Knowledge of Clinical Context
Dr M described a web of problems in her clinical context that constrained her interactions with patients. Every day she contended with numerous barriers to patient care created by a medical care system that ignored the health concerns of the poor. Chronic staffing and resource problems within the health center created situations where she spent a large proportion of her time away from direct patient care. Within this context, she developed an approach to make the most efficient use of her time with patients.
Dr M and Patient C: A Cycle of Hopelessness
Although interactions with all of the patients were used in developing these interpretations, the findings from a crucial discussion with Patient C show the way detachment emerged in practice for Dr M. In the fourth recorded interaction between Patient C and Dr M Table 5, Patient C first told Dr M that she was not taking her prescribed medicine. Dr M interpreted this revelation as shown in Table 4. Although Patient C’s truth telling could have opened up the relationship, instead it confirmed Dr M’s previous beliefs about Patient C. Within Dr M’s practice constraints, Patient C was viewed as a chaotic, noncompliant alcoholic, and thus Dr M’s time could be more effectively spent by detaching from Patient C and attending to other patients she might change. In contrast to Dr M’s constructed reasons explaining Patient C’s elevated blood sugars, Patient C tells a different story about her personal struggles with alcohol and diabetes while living in poverty. Patient C’s interview was conducted a few months after she moved from the streets to a low-income apartment and 3 months before the fourth recorded interaction Table 6.
Patient C distrusted the “white man’s medicine” and was preparing to tell Dr M about her reluctance to take the medicine. Patient C’s belief that some physicians “care” suggests that she valued attributes of a physician separately from their approach to illness. Although Patient C’s honesty may have opened up the possibility for dialogue about differing interpretations of diabetes illness experience and self-care, Dr M’s stance blocked her ability to enter into the very dialogue needed to potentially reconstruct the relationship with this patient.
Patient-Specific Narratives: Stories about People, Disease, and Clinical Context
Dr M implicitly used patient-specific narratives as powerful instruments to identify aspects of patients’ illness experiences that she considered clinically important and potentially manageable. To construct her story about a patient, Dr M combined narratives gathered from her cumulative interactions with a patient in the health center, her interactions with people in the community, and her discussions with others working at the health center. In addition, the stories were broadened by Dr M’s patient-specific application of disease theory and the particular pressures of her practice environment.
Discussion
Important theoretical models for primary care physician-patient relationships include sustained partnership, patient-centered care, and enhanced autonomy.27-29 Although they advance somewhat different theoretical claims, each of these models emphasizes knowing the “whole person,” fostering empathy and trust, and engaging in shared decision making. With a focus on “the patient” or “the relationship” in these models, “disease” is often marginalized or considered only as an important outcome variable for measuring the impact of physician-patient interactions.30 In contrast to patient- or relationship-centered models, the biopsychosocial model is frequently assumed to combine a holistic understanding of disease-illness processes with attention to the primary care relationship. This study demonstrates that biopsychosocial models of disease may actually conflict with patient-centered approaches to communication.
Biopsychosocial models are integrated theories of disease, not models for physician-patient interactions in family practice. There are at least 2 distinct strategies for working with biopsychosocial understandings of disease. In an instrumental approach, the family physician strives to change the patient’s perspective to adapt to the physician’s biopsychosocial understanding of disease and illness care. In a dialogical approach, the family physician interacts with the patient to understand the biopsychosocial disease and co-construct the approach to illness care over time. Both strategies can claim to be directly applying biopsychosocial models, and both might be successful in various clinical contexts. In this study, Dr M took the first approach and found herself left with an unbridgeable gap in communication.
The misunderstandings, mistrust, and constrained interactions found in this study point to deeper problems with the way knowledge is formed in clinical practice. Physicians construct their understanding of disease in individual patients through patient-specific narratives that combine knowledge of disease, patients, and clinical context. These narratives may gain richness, depth, and complexity over time, but they may also become static forms of representation. Knowledge of the illness experience of patients with chronic diseases like type 2 diabetes is expanding; however, our understanding of the practice experience of primary care physicians is limited.31-33