Written by Bente Prytz Mjølstad
(#3 of the Whole Person reflections series)
Have you ever thought about whether your regular GP knows more about you than your blood pressure or cholesterol levels? If so, might such knowledge be of any medical relevance?
Most of us visit our regular GP once or twice a year for more or less trivial complaints, and you are probably most interested in the GPs medical skills, and not so concerned about whether the doctor knows you as person or not. However, if you got seriously ill or had a chronic illness, would it still not matter?
I have been working as a regular GP in a listing-system for many years and experienced how useful it is to know patients as persons. Through repeated encounters over time, I became familiar with many of my patients as persons—who they were and how they lived their lives—whether I was aiming for it or not. Although such information may be of medical relevance, it is rarely written down in the medical records. In many aspects, it is tacit knowledge. Nevertheless, as GPs we use this kind of knowledge all the time in everyday medical practice, tailoring the approach and follow-up of individual patients, especially when we are dealing with the patients we see the most. There is also a growing body of research documenting that adverse life experiences can have a decisive impact on people’s health. However, traditional biomedicine, the dominant perspective through which today’s medical practice is conceptualized, has placed little emphasis on expert findings, such as those within modern stress physiology, indicating that biographical and person-related knowledge has medical relevance.
This was the starting point for my entry into research, which resulted in a Ph.D. thesis in 2015 with the title: Knowing patients as persons. A theory-driven qualitative study of the relevance of person-related knowledge in primary health care. The primary aim of the project was to explore the person-related knowledge GPs had about their patients and the degree to which they ascribed medical relevance to it. We also sought to assess the importance given to person-related knowledge by patients undergoing rehabilitation, and to explore the interactions between GPs and health care personnel at a nursing home rehabilitation unit regarding the transfer of such knowledge.
What do GPs actually know about their patients as persons?
We found that GPs generally considered person-related knowledge about patients to be important. The more clinical experience the GPs acquired, the more they appraised biographical information about their patients as being relevant to their medical task. Experience seemed to enhance the professional’s awareness that a person’s life-world is highly relevant to his or her health.
Most of the GPs participating in the intervention study could describe the personality of their patients adequately and, to some extent, their working life and close relationships (partner, children). They had less knowledge about their patients’ interests (hobbies, activities), social networks and relationships to parents and siblings. They had little or no knowledge, however, about their patients’ childhood as regards either facts or conditions, or significant events or experiences. Identifying such “knowledge holes” was perhaps not so surprising. However, the reactions of the GPs were. Some of the GPs expressed surprise at how little they actually knew about their patients, despite a long doctor-patient relationship.
Standardization meets stories
When we did the intervention study at the nursing home, we found that even though patients’ narratives were available, they were not taken up by the staff. These narratives can be part of what is called a biographical overview or record, that patients can agree to having handed over to other health professionals. We found that, in these records, this small group of fragile patients we studied had provided many narratives with clear relevance to their health situation and the rehabilitation process. However, despite the institution’s clear intentions to create individualized treatment plans, the plans themselves tended to consist primarily of standardized procedures. They failed to take into consideration recommendations from GPs and patients’ wishes when building these plans, even when the institution would have been well equipped to do so. Narratives were barely addressed by or integrated into the treatment actually provided, as illustrated in the following case:
The Sea Captain and the fear of being abandoned
Patient A, an 83-year-old, man suffering from Parkinson’s disease, was in need of rehabilitation. He was a steady and somewhat introverted person, who in his earlier years used to work as a Sea Captain of oil tankers crossing the Atlantic. He now lived at home with his wife, his main caretaker, and his need for comprehensive and reliable care was considerable. GP A, who had known the patient for 25 years, perceived that the high level of strain in his marital relationship was a topic which would be crucial for the health personnel at the rehabilitation unit to bring up and respond to since it posed a threat, potentially jeopardizing not only the man’s confidence but also his actual safety. In addition to his fear of being abandoned by his wife, he also expressed a worry that death from his Parkinson’s disease, his main diagnosis, was imminent. The interview also revealed important biographical information that could have helped the health personnel to understand his great fear of being abandoned: he was born an illegitimate child and lost his mother at the age of 12, which meant that he had to move in with a foster family. He stayed there until he was 15 years old before he went to sea to become a sailor. Although these existential matters were clearly documented in the biographical record, the consulting physician never addressed the topic during the patient’s stay. One reason the doctor gave was that it would have been too time-consuming.
Our interpretation was that the institutional voice of medicine tended to override the voice of the patient’s life-world: that is, patients’ stories were subordinated to the institution’s routines. Consequently, and despite the institution’s best intentions, the staff’s efforts to provide appropriate rehabilitation in every case was, to some extent, jeopardized. All three articles upon which this dissertation is based (see below) discuss the need for a more flexible and person-oriented approach to patients.* This would enable public health services to provide more genuinely tailored treatment which, to a greater extent, takes the individual patient’s specific life-world into consideration.
* Mjølstad, Bente Prytz; Kirkengen, Anna Luise; Getz, Linn; Hetlevik, Irene. Knowing patients as persons: Senior and Junior GPs explore a professional resource. European Journal for Person Centered Healthcare 2013 ;Volum 1, 88-99
Mjølstad, Bente Prytz; Kirkengen, Anna Luise; Getz, Linn; Hetlevik, Irene. What Do GPs Actually Know About Their Patients As Persons? European Journal for Person Centered Healthcare 2013 ;Volum 1, 149-160
Mjølstad, Bente Prytz; Kirkengen, Anna Luise; Getz, Linn; Hetlevik, Irene. Standardization meets stories: contrasting perspectives on the needs of frail individuals at a rehabilitation unit. International Journal of Qualitative Studies on Health and Well-being 2013 ;Volume 8. Issue 1, 21498
Causality, Complexity and Evidence in Health Sciences 