors offer an argument for a ‘humanist’ or moral component in understanding medicine.
Isn’t it great? Yes, it is. Personally, I don’t understand why it’s only patients who are questioned as rational beings and doctors somehow get off scot-free. But, even though it’s irritating, it’s a minor thing.
The main problem I have with the manifesto is that it inevitably takes a broad-brush macro-perspective of medical care or primary care or whatever else. Even though it explicitly challenges the large-scale framework currently on offer, implicitly, it offers its replacement with a new large-scale perspective. The humanist perspective it offers is one in which the individual is lost, rather it talks about patients, theories, approaches. And I, a patient, would like to suggest something different. So here is my manifesto for manifestos.
I think that medical/primary care happens one visit/consultation at a time. The moment I enter your surgery, doctor, close the door, nothing else matters. The system, the theory, let alone the groups of people you identify. Yes, all that the eight authors write is true, important and wonderful. And I am absolutely certain it felt good writing it. But as I sit down on a wonky chair, twisting my body in order to face you, as you adjust yourself to be even more comfortable in your large armchair, we are beginning to create ‘primary care’. And more often than not, all that wonder of the manifesto for primary care disappears and, to be completely honest, I just want to ask: Have you, for pity’s sake, seen a doctor recently? How was it for you?
The large-scale perspective, lovely as it is, doesn’t mean zilch, if Dr X who is sitting in front of me doesn’t understand that putting me in a group of passive or active patients is as useless as it is to see me as a system of organs with, say, antibiotics taking the function of a screwdriver. Primary care, I think, is about this one interaction with DG, who, as it happens, is irritated, in pain, and makes fun of what you say, only to withdraw helplessly as you repeat my favourite phrase, as you look at the computer screen:
So, the evidence is…
Go classify this!
Wonderful as the manifesto for primary care is, it will invite yet another set of communication skills for ‘recovering the self’. For the fragment I quoted above is just about meaningless, unless you understand it in an interaction with me, here and now. And it doesn’t matter at all how many times you repeat ‘genuinely person centred-primary care’, unless you start wondering what it means to me. Yes, not you, me! Otherwise, I will be getting another set of wonder-questions which score high on a variety of person-centred care scales. And they will be consistent with another set of communication skills which medics across the country and, possibly, the world will be swotting up on. After all, they also want to be person-centred in a suitably measured way. Very quickly I get lost in all that, which you will regret very much.
So, my manifesto for primary-care manifestos is that they look at things from the bottom upwards. I dream of a manifesto that looks at medical care through my eyes, as I walk into a surgery and I am greeted by my first name, as if we were on first-name basis. We are bloody not and I don’t want you to call me Dariusz! How about putting this in your manifesto?
I see the argument that the manifesto at hand introduces a value system which is to underpin what I am talking about. But let’s face it, in the system the authors challenge, I found a doctor (one in 27 years I’ve been here) who used my surname in addressing me. And you will find many other doctors who somehow manage to ‘beat the system’. On the other hand, I have read so many versions of this manifesto that if there were any chance it would work, every GP’s second name would be ‘person-centred’. Somehow, no matter how many times you write it, I still meet lovely and well-meaning doctors who simply don’t get it.
So perhaps, just perhaps, you could reflect on this and wonder about changing the macro approach into a micro approach. Primary care is here and now, co-constructed by you and me in the 10 minutes we have. What do you do in those 10 minutes with me? Not a passive/active patient, not even a person, a human being, or a not-a-disease individual. Me! I think, at the moment, your manifesto doesn’t even begin to answer such a question.